Exhibit 10.20

LOGO [g275632ex1020p01.jpg]   

 

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

AHCCCS Contract Number: YH17-0003-02

CONTRACT COVER PAGE

 

 

1.      AMENDMENT #:

  

2.      CONTRACT:

  

3.      EFFECTIVE DATE OF AMENDMENT:

  

4.      PROGRAM

DHCM – RBHA

1    YH17-0003-02    July 1, 2016    Greater Arizona

 

5. CONTRACTOR NAME AND ADDRESS:

Health Choice Integrated Care, LLC

1300 South Yale Street

Flagstaff, AZ 86001

 

6. PURPOSE: The purpose of this amendment is to amend the Contract for the
period July 1, 2016 through September 30, 2016 and to the amend Sections,
Uniform Terms and Conditions, Special Terms and Conditions, Scope of Work,
Exhibit Summary, Exhibit-1, Definitions, Exhibit-2, Acronyms, Exhibit-3,
Exhibit-5, Exhibit-4, Exhibit-5, Exhibit-7, Exhibit-8, Exhibit-9, Exhibit-11,
Exhibit-12, Exhibit-13, Endnotes

 

7. THE ABOVE REFERENCED CONTRACT IS HEREBY AMENDED AS FOLLOWS:

This Contract amendment is entered into by and between the Regional Behavioral
Health Authority and the Arizona Health Care Cost Containment System (AHCCCS).

Arizona Laws 2015, Chapter 19, Section 9 (SB 1480) enacts that from and after
June 30, 2016, the provision of behavioral health services under the Division of
Behavioral Health Services (DBHS) in the Department of Health Services is
transferred to and shall be administered by the Arizona Health Care Cost
Containment System (AHCCCS). From and after June 30, 2016, the AHCCCS
administration succeeds to the authority, powers, duties and responsibilities of
DBHS with the exception of the Arizona State Hospital. Administrative rules and
orders that were adopted by DBHS continue in effect until superseded by
administrative action by AHCCCS. Until administrative action is taken by AHCCCS,
any reference to DBHS in rules and orders is considered to refer to AHCCCS.

All administrative matters, contracts and judicial and quasi-judicial actions,
whether completed, pending or in process, of DBHS on July 1, 2016 are
transferred to and retain the same status with AHCCCS.

This contract amendment constitutes a full removal and replacement of the prior
contract provisions regarding provision of Non-Title XIX services for Title XIX
and Non-Title XIX members accessing behavioral health services as previously
delineated between the Regional Behavioral Health Authority and the Arizona
Department of Health Services/Division of Behavioral Health Services under
Contract #ADHS15-085892.

Contract Sections Amended:

 

  •   Uniform Terms and Conditions - Replaced with Terms and Conditions

 

  •   Special Terms and Conditions - Replaced with Terms and Conditions

 

  •   Scope of Work

 

  •   Exhibit Summary - RESERVED

 

  •   Exhibit-1, Definitions

 

  •   Exhibit-2, Acronyms - RESERVED

 

  •   Exhibit-3, Medicare Requirement to Coordinate Care for Dual Eligible SMI
Members

 

  •   Exhibit-4, PLACEHOLDER

 

  •   Exhibit-5, Arizona Vision – Twelve Principles for Children Services
Delivery - Reserved

 

  •   Exhibit-7, Documents Incorporated by Reference - RESERVED

 

  •   Exhibit-8, Informational Documents - RESERVED

 

  •   Exhibit-9, Deliverables

 

  •   Exhibit-11, Capitation Rates – NAME REVISED TO: Capitation Rates and
Contractor Specific Requirements

 

  •   Exhibit-12, PLACEHOLDER

 

  •   Exhibit-13, Pledge to Protect Confidential Information – RESERVED

 

  •   Endnotes

Refer to the individual Contract sections for specific changes.

 

8. Authority: AHCCCS is duly authorized to execute and administer agreements
pursuant to A.R.S. §36-2903 et seq. and §36-2932 et seq. These
contracts/amendments are exempt from the Procurement Code pursuant to A.R.S.
§41-2501(H) (as effective on July 1, 2016).

IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT

 

9.     SIGNATURE OF AUTHORIZED REPRESENTATIVE:   10. SIGNATURE OF AHCCCS
CONTRACTING OFFICER: LOGO [g275632ex1020p01a.jpg]   LOGO [g275632ex1020p01b.jpg]
TYPED NAME:  

 

SHAWN NAU

  TYPED NAME:  

 

MEGGAN HARLEY

TITLE:  

 

CHIEF EXECUTIVE OFFICER

  TITLE:  

 

ACTING CHIEF PROCUREMENT OFFICER

DATE:  

 

6/24/16

  DATE:  

 

6/15/2016

 

1

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

TERMS AND CONDITIONS

TERMS AND CONDITIONS

 

  1. ADVERTISING AND PROMOTION OF CONTRACT

The Contractor shall not advertise or publish information for commercial benefit
concerning this contract without the prior written approval of the Contracting
Officer.

 

  2. APPLICABLE LAW

Arizona Law - The law of Arizona applies to this contract including, where
applicable, the Uniform Commercial Code, as adopted in the State of Arizona.

Implied Contract Terms - Each provision of law and any terms required by law to
be in this contract are a part of this contract as if fully stated in it.

 

  3. ARBITRATION

The parties to this contract agree to resolve all disputes arising out of or
relating to this contract through arbitration, after exhausting applicable
administrative review, to the extent required by A.R.S. §12-1518 except as may
be required by other applicable statutes.

 

  4. ASSIGNMENT AND DELEGATION

The Contractor shall not assign any rights nor delegate all of the duties under
this contract. Delegation of less than all of the duties of this contract must
conform to the requirements of Scope of Work, Subcontracting Requirements.

 

  5. ASSIGNMENT OF CONTRACT AND BANKRUPTCY

This contract is voidable and subject to immediate cancellation by AHCCCS upon
the Contractor becoming insolvent or filing proceedings in bankruptcy or
reorganization under the United States Code, or assigning rights or obligations
under this contract without the prior written consent of AHCCCS.

 

  6. AUDITS AND INSPECTIONS

The Contractor shall comply with all provisions specified in applicable A.R.S.
§35-214 and §35-215 and AHCCCS rules and policies and procedures relating to the
audit of the Contractor’s records and the inspection of the Contractor’s
facilities. The Contractor shall fully cooperate with AHCCCS staff and allow
them reasonable access to the Contractor’s staff, subcontractors, members, and
records [42 CFR 438.6(g)].

At any time during the term of this contract, and five (5) years thereafter
unless a longer time is otherwise required by law, the Contractor’s or any
subcontractor’s books and records shall be subject to audit by AHCCCS and, where
applicable, the Federal government, to the extent that the books and records
relate to the performance of the contract or subcontracts [42 CFR
438.242(b)(3)].

 

2

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

TERMS AND CONDITIONS

 

AHCCCS, or its duly authorized agents, and the Federal government may evaluate
through on-site inspection or other means, the quality, appropriateness and
timeliness of services performed under this contract.

 

  7. AUTHORITY

This contract is issued under the authority of the Contracting Officer who
signed this contract. Changes to the contract, including the addition of work or
materials, the revision of payment terms, or the substitution of work or
materials, directed by an unauthorized state employee or made unilaterally by
the Contractor are violations of the contract and of applicable law. Such
changes, including unauthorized written contract amendments, shall be void and
without effect, and the Contractor shall not be entitled to any claim under this
contract based on those changes.

 

  8. CHANGES

AHCCCS may at any time, by written notice to the Contractor, make changes within
the general scope of this contract. If any such change causes an increase or
decrease in the cost of, or the time required for, performance of any part of
the work under this contract, the Contractor may assert its right to an
adjustment in compensation paid under this contract. The Contractor must assert
its right to such adjustment within 30 days from the date of receipt of the
change notice. Any dispute or disagreement caused by such notice shall
constitute a dispute within the meaning of Section, Contract Terms and
Conditions, Disputes, and be administered accordingly.

When AHCCCS issues an Amendment to modify the Contract, the Contractor shall
ensure contract amendments are signed and submitted to AHCCCS by the date
specified by AHCCCS. The provisions of such amendment will be deemed to have
been accepted on the day following the date AHCCCS requires an executed
amendment, even if the amendment has not been signed by the Contractor, unless
within that time the Contractor notifies AHCCCS in writing that it refuses to
sign the amendment. If the Contractor provides such notification, AHCCCS will
initiate termination proceedings.

 

  9. CHOICE OF FORUM

The parties agree that jurisdiction over any action arising out of or relating
to this contract shall be brought or filed in a court of competent jurisdiction
located in the State of Arizona.

 

  10. COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS

The Contractor shall comply with all applicable Federal and State laws and
regulations including Title VI of the Civil Rights Act of 1964; Title IX of the
Education Amendments of 1972 (regarding education programs and activities); the
Age Discrimination Act of 1975; the Rehabilitation Act of 1973 (regarding
education programs and activities), and the Americans with Disabilities Act; EEO
provisions; Copeland Anti-Kickback Act; Davis-Bacon Act; Contract Work Hours

 

3

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

TERMS AND CONDITIONS

 

and Safety Standards; Rights to Inventions Made Under a Contract or Agreement;
Clean Air Act and Federal Water Pollution Control Act; Byrd Anti-Lobbying
Amendment. The Contractor shall maintain all applicable licenses and permits.

 

  11. CONFIDENTIALITY AND DISCLOSURE OF CONFIDENTIAL INFORMATION

The Contractor shall safeguard confidential information in accordance with
Federal and State laws and regulations, including but not limited to, 42 CFR
431, Subpart F, A.R.S. §36-107, §36-2903 (for Acute), §36-2932 (for ALTCS),
§41-1959 and §46-135, the Health Insurance Portability and Accountability Act
(Public Law 107-191 Statutes 1936), 45 CFR parts 160 and 164, and AHCCCS Rules.

The Contractor shall establish and maintain procedures and controls that are
acceptable to AHCCCS for the purpose of assuring that no information contained
in its records or obtained from AHCCCS or others carrying out its functions
under the contract shall be used or disclosed by its agents, officers or
employees, except as required to efficiently perform duties under the contract.
Except as required or permitted by law, the Contractor also agrees that any
information pertaining to individual persons shall not be divulged other than to
employees or officers of the Contractor as needed for the performance of duties
under the contract, unless otherwise agreed to, in writing, by AHCCCS.

The Contractor shall not, without prior written approval from AHCCCS, either
during or after the performance of the services required by this contract, use,
other than for such performance, or disclose to any person other than AHCCCS
personnel with a need to know, any information, data, material, or exhibits
created, developed, produced, or otherwise obtained during the course of the
work required by this contract. This nondisclosure requirement shall also
pertain to any information contained in reports, documents, or other records
furnished to the Contractor by AHCCCS.

 

  12. CONFLICT OF INTEREST

The Contractor shall not undertake any work that represents a potential conflict
of interest, or which is not in the best interest of AHCCCS or the State without
prior written approval by AHCCCS. The Contractor shall fully and completely
disclose any situation that may present a conflict of interest. If the
Contractor is now performing or elects to perform during the term of this
contract any services for any AHCCCS health plan, provider or Contractor or an
entity owning or controlling same, the Contractor shall disclose this
relationship prior to accepting any assignment involving such party.

 

  13. CONTINUATION OF PERFORMANCE THROUGH TERMINATION

The Contractor shall continue to perform, in accordance with the requirements of
the contract, up to the date of termination and as directed in the termination
notice.

 

4

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

TERMS AND CONDITIONS

 

  14. CONTRACT

The Contract between AHCCCS and the Contractor shall include: 1) the Request for
Proposal (RFP) including AHCCCS policies and procedures incorporated by
reference as part of the RFP, 2) the proposal submitted by the Contractor in
response to the RFP including any Best and Final Offers, and 3) any Contract
amendments. In the event of a conflict in language between the proposal
(including any Best and Final Offers) and the RFP (including AHCCCS policies and
procedures incorporated by reference), the provisions and requirements set forth
and/or referenced in the RFP (including AHCCCS policies and procedures
incorporated by reference) shall govern.

The Contract shall be construed according to the laws of the State of Arizona.
The State of Arizona is not obligated for the expenditures under the contract
until funds have been encumbered.

 

  15. CONTRACT INTERPRETATION AND AMENDMENT

No Parole Evidence - This contract is intended by the parties as a final and
complete expression of their agreement. No course of prior dealings between the
parties and no usage of the trade shall supplement or explain any term used in
this contract.

No Waiver - Either party’s failure to insist on strict performance of any term
or condition of the contract shall not be deemed a waiver of that term or
condition even if the party accepting or acquiescing in the non-conforming
performance knows of the nature of the performance and fails to object to it.

Written Contract Amendments - The contract shall be modified only through a
written contract amendment within the scope of the contract signed by the
procurement officer on behalf of the State and signed by a duly authorized
representative of the Contractor.

 

  16. COOPERATION WITH OTHER CONTRACTORS

AHCCCS may award other contracts for additional work related to this contract
and Contractor shall fully cooperate with such other contractors and AHCCCS
employees or designated agents. The Contractor shall not commit or permit any
act which will interfere with the performance of work by any other Contractor or
by AHCCCS employees.

 

  17. COVENANT AGAINST CONTINGENT FEES

The Contractor warrants that no person or agency has been employed or retained
to solicit or secure this contract upon an agreement or understanding for a
commission, percentage, brokerage or contingent fee. For violation of this
warranty, AHCCCS shall have the right to annul this contract without liability.

 

  18. DATA CERTIFICATION

The Contractor shall certify that financial and encounter data submitted to
AHCCCS is complete, accurate and truthful. Certification of financial and
encounter data must be submitted concurrently with the data. Certification may

 

5

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

TERMS AND CONDITIONS

 

be provided by the Contractor CEO, CFO or an individual who is delegated
authority to sign for, and who reports directly to the CEO or CFO [42 CFR
438.604 et seq.].

 

  19. DISPUTES

Contract claims and disputes shall be adjudicated in accordance with State Law,
AHCCCS Rules and this contract.

Except as provided by 9 A.A.C. Chapter 22, Article 6, the exclusive manner for
the Contractor to assert any dispute against AHCCCS shall be in accordance with
the process outlined in 9 A.A.C. Chapter 34 and A.R.S. §36-2932. All disputes
except as provided under 9 A.A.C. Chapter 22, Article 6 shall be filed in
writing and be received by AHCCCS no later than 60 days from the date of the
disputed notice. All disputes shall state the factual and legal basis for the
dispute. Pending the final resolution of any disputes involving this contract,
the Contractor shall proceed with performance of this contract in accordance
with AHCCCS’ instructions, unless AHCCCS specifically, in writing, requests
termination or a temporary suspension of performance.

 

  20. E-VERIFY REQUIREMENTS

In accordance with A.R.S §41-4401, the Contractor warrants compliance with all
Federal immigration laws and regulations relating to employees and warrants its
compliance with Section A.R.S. §23-214, Subsection A.

 

  21. EFFECTIVE DATE

The effective date of this contract shall be the Offer and Acceptance date
referenced on page 1 of this contract.

 

  22. ELIGIBILITY FOR STATE OR LOCAL PUBLIC BENEFITS; DOCUMENTATION AND
VIOLATIONS

To the extent permitted by Federal Law:

The Contractor shall comply with A.R.S § 1-502. A.R.S § 1-502 requires each
person applying or receiving a public benefit to provide documented proof which
demonstrates a lawful presence in the United States.

The State shall reserve the right to conduct unscheduled, periodic process and
documentation audits to ensure Contractor compliance. All available Contract
remedies, up to and including termination may be taken for failure to comply
with A.R.S § 1-502 in the delivery of services under this Contract.

 

  23. EMPLOYEES OF THE CONTRACTOR

All employees of the Contractor employed in the performance of work under the
Contract shall be considered employees of the Contractor at all times, and not
employees of AHCCCS or the State. The Contractor shall comply with the Social
Security Act, Workman’s Compensation laws and Unemployment laws of the State of
Arizona and all State, local and Federal legislation relevant to the
Contractor’s business.

 

6

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

TERMS AND CONDITIONS

 

  24. FEDERAL IMMIGRATION AND NATIONALITY ACT

The Contractor shall comply with all Federal, State and local immigration laws
and regulations relating to the immigration status of their employees during the
term of the contract. Further, the Contractor shall flow down this requirement
to all subcontractors utilized during the term of the contract. The State shall
retain the right to perform random audits of Contractor and subcontractor
records or to inspect papers of any employee thereof to ensure compliance.
Should the State determine that the Contractor and/or any subcontractors be
found noncompliant, the State may pursue all remedies allowed by law, including,
but not limited to; suspension of work, termination of the contract for default
and suspension and/or debarment of the Contractor.

 

  25. GRATUITIES

AHCCCS may, by written notice to the Contractor, immediately terminate this
contract if it determines that employment or a gratuity was offered or made by
the Contractor or a representative of the Contractor to any officer or employee
of the State for the purpose of influencing the outcome of the procurement or
securing the contract, an amendment to the contract, or favorable treatment
concerning the contract, including the making of any determination or decision
about contract performance. AHCCCS, in addition to any other rights or remedies,
shall be entitled to recover exemplary damages in the amount of three times the
value of the gratuity offered by the Contractor.

 

  26. INCORPORATION BY REFERENCE

This solicitation and all attachments and amendments, the Contractor’s proposal,
best and final offer accepted by ADHS/DBHS, and any approved subcontracts are
hereby incorporated by reference into the contract.

 

  27. INDEMNIFICATION

Contractor/Vendor Indemnification (Not Public Agency):

The parties to this contract agree that the State of Arizona, its departments,
agencies, boards and commissions shall be indemnified and held harmless by the
Contractor for the vicarious liability of the State as a result of entering into
this contract. The Contractor agrees to indemnify, defend, and hold harmless the
State from and against any and all claims, losses, liability, costs, and
expenses, including attorney’s fees and costs, arising out of litigation against
AHCCCS including, but not limited to, class action lawsuits challenging actions
by the Contractor. The requirement for indemnification applies irrespective of
whether or not the Contractor is a party to the lawsuit. Each Contractor shall
indemnify the State, on a pro rata basis based on population, attorney’s fees
and costs awarded against the State as well as the attorney’s fees and costs
incurred by the State in defending the lawsuit. The Contractor shall also
indemnify AHCCCS, on a pro rata basis based on population, the administrative
expenses incurred by AHCCCS to address Contractor deficiencies arising out of
the litigation. The parties further agree that the State of Arizona, its

 

7

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

TERMS AND CONDITIONS

 

departments, agencies, boards and commissions shall be responsible for its own
negligence and/or willful misconduct. Each party to this contract is responsible
for its own negligence and/or willful misconduct.

Contractor/Vendor Indemnification (Public Agency):

Each party (“as indemnitor”) agrees to indemnify, defend, and hold harmless the
other party (“as indemnitee”) from and against any and all claims, losses,
liability, costs, or expenses (including reasonable attorney’s fees)
(hereinafter collectively referred to as ‘claims’) arising out of bodily injury
of any person (including death) or property damage but only to the extent that
such claims which result in vicarious/derivative liability to the indemnitee,
are caused by the act, omission, negligence, misconduct, or other fault of the
indemnitor, its officers, officials, agents, employees, or volunteers.

 

  28. INDEMNIFICATION - PATENT AND COPYRIGHT

To the extent permitted by applicable law the Contractor shall defend, indemnify
and hold harmless the State against any liability including costs and expenses
for infringement of any patent, trademark or copyright arising out of contract
performance or use by the State of materials furnished or work performed under
this contract. The State shall reasonably notify the Contractor of any claim for
which it may be liable under this paragraph.

 

  29. INSURANCE

The Contractor is required to maintain insurance, at a minimum, as specified in
Attachment E-1 Standard Professional Service Contracts. For policies for
insurance for professional service contracts working with children or vulnerable
adults, the policy may be endorsed to include coverage for sexual abuse and
molestation.

 

8

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

TERMS AND CONDITIONS

 

ATTACHMENT E-1

STANDARD PROFESSIONAL SERVICE CONTRACT

INDEMNIFICATION CLAUSE:

To the fullest extent permitted by law, Contractor shall defend, indemnify, save
and hold harmless the State of Arizona, and its departments, agencies, boards,
commissions, universities, officers, officials, agents, and employees
(hereinafter referred to as “Indemnitee”) from and against any and all claims,
actions, liabilities, damages, losses, or expenses (including court costs,
attorneys’ fees, and costs of claim processing, investigation and litigation)
(hereinafter referred to as “Claims”) for bodily injury or personal injury
(including death), or loss or damage to tangible or intangible property caused,
or alleged to be caused, in whole or in part, by the negligent or willful acts
or omissions of Contractor or any of its owners, officers, directors, agents,
employees or subcontractors. This indemnity includes any claim or amount arising
out of or recovered under the Workers’ Compensation Law or arising out of the
failure of such Contractor to conform to any Federal, State or local law,
statute, ordinance, rule, regulation or court decree. It is the specific
intention of the parties that the Indemnitee shall, in all instances, except for
Claims arising solely from the negligent or willful acts or omissions of the
Indemnitee, be indemnified by Contractor from and against any and all claims. It
is agreed that Contractor will be responsible for primary loss investigation,
defense and judgment costs where this indemnification is applicable. In
consideration of the award of this contract, the Contractor agrees to waive all
rights of subrogation against the State of Arizona, its officers, officials,
agents and employees for losses arising from the work performed by the
Contractor for the State of Arizona.

This indemnity shall not apply if the Contractor or subcontractor(s) is/are an
agency, board, commission or university of the State of Arizona.

 

  1. INSURANCE REQUIREMENTS:

Contractors shall procure and maintain until all of their obligations have been
discharged, including any warranty periods under this Contract, insurance
against claims for injury to persons or damage to property arising from or in
connection with the performance of the work hereunder by the Contractor, its
agents, representatives, employees or subcontractors.

The insurance requirements herein are minimum requirements for this Contract and
in no way limit the indemnity covenants contained in this Contract. The State of
Arizona in no way warrants that the minimum limits contained herein are
sufficient to protect the Contractor from liabilities that arise out of the
performance of the work under this contract by the Contractor, its agents,
representatives, employees or subcontractors, and the Contractor is free to
purchase additional insurance.

 

A. MINIMUM SCOPE AND LIMITS OF INSURANCE: Contractor shall provide coverage with
limits of liability not less than those stated below.

 

  1. Commercial General Liability (CGL) – Occurrence Form

Policy shall include bodily injury, property damage, and broad form contractual
liability coverage.

 

9

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

TERMS AND CONDITIONS

 

•       General Aggregate

   $ 2,000,000   

•       Products – Completed Operations Aggregate

   $ 1,000,000   

•       Personal and Advertising Injury

   $ 1,000,000   

•       Damage to Rented Premises

   $ 50,000   

•       Each Occurrence

   $ 1,000,000   

 

  a. The policy shall be endorsed, as required by this written agreement, to
include the State of Arizona, and its departments, agencies, boards,
commissions, universities, officers, officials, agents, and employees as
additional insureds with respect to liability arising out of the activities
performed by or on behalf of the Contractor.

 

  b. Policy shall contain a waiver of subrogation endorsement, as required by
this written agreement, in favor of the State of Arizona, and its departments,
agencies, boards, commissions, universities, officers, officials, agents, and
employees for losses arising from work performed by or on behalf of the
Contractor.

 

  2. Business Automobile Liability

Bodily Injury and Property Damage for any owned, hired, and/or non-owned
vehicles used in the performance of this Contract.

 

•       Combined Single Limit (CSL)

   $ 1,000,000   

 

  a. Policy shall be endorsed, as required by this written agreement, to include
the State of Arizona, and its departments, agencies, boards, commissions,
universities, officers, officials, agents, and employees as additional insureds
with respect to liability arising out of the activities performed by or on
behalf of the Contractor, involving automobiles owned, leased, hired, and/or
non-owned by the Contractor.

 

  b. Policy shall contain a waiver of subrogation endorsement, as required by
this written agreement, in favor of the State of Arizona, and its departments,
agencies, boards, commissions, universities, officers, officials, agents, and
employees for losses arising from work performed by or on behalf of the
Contractor.

 

  c. Policy shall contain a severability of interest provision.

 

  3. Worker’s Compensation and Employers’ Liability

 

  •   Workers’ Compensation Statutory

 

  •   Employers’ Liability

 

Each Accident

   $ 500,000   

Disease – Each Employee

   $ 500,000   

Disease – Policy Limit

   $ 1,000,000   

 

  a. Policy shall contain a waiver of subrogation endorsement, as required by
this written agreement, in favor of the State of Arizona, and its departments,
agencies, boards, commissions, universities, officers, officials, agents, and
employees for losses arising from work performed by or on behalf of the
Contractor.

 

  b. This requirement shall not apply to each Contractor or subcontractor that
is exempt under A.R.S. §23-901, and when such Contractor or subcontractor
executes the appropriate waiver form (Sole Proprietor or Independent
Contractor).

 

10

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

TERMS AND CONDITIONS

 

  4. Professional Liability (Errors and Omissions Liability)

 

Each Claim

   $ 1,000,000   

Annual Aggregate

   $ 2,000,000   

 

  a. In the event that the Professional Liability insurance required by this
Contract is written on a claims-made basis, Contractor warrants that any
retroactive date under the policy shall precede the effective date of this
Contract; and either continuous coverage will be maintained or an extended
discovery period will be exercised for a period of two years beginning at the
time work under this Contract is completed.

 

  b. The policy shall cover professional misconduct or negligent acts for those
positions defined in the Scope of Work of this Contract.

 

B. ADDITIONAL INSURANCE REQUIREMENTS: The policies shall include, or be endorsed
to include, as required by this written agreement, the following provisions:

 

  1. The Contractor’s policies shall stipulate that the insurance afforded the
Contractor shall be primary and that any insurance carried by AHCCCS, its
agents, officials, employees or the State of Arizona shall be excess and not
contributory insurance, as provided by A.R.S. §41-621 (E).

 

  2. Insurance provided by the Contractor shall not limit the Contractor’s
liability assumed under the indemnification provisions of this Contract.

 

C. NOTICE OF CANCELLATION: For each insurance policy required by the insurance
provisions of this Contract, the Contractor must provide to the State of
Arizona, within two (2) business days of receipt, a notice if a policy is
suspended, voided, or cancelled for any reason. Such notice shall be sent to
AHCCCS Contracts Unit, Mail Drop 5700, Division of Business and Finance, 701 E.
Jefferson St., Phoenix, AZ 85034.

 

D. ACCEPTABILITY OF INSURERS: Contractor’s insurance shall be placed with
companies licensed in the State of Arizona or hold approved non-admitted status
on the Arizona Department of Insurance List of Qualified Unauthorized Insurers.
Insurers shall have an “A.M. Best” rating of not less than A- VII. The State of
Arizona in no way warrants that the above-required minimum insurer rating is
sufficient to protect the Contractor from potential insurer insolvency.

 

E. VERIFICATION OF COVERAGE: Contractor shall furnish the State of Arizona with
certificates of insurance (valid ACORD form or equivalent approved by the State
of Arizona) as required by this Contract and as specified in Exhibit-9,
Deliverables. An authorized representative of the insurer shall sign the
certificates.

All certificates and endorsements, as required by this written agreement, are to
be received and approved by the State of Arizona before work commences. Each
insurance policy required by this Contract must be in effect at or prior to
commencement of work under this Contract. Failure to maintain the insurance
policies as required by this Contract, or to provide evidence of renewal, is a
material breach of Contract.

 

11

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

TERMS AND CONDITIONS

 

All certificates required by this Contract shall be sent directly to AHCCCS
Contracts Unit, Mail Drop 5700, Division of Business and Finance, 701 E.
Jefferson St., Phoenix, AZ 85034. All subcontractors are required to maintain
insurance and to provide verification upon request. The AHCCCS project/contract
number and project description shall be noted on the certificate of insurance.
The State of Arizona and AHCCCS reserves the right to require complete,
certified copies of all insurance policies required by this Contract at any
time.

 

F. SUBCONTRACTORS: Contractors’ certificate(s) shall include all subcontractors
as insureds under its policies or Contractor shall be responsible for ensuring
and/or verifying that all subcontractors have valid and collectable insurance as
evidenced by the certificates of insurance and endorsements for each
subcontractor. All coverages for subcontractors shall be subject to the AHCCCS
Minimum Subcontract Provisions located on the AHCCCS website. AHCCCS reserves
the right to require, at any time throughout the life of this contract, proof
from the Contractor that its subcontractors have the required coverage.

 

G. APPROVAL AND MODIFICATIONS: AHCCCS, in consultation with State Risk, reserves
the right to review or make modifications to the insurance limits, required
coverages, or endorsements throughout the life of this contract, as deemed
necessary. Such action will not require a formal contract amendment but may be
made by administrative action.

 

H. EXCEPTIONS: In the event the Contractor or subcontractor(s) is/are a public
entity, then the Insurance Requirements shall not apply. Such public entity
shall provide a certificate of self-insurance. If the Contractor or
subcontractor(s) is/are a State of Arizona agency, board, commission, or
university, none of the above shall apply.

[END OF ATTACHMENT E-1]

 

  30. IRS W9 FORM

In order to receive payment under any resulting contract, the Contractor shall
have a current IRS W9 Form on file with the State of Arizona.

 

  31. LOBBYING

No funds paid to the Contractor by AHCCCS, or interest earned thereon, shall be
used for the purpose of influencing or attempting to influence an officer or
employee of any Federal or State agency, a member of the United States Congress
or State Legislature, an officer or employee of a member of the United States
Congress or State Legislature in connection with awarding of any Federal or
State contract, the making of any Federal or State grant, the making of any
Federal or State loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment or modification of any Federal or
State contract, grant, loan, or cooperative agreement. The Contractor shall
disclose if any funds paid to the Contractor by AHCCCS have been used or will be
used to influence the persons and entities indicated above and will assist
AHCCCS in making such disclosures to CMS.

 

  32. NO GUARANTEED QUANTITIES

AHCCCS does not guarantee the Contractor any minimum or maximum quantity of
services or goods to be provided under this contract.

 

12

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

TERMS AND CONDITIONS

 

  33. NON-DISCRIMINATION

In accordance with A.R.S. §41-1461 et seq. and Executive Order 2009-09, the
Contractor shall provide equal employment opportunities for all persons,
regardless of race, color, religion, creed, sex, age, national origin,
disability or political affiliation. The Contractor shall comply with the
Americans with Disabilities Act.

 

  34. NON-EXCLUSIVE REMEDIES

The rights and the remedies of AHCCCS under this contract are not exclusive.

 

  35. OFF-SHORE PERFORMANCE OF WORK PROHIBITED

Any services that are described in the specifications or scope of work that
directly serve the State of Arizona or its clients and involve access to secure
or sensitive data or personal client data shall be performed within the defined
territories of the United States. Unless specifically stated otherwise in the
specifications, this paragraph does not apply to indirect or “overhead”
services, redundant back-up services or services that are incidental to the
performance of the contract. This provision applies to work performed by
subcontractors at all tiers.

 

  36. ORDER OF PRECEDENCE

The parties to this contract shall be bound by all terms and conditions
contained herein. For interpreting such terms and conditions the following
sources shall have precedence in descending order: The Constitution and laws of
the United States and applicable Federal regulations; the terms of the CMS 1115
waiver for the State of Arizona; the Constitution and laws of Arizona, and
applicable State Rules; the terms of this contract which consists of the RFP,
the proposal of the successful Offeror, and any Best and Final Offer including
any attachments, executed amendments and modifications; and AHCCCS policies and
procedures.

 

  37. OWNERSHIP OF INFORMATION AND DATA

Materials, reports and other deliverables created under this contract are the
sole property of AHCCCS. The Contractor is not entitled to any rights to those
materials and may not transfer any rights to anyone else. Except as necessary to
carry out the requirements of this contract, as otherwise allowed under this
contract, or as required by law, the Contractor shall not use or release data,
information or materials, reports, or deliverables derived from that data or
information without the prior written consent of AHCCCS. Data, information and
reports collected or prepared by the Contractor in the course of performing its
duties and obligations under this contract shall not be used by the Contractor
for any independent project of the Contractor or publicized by the Contractor
without the prior written permission of AHCCCS. Subject to applicable state and
Federal laws and regulations, AHCCCS shall have full and complete rights to
reproduce, duplicate, disclose and otherwise use all such information.

 

13

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

TERMS AND CONDITIONS

 

At the termination of the contract, the Contractor shall make available all such
data to AHCCCS within 30 days following termination of the contract or such
longer period as approved by AHCCCS, Office of the Director. For purposes of
this subsection, the term “data” shall not include member medical records.

Except as otherwise provided in this section, if any copyrightable or patentable
material is developed by the Contractor in the course of performance of this
contract, the Federal government, AHCCCS and the State of Arizona shall have a
royalty-free, nonexclusive, and irrevocable right to reproduce, publish, or
otherwise use, and to authorize others to use, the work for state or Federal
government purposes. The Contractor shall additionally be subject to the
applicable provisions of 45 CFR Part 74.

 

  38. RESERVED

 

  39. RELATIONSHIP OF PARTIES

The Contractor under this contract is an independent Contractor. Neither party
to this contract shall be deemed to be the employee or agent of the other party
to the contract.

 

  40. RIGHT OF OFFSET

AHCCCS shall be entitled to offset against any sums due the Contractor any
expenses or costs incurred by AHCCCS or damages assessed by AHCCCS concerning
the Contractor’s non-conforming performance or failure to perform the contract,
including but not limited to expenses, costs and damages.

 

  41. RIGHT TO ASSURANCE

If AHCCCS, in good faith, has reason to believe that the Contractor does not
intend to perform or is unable to continue to perform this contract, the
procurement officer may demand in writing that the Contractor give a written
assurance of intent to perform. The demand shall be sent to the Contractor by
certified mail, return receipt required. Failure by the Contractor to provide
written assurance within the number of days specified in the demand may, at the
State’s option, be the basis for terminating the contract.

 

  42. RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS

AHCCCS may, at reasonable times, inspect the part of the plant or place of
business of the Contractor or subcontractor that is related to the performance
of this contract, in accordance with A.R.S. §41-2547.

 

  43. RESERVED

 

14

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

TERMS AND CONDITIONS

 

  44. SEVERABILITY

The provisions of this contract are severable. Any term or condition deemed
illegal or invalid shall not affect any other term or condition of the contract.

 

  45. SUSPENSION OR DEBARMENT

The Contractor shall not employ, consult, subcontract or enter into any
agreement for services with any person or entity who is debarred, suspended or
otherwise excluded from Federal procurement activity or from participating in
non-procurement activities under regulations issued under Executive Order 12549
[42 CFR 438.610(a)(b)] or under guidelines implementing Executive Order 12549.
This prohibition extends to any entity which employs, consults, subcontracts
with or otherwise reimburses for services any person substantially involved in
the management of another entity which is debarred, suspended or otherwise
excluded from Federal procurement activity. The Contractor is obligated to
screen all employees and contractors to determine whether any of them have been
excluded from participation in Federal health care programs. The Contractor can
search the HHS-OIG website by the names of any individuals. The database can be
accessed at http://www.oig.hhs.gov/fraud/exclusions.asp.

The Contractor shall not retain as a director, officer, partner or owner of 5%
or more of the Contractor entity, any person, or affiliate of such a person, who
is debarred, suspended or otherwise excluded from Federal procurement activity.

AHCCCS may, by written notice to the Contractor, immediately terminate this
contract if it determines that the Contractor has been debarred, suspended or
otherwise lawfully prohibited from participating in any public procurement
activity.

 

  46. TEMPORARY MANAGEMENT/OPERATION OF A CONTRACTOR

Temporary Management/Operation by AHCCCS: Pursuant to the Medicaid Managed Care
Regulations, 42 CFR 438.700 et seq. and State Law A.R.S. §36-2903, AHCCCS is
authorized to impose temporary management for a Contractor under certain
conditions. Under Federal law, temporary management may be imposed if AHCCCS
determines that there is continued egregious behavior by the Contractor,
including but not limited to the following: substantial failure to provide
medically necessary services the Contractor is required to provide; imposition
on enrollees premiums or charges that exceed those permitted by AHCCCS,
discrimination among enrollees on the basis of health status or need for health
care services; misrepresentation or falsification of information to AHCCCS or
CMS; misrepresentation or falsification of information furnished to an enrollee
or provider; distribution of marketing materials that have not been approved by
AHCCCS or that are false or misleading; or behavior contrary to any requirements
of Sections 1903(m) or 1932 of the Social Security Act. Temporary management may
also be imposed if AHCCCS determines that there is substantial risk to
enrollees’ health or that temporary management is necessary to ensure the health
of enrollees while the Contractor is correcting the deficiencies noted above or
until there is an orderly transition or reorganization of the Contractor. Under
Federal law, temporary management is mandatory if AHCCCS determines that the
Contractor has repeatedly failed to meet

 

15

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

TERMS AND CONDITIONS

 

substantive requirements in Sections 1903(m) or 1932 of the Social Security Act.
Pursuant to 42 CFR 438.706, AHCCCS shall not delay imposition of temporary
management to provide a hearing before imposing this sanction.

If AHCCCS undertakes direct operation of the Contractor, AHCCCS, through
designees appointed by the Director, shall be vested with full and exclusive
power of management and control of the Contractor as necessary to ensure the
uninterrupted care to persons and accomplish the orderly transition of persons
to a new or existing Contractor, or until the Contractor corrects the contract
performance failure to the satisfaction of AHCCCS. AHCCCS shall have the power
to employ any necessary assistants, to execute any instrument in the name of the
Contractor, to commence, defend and conduct in its name any action or proceeding
in which the Contractor may be a party; such powers shall only apply with
respect to activities occurring after AHCCCS undertakes direct operation of the
Contractor in connection with this Section.

All reasonable expenses of AHCCCS related to the direct operation of the
Contractor, including attorney fees, cost of preliminary or other audits of the
Contractor and expenses related to the management of any office or other assets
of the Contractor, shall be paid by the Contractor or withheld from payment due
from AHCCCS to the Contractor.

 

  47. TERM OF CONTRACT AND OPTION TO RENEW

The “Term of Contract” shall commence on the Contract Award Date, include the
Contract Transition Period (the time period between the Contract Award Date to
the Contract Performance Start Date) and end 36 months after the Contract
Performance Start Date. Contract Performance Start Date will begin on October 1,
2015, and shall continue for a period of three years thereafter, unless
terminated, canceled or extended as otherwise provided herein. The total
Contract term for this section will be for three years delivering services to
members, plus the Contract Transition Period. The contract cycle is October 1
through September 30 with an annual October 1 renewal. The State refers to the
first three Contract periods during the Term of Contract as:

First Contract period: Starts on the Contract Award Date, includes the Contract
Transition Period, and ends 12 months after Contract Performance Start Date.

Second Contract period: Starts after the end of the first Contract period and
ends 12 months later.

Third Contract period: Starts after the end of the second Contract period and
ends twelve 12 months later.

The terms and conditions of any such contract extension shall remain the same as
the original contract, as amended. Any contract extension shall be through
contract amendment, and shall be at the sole option of AHCCCS.

 

16

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

TERMS AND CONDITIONS

 

If the Contractor has been awarded a contract in more than one GSA, each such
contract will be considered separately renewable. AHCCCS may renew the
Contractor’s contract in one GSA, but not in another. In the event AHCCCS
determines there are issues of noncompliance by the Contractor in one GSA,
AHCCCS may request an enrollment cap for the Contractor’s contracts in all other
GSAs. Further, AHCCCS may require the Contractor to renew all currently awarded
GSAs, or may terminate the contract if the Contractor does not agree to renew
all currently awarded GSAs.

When the Contracting Officer issues an amendment to extend the contract, the
provisions of such extension will be deemed to have been accepted 30 days after
the date of mailing by the Contracting Officer, unless a different time period
is specified by AHCCCS, even if the extension amendment has not been signed by
the Contractor, unless within that time the Contractor notifies the Contracting
Officer in writing that it refuses to sign the extension amendment. Failure of
an existing Contractor to accept an amendment (or renew) may result in immediate
suspension/termination of member assignment. If the Contractor provides such
notification, the Contracting Officer will initiate contract termination
proceedings.

If the Contractor chooses not to renew this contract, the Contractor may be
liable for certain costs associated with the transition of its members to a
different Contractor. The Contractor is required to provide 180 days advance
written notice to the Contracts and Purchasing Administrator of its intent not
to renew the contract. If the Contractor provides the Contracts and Purchasing
Administrator written notice of its intent not to renew this contract at least
180 days before its expiration, this liability for transition costs may be
waived by the Contracting Officer.

Contract extension periods shall, if authorized by the State, begin after the
“Term of Contract” section of these Contract Terms and Conditions. This Contract
is subject to two additional successive periods of up to 24 months per extension
period. The State refers to Contract periods four and five during the Contract
Extensions period as:

Fourth Contract period: Starts after the end of the third Contract period and is
extended for a period of time not to exceed 24 months.

Fifth Contract period: Starts after the end of the fourth Contract period and is
extended for a period of time not to exceed 24 months.

 

  48. TERMINATION

AHCCCS reserves the right to terminate this contract in whole or in part by
reason of force majeure, due to the failure of the Contractor to comply with any
term or condition of the contract, including, but not limited to, circumstances
which present risk to member health or safety, and as authorized by the Balanced
Budget Act of 1997 and 42 CFR 438.708. The term force majeure means an
occurrence that is beyond the control of AHCCCS and occurs without its fault or
negligence. Force majeure includes acts of God and other similar occurrences
beyond the control of AHCCCS which it is unable to prevent by exercising
reasonable diligence.

 

17

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

TERMS AND CONDITIONS

 

If the Contractor is providing services under more than one contract with
AHCCCS, AHCCCS may deem unsatisfactory performance under one contract to be
cause to require the Contractor to provide assurance of performance under any
and all other contracts. In such situations, AHCCCS reserves the right to seek
remedies under both actual and anticipatory breaches of contract if adequate
assurance of performance is not received. The Contracting Officer shall mail
written notice of the termination and the reason(s) for it to the Contractor by
certified mail, return receipt requested. Pursuant to the Balanced Budget Act of
1997 and 42 CFR 438.708, AHCCCS shall provide the Contractor with a
pre-termination hearing before termination of the contract.

Upon termination, all documents, data, and reports prepared by the Contractor
under the contract shall become the property of and be delivered to immediately
AHCCCS on demand.

AHCCCS may, upon termination of this contract, procure on terms and in the
manner that it deems appropriate, materials or services to replace those under
this contract. The Contractor shall be liable for any excess costs incurred by
AHCCCS in re-procuring the materials or services.

 

  49. TERMINATION - AVAILABILITY OF FUNDS

Funds are not presently available for performance under this contract beyond the
current fiscal year. No legal liability on the part of AHCCCS for any payment
may arise under this contract until funds are made available for performance of
this contract.

Notwithstanding any other provision in the Agreement, this Agreement may be
terminated by Contractor, if, for any reason, there are not sufficient
appropriated and available monies for the purpose of maintaining this Agreement.
In the event of such termination, the Contractor shall have no further
obligation to AHCCCS.

 

  50. TERMINATION FOR CONFLICT OF INTEREST

AHCCCS may cancel this contract without penalty or further obligation if any
person significantly involved in initiating, negotiating, securing, drafting or
creating the contract on behalf of AHCCCS is, or becomes at any time while the
contract or any extension of the contract is in effect, an employee of, or a
consultant to, any other party to this contract with respect to the subject
matter of the contract. The cancellation shall be effective when the Contractor
receives written notice of the cancellation unless the notice specifies a later
time.

If the Contractor is a political subdivision of the State, it may also cancel
this contract as provided by A.R.S. §38-511.

 

  51. TERMINATION FOR CONVENIENCE

AHCCCS reserves the right to terminate the contract in whole or in part at any
time for the convenience of the State without penalty or recourse. The
Contracting Officer shall give written notice by certified mail, of the
termination at

 

18

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

TERMS AND CONDITIONS

 

least 90 days before the effective date of the termination. Upon receipt of
written notice, the Contractor shall stop all work, as directed in the notice,
notify all subcontractors of the effective date of the termination and minimize
all further costs to the State. In the event of termination under this
paragraph, all documents, data and reports prepared by the Contractor under the
contract shall become the property of and be delivered to AHCCCS immediately on
demand. The Contractor shall be entitled to receive just and equitable
compensation for work in progress, work completed and materials accepted before
the effective date of the termination.

 

  52. TERMINATION UPON MUTUAL AGREEMENT

This Contract may be terminated by mutual written agreement of the parties
effective upon the date specified in the written agreement. If the parties
cannot reach agreement regarding an effective date for termination, AHCCCS will
determine the effective date.

 

  53. THIRD PARTY ANTITRUST VIOLATIONS

The Contractor assigns to the State any claim for overcharges resulting from
antitrust violations to the extent that those violations concern materials or
services supplied by third parties to the Contractor toward fulfillment of this
contract.

 

  54. TYPE OF CONTRACT

Fixed-Price, stated as capitated per member per month, except as otherwise
provided.

 

  55. WARRANTY OF SERVICES

The Contractor warrants that all services provided under this contract will
conform to the requirements stated herein. AHCCCS’ acceptance of services
provided by the Contractor shall not relieve the Contractor from its obligations
under this warranty. In addition to its other remedies, AHCCCS may, at the
Contractor’s expense, require prompt correction of any services failing to meet
the Contractor’s warranty herein. Services corrected by the Contractor shall be
subject to all of the provisions of this contract in the manner and to the same
extent as the services originally furnished.

 

19

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

TABLE OF CONTENTS

 

1   

INTRODUCTION

     27    1.1   

Overview

     27    1.2   

System Values and Guiding Principles:

     27    1.3   

Integrated Health Care Service Delivery Principles for Persons with Serious
Mental Illness

     27    2   

ELIGIBILITY

     27    2.1   

Medicaid Eligible Populations

     27    2.2   

Special Medicaid Eligibility-Members Awaiting Transplants

     28    2.3   

Non-Medicaid Eligible Populations

     28    2.4   

Eligibility and Member Verification

     28    2.5   

Medicaid Eligibility Determination

     28    2.6   

Federal Health Insurance Exchange

     28    3   

ENROLLMENT AND DISENROLLMENT

     29    3.1   

Enrollment and Disenrollment of Populations

     29    3.2   

Opt-Out for Cause

     29    3.3   

Prior Quarter Coverage

     29    3.4   

Prior Period Coverage

     29    3.5   

Hospital Presumptive Eligibility

     29    4   

SCOPE OF SERVICES

     29    4.1   

Overview

     29    4.2   

General Requirements for the System of Care

     30    4.3   

Behavioral Health Covered Services

     30    4.4   

Behavioral Health Service Delivery Approach

     33    4.5   

Behavioral Health Services for Adult Members

     33    4.6   

Behavioral Health Services for Child Members

     34    4.7   

Physical Health Care Covered Services

     34    4.8   

Integrated Health Care Service Delivery for SMI Members

     34    4.9   

Health Education and Health Promotion Services

     34    4.10   

American Indian Member Services

     34    4.11   

Medications

     34    4.12   

Prescription Medications

     34    4.13   

Medication Management Services

     34    4.14   

Laboratory Testing Services

     35    4.15   

Crisis Services Overview

     35    4.16   

Crisis Services-General Requirements

     35    4.17   

Crisis Services-Telephone Response

     35    4.18   

Crisis Services-Mobile Crisis Teams

     35   

 

20

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

TABLE OF CONTENTS

 

4.19   

Crisis Services-Crisis Stabilization Settings

     35    4.20   

Pediatric Immunizations and the Vaccines for Children Program

     35    4.21   

Medicaid School Based Claiming Program (MSBC)

     35    4.22   

Special Health Care Needs

     35    4.23   

Special Assistance for SMI Members

     35    4.24   

Psychiatric Rehabilitative Services-Employment

     35    4.25   

Psychiatric Rehabilitative Services-Peer Support

     35    4.26   

Psychiatric Rehabilitative Services- Housing

     35    4.27   

Prevention Services

     36    5   

CARE COORDINATION AND COLLABORATION

     36    5.1   

Care Coordination

     36    5.2   

Care Coordination for Dual Eligible SMI Members

     37    5.3   

Coordination with AHCCCS Contractors and Primary Care Providers

     37    5.4   

Collaboration with System Stakeholders

     37    5.5   

Collaboration to Improve Health Care Service Delivery

     37    5.6   

Collaboration with Peers and Family Members

     37    5.7   

Collaboration with Tribal Nations

     37    5.8   

Coordination for Transitioning Members

     37    6   

PROVIDER NETWORK

     37    6.1   

Network Development

     37    6.2   

Network Development for Integrated Health Care Service Delivery

     37    6.3   

Network Management

     37    6.4   

Out of Network Providers

     37    6.5   

Material Change to Provider Network

     38    6.6   

Provider Affiliation Transmission

     38    7   

PROVIDER REQUIREMENTS

     38    7.1   

Provider General Requirements

     38    7.2   

Provider Registration Requirements

     38    7.3   

Provider Manual Policy Requirements

     38    7.4   

Provider Manual Policy Network Requirements

     38    7.5   

Specialty Service Providers

     38    7.6   

Primary Care Provider Standards

     38    7.7   

Maternity Care Provider Standards

     38    7.8   

Federally Qualified Health Centers and Rural Health Clinics

     38    8   

MEDICAL MANAGEMENT

     39    8.1   

General Requirements

     39    8.2   

Utilization Data Analysis and Data Management

     39   

 

21

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

TABLE OF CONTENTS

 

8.3   

Prior Authorization and Referral Management

     39    8.4   

Notice of Action

     39    8.5   

Concurrent Review

     39    8.6   

Discharge Planning

     39    8.7   

Inter-rater Reliability

     39    8.8   

Retrospective Review

     39    8.9   

Development and/or Adoption of Practice Guidelines

     39    8.10   

New Medical Technologies and New Uses of Existing Technologies

     39    8.11   

Continuity and Care Coordination

     39    8.12   

Disease Management

     39    8.13   

Care Management Program-Goals

     39    8.14   

Care Management Program-General Requirements

     40    8.15   

Drug Utilization Review

     40    8.16   

Pre-Admission Screening and Resident Review (PASRR) Requirements

     40    8.17   

Engaging Members Through Technology

     40    8.18   

Medical Management Reporting Requirements

     40    8.19   

Additional Authorization Requirements

     40    9   

APPOINTMENT AND REFERRAL REQUIREMENTS

     40    9.1   

Appointments for Behavioral Health Services

     40    9.2   

Additional Appointment Requirements for SMI Members

     41    9.3   

Referral Requirements

     41    9.4   

Disposition of Referrals

     42    9.5   

Provider Directory

     42    9.6   

Referral for a Second Opinion

     42    9.7   

Additional Referral Requirements for SMI Members

     42    10   

QUALITY MANAGEMENT

     42    10.1   

General Requirements

     42    10.2   

Credentialing

     42    10.3   

Incident, Accident and Death Reports

     42    10.4   

Quality of Care Concerns and Investigations

     42    10.5   

Performance Measures

     42    10.6   

Performance Improvement Projects

     43    10.7   

Data Collection Procedures

     43    10.8   

Member Satisfaction Survey

     43    10.9   

Provider Monitoring

     43    10.10   

Quality Management Reporting Requirements

     43   

 

22

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

TABLE OF CONTENTS

 

11   

COMMUNICATIONS

     43    11.1   

Member Information

     43    11.2   

Translation Services

     43    11.3   

Member Handbooks

     43    11.4   

Member Newsletters

     43    11.5   

Health Promotion

     43    11.6   

Marketing

     43    11.7   

Web Site Requirements

     44    11.8   

Social Networking Requirements

     44    11.9   

Outreach

     44    11.10   

Identification Cards for SMI Members Receiving Physical Health Care Services

     44    12   

CULTURAL COMPETENCY

     44    12.1   

General Requirements

     44    12.2   

Accommodating AHCCCS Members

     44    13   

GRIEVANCE AND APPEAL SYSTEM REQUIREMENTS

     44    13.1   

General Requirements

     44    13.2   

Member Grievances

     46    13.3   

TXIX/XXI Member Appeals

     47    13.4   

Claim Disputes

     47    13.5   

Grievance and Appeal System Reporting Requirements

     47    13.6   

SMI Grievances

     47    13.7   

SMI Appeals

     48    14   

CORPORATE COMPLIANCE PROGRAM

     48    14.1   

General Requirements

     48    14.2   

Fraud, Waste and Abuse

     48    14.3   

Disclosure of Ownership and Control

     48    14.4   

Disclosure of Information on Persons Convicted of Crimes

     48    15   

FINANCIAL MANAGEMENT

     48    15.1   

General Requirements:

     48    15.2   

Performance Bond

     48    15.3   

Financial Reports:

     48    15.4   

Financial Viability/Performance Standards:

     49    15.5   

Health Insurer Fee

     49    15.6   

Compensation

     49    15.7   

Capitation Adjustments

     49    15.8   

Payments

     49    15.9   

Community Reinvestment

     49    15.10   

Recoupments:

     49   

 

23

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

TABLE OF CONTENTS

 

15.11   

Financial Responsibility for Referrals and Coordination with Acute Health Plans
and the Courts

     49    15.12   

Advances, Equity Distributions, Loans, and Investments

     49    15.13   

Member Billing and Liability for Payment:

     49    15.14   

Medicare Services and Cost Sharing Requirements

     50    15.15   

Capitalization Requirements

     50    15.16   

Coordination of Benefits and Third Party Liability Requirements

     50    15.17   

Post-payment Recovery Requirements

     50    15.18   

Retroactive Recoveries

     50    15.19   

Total Plan Case Requirements

     50    15.20   

Joint and Mass Tort Cases

     50    15.21   

Value Based Purchasing

     50    15.22   

Other Financial Obligations

     50    15.23   

Sources of Revenue

     51    15.24   

Non-Title XIX/XXI Encounter Valuation for Grant, County, Non-Title XIX/XXI and
Other Funds

     51    15.25   

Profit Limit for Non-Title XIX/XXI Funds

     51    15.26   

Mortgages and Financing of Property

     52    15.27   

Management of Federal Block Grant Funds and other Federal Grants

     52    16   

PROVIDER AGREEMENT REIMBURSEMENT

     54    16.1   

Physician Incentive Requirements

     54    16.2   

Nursing Facility Reimbursement

     54    17   

INFORMATION SYSTEMS AND DATA EXCHANGE REQUIREMENTS

     54    17.1   

Overview

     54    17.2   

Systems Function and Capacity

     54    17.3   

Encounter Data Reporting

     55    17.4   

Enrollment and Capitation Transaction Updates

     55    17.5   

Electronic Transactions

     55    17.6   

General Claims Processing Requirements

     55    17.7   

Claims System Reporting

     55    17.8   

Demographic Data Submission

     55    17.9   

Participation in Information Systems Work Groups/Committees

     55    17.10   

Claims and Encounter Submission and Processing Requirements

     56    18   

ADMINISTRATIVE REQUIREMENTS

     56    18.1   

General Requirements

     56    18.2   

AHCCCS Guidelines, Policies and Manuals

     56    18.3   

Organizational Structure

     56   

 

24

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

TABLE OF CONTENTS

 

18.4   

Peer Involvement and Participation

     56    18.5   

Key Staff

     56    18.6   

Organizational Staff

     56    18.7   

Liaisons and Coordinators

     57    18.8   

Training Program Requirements

     57    18.9   

Training Reporting Requirements

     57    18.10   

Medical Records

     57    18.11   

Consent and Authorization

     57    18.12   

Advance Directives

     57    18.13   

Business Continuity and Recovery Plan

     57    18.14   

Emergency Preparedness

     57    18.15   

Legislative, Legal and Regulatory Issues

     58    18.16   

Pending Issues

     58    18.17   

Copayments

     58    18.18   

Administrative Performance Standards

     59    18.19   

SMI Eligibility Determination

     59    18.20   

Material Change to Business Operations

     59    18.21   

Governance Board

     59    18.22   

Merger, Acquisition, Reorganization, Joint Venture and Change in Ownership

     59    18.23   

Separate Incorporation and Prohibition Against Direct Service Delivery

     59    19   

MONITORING and Operational reviews (OR)

     60    19.1   

Reporting Requirements

     60    19.2   

Records Retention

     60    19.3   

Requests for Information

     60    19.4   

Surveys

     60    19.5   

Monitoring and Independent Review of the Contractor

     60    19.6   

Sanctions

     60    20   

SUBCONTRACTING REQUIREMENTS

     60    20.1   

Subcontract Relationships and Delegation

     60    20.2   

Hospital Subcontracts and Reimbursement

     61    20.3   

Management Services Agreements

     61    20.4   

Prior Approval

     61    20.5   

AHCCCS Minimum Subcontract Provisions

     61    20.6   

Subcontracting Reporting Requirements

     61    EXHIBITS      62    Exhibit-1 - Definitions      62    Exhibit-2 –
Reserved      64   

 

25

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

TABLE OF CONTENTS

 

Exhibit-3 - Medicare Requirement to Coordinate Care for Dual Eligible SMI
Members    64 Exhibit-4 - Placeholder    64 Exhibit-5 - Reserved    64 Exhibit-6
- Adult Service Delivery System-Nine Guiding Principles    64 Exhibit-7 –
Reserved    64 Exhibit-8 - Reserved    64 Exhibit-9 - Deliverables    65
Exhibit-10 - Greater Arizona Zip Codes    69 Exhibit-11 - Capitation Rates and
Contractor Specific Requirements    69 Exhibit-12 – Placeholder    69 Exhibit-13
- Reserved    69 Exhibit-14 - Enrollee Grievance and Appeal System Standards   
69 Exhibit-15 - Provider Claim Dispute Standards    69 Endnotes    69

 

26

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

SCOPE OF WORK

 

1. INTRODUCTION

This contract describes the responsibilities for provision of Non-Title XIX/XXI
services for Title XIX and Non-Title XIX/XXI members accessing behavioral health
services. For ease of reference, the sections in this Contract correspond to the
related sections in the Title XIX Contract YH17-0001. The Contractor shall
adhere to all requirements and provisions of the Title XIX YH17-0001 Contract
for all populations under this contract except when noted ‘Exempt’. In instances
where the requirements and provisions of the Title XIX Contract YH17-0001 apply
to the populations under this contract, the following text is used: “Refer to
Title XIX Contract YH17-0001.” In instances where the requirements and
provisions of both Title XIX Contract YH17-0001 and supplementary requirements
apply to the populations under this contract, the following text is used: “Refer
to Title XIX Contract YH17-0001 and.” In instances where language contained in
this contract differs from the Title XIX YH17-001 Contract, the language in this
contract will prevail only with regard to administration of the Non-Title
XIX/XXI services provided to populations under this contract.

No requirements related to the coverage of physical health services specified in
the Title XIX YH17-0001 Contract are applicable herein, including instances when
this contract refers to the Title XIX Contract.

Based on funding availability, the U.S. Government may make additional grant
funding available to AHCCCS for the populations served under this Contract
(“Future Grant”). At its sole discretion, AHCCCS may notify the Contractor in
writing of an offer to become a sub-recipient of the Future Grant and the
requirements of the Future Grant. Should the Contractor agree to be a
sub-recipient of the Future Grant, it shall notify AHCCCS in writing of the
acceptance of AHCCCS’ offer. The Contractor’s acceptance of this grant funding
shall amend this Contract to obligate the Contractor to fulfill all requirements
of the Future Grant (“Future Grant Amendment”). All other provisions of this
Contract shall remain unchanged and shall apply to any Future Grant
Amendment. If a provision of the Future Grant Amendment conflicts with this
Contract, the Future Grant Amendment shall control.

 

1.1 Overview

 

  •   Refer to Title XIX Contract YH17-0001

 

1.2 System Values and Guiding Principles

 

  •   Refer to Title XIX Contract YH17-0001

 

1.3 Integrated Health Care Service Delivery Principles for Persons with Serious
Mental Illness

 

  •   Refer to Title XIX Contract YH17-0001

 

2 ELIGIBILITY

 

  2.1 Medicaid Eligible Populations

 

  •   Refer to Title XIX Contract YH17-0001 and:

 

  •   The Contractor is also responsible for the provision of State Only
services for CRS members. See also ACOM Policy 426.

 

27

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

SCOPE OF WORK

 

  2.2 Special Medicaid Eligibility-Members Awaiting Transplants

 

  •   Refer to Title XIX Contract YH17-0001

 

  2.3 Non-Medicaid Eligible Populations

The Contractor shall be responsible to provide covered behavioral health
services to non-Medicaid eligible children and adults subject to available
funding allocated to the Contractor.

 

  •   Non-Medicaid eligible children and adults

 

  •   Substance Abuse Block Grant (SABG) recipients

SABG funds are used to ensure access to treatment and long-term recovery support
services for (in order of priority):

 

  •   Pregnant women/teenagers who use drugs by injection;

 

  •   Pregnant women/teenagers who use substances;

 

  •   Other persons who use drugs by injection;

 

  •   Substance using women and teenagers with dependent children and their
families, including females who are attempting to regain custody of their
children; and

 

  •   All other clients with a substance use disorder, regardless of age, gender
or route of use (as funding is available).

 

  •   Persons must indicate active substance use within the previous 12-month
period to be eligible for SABG funded services.

 

  •   Mental Health Block Grant (MHBG) Recipients

 

  •   MHBG funds are used to provide services for adults with Serious Mental
Illness (SMI) and children with serious emotional disturbance (SED).

 

  2.4 Eligibility and Member Verification

 

  •   Refer to Title XIX Contract YH17-0001

 

  2.5 Medicaid Eligibility Determination

 

  •   Exempt

 

  2.6 Federal Health Insurance Exchange

The Contractor and contracted providers must educate and encourage Non-Title
XIX/XXI SMI members to enroll in a qualified health plan through the federal
health insurance exchange and offer assistance for those choosing to

 

28

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

SCOPE OF WORK

 

enroll during open enrollment periods and qualified life events. The following
applies for members who enroll in a qualified health plan through the federal
insurance exchange:

 

  •   Members enrolled in a qualified health plan through the federal health
insurance exchange continue to be eligible for Non-Title XIX/XXI covered
services that are not covered under the exchange plan.

 

  •   Non-Title XIX/XXI funds may not be used to cover premiums or co-pays
associated with qualified health plans through the federal exchange or other
third party liability premiums or co-pays other than Medicare Part D for SMI
members. See also, ACOM Policy 434.

 

  •   The Contractor must issue approval prior to any utilization of Non-Title
XIX/XXI funding for services otherwise covered under a qualified plan through
the federal exchange.

 

3 ENROLLMENT AND DISENROLLMENT

 

  3.1 Enrollment and Disenrollment of Populations

 

  •   Refer to Title XIX Contract YH17-0001 and:

The Contractor shall comply with the requirements in the Technical Interface
Guidelines (TIG).

 

  •   Defer to AHCCCS, which has exclusive authority to designate who will be
enrolled and disenrolled as Non-Medicaid eligible members.

 

  •   For a Non-Title XIX/XXI eligible person to be enrolled, providers must
submit an 834 enrollment transaction to the Contractor.

 

  3.2 Opt-Out for Cause

 

  •   Exempt

 

  3.3 Prior Quarter Coverage

 

  •   Refer to Title XIX Contract YH17-0001

 

  3.4 Prior Period Coverage

 

  •   Refer to Title XIX Contract YH17-0001

 

  3.5 Hospital Presumptive Eligibility

 

  •   Refer to Title XIX Contract YH17-0001

 

4 SCOPE OF SERVICES

 

  4.1 Overview

 

  •   Refer to Title XIX Contract YH17-0001

 

29

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

SCOPE OF WORK

 

  4.2 General Requirements for the System of Care

 

  •   Refer to Title XIX Contract YH17-0001

 

  4.3 Behavioral Health Covered Services

 

  •   Refer to Title XIX Contract YH17-0001, and

 

  •   See AMPM Exhibit 300-2, AMPM Policy 320-T, and:

The Contractor shall:

 

  •   Ensure the delivery of medically necessary and clinically appropriate
covered behavioral health services to eligible members in conformance with the
AHCCCS Covered Behavioral Health Services Guide.

 

  •   Deliver covered behavioral health services under the Mental Health (MHBG)
Block Grant, the Substance Abuse Prevention and Treatment Block Grant (SABG) and
other grant funding as available.

 

  •   Persons receiving substance use disorder treatment services under the SABG
have the right to receive services from a provider to whose religious character
they do not object.

 

  •   Behavioral health subcontractors providing substance abuse services under
the SABG must notify persons of this right using Policy Attachment 110.1, or its
successor. Providers must document that the person has received notice in the
person’s comprehensive clinical record.

 

  •   If a person objects to the religious character of a behavioral health
provider, the provider must refer the person to an alternative provider within 7
days, or earlier when clinically indicated, after the date of the objection.
Upon making such a referral, providers must notify the Contractor of the
referral and ensure that the person makes contact with the alternative provider.

 

  •   The Contractor must develop and make available policies and procedures
that indicate who and how providers should notify the Contractor of these
referrals.

 

  •   Submit reports on use of MHBG and SABG programs and funds in accordance
with Block Grant reporting requirements and in accordance with Exhibit-9,
Deliverables.

 

  •   Deliver covered behavioral health services in accordance with the terms of
the Intergovernmental Agreement (IGA) between AHCCCS and all County agreements
for court ordered evaluations (COE). See also AMPM Policy 320-U.

 

30

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

SCOPE OF WORK

 

  •   The Contractor in the Southern GSA shall:

 

  •   Utilize the Pima County IGA funding listed in the allocation schedule to
support Crisis activities; and

 

  •   Provide services as prescribed in this Contract and A.R.S. 4-203.01 (1)
and A.R.S. 36-2021 through A.R.S. 36-2031 for substance use services in Pima
County including crisis, detoxification services, and outpatient services
utilizing the Liquor Fees funding listed in the allocation schedule.

 

  •   The Contractor in the Northern GSA shall:

 

  •   Utilize the Coconino County funding listed in the allocation schedule for
court ordered evaluations (COE).

Substance Abuse Block Grant (SABG)

 

  •   The following services must be made available to SABG special populations:

 

  •   Behavioral health providers must provide specialized, gender-specific
treatment and recovery support services for females who are pregnant or have
dependent children and their families in outpatient/residential treatment
settings.

 

  •   Services are also provided to mothers who are attempting to regain custody
of their children.

 

  •   Services must treat the family as a unit.

 

  •   As needed, providers must admit both mothers and their dependent children
into treatment.

 

  •   The following services are provided or arranged as needed:

 

  •   Referral for primary medical care for pregnant females;

 

  •   Referral for primary pediatric care for children;

 

  •   Gender-specific substance abuse treatment; and

 

  •   Therapeutic interventions for dependent children.

 

  •   The Contractor must ensure the following issues do not pose barriers to
access to obtaining substance use treatment:

 

  •   Child care;

 

  •   Case management; and

 

  •   Transportation

 

31

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

SCOPE OF WORK

 

  •   The Contractor must publicize the availability of gender-based substance
use treatment services for females who are pregnant or have dependent children.
Publicizing must include at a minimum the posting of fliers at each site
notifying the right of pregnant females and females with dependent children to
receive substance abuse treatment services at no cost.

 

  •   The Contractor must develop and make available to providers specific
language with regards to providing the specialty program services for women and
children.

 

  •   Interim Services for Pregnant Women/Injection Drug Users (Non-Title
XIX/XXI only).

 

  •   The purpose of interim services is to reduce the adverse health effects of
substance use, promote the health of the individual, and reduce the risk of
transmission of disease for priority population members awaiting placement in a
Residential Treatment Facility.

 

  •   Provision of interim services must be documented in the member’s chart as
well as reported to AHCCCS through the online residential waitlist. Interim
services are required for Non-Title XIX/XXI priority populations who are
maintained on an actively managed waitlist while awaiting placement in a
Residential Treatment Facility.

 

  •   Title XIX/XXI eligible persons who also meet a priority population type
may not be placed on a waitlist.

For pregnant females the reporting requirement is within 48 hours, for women
with dependent children the requirement is within five calendar days, and for
all IVDUs the requirement is within 14 calendar days.

The minimum required interim services include education and referral that cover:

 

  •   Prevention of and types of behaviors which increase the risk of
contracting HIV, Hepatitis C and other sexually transmitted diseases;

 

  •   Effects of substance use on fetal development;

 

  •   Risk assessment/screening;

 

  •   Referrals for HIV, Hepatitis C, and tuberculosis screening and services;
and

 

  •   Referrals for primary and prenatal medical care.

Mental Health Services Block Grant (MHBG)

The MHBG provides non-Title XIX/XXI behavioral health services to adults with
SMI and children with SED. MHBG funds are only to be used

 

32

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

SCOPE OF WORK

 

for allowable services identified in the AHCCCS Covered Behavioral Health
Services Guide for Non-Title XIX/XXI members with SMI or SED or Non-Title
XIX/XXI services for Title XIX/XXI members. Members shall not be charged a
copayment, or any other fee, for treatment services funded by the MHBG.

 

  •   The MHBG must be used to:

 

  •   Ensure access to a comprehensive system of care, including employment,
housing, case management, rehabilitation, dental, and health services, as well
as mental health services and supports;

 

  •   Promote participation by consumer/survivors and their families in planning
and implementing services and programs, as well as in evaluating State mental
health systems;

 

  •   Ensure access for underserved populations, including people who are
homeless, residents of rural areas, and older adults; and

 

  •   Promote recovery and community integration for adults with SMI and
children with SED.

 

  •   The Contractor shall not be responsible to pay for the costs associated
with Court Ordered Evaluation (COE) unless prior payment arrangements have been
made with another entity (e.g. County, hospital, provider).

 

  •   The Contractor and its providers must comply with state recognized tribal
court orders for Title XIX/XXI and Non-Title XIX/XXI SMI persons. When tribal
providers are also involved in the care and treatment of court ordered tribal
members, the Contractor and its providers must involve tribal providers to
ensure the coordination and continuity of care of the members for the duration
of court ordered treatment (COT) and when members are transitioned to services
on the reservation, as applicable. The Contractor is encouraged to enter into
agreements with tribes to address behavioral health needs and improve the
coordination of care for tribal members. See also, AMPM Policy 320-U and ACOM
Policy 423.

 

  •   Domestic Violence (DV) Offender Treatment:

For Non-TXIX/XXI eligible persons court ordered for DV treatment, the individual
can be billed for the DV services. See also, ACOM Policy 423.

 

  4.4 Behavioral Health Service Delivery Approach

 

  •   Refer to Title XIX Contract YH17-0001

 

  4.5 Behavioral Health Services for Adult Members

 

  •   Refer to Title XIX Contract YH17-0001 and:

 

33

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

SCOPE OF WORK

 

The Contractor shall:

 

  •   Implement the following service delivery programs for members determined
to have SMI consistent with U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration’s (SAMHSA) established
program models:

 

  •   Assertive Community Treatment (ACT);

 

  •   Permanent Supportive Housing;

 

  •   Supported Employment; and

 

  •   Consumer Operated Services.

Monitor fidelity to the service delivery programs annually using the AHCCCS
adopted measurement instrument, for example, the SAMHSA Fidelity Scale and
General Organizational Index.

 

  4.6 Behavioral Health Services for Child Members

 

  •   Refer to Title XIX Contract YH17-0001

 

  4.7 Physical Health Care Covered Services

 

  •   Exempt

 

  4.8 Integrated Health Care Service Delivery for SMI Members

 

  •   Exempt

 

  4.9 Health Education and Health Promotion Services

 

  •   Refer to Title XIX Contract YH17-0001

 

  4.10 American Indian Member Services

 

  •   Refer to Title XIX Contract YH17-0001

 

  4.11 Medications

 

  •   Members with SMI (whether funded through State Funds or MHBG): Refer to
Title XIX Contract YH17-0001: and

 

  •   Members receiving services through SABG: SABG funding should be directed
to service delivery. The Contractor should utilize other fund sources to provide
medications. Medication Assisted Treatments (MAT) identified by AHCCCS as
SABG-covered medications are excluded from this restriction.

 

  4.12 Prescription Medications

 

  •   Refer to Title XIX Contract YH17-0001

 

  4.13 Medication Management Services

 

  •   Exempt

 

34

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

SCOPE OF WORK

 

  4.14 Laboratory Testing Services

 

  •   Refer to Title XIX Contract YH17-0001

 

  4.15 Crisis Services Overview

 

  •   Refer to Title XIX Contract YH17-0001

 

  4.16 Crisis Services-General Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  4.17 Crisis Services-Telephone Response

 

  •   Refer to Title XIX Contract YH17-0001

 

  4.18 Crisis Services-Mobile Crisis Teams

 

  •   Refer to Title XIX Contract YH17-0001

 

  4.19 Crisis Services-Crisis Stabilization Settings

 

  •   Refer to Title XIX Contract YH17-0001

 

  4.20 Pediatric Immunizations and the Vaccines for Children Program

 

  •   Exempt

 

  4.21 Medicaid School Based Claiming Program (MSBC)

 

  •   Exempt

 

  4.22 Special Health Care Needs

 

  •   Refer to Title XIX Contract YH17-0001

 

  4.23 Special Assistance for SMI Members

 

  •   Refer to Title XIX Contract YH17-0001

 

  4.24 Psychiatric Rehabilitative Services-Employment

 

  •   Refer to Title XIX Contract YH17-0001

 

  4.25 Psychiatric Rehabilitative Services-Peer Support

 

  •   Refer to Title XIX Contract YH17-0001

 

  4.26 Psychiatric Rehabilitative Services- Housing

 

 

35

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

The Contractor shall:

 

  •   Develop and maintain a housing continuum for members determined to have
SMI as well as all other eligible members in conformance with ACOM Policy 448.

 

  •   Collaborate with community stakeholders, state agency partners, federal
agencies and other entities to identify, apply for or leverage alternative
funding sources for housing programs.

 

  •   Develop and manage state and federal housing programs and deliver housing
related services.

 

  •   Utilize all housing units previously purchased in the GSA for purposes of
providing housing for SMI members.

 

  •   Evaluate and report annually the fidelity of the Housing program through
utilizing SAMHSA’s Permanent Supportive Housing toolkit.

 

  •   Comply with all federally funded and state funded housing requirements as
directed by AHCCCS.

 

  •   Submit the deliverables related to the Housing Program in accordance with
Exhibit-9, Deliverables, including an Annual Housing Needs Assessment as
described in ACOM Policy 448.

 

  •   The Contractor shall not utilize state funding sources in any capacity at
unlicensed boarding homes, or other similar unlicensed facilities.

 

  4.27 Prevention Services

The Contractor shall:

 

  •   Administer a prevention system;

 

  •   Collect progress reports from subcontracted providers, including HIV Early
Intervention Services Providers;

 

  •   Conduct biannual site visits to HIV Early Intervention Service providers
where the AHCCCS HIV Coordinator, Contractor HIV Coordinator, and provider staff
and supervisors are present;

 

  •   Administer a minimum of 1 test per $600 in SABG HIV services funding; and

 

  •   Submit deliverables related to Prevention Services in accordance with
Exhibit-9 Deliverables.

 

5 CARE COORDINATION AND COLLABORATION

 

  5.1 Care Coordination

 

  •   Refer to Title XIX Contract YH17-0001 and AMPM Policy 541

 

36

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

SCOPE OF WORK

 

  5.2 Care Coordination for Dual Eligible SMI Members

 

  •   Refer to Title XIX Contract YH17-0001

 

  5.3 Coordination with AHCCCS Contractors and Primary Care Providers

 

  •   Refer to Title XIX Contract YH17-0001

 

  5.4 Collaboration with System Stakeholders

 

  •   Refer to Title XIX Contract YH17-0001 and:

The Contractor shall meet, agree upon, and reduce to writing collaborative
protocols with each County, District, or Regional Office of the Arizona
Department of Economic Security/Rehabilitative Services Administration.

 

  5.5 Collaboration to Improve Health Care Service Delivery

 

  •   Refer to Title XIX Contract YH17-0001

 

  5.6 Collaboration with Peers and Family Members

 

  •   Refer to Title XIX Contract YH17-0001

 

  5.7 Collaboration with Tribal Nations

 

  •   Refer to Title XIX Contract YH17-0001

 

  5.8 Coordination for Transitioning Members

 

  •   Refer to Title XIX Contract YH17-0001

 

6 PROVIDER NETWORK

 

  6.1 Network Development

 

  •   Refer to Title XIX Contract YH17-0001 and ACOM Policy 415

 

  6.2 Network Development for Integrated Health Care Service Delivery

 

  •   Exempt

 

  6.3 Network Management

 

  •   Refer to Title XIX Contract YH17-0001 and ACOM Policy 415 and submit
deliverables related to Prevention Services reporting in accordance with
Exhibit-9, Deliverables.

 

  6.4 Out of Network Providers

 

  •   Refer to Title XIX Contract YH17-0001

 

37

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

SCOPE OF WORK

 

  6.5 Material Change to Provider Network

 

  •   Refer to Title XIX Contract YH17-0001 and:

The Contractor shall

 

  •   Offer a full array of service providers to meet the needs of the actual
and anticipated number of persons eligible to receive services under this
Contract;

 

  •   Notify AHCCCS within seven business days of notifying provider or
receiving notification from a provider receiving AHCCCS-administered grant
funding will be terminating their contract with the Contractor.

 

  •   Submit deliverables related to Provider Network change reporting in
accordance with Exhibit-9, Deliverables.

 

  6.6 Provider Affiliation Transmission

 

  •   Refer to Title XIX Contract YH17-0001

 

7 PROVIDER REQUIREMENTS

 

  7.1 Provider General Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  7.2 Provider Registration Requirements

 

  •   Refer to Title XIX Contract YH17-0001 and:

The Contractor shall require that all entities receiving SABG or MHBG funds to
obtain and maintain an Inventory of Behavioral Health Services (I-BHS) number
through SAMHSA.

 

  7.3 Provider Manual Policy Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  7.4 Provider Manual Policy Network Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  7.5 Specialty Service Providers

 

  •   Exempt

 

  7.6 Primary Care Provider Standards

 

  •   Exempt

 

  7.7 Maternity Care Provider Standards

 

  •   Exempt

 

  7.8 Federally Qualified Health Centers and Rural Health Clinics

 

  •   Exempt

 

38

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

SCOPE OF WORK

 

8 MEDICAL MANAGEMENT

 

  8.1 General Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  8.2 Utilization Data Analysis and Data Management

 

  •   Refer to Title XIX Contract YH17-0001

 

  8.3 Prior Authorization and Referral Management

 

  •   Refer to Title XIX Contract YH17-0001

 

  8.4 Notice of Action

 

  •   Refer to Title XIX Contract YH17-0001

 

  8.5 Concurrent Review

 

  •   Refer to Title XIX Contract YH17-0001

 

  8.6 Discharge Planning

 

  •   Refer to Title XIX Contract YH17-0001 and AMPM Policy 320-O

 

  8.7 Inter-rater Reliability

 

  •   Refer to Title XIX Contract YH17-0001

 

  8.8 Retrospective Review

 

  •   Refer to Title XIX Contract YH17-0001

 

  8.9 Development and/or Adoption of Practice Guidelines

 

  •   Refer to Title XIX Contract YH17-0001

 

  8.10 New Medical Technologies and New Uses of Existing Technologies

 

  •   Refer to Title XIX Contract YH17-0001

 

  8.11 Continuity and Care Coordination

 

  •   Refer to Title XIX Contract YH17-0001 and AMPM Policy 541

 

  8.12 Disease Management

 

  •   Refer to Title XIX Contract YH17-0001

 

  8.13 Care Management Program-Goals

 

  •   Refer to Title XIX Contract YH17-0001

 

39

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

SCOPE OF WORK

 

  8.14 Care Management Program-General Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  8.15 Drug Utilization Review

 

  •   Refer to Title XIX Contract YH17-0001

 

  8.16 Pre-Admission Screening and Resident Review (PASRR) Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  8.17 Engaging Members through Technology

 

  •   Refer to Title XIX Contract YH17-0001

 

  8.18 Medical Management Reporting Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  8.19 Additional Authorization Requirements

 

  •   Refer to Title XIX Contract YH17-0001 and:

The Contractor shall comply with member notice requirements as outlined in ACOM
Policy 444.

 

9 APPOINTMENT AND REFERRAL REQUIREMENTS

 

  9.1 Appointments for Behavioral Health Services

 

  •   Refer to Title XIX Contract YH17-0001 and:

For all populations covered under this Contract, the Contractor shall provide
appointments to members as follows:

 

  •   Emergency appointments within 24 hours of referral, including, at a
minimum, the requirement to respond to hospital referrals for Non-Title XIX/XXI
members with SMI;

 

  •   Accept and respond to emergency referrals of Non-Title XIX/XXI members
with SMI 24 hours a day, seven days a week. Emergency referrals do not require
prior authorization. Emergency referrals include those initiated for Non-Title
XIX/XXI with SMI members admitted to a hospital or treated in the emergency
room.

 

40

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

SCOPE OF WORK

 

Response Times for Designated Behavioral Health Services under the SABG Block
Grant:

 

WHEN

  

WHAT

  

WHO

Behavioral health services provided within a timeframe indicated by clinical
need, but no later than 48 hours from the referral/initial request for services.
  

Any needed covered behavioral health service, including admission to a
residential program if clinically indicated;

 

If a residential program is temporarily unavailable, an attempt shall be made to
place the person within another provider agency facility, including those in
other geographic service areas. If capacity still does not exist, the person
shall be placed on an actively managed residential wait list and interim
services must be provided until the individual is admitted. Interim services
include: counseling/education about HIV and Tuberculosis (include the risks of
transmission), the risks of needle sharing and referral for HIV and TB treatment
services if necessary, counseling on the effects of alcohol/drug use on the
fetus and referral for prenatal care.

   Pregnant women/teenagers referred for substance use treatment (includes
pregnant injection drug users and pregnant substance users) and Substance-using
females with dependent children, including those attempting to regain custody of
their child(ren)

Behavioral health services provided within a timeframe indicated by clinical
need but no later than 14 days following the initial request for
services/referral.

 

All subsequent behavioral health services must be provided within timeframes
according to the needs of the person.

 

  

Includes any needed covered behavioral health services;

 

Admit to a clinically appropriate substance use treatment program (can be
residential or outpatient based on the person’s clinical needs); if unavailable,
interim services must be offered to the person. Interim services shall minimally
include education/interventions with regard to HIV and tuberculosis and the
risks of needle sharing and must be offered within 48 hours of the request for
treatment.

   All other injection drug users

Behavioral health services provided within a timeframe indicated by clinical
need but no later than 23 days following the initial assessment.

 

All subsequent behavioral health services must be provided within timeframes
according to the needs of the person.

   Includes any needed covered behavioral health services.    All other persons
in need of substance use treatment

 

  9.2 Additional Appointment Requirements for SMI Members

 

  •   Refer to Title XIX Contract YH17-0001

 

  9.3 Referral Requirements

 

  •   Refer to Title XIX Contract YH17-0001, AMPM Policy 580 and:

 

  •   Accept and respond to emergency referrals of and Non-Title XIX/XXI members
with SMI 24 hours a day, seven days a week. Emergency referrals do not require
prior authorization. Emergency referrals include those initiated for Non-Title
XIX/XXI with SMI members admitted to a hospital or treated in the emergency
room.

 

41

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

SCOPE OF WORK

 

  9.4 Disposition of Referrals

 

  •   Refer to Title XIX Contract YH17-0001

 

  9.5 Provider Directory

 

  •   Refer to Title XIX Contract YH17-0001

 

  9.6 Referral for a Second Opinion

 

  •   Refer to Title XIX Contract YH17-0001

 

  9.7 Additional Referral Requirements for SMI Members

 

  •   Refer to Title XIX Contract YH17-0001

 

10 QUALITY MANAGEMENT

 

  10.1 General Requirements

 

  •   Refer to Title XIX Contract YH17-0001 and:

The Contractor shall comply with requirements to assure member rights and
responsibilities in conformance with Contract YH17-0001, ACOM Policy 444, ACOM
Policy 446, and AMPM Policy 320-Rand the AHCCCS policy on Notice Requirements
and Appeal Process for Title XIX and Title XXI Eligible Persons and the AHCCCS
Medical Policy Manual, 42 CFR 438.100(a)(2); and comply with any other
applicable federal and State laws (such as Title VI of the Civil Rights Act of
1964, etc.) including other laws regarding privacy and confidentiality, 42 CFR
438.100(d).

 

  10.2 Credentialing

 

  •   Refer to Title XIX Contract YH17-0001

 

  10.3 Incident, Accident and Death Reports

 

  •   Refer to Title XIX Contract YH17-0001

 

  10.4 Quality of Care Concerns and Investigations

 

  •   Refer to Title XIX Contract YH17-0001

 

  10.5 Performance Measures

 

  •   Exempt

 

42

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

SCOPE OF WORK

 

  10.6 Performance Improvement Projects

 

  •   Exempt

 

  10.7 Data Collection Procedures

 

  •   Exempt

 

  10.8 Member Satisfaction Survey

 

  •   Refer to Title XIX Contract YH17-0001

 

  10.9 Provider Monitoring

 

  •   Refer to Title XIX Contract YH17-0001

 

  10.10 Quality Management Reporting Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

11 COMMUNICATIONS

 

  11.1 Member Information

 

  •   Refer to Title XIX Contract YH17-0001 and ACOM Policy 404

 

  11.2 Translation Services

 

  •   Refer to Title XIX Contract YH17-0001

 

  11.3 Member Handbooks

 

  •   Refer to Title XIX Contract YH17-0001 and:

 

  •   Provide the Contractor’s Member Handbook to each member as follows:

 

  •   For Non-Title XIX/XXI members within 12 business days of the member
receiving the initial behavioral health covered service;

 

  11.4 Member Newsletters

 

  •   Refer to Title XIX Contract YH17-0001

 

  11.5 Health Promotion

 

  •   Refer to Title XIX Contract YH17-0001 and:

The Contractor shall ensure all providers receiving SABG funds have posters
displayed in accordance with 45 CFR 96.131.

 

  11.6 Marketing

 

  •   Refer to Title XIX Contract YH17-0001

 

43

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

SCOPE OF WORK

 

  11.7 Web Site Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  11.8 Social Networking Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  11.9 Outreach

 

  •   Refer to Title XIX Contract YH17-0001 and:

 

  •   AMPM Policy 1040

 

  11.10 Identification Cards for SMI Members Receiving Physical Health Care
Services

 

  •   Exempt

 

12 CULTURAL COMPETENCY

 

  12.1 General Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  12.2 Accommodating AHCCCS Members

 

  •   Refer to Title XIX Contract YH17-0001

 

13 GRIEVANCE AND APPEAL SYSTEM REQUIREMENTS

 

  13.1 General Requirements

For all populations eligible for services under this Contract, the Contractor
shall:

 

  •   Implement and administer a Grievance and Appeal System for members,
subcontractors and providers which include processes for the following:

 

  •   Provision of required Notice to members;

 

  •   Member Grievance

 

  •   SMI Grievance;

 

  •   SMI Appeal;

 

  •   Claim Dispute; and

 

  •   Access to the state fair hearing system.

 

  •   Ensure a Grievance and Appeal System that complies with all applicable
requirements in the federal and state laws and regulations, AHCCCS’ Contractor
Operations Manual, AHCCCS Medical Policy Manual, A.A.C. Title 9, Chapter 21,
Article 4, and the requirements under this Contract.

 

44

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

SCOPE OF WORK

 

  •   Not delegate or subcontract the administration or performance of the
Member Grievance, SMI Grievance, SMI Appeal, or Claim Dispute processes.

 

  •   Provide written notification of the Contractor’s Grievance and Appeal
System processes to all subcontractor and providers at the time of entering into
a subcontract.

 

  •   Provide written notification with information about Contractor’s Grievance
and Appeal System to members in the Member Handbook in conformance with the
Contract Section on, Member Handbooks.

 

  •   Provide written notification to members at least 30 days prior to the
effective date of a change in a Grievance and Appeal System policy.

 

  •   Administer all Grievance and Appeal System processes competently,
expeditiously, and equitably for all members, subcontractors, and providers to
ensure that member grievances, appeals, SMI grievances and claim disputes are
effectively and efficiently adjudicated and/or resolved.

 

  •   Continuously review Grievance and Appeal System data to identify trends
and opportunities for system improvement; take action to correct identified
deficiencies; and otherwise implement modifications which improve Grievance and
Appeal System operations and efficiency.

 

  •   Comply with the provisions in the Contract Section on, Administrative
Requirements, which shall include having all professional, paraprofessional, and
clerical/administrative resources to represent the Contractor’s, subcontractor’s
and/or provider’s interests for Grievance and Appeal System cases that rise to
the level of an administrative or judicial hearing or proceeding, except for a
claim dispute.

 

  •   In the event of a claim dispute, the Contractor and the claimant are
responsible to provide the necessary professional, paraprofessional and
administrative resources to represent each of its respective interest. Absent
written agreement to the contrary, the Contractor shall be responsible for
payment of attorney fees and costs awarded to a claimant in any administrative
or judicial proceeding.

 

  •   Provide AHCCCS with any Grievance and Appeal System information, report or
document within the time specified within AHCCCS’ request.

 

  •   Fully cooperate with AHCCCS in the event AHCCCS decides to intervene in,
participate in or review any Notice, Member Grievance, SMI Grievance, SMI
Appeal, or Claim Dispute or any other Grievance and Appeal System process or
proceeding. Contractor shall comply with or implement any AHCCCS directive
within the time specified pending formal resolution of the issue.

 

45

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

SCOPE OF WORK

 

  •   Consider the best clinical interests of the member when addressing
provider or member Grievance and Appeal System-related concerns. When such
concerns are communicated to designated staff, communicate the concern, at a
minimum and when appropriate, to Contractor’s senior management team, AHCCCS
leadership, government officials, legislators, or the media.

 

  •   Conduct a review and take any clinical interventions, revisions to service
planning or referrals to Contractor’s Care Management Program as indicated when
the data shows that a particular member is an outlier by filing repetitive
grievances and/or appeals. See also, AMPM Policy 320-O.

 

  •   Regularly review Grievance and Appeal System data to identify members that
utilize Grievance and Appeal System processes at a significantly higher rate
than others.

 

  •   Submit quarterly reports to AHCCCS, in a prior-approved format, of SMI
grievances, SMI Appeals, non-TXIX/TXXI member grievances/complaints, and
non-TXIX/TXXI provider claim disputes as specified in Exhibit-9, Deliverables.

 

  •   Designate a qualified individual staff person to collaborate with AHCCCS
to address provider or member Grievance and Appeal System-related concerns
consistent with the requirements of this Contract.

 

  •   Require the designated individual staff person to perform the following
activities:

 

  •   Collect necessary information;

 

  •   Consult with the treatment team, Contractor’s CMO or a Care Manager for
clinical recommendations when applicable;

 

  •   Develop communication strategies in accordance with confidentiality laws;
and

 

  •   Develop a written plan to address and resolve the situation to be approved
by AHCCCS when applicable, prior to implementation.

 

  13.2 Member Grievances

The Contractor shall:

 

  •   Develop and maintain a dedicated department to acknowledge, investigate,
and resolve member grievances. The distinct department should be accessible to
members, providers and other stakeholders via a designated phone number that can
be accessed directly or by a telephone prompt on the contractor’s messaging
system.

 

  •   Respond to and resolve member grievances in a courteous, responsive,
effective, and timely manner.

 

46

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

SCOPE OF WORK

 

  •   Actively engage and become involved in resolving member grievances in a
manner that holds subcontractors and providers accountable for their actions
that precipitated or caused the complaint.

 

  •   Not engage in conduct to prohibit, discourage or interfere with a member’s
or a provider’s right to assert a member grievance, appeal, SMI grievance, claim
dispute or use any Grievance and Appeal System process.

 

  •   Submit response to the resolution of member grievances as directed by
AHCCCS.

 

  •   Efforts to resolve member grievances through the member grievance process
do not preclude access to applicable appeal and SMI grievance processes.

 

  13.3 TXIX/XXI Member Appeals

 

  •   Refer to Title XIX Contract YH17-0001

 

  13.4 Claim Disputes

The Contractor shall:

 

  •   Provide subcontractors with the Contractor’s Claim Dispute Policy at the
time of entering into a subcontract. The Contractor shall provide non-contracted
providers with the Contractor’s Claim Dispute Policy with a remittance advice.
The Contractor shall send the remittance advice and policy within 45 days of
receipt of a claim.

 

  13.5 Grievance and Appeal System Reporting Requirements

The Contractor shall submit all deliverables related to the Grievance and Appeal
System in accordance with Exhibit-9, Deliverables.

 

  13.6 SMI Grievances

The Contractor shall:

 

  •   Develop and maintain an SMI Grievance process as delineated in A.A.C.
Title 9, Chapter 21, Article 4 that supports the protection of the rights of SMI
members and has mechanisms to correct identified deficiencies on both an
individual and systemic level.

 

  •   Require SMI Grievance investigators to be certified by Council on
Licensure, Enforcement and Regulation (CLEAR) or by an equivalent certification
program approved by AHCCCS.

 

  •   Refer to ACOM Policy 446.

 

47

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

SCOPE OF WORK

 

  13.7 SMI Appeals

 

  •   The Contractor shall:

 

  •   Implement all SMI appeal processes as delineated in A.A.C. Title 9,
Chapter 21, Article 4, in a manner that offers appellants an opportunity to
present an appeal in person at a convenient time and location for the member,
and provide the privacy required by law.

 

  •   Require all staff facilitating in-person SMI appeal conferences to have
training in mediation, conflict resolution or problem solving techniques.

 

  •   Refer to ACOM Policy 444.

 

14 CORPORATE COMPLIANCE PROGRAM

 

  14.1 General Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  14.2 Fraud, Waste and Abuse

 

  •   Refer to Title XIX Contract YH17-0001

 

  14.3 Disclosure of Ownership and Control [42 CFR 455.104 (through
106)(SMDL09-001] (Sections 1124(a)(2)(A) and 1903(m)(2)(A)(viii) of the Social
Security Act)

 

  •   Refer to Title XIX Contract YH17-0001

 

  14.4 Disclosure of Information on Persons Convicted of Crimes [42 CFR 455.101;
106; 436][SMDL09-001]

 

  •   Refer to Title XIX Contract YH17-0001

 

15 FINANCIAL MANAGEMENT

 

  15.1 General Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  15.2 Performance Bond

 

  •   Refer to Title XIX Contract YH17-0001 and ACOM Policy 305

 

  15.3 Financial Reports

 

  •   Refer to Title XIX Contract YH17-0001 and:

 

  •   The Contractor shall provide an annual Single Audit Report prepared in
accordance with 2 CFR Part 200 Subpart F (whether for profit or non-profit) and
an approved cost allocation plan. Notwithstanding the 2 CFR Part 200 Subpart F
regulations, the Contractor shall include the SABG and MHBG as major programs
for the purpose of this Contract. Additional agreed upon procedures and
attestations may be required of the Contractor’s auditor as determined by
AHCCCS.

 

48

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

SCOPE OF WORK

 

  15.4 Financial Viability/Performance Standards

 

  •   Refer to Title XIX Contract YH17-0001 ACOM Policy 305 and:

 

  •   Total Non-Title XIX/XXI Administrative Expenses divided by total Non-Title
XIX/XXI Revenue shall be less than or equal to 8%.

 

  •   Total Non-Title XIX/XXI Service Expense divided by total Non-Title XIX/XXI
Revenue shall be no less than 88.3%.

 

  15.5 Health Insurer Fee

 

  •   Exempt and:

 

  •   AHCCCS does not reimburse the Contractor for any Health Insurer Fee
payments on non-Title XIX/XXI revenue.

 

  15.6 Compensation

 

  •   Exempt and:

 

  •   Non-Title XIX/XXI payments are not subject to premium tax. See ACOM Policy
304 for additional details.

 

  15.7 Capitation Adjustments

 

  •   Exempt

 

  15.8 Payments

 

  •   Refer to Contract YH17-0001

 

  15.9 Community Reinvestment

 

  •   Refer to Title XIX Contract YH17-0001

 

  15.10 Recoupments

 

  •   Refer to Title XIX Contract YH17-0001

 

  15.11 Financial Responsibility for Referrals and Coordination with Acute
Health Plans and the Courts

 

  •   Refer to Title XIX Contract YH17-0001 and ACOM Policy 423,

 

  •   15.11.5 Exempt.

 

  15.12 Advances, Equity Distributions, Loans, and Investments

 

  •   Refer to Title XIX Contract YH17-0001

 

  15.13 Member Billing and Liability for Payment

 

  •   Exempt

 

49

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

SCOPE OF WORK

 

  15.14 Medicare Services and Cost Sharing Requirements

For Medicare Part D the Contractor shall utilize state funds to pay or reimburse
Medicare Part D cost sharing for dual eligible members or Non-Title XIX/XXI
Medicare eligible SMI members in accordance with ACOM Policy 201.

 

  15.15 Capitalization Requirements

 

  •   Refer to Title XIX Contract YH17-0001 and ACOM Policy 305

 

  15.16 Coordination of Benefits and Third Party Liability Requirements

 

  •   Refer to Title XIX Contract YH17-0001 and:

 

  •   Grant funding is the payor of last resort for Title XIX/XXI covered
services which have been exhausted and Non-Title XIX/XXI covered services, and
for Non-Title XIX/XXI members for any services. Refer to the AHCCCS Financial
Reporting Guide for RBHA Contractors; and

 

  •   See also ACOM Policy 426, and ACOM Policy 434

 

  15.17 Post-payment Recovery Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  15.18 Retroactive Recoveries

 

  •   Refer to Title XIX Contract YH17-0001

 

  15.19 Total Plan Case Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  15.20 Joint and Mass Tort Cases

 

  •   Refer to Title XIX Contract YH17-0001

 

  15.21 Value Based Purchasing

 

  •   Refer to Title XIX Contract YH17-0001and ACOM Policy 322

 

  15.22 Other Financial Obligations

 

  •   Refer to Title XIX Contract YH17-0001 and:

 

  •   The Contractor shall reimburse AHCCCS immediately upon demand all funds
not expended in accordance with the terms of this Contract as determined by
AHCCCS or the Arizona Auditor General.

 

50

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

SCOPE OF WORK

 

  15.23 Sources of Revenue

AHCCCS Shall:

 

  •   Annually prepare the Non-Title XIX/XXI Allocation Schedule, which is
subject to change during the fiscal year, to specify the Non-Title XIX/XXI
non-capitated funding sources by program including MHBG and SABG Federal Block
Grant funds, State General Fund appropriations, county and other funds, which
are used for services not covered by Title XIX/XXI funding and for populations
not otherwise covered by Title XIX/XXI funding.

 

  •   Make payments to Contractor according the Non-Title XIX/XXI Allocation
Schedule which includes all administrative costs to the Contractor. Payments
shall be made in 12 monthly installments through the Contract year no later than
the 10th business day of each month. AHCCCS retains the discretion to make
payments using an alternative payment schedule.

 

  •   Make payments to Contractor that are conditioned upon the availability of
funds authorized, appropriated and allocated to AHCCCS for expenditure in the
manner and for the purposes set forth in this Contract.

 

  •   Not be responsible for payment to Contractor for any purchases,
expenditures or subcontracts made by the Contractor in anticipation of funding.

 

  •   The Contractor shall manage available funding in order to continuously
provide services throughout the funding period.

 

  15.24 Non-Title XIX/XXI Encounter Valuation for Grant, County, Non-Title
XIX/XXI and Other Funds

The Contractor shall:

 

  •   Submit the volume of Non-Title XIX/XXI encounters so that the valuation
level equals 85% of the total service revenue without inclusion of any crisis
capacity credit.

 

  •   Have the discretion to recoup the difference between a subcontractor’s
total value of encounters submitted to the Contractor and 85% of the
subcontractor’s total service revenue contract amount.

AHCCCS shall:

 

  •   Monitor the value of submitted encounters on a quarterly basis.

 

  •   Have the discretion to calculate an encounter valuation penalty if the
contractor does not meet the above volume requirement.

 

  15.25 Profit Limit for Non-Title XIX/XXI Funds

 

  •   Refer to ACOM Policy 323, and

 

51

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

SCOPE OF WORK

 

AHCCCS shall:

 

  •   On a state fiscal year basis, not allow the Contractor to earn a profit
from allocated funds for Supported Housing, Crisis and Non-Title XIX/XXI SMI.
There is no maximum loss for Non-Title XIX/XXI funded programs.

 

  •   Establish a profit limit on the Contractor’s potential profits from the
SABG, MHBG, County, and Non-Title XIX/XXI Other funds.

 

  •   Refer to ACOM 323 Policy 323 for additional information.

 

  15.26 Mortgages and Financing of Property

AHCCCS shall be under no obligation to assist, facilitate, or help the
Contractor secure the mortgage or financing if a Contractor intends to obtain a
mortgage or financing for the purchase of real property or construction of
buildings on real property.

 

  15.27 Management of Federal Block Grant Funds and other Federal Grants

The Contractor shall be authorized to expend:

 

  •   Substance Abuse Block Grant funds (SABG) for planning, implementing, and
evaluating activities to prevent and treat substance use and related activities
addressing HIV and tuberculosis services;

 

  •   Mental Health Block Grant funds (MHBG) for services for adults with
Serious Mental Illness (SMI) and children with serious emotional disturbance
(SED), Evidence Based Practices for First Episode Psychosis; and

 

  •   Other federal grant funding as allocated by AHCCCS as directed for
purposes set forth in the federal grant requirements.

The Contractor shall:

 

  •   Manage, record, and report Federal Grant funds in accordance with the
practices, procedures, and standards in the State of Arizona Accounting Manual
(SAAM), 2 CFR Part 200, and federal grant requirements.

 

  •   Report financial information related to Federal Grants in conformance with
the AHCCCS Financial Reporting Guide for RBHA Contractors.

 

  •   Comply with all terms, conditions, and requirements of the SABG and MHBG
Block Grants, including but not limited to:

 

  •   Confidentiality of Alcohol and Drug Patient Records (42 CFR Part 2);

 

  •   Charitable Choice Provisions; Final Rule (42 CFR Part 54 and 54a);

 

  •   Substance Abuse Prevention and Treatment Block Grant; Interim Final Rule
(45 CFR 96.45, 96.51, and 96.120-121);

 

52

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

SCOPE OF WORK

 

  •   Health Omnibus Programs Extension Act of 1988, Subtitle E General
Provisions, November 4, 1988 (P.L.100-607) (.pdf) (42 U.S.C. 300ee-5);

 

  •   Children’s Health Act of 2000 (P.L. 106-310), October 17, 2000;

 

  •   ADAMHA Reorganization Act of 1992 (P.L. 102-321), July 10, 1992; and

 

  •   Public Health Service Act (includes Title V and Title XIX).

 

  •   Develop and maintain fiscal controls in accordance with authorized
activities of the Federal Block Grants and other Federal Grant funds, this
Contract, and AMPM Policy 320-T, the MHBG and SABG FAQs on the AHCCCS website,
State of Arizona Accounting Manual (SAAM), and 2 CFR Part 200.

 

  •   Report MHBG and SABG grant funds and services separately and provide
information related to block grant expenditures to AHCCCS upon request.

 

  •   Submit Contractor and provider level expenditure data to AHCCCS consistent
with the annual funding levels in the AHCCCS Allocation Schedule for certain
allocations of the SABG including substance use treatment services, crisis
services, primary prevention services, specialty programs and services for
pregnant women and women with dependent children and HIV Early Intervention
Services and the MHBG including SED and SMI services and Evidenced Based
Practices (EBP) for First Episode Psychosis.

 

  •   Manage the Federal Block Grant funds during each fiscal year to make funds
available for obligation and expenditure until the end of the fiscal year for
which the funds were paid. When making transfers involving Federal Block Grant
funds, the Contractor shall comply with the requirements in accordance with the
Federal Block Grant Funds Transfers Cash Management Improvement Act of 1990 and
any rules or regulations promulgated by the U.S. Department of the Treasury
including, 31 CFR Part 205 and the State of Arizona Accounting Manual (SAAM).

 

  •   Not discriminate against non-governmental organizations on the basis of
religion in the distribution of Block Grant funds.

 

  •   Not expend Federal Block Grant funds for any of the following prohibited
activities:

 

  •   Inpatient hospital services;

 

  •   Acute Care or physical health care services including payment of copays;

 

  •   Make cash payments to intended recipients of health services;

 

53

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

SCOPE OF WORK

 

  •   Purchase or improve land; purchase, construct, or permanently improve any
building or facility except for minor remodeling with written approval from
AHCCCS;

 

  •   Purchase major medical equipment;

 

  •   To satisfy any requirement for the expenditure of non-federal funds as a
condition for the receipt of federal funds;

 

  •   Provide financial assistance to any entity other than a public or
non-profit private entity;

 

  •   Provide individuals with hypodermic needles or syringes for illegal drug
use, unless the Surgeon General of the Public Health Service determines that a
demonstration needle exchange program would be effective in reducing drug use
and the risk that the public will become infected with the etiologic agent for
AIDS;

 

  •   Pay the salary of an individual through a grant or other extramural
mechanism at a rate in excess of Level I of the Executive Salary Schedule for
the award year; see http://grants.nih.gov/grants/policy/salcap summary.htm;

 

  •   Purchase treatment services in penal or correctional institutions in the
State of Arizona;

 

  •   Flex funds purchases;

 

  •   Comply with prevention funds management; and

 

  •   Comply with all terms, conditions, and requirements for any Federal Grant
funding as outlined in AHCCCS allocation schedule and letters.

 

16 PROVIDER AGREEMENT REIMBURSEMENT

 

  16.1 Physician Incentive Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  16.2 Nursing Facility Reimbursement

 

  •   Exempt

 

17 INFORMATION SYSTEMS AND DATA EXCHANGE REQUIREMENTS

 

  17.1 Overview

 

  •   Refer to Title XIX Contract YH17-0001

 

  17.2 Systems Function and Capacity

 

  •   Refer to Title XIX Contract YH17-0001

 

54

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

SCOPE OF WORK

 

  17.3 Encounter Data Reporting

 

  •   Refer to Title XIX Contract YH17-0001

 

  17.4 Enrollment and Capitation Transaction Updates

 

  •   Refer to Title XIX Contract YH17-0001

 

  17.5 Electronic Transactions

 

  •   Refer to Title XIX Contract YH17-0001

 

  17.6 General Claims Processing Requirements

 

  •   Refer to Title XIX Contract YH17-0001 and:

 

  17.7 Claims System Reporting

 

  •   Refer to Title XIX Contract YH17-0001

 

  17.8 Demographic Data Submission

 

  •   Refer to Title XIX Contract YH17-0001

 

  17.9 Participation in Information Systems Work Groups/Committees:

The Contractor should execute a contract with AzHEC; including support in the
execution of the provider participation agreements. The Contractor is
responsible for making quarterly payments to AzHEC and providing proof to AHCCCS
upon payment. Proof of payment shall be due as specified in Exhibit-9,
Deliverables. They should identify Contractor priority order of connectivity for
providers and assist AzHEC in determining the schedule of provider
connectivity. The Contractor should participate in quarterly HIE meetings with
AzHEC and AHCCCS.

Each RBHA has collaboratively participated in a process of selecting the
prioritized providers for connectivity during the next two years. Given many
providers operate in multiple locations throughout the state and the information
they contribute may benefit all contracted RBHAs, the expectation is that the
Contractor will each contribute their expected allocation to support project
completion.

The Contractor is responsible for providing AHCCCS the connectivity progress of
the providers on a quarterly basis. Information reported should include the
providers connectivity status (planning, underway, operational, etc.), barriers
encountered that are delaying connections, and other key indicators of progress
for the project overall. Additional information reported should include the
providers who have achieved operational status with any HIE status, including
but not limited to unidirectional connectivity, bidirectional connectivity,
alerts and notifications, portal access, direct secure email, etc. The report
should also include a projection of which providers and their respective
services are expected to be completed within the next quarter. The report shall
be due as specified in Exhibit-9, Deliverables.

 

55

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

SCOPE OF WORK

 

The Contractor should provide proposed connectivity schedules and regular
updates to providers and facilitate AzHEC education with providers.

 

  17.10 Claims and Encounter Submission and Processing Requirements

 

  •   Refer to Title XIX Contract YH17-0001 and:

 

  •   Submitted encounters for services delivered to Non-Title XIX/XXI enrolled
persons must be submitted in the same manner and timeframes as described in the
AHCCCS Encounter Manual.

 

18 ADMINISTRATIVE REQUIREMENTS

 

  18.1 General Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  18.2 AHCCCS Guidelines, Policies and Manuals

 

  •   Refer to Title XIX Contract YH17-0001

 

  18.3 Organizational Structure

 

  •   Refer to Title XIX Contract YH17-0001

 

  18.4 Peer Involvement and Participation

 

  •   Refer to Title XIX Contract YH17-0001

 

  18.5 Key Staff

 

  •   Refer to Title XIX Contract YH17-0001

 

  18.6 Organizational Staff

 

  •   Refer to Title XIX Contract YH17-0001 and:

 

  •   The Contractor shall have the following Organizational Staff

 

  •   Housing Administrator:

 

  •   Resides in Arizona within the assigned Geographic Service Area in Greater
Arizona;

 

  •   Acts as the interagency liaison with Arizona Department of Housing (ADOH);
and

 

  •   Manages and oversees housing programs, including grants, special housing
planning initiatives, and development and expansion of housing availability for
members.

 

56

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

SCOPE OF WORK

 

  •   Other SABG Requirements:

The Contractor must designate:

 

  •   A lead substance use treatment coordinator who will be responsible for
ensuring Contractor compliance with all SABG requirements;

 

  •   A women’s treatment coordinator;

 

  •   An opioid treatment coordinator; and

 

  •   An HIV early intervention services coordinator.

 

  18.7 Liaisons and Coordinators

 

  •   Refer to Title XIX Contract YH17-0001

 

  18.8 Training Program Requirements

 

  •   Refer to Title XIX Contract YH17-000

 

  18.9 Training Reporting Requirements

 

  •   Refer to Title XIX Contract YH17-0001 and:

 

  •   The Contractor and their providers must ensure the following within 90
days of the staff person’s hire date, as relevant to each staff person’s job
duties and responsibilities and annually as applicable for training requirements
applicable to Community Service Agencies. In addition, training requirements
include behavioral health recipient benefit options such as: Medicare
Modernization Act (MMA), Department of Economic Security/Rehabilitation Services
Administration (DES/RSA), and SABG.

 

  18.10 Medical Records

 

  •   Refer to Title XIX Contract YH17-0001 and AMPM Policy 940

 

  18.11 Consent and Authorization

 

  •   Refer to Title XIX Contract YH17-0001 and ACOM Policy 447

 

  18.12 Advance Directives

 

  •   Refer to Title XIX Contract YH17-0001

 

  18.13 Business Continuity and Recovery Plan

 

  •   Refer to Title XIX Contract YH17-0001

 

  18.14 Emergency Preparedness

 

  •   Refer to Title XIX Contract YH17-0001

 

57

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

SCOPE OF WORK

 

  18.15 Legislative, Legal and Regulatory Issues

 

  •   Refer to Title XIX Contract YH17-0001 and:

The Contractor shall comply with the following:

 

  •   ACOM Policy 448;

 

  •   Application for Housing Development Under the AZ Dept. of Health Services,
or its successor;

 

  •   ADHS/DBHS T/RBHA Housing Project Proposal Outline Form (page 358), or its
successor;

 

  •   ISA between AHCCCS and ADOH ISA for Housing Technical Assistance;

 

  •   ISA between AHCCCS and ADOH for State Housing Trust Fund;

 

  •   ISA between AHCCCS and ADOH for Administration of Housing Funds;

 

  •   Pima County IGA;

 

  •   Coconino County IGA;

 

  •   ISA between AHCCCS and ADES-RSA;

 

  •   Substance Abuse Informational Materials;

 

  •   SABG/MHBG Joint Block Grant Planning Application;

 

  •   SABG/MHBG Frequently Asked Questions (FAQs);

 

  •   SYNAR Report

 

  18.16 Pending Issues

 

  •   Refer to Title XIX Contract YH17-0001, and

 

  •   As policies, guides, and other documents are transitioned to AHCCCS,
publishing of AHCCCS final integrated policies and other guidance documents may
be delayed. In the interim, should the Contractor require clarification
regarding contract provisions and associated policies, guides or manuals
incorporated by reference, the Contractor may contact AHCCCS, DHCM for further
instruction. To the extent there is a DBHS policy which provides directive and
it does not conflict with existing contract provisions, the Contractor should
consult those documents until such time that AHCCCS provides updates. DBHS
Policies, Guides and Manuals are available on the AHCCCS website for reference.

 

  18.17 Copayments

 

  •   Refer to Title XIX Contract YH17-0001 and:

For individuals who are Non-Title XIX/XXI eligible persons who are determined to
have a Serious Mental Illness, AHCCCS has established a copayment to be charged
to these members for covered services (A.R.S. 36-3409). The Contractor is
required to comply with the following:

 

  •   Copayment requirements are not applicable to services funded by the
Substance Abuse Block Grant (SABG) or Mental Health Block Grant (MHBG).

 

  •   Copayments are not assessed for crisis services or collected at the time
crisis services are provided.

 

  •   Persons determined to have SMI must be informed prior to the provision of
services of any fees associated with the services (R9-21-202(A)(8)), and
providers must document such notification to the person in his/her comprehensive
clinical record.

 

  •   Copayments assessed for Non-Title XIX/XXI persons determined to have SMI
are intended to be payments by the member for all covered behavioral health
services, but copayments are only collected at the time of the psychiatric
assessment and psychiatric follow up appointments.

 

58

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

SCOPE OF WORK

 

  •   Copayments are:

 

  •   A fixed dollar amount of $3;

 

  •   Applied to in network services; and

 

  •   Collected at the time services are rendered.

 

  •   The Contractor must establish methods to encourage a collaborative
approach to resolve non-payment issues, which may include the following:

 

  •   Engage in informal discussions and avoid confrontational situations;

 

  •   Re-screen the person for AHCCCS eligibility; and

 

  •   Present other payment options, such as payment plans or payment deferrals,
and discuss additional payment options as requested by the person.

 

  •   Individuals receiving services through SABG, MHBG, and discretionary
grants are not assessed copays. See also, AMPM Policy 320-T.

 

  18.18 Administrative Performance Standards

 

  •   Refer to Title XIX Contract YH17-0001

 

  18.19 SMI Eligibility Determination

 

  •   Refer to Title XIX Contract YH17-0001

 

  18.20 Material Change to Business Operations

 

  •   Refer to Title XIX Contract YH17-0001

 

  18.21 Governance Board

 

  •   Refer to Title XIX Contract YH17-0001

 

  18.22 Merger, Acquisition, Reorganization, Joint Venture and Change in
Ownership

 

  •   Refer to Title XIX Contract YH17-0001

 

  18.23 Separate Incorporation and Prohibition Against Direct Service Delivery

 

  •   Refer to Title XIX Contract YH17-0001

 

59

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

SCOPE OF WORK

 

19 MONITORING AND OPERATIONAL REVIEWS (OR)

 

  19.1 Reporting Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

  19.2 Records Retention

 

  •   Refer to Title XIX Contract YH17-0001

 

  19.3 Requests for Information

 

  •   Refer to Title XIX Contract YH17-0001

 

  19.4 Surveys

 

  •   Refer to Title XIX Contract YH17-0001

 

  19.5 Monitoring and Independent Review of the Contractor

 

  •   Refer to Title XIX Contract YH17-0001

 

  19.6 Sanctions

 

  •   Refer to Title XIX Contract YH17-0001

 

20 SUBCONTRACTING REQUIREMENTS

 

  20.1 Subcontract Relationships and Delegation

 

  •   Refer to Title XIX Contract YH17-0001 and:

 

  •   Prevention Subcontracts

 

  •   For prevention service delivery subcontracts, the Contractor shall:

 

  •   Require the subcontractor to comply with the Strategic Prevention
Framework (SPF) Model.

 

  •   Require the subcontractor to specify the work to be performed; type,
duration and scope of the prevention strategy to be delivered; and approximate
number of participants to be served.

 

  •   Require the subcontractor to describe the evaluation methods to monitor
performance and with the specific reporting requirements.

 

  •   Require the subcontractor to comply with SABG requirements.

 

  •   Not incorporate prevention requirements into subcontracts for other
covered services.

 

60

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

SCOPE OF WORK

 

  20.2 Hospital Subcontracts and Reimbursement

 

  •   Exempt

 

  20.3 Management Services Agreements

 

  •   Refer to Title XIX Contract YH17-0001

 

  20.4 Prior Approval

 

  •   Refer to Title XIX Contract YH17-0001

 

  20.5 AHCCCS Minimum Subcontract Provisions

 

  •   Refer to Title XIX Contract YH17-0001

 

  20.6 Subcontracting Reporting Requirements

 

  •   Refer to Title XIX Contract YH17-0001

 

61

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

EXHIBIT-1

DEFINITIONS

Exhibit-1, Definitions

 

  •   Refer to Title XIX Contract YH17-0001 and:

 

Mental Health Block Grant (MHBG)    An annual formula grant that provides
federal grant funds from The Substance Abuse and Mental Health Services
Administration (SAMHSA) created pursuant to Division B, Title XXXII, and
Section 3204 of the Children’s Health Act of 2000. It supports Non-Title XIX/XXI
services for children with a serious emotional disturbance (SED), adults
determined to have a SMI, and evidence-based practices for first episode
psychosis. Non-Title XIX/XXI Funding    Fixed, non-capitated funds, including
but not limited to funds from MHBG, SABG, County, other funds and State
appropriations (excluding state appropriations for state match to support Title
XIX and Title XXI programs), which are used to fund services to Non-Title
XIX/XXI eligible persons and for medically necessary services not covered by
Title XIX or Title XXI programs.

Non-Title XIX/XXI Member or

Non-Title XIX/XXI Person

   An individual who needs or may be at risk of needing covered health-related
services, but does not meet federal and State requirements for Title XIX or
Title XXI eligibility. Non-Title XIX/XXI SED Member    A Non-Title XIX/XXI
member who has met the criteria to be designated with Serious Emotional
Disturbance (SED). Non-Title XIX/XXI SMI Member    A Non-Title XIX/XXI member
who has met the criteria to be designated as Seriously Mentally Ill. Substance
Abuse Block Grant (SABG)    An annual formula grant that provides federal grant
funds from The Substance Abuse and Mental Health Services Administration
(SAMHSA) that supports primary prevention services and treatment services for
persons with substance use disorders. It is used to plan, implement

 

62

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

EXHIBIT-1

DEFINITIONS

 

   and evaluate activities to prevent and treat substance use. Grant funds are
also used to provide early intervention services for HIV and tuberculosis
disease in high-risk substance users.

 

63

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

EXHIBITS

 

Exhibit-2, Reserved

 

  •   Refer to Title XIX Contract YH17-0001

Exhibit-3, Medicare Requirement to Coordinate Care for Dual Eligible SMI Members

 

  •   Refer to Title XIX Contract YH17-0001

Exhibit-4, Placeholder

 

  •   Refer to Title XIX Contract YH17-0001

Exhibit-5, Reserved

 

  •   Refer to Title XIX Contract YH17-0001

Exhibit-6, Adult Service Delivery System-Nine Guiding Principles

 

  •   Refer to Title XIX Contract YH17-0001

Exhibit-7, Reserved

 

  •   Refer to Title XIX Contract YH17-0001

Exhibit-8, Reserved

 

  •   Refer to Title XIX Contract YH17-0001

 

64

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

EXHIBIT-9

DELIVERABLES

 

Exhibit-9, Deliverables

 

  •   Refer to Title XIX Contract YH17-0001 and:

All deliverables which are noted to be submitted via SharePoint are to be
submitted to the SharePoint Contract Compliance Site at:
http://bhs-compliance.azahcccs.gov. Should AHCCCS modify the submission process
for deliverables, AHCCCS shall provide a letter of instruction to the Contractor
outlining changes to the deliverable submission process.

 

Area

 

Timeframe

 

Report

 

When Due

 

Contract Section

 

Reference/

Policy

 

Send To

 

Submitted Via

BEHAVIORAL HEALTH GRIEVANCE AND APPEALS   Quarterly   Serious Mental Illness
(SMI) Grievance, Appeal Member Grievances/Complaints and Provider Claims Dispute
Report   30 days after quarter end   Grievance and Appeal System Requirements  

ACOM

Policy 444

  Office Chief, BH Grievance and Appeals   SharePoint DHCM FINANCE   Annually  
Notification of Unexpended Funds   April 15th   Financial Reports   N/A  
Financial Consultant   SharePoint DHCM FINANCE   Annually   SABG/MHBG Provider
Expenditure Report   October 15th and upon AHCCCS request   Finance   N/A  
Financial Consultant   SharePoint DHCM FINANCE   Quarterly   Proof of AzHEC
Quarterly HIE Connectivity payment   10 days after payment  

Participation in Information

Systems Work Groups/Committees

  N/A   Finance Manager   SharePoint

 

65

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

EXHIBIT-9

DELIVERABLES

 

Area

 

Timeframe

 

Report

 

When Due

 

Contract Section

 

Reference/

Policy

 

Send To

 

Submitted Via

DHCM FINANCE   Quarterly   Provider HIE Connectivity Quarterly Report   30 days
after quarter end  

Participation in Information

Systems Work Groups/Committees

  N/A   Finance Manager   SharePoint DHCM OPERATIONS   Ad Hoc   Community
Development Corporation or Non-Profit Entity Contract Services Management Plan  
Upon Request   Housing  

ACOM

Policy 448

  Housing Administrator   SharePoint DHCM OPERATIONS   Ad Hoc   Housing Related
Support Services Plan   Upon Request   Housing  

ACOM

Policy 448

  Housing Administrator   SharePoint DHCM OPERATIONS   Ad Hoc  
Initial Housing Plan   60 days prior to Contract start date and upon AHCCCS
request   Housing  

ACOM

Policy 448

  Housing Administrator   SharePoint DHCM OPERATIONS   Ad Hoc  
Internal Property Acquisition Maintenance and Inspection Plan   Upon Request  
Housing  

ACOM

Policy 448

  Housing Administrator   SharePoint DHCM OPERATIONS   Ad Hoc   Material Change
to Provider Network (Grants)   Within 7 days of notification   System of Care  
N/A   System of Care/Grants Administrator   SharePoint

 

66

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

EXHIBIT-9

DELIVERABLES

 

Area

 

Timeframe

 

Report

 

When Due

 

Contract Section

 

Reference/

Policy

 

Send To

 

Submitted Via

DHCM OPERATIONS   Ad Hoc   Real Property Transaction Notice   Within 15 days
Transaction   Housing  

ACOM

Policy 448

  Housing Administrator   SharePoint DHCM OPERATIONS   Annually   Comprehensive
Regional Prevention Needs Assessment   April 15th   Prevention   N/A   System of
Care/Grants Administrator   SharePoint DHCM OPERATIONS   Annually   Regional
SABG Treatment Needs Assessment   April 15th   System of Care   N/A   System of
Care/Grants Administrator   SharePoint DHCM OPERATIONS   Annually   Housing
Needs Assessment   April 15th   Housing  

ACOM

Policy 448

  Housing Administrator   SharePoint DHCM OPERATIONS   Annually   Housing
Spending Plan   No later than 30 days from notification by AHCCCS that State
funds have been allocated for housing development   Housing  

ACOM

Policy 448

  Housing Administrator   SharePoint DHCM OPERATIONS   Annually  
Prevention Program Description and Prevention Planned Allocation of Funds   July
1st   Prevention   N/A   System of Care/Grants Administrator   SharePoint DHCM
OPERATIONS   Annually   SABG/MHBG Block Grant Goal Reporting   November 1st  
System of Care   N/A   System of Care/Grants Administrator   SharePoint

 

67

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

EXHIBIT-9

DELIVERABLES

 

Area

 

Timeframe

 

Report

 

When Due

 

Contract Section

 

Reference/

Policy

 

Send To

 

Submitted Via

DHCM OPERATIONS   Annually   SABG Primary Prevention Report   October 15th  
Prevention   N/A   System of Care/Grants Administrator   SharePoint DHCM
OPERATIONS   Annually   SABG Provider Directory   February 1st   System of Care
  N/A   System of Care/Grants Administrator   SharePoint DHCM OPERATIONS  
Monthly   Housing Subsidy Program for Bridge Subsidy Program Tenants   15th day
of the following month   Housing  

ACOM

Policy 448

  Housing Administrator   SharePoint DHCM OPERATIONS   Quarterly   HIV Activity
Report   30 days after end of quarter   Prevention   N/A   System of Care/Grants
Administrator   SharePoint DHCM OPERATIONS   Quarterly   Housing Inventory  
15 days after quarter end   Housing  

ACOM

Policy 448

  Housing Administrator   SharePoint DHCM OPERATIONS   Quarterly  
RBHA Supervisory Care Home Quarterly Census Report   30 days after quarter end  
Housing  

ACOM

Policy 448

  Housing Administrator   SharePoint DHCM OPERATIONS   Quarterly   SABG Priority
Population Wait List Report   30 days after end of quarter   System of Care  
AMPM 320-T   System of Care/Grants Administrator   SharePoint

 

68

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

EXHIBITS

 

Exhibit-10, Greater Arizona Zip Codes

 

  •   Refer to Title XIX Contract YH17-0001

Exhibit-11, Capitation Rates and Contractor Specific Requirements

 

  •   Capitation Rates: Exempt

 

  •   Contractor Specific Requirements: Refer to Title XIX Contract YH17-0001

Exhibit-12, Placeholder

 

  •   Refer to Title XIX Contract YH17-0001

Exhibit-13, Reserved

 

  •   Refer to Title XIX Contract YH17-0001

Exhibit-14, Enrollee Grievance and Appeal System Standards

 

  •   Refer to Title XIX Contract YH17-0001, and ACOM Policy 444 and 446

Exhibit-15, Provider Claim Dispute Standards

 

  •   Refer to Title XIX Contract YH17-0001

Endnotes

 

  •   Refer to Title XIX Contract YH17-0001

 

69