Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

SCHOOL-BASED HEALTH CENTERS 

AND MANAGED CARE: 

EXAMPLES OF COORDINATION 

DECEMBER 1993 
OFFICE OF INSPECTOR GENERAL 

The mission oftheOffice ofInspector General (OIG),asmandated byPublic Law 95-452,
 as


amended, istoprotect theintegrity oftheDepartment ofHealth andHuman Services’
 (HHS)


programs aswellasthehealth andwelfare ofbeneficiaries served bythose programs.
 This


statutory mission iscarried outthrough a nationwide ntwork ofaudits, investigations,
 and


inspections conducted bythree OIG operating components: theOffice ofAuditServices,
 the


Office ofInvestigations, andtheOffice ofEvaluation andInspections. The OIG also
info­


theSecretary ofHHS ofprogramandmanagement problems andrecommends courses
 to


correct
 them.


OFFICE OF AUDIT SERVICES 

The OIGS Office ofAuditServices (OAS)providesall auditing services forHHS, either
 by


conducting audits withits own audit resources orbyoverseeing audit
workdonebyothers.


Audits examine theperformance ofHHS programs and/or its grantees andcontractors
 in


carrying outtheir respective responsibilities andareintended toprovide
 independent


assessments ofHHS programs andoperations inordertoreduce waste, abuse,
and


mismanagement andtopromoteeconomyandefficiency throughout
 theDepartment.


OFFICE OF INVESTIGATIONS 

The OIGS Office ofInvestigations (01)conducts criminal, civil,
 andadministrative


investigations ofallegations ofwrongdoing inHHS programs ortoHHS beneficiaries
 andof


unjust enrichment byproviders. The investigative efforts of01 leadtocriminal
 convictions,


administrative sanctions, orcivil moneypenalties. The 01 alsoversees State Medicaid
fraud


control units whichinvestigate andprosecute fraud andpatient abuseintheMedicaid
program.


OFFICE OF EVALUATION AND lNSPECITONS 

The OIGS Office ofEvaluation adInspections (OEI)conducts short-term management
and


programevaluations (called inspections) that focus on issues ofconcern
totheDepartment,


theCongress, andthepublic. The findings andrecommendations contained inthese
inspection


reports generate rapid, accurate, andup-to-date information on theefficiency,
 vulnerability,


andeffectiveness ofdepartmental
 programs.


Thisreport wasprepared underthedirection ofWilliam C.Moran,Regional
 Inspector


General, andNatalie Coen,DeputyRegional Inspector General, Office ofEvaluation
 ad


Inspections, RegionV. Participating inthis project
 were:


REGION V HEADQUARTERS 

JosephL.Penkrot (Project
 Leader) MaryBethClarke


Ellen
R.Meara(LeadAnalyst)


Jeffrey
 J.Donarski

Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

SCHOOL-BASED HEALTH CENTERS AND


MANAGED CARE:


EXAMPLES OF COORDINATION 

DECEMBER 1993 05-92-00681

TABLE OF CONTENTS 

PAGE 

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...1


ExAMPm . . . . . . . .. o........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...3


“Multnomah County, Oregon... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4


�St. Paul, Minnesota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...6


.Baltimore, Maryland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...7


“Minneapolis, Minnesota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...11


“Brooklyn, New York . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...13


“Hillsborough County, Florida.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...15


.San Francisco, California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...18


APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. A-l 

AOregon Senate Bi11760 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1


B Contract Between Multnomah County and Good Health Plan . . . . . . . . . . . . B-1


(2 Contract Between Health Start and RamseyCare . . . . . . . . . . . . . . . . . . . ..C-1

INTRODUCTION 

PURPOSE 

The purpose of this report is to describe a variety of ways school-based health centers 

coordinate services with managed care providers. The examples described here were 

found while collecting data for our report, School-basedHealth Centers and Managed 

Care, 0EI-05-92-O0680. That report examined the relationship between school-based 

health centers and managed care providers. 

BACKGROUND 

Both school-based health centers and managed care were created to increase access to


health care services. Some managed care providers recognize the special expertise


school-based health centers can provide to meet the compelling health needs of


adolescents. A number of these managed care providers have entered into


agreements with school-based health centers so adolescents covered by their plan have


the advantages of medical treatment at both sites.


This report describes seven examples of coordination between school-based health


centers and managed care providers. In our earlier report, after we reviewed current


literature and consulted with experts on this topic, we visited all known sites where


coordination exists. During on-site visits we used in-depth, structured personal


interviews with representatives from the school-based health centers and managed


care providers. The seven examples cited here represent different methods of


coordination. Because agreements are new and still being developed, this report does


not represent a comprehensive list of agreements between managed care providers


and school-based health centers. Nor does it address all operational and policy


related questions which present themselves in discussions of this topic, such as the


appropriateness of funding streams between managed care organizations and school-


based health centers. For further background information on school-based health


centers and managed care, consult the companion report, School-basedHealth


Centersand Managed Care.


The level of coordination between managed care providers and school-based health


centers, where it exists at all, varies widely across the country. The agreements


described in this report represent cooperation at different points along a spectrum,


ranging from school-based health centers being reimbursed for all services they


perform for managed care plan children, to school-based health centers needing prior


authorization from a managed care plan before providing a very limited number of


services. Managed care plans and school-based health centers are still evolving;


agreements between them are embryonic.


1

As health care reform takes shape, it is crucial to examine how these two types of 

medical providers coordinate. Both managed care and school-based health centers 

have important roles in providing universal access to health care services. 

2

EXAMPLES


For each example, we describe the community where the agreement originated, the 

conditions that promoted coordination, and the mechanism for coordinating. 

Mtitnomah County,Oregon: State law requiring Medicaid managed care providers to 

coordinate with school-based health centers 

St. Pad Minnesotix Legal contract between managed care provider and school-based 

health center 

Baltimore,Maryland Protocol for referral and treatment between managed care 

provider and school-based health center 

Minneapolis,Minnesota: Including managed care providers in coalitions which fund 

and develop school-based health centers 

Brooldyq New York Public entities thatadminister bothschool-basedhealthcenters 

and managed careplans 

Hillsboro@ County,Floridz Managed care providers authorize school-based health 

centers to provide care and bill Medicaid directly for service 

San Francisco,California: Managed caregivesexpedited patient careon school-based

healthcenterreferrals 

3

Multnomah County, Oregon 

Statelaw requiringMedicaid managedcare providersto coordinatewith school-based 

healthcenters 

State laws are playing a major role in increasing coordination between school-based 

health centers and managed care providers in Oregon. First, in 1991, Oregon enacted 

Senate Bill 760 (SB 760) affecting county health departments “and other publicly 

supported programs” that provide services to children and adolescents. (Appendix A 

contains a copy of SB 760.) The bill requires prepaid Medicaid health providers to 

contract with these public health providers for certain types of services. Since all 

Oregon school-based health centers are publicly funded, they are included under this 

statute. Then in 1992, Oregon passed the Oregon Health Plan, a State health care 

reform, setting a February 1, 1994 deadline for agreements between managed care 

providers and public health providers. 

Under SB 760, Medicaid prepaid health plans are required to pay public health 

providers for immunizations, diagnosis and treatment of sexually transmitted diseases, 

and testing and treatment of tuberculosis. The managed care providers are also 

encouraged to contract with these providers for maternity case management, well-child 

care, and pre-natal care. Under this law, public health providers bill Medicaid directly 

on a fee-for-service basis for HIV counseling and family planning services. 

In response to SB 760 and the Oregon Health Plan, negotiations are underway 

between the Multnomah County health department and the 12 managed care plans in 

Multnomah County. In addition to the community based clinics operated by 

Multnomah County, the County also operates seven school-based health centers. 

Services provided at the school-based health centers are considered part of the 

County’s primary care clinic system. 

While mandated contracts have begun to open lines of communication between 

managed care providers and school-based health centers, school-based health centers 

still will not receive reimbursement for services they provide that are not specifically 

covered by SB 760. 

One managed care plan, Good Health Plan of Oregon, has contracted with 

Multnomah County to meet the requirements of SB 760. (Appendix B contains a 

copy of this contract.) Although this fee-for-service contract runs through 1993, no 

bills have been submitted to the managed care plan for any Multnomah County 

semices to date. Multnomah County is working with all managed care plans to agree 

to terms so they may establish common billing protocols, procedures and 

communications. Without this standardization, receiving reimbursement from 

managed care plans may result in prohibitive costs to the county. 

4

Unlike other areas where school-based health centers have negotiated with managed 

care providers, Oregon’s school-based health centers face few obstacles when keeping 

certain health care services confidential. Under Oregon law, children who have 

reached age 15 have control over their medical care. 

5

St. Paul, Minnesota 

Legal contractbetween managed care provider and school-basedhealthcenter 

Comprehensive school-based health centers and managed health care emerged in the 

early 1970’s in St. Paul. Today, Health Start, a nonprofit corporation, operates schoolbased health centers in six St. Paul high schools, seining over 3,000 students annually. 

Approximately half of the students treated at the St. Paul school-based health centers 

are covered by Medicaid. Health Start has been a Medicaid fee-for-service provider 

and obtains a sizable amount of its funding from Medicaid billings. 

In the spring of 1993, the Minnesota State Medicaid agency required Medicaid 

recipients in Ramsey County, where St. Paul is located, to choose a managed care 

provider. The State also encouraged Medicaid managed care providers to coordinate 

with school-based health centers. By the end of 1994, Health Start estimates that 75 

percent of school-based health center enrollees will be covered by managed care 

plans. 

Anticipating the considerable impact Medicaid managed care would have on their 

ability to continue providing sexvices and the reduction in their largest funding stream, 

Health Start began negotiations with RamseyCare, the largest Medicaid managed care 

provider in Ramsey County. Both parties agreed to a contract that made the schoolbased health centers primary care clinic providers and care coordinators for 

adolescents enrolled in RamseyCare. (Appendix C contains a copy of this contract.) 

Under the contract, RamseyCare reimburses Health Start on a fee-for-semice basis, 

using Medicaid reimbursement rates plus 15 percent. Health Start also bills 

RamseyCare for Early, Periodic, Screening, Diagnostic, and Treatment (EPSDT) 

services provided to patients. 

This contract allows Health Start to receive reimbursement for confidential services 

the school-based health centers provide (e.g. mental health sexvices). In the past, the 

school-based health centers would not bill certain services to Medicaid because of the 

Medicaid requirement to noti~ the parents by an explanation of benefits of services 

provided to their children. This requirement had the potential to inhibit students from 

using services, so the school-based health centers chose not to bill for these services. 

Medical information is exchanged between Health Start and RamseyCare. The 

school-based health centers provide medical information to RamseyCare through their 

billing for services. In addition, RamseyCare must give prior authorization for all 

specialty semices. In turn, RamseyCare notifies their primary care clinics whenever 

emergency room visits are used. 

Quality of care is also addressed in the contract. Health Start school-based health 

centers participate in RamseyCare quality assurance and utilization review programs. 

6

Baltimore. Maryland 

Protocolfor referral and treatmentbetween managedcare provider and school-based 

healthcenter 

The Baltimore City Health Department began operating school-based health centers 

in 1985. It now operates 7 of the 10 school-based health centers in middle and high 

schools throughout the city. The centers provide a range of primary and preventive 

care aimed at improving primary care for children, promoting positive health 

behaviors, and increasing health knowledge and decision making skills. The full time 

staff at most school-based health centers includes: a nurse practitioner, a school nurse, 

a mental health counselor, a health educator, a medical office assistant, and a health 

aid. Part time staffing includes supervisory physicians, additional nurse practitioners, 

substance abuse counselors, case managers, social workers, and nutritionists. 

As part of services delivered at the Baltimore school-based health centers, case 

managers help students make appointments with primary care providers for EPSDT 

screenings. Many children are enrolled in both a managed care program and a 

school-based health center. When the case managers noticed that some children with 

managed care providers waited as much as 6 months for appointments, the schoolbased health centers began providing EPSDT services to students assigned to managed 

care providers. 

In the school-based health centers, an increasing number of children changed from 

fee-for-service Medicaid to managed care Medicaid. Many of the students the schoolbased health centers were treating belonged to Total Health Care, a managed care 

plan operated by a federally funded community health center. The school-based 

health centers, which had always provided sexvices to some of these children, initiated 

a relationship with Total Health Care to become a sub-contractor providing EPSDT 

exams for students who were not using Total Health Care. At first, this was a 

contentious issue because Total Health Care viewed this as the school-based health 

centers taking patients away from their medical home. They saw it as a threat to 

continuity of care. Eventually, both providers met and worked out an informal 

agreement on how the Total Health Care enrollees should be treated. 

The agreement defines when the school-based health centers should see patients and 

when they should be referred to Total Health Care. They devised a referral process 

with a flow chart outlining different situations students may present and what actions 

should be taken by the school-based health center. The flow chart on the following 

page gives detail about how and where Total Health Care students receive semices 

depending on the situation. In a letter of agreement to the Baltimore Health 

Department, Total Health Care guaranteed reimbursement at Medicaid rates for 

authorized semices provided in school-based health centers. 

7

BALTIMORE CITY HEALTH DEPARTMENT SBHCS & TOTAL HEALTH CARE HMO CLIENTS


FiAw SHEET


I


Child needs mepisodic cue

1 I 

1 

Go


H- N

Paticntseen by school 

PNP&rcport=@m 

THC Medical Recmh 

I 

m 

“ 

1.	 PNPc.aUs911&ti 

patient toEmrqpcy 

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2. PNPnotificacrthat 

paticntcmvmyto 

Emergency Room 

3. crwiUDotify@=l’8


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rcfa’ral&~--mv” 

II 

I 

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PNP sendsreferral 14 

m. ‘ 

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2. Notca “school
 bcalth”

incommcntncdmd


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3. CQmplcta �ppt. dip& 

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b. Saukuqym*l 

nurse 

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rcfard & alv. ta 

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J1


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 1 1 

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Under the agreement, the school-based health centers recognize the managed care 

provider as the medical home for the child. The school-based health centers try to 

arrange for students to receive care at Total Health Care. When a Studenthas an 

acute care need, the nurse practitioner at the school-based health center calls Total 

Health Care’s clinical tracking department to try to arrange for an appointment. If 

Total Health Care cannot see the student the same day, the school-based health 

center is authorized to provide the treatment needed. 

For regular EPSDT screenings, if the student has never been to Total Health Care, 

the school-based health center performs the screening and sends a copy of the 

information to Total Health Care’s records department. The school-based health 

centers learn which students have never been to Total Health Care by sending a 

computer file with students registered for the school-based health centers to Total 

Health Care and having Total Health Care indicate which ones are members, and 

which of these have never been to Total Health Care. In all other instances, Total 

Health Care performs EPSDT screenings. The school-based health centers facilitate 

these EPSDT screenings by making appointments for students to be screened and by 

sending appointment reminders home with students. 

Whenever the school-based health center provides any service to a student enrolled in 

Total Health Care, they must send a bill for the service and a medical report to be 

included in Total Health Care records. This helps preserve the continuity of care for 

patients. 

In addition to authorizing and reimbursing the school-based health centers for services, 

Total Health Care has several responsibilities under the agreement. When scheduling 

appointments, Total Health Care gives priority to students referred by the schoolbased health centers. When Total Health Care sees a patient referred by the schoolbased health centers, a referral form is sent back to the school-based health centers to 

confirm that the student has completed the referral. 

Both Total Health Care and the Baltimore Health Department said that the biggest 

barrier they had to overcome before reaching an agreement was who would have 

“ownership” of the patient. At first, the school-based health centers did not want to 

recognize the managed care provider as the medical home for students. At the same 

time, Total Health Care felt they should be responsible for all care of each patient. 

They looked at visits to the school-based health centers as out-of-plan utilization, and 

did not want to authorize screenings or reimburse the centers for the bills submitted 

despite their long delays in scheduling EPSDT screenings. Each provider had to 

develop a mutual respect for the other and see how the other was concerned for the 

patients. 

9

One way that Total Health Care and the Baltimore Health Department are 

developing a mutual understanding is through special events that expose each provider 

to the other and teach students how to use services. The school-based health centers 

held an educational session for all Total Health Care physicians to explain schoolbased health centers. ~eyintited physicians tothehealth center site andaUowed 

them toseehow andwhere their patients would retreated. Theschool-based health 

centers sponsor field trips to Total Health Care for students who have never been to 

their clinics before. The students are transported to the Total Health Care clinics by 

bus, and Total Health Care teaches them how to access the clinics, provides lunch, 

gives a tour, and allows students to meet the doctors. Parents may also join this trip 

to Total Health Care. 

Duringthefirst 5 monthsoftheagreement, TotalHealthCarereimbursed
the


Baltimore HealthDepartmentfor120EPSDT visits. They alsowill reimburse
the


HealthDepartmentforsome authorized follow-up treatment visits, increasing
 revenue


fortheBaltimore school-based healthcenters. Inaddition tothis, coordination
 has


improvedcontinuity ofcaretostudents who normally
wouldnothaveit.


Wliile the agreement between Total Health Care and Baltimore’s Health Department 

allows students to receive EPSDT screening at the school-based health centers, it 

cannot address many other issues regarding the school-based health centers and 

managed care providers. The agreement covers a limited number of services, omitting 

issues such as how confidential reproductive health services should be delivered by 

school-based health centers. It does not address how services other than EPSDT 

should be reimbursed, and State Medicaid managed care contracts are unclear on this 

issue, creating dispute over which services should be reimbursed and at what rates. 

Also, the agreement applies only to interaction with Total Health Care. It cannot 

address how the school-based health centers coordinate with other managed care 

providers in the Baltimore area. 

Even with an agreement, Baltimore school-based health centers still face barriers 

providing services to students who need them, collecting reimbursement for these 

services, and keeping patient information confidential. 

10

Minneawlis. Minnesota 

Includingmanaged care providersin coalitionswhichfund and develop school-based 

healthcenters 

The Minneapolis Board of Education established school-based health centers in their 

high schools 14 years ago. Today these school-based health centers serve over 10,000 

students. Hennepin County, the city of Minneapolis, the Minneapolis Children’s 

Medical Center, the University of Minnesota, the Robert Wood Johnson Foundation, 

Maternal and Child Health block grants, and the local health department provide 

major funding for the school-based health centers. 

There is broad based community support for the Minneapolis school-based health 

centers. Four health care agencies are major medical sponsors for the school-based 

health centers, providing medical staff and other support. In addition to these 

sponsors, numerous other agencies co-locate staff in the school-based health centers. 

The Minneapolis-St. Paul area is home to a very competitive managed care market. 

As Minnesota Medicaid expanded managed care into Hennepin County, Medicaid 

recipients were required to choose a managed care plan for themselves and their 

children. Forty percent of the school-based health center patients are Medicaid 

managed care patients. Of the managed care plans, Medics, a primary care case 

manager plan, currently covers approximately 70 percent of the Minneapolis Medicaid 

enrollees. 

In recent years, some of the school-based health center’s sponsoring agencies 

attempted, without success, to bring together all involved in adolescent health to 

discuss the role of school-based health centers in the community and to obtain 

additional funding or support. But in 1992, Medics performed a utilization study of 

their members and found that adolescents were not receiving many primary care 

services from Medics providers. In February 1993, school-based health centers and 

their community sponsors began negotiating with Medics and other managed care 

providers to address school-based health centers’ providing services to adolescents 

covered by managed care providers. 

As a result of these meetings, Medics, through a foundation, is underwriting the full 

cost of the Minneapolis school-based health center at Southwest High School for a 

year. During this year, this school-based health center will not bill Medics for any 

treatments provided to children enrolled with Medics. 

The other managed care plans are collaborating with the school-based health center 

program and are considering pledging $1 million to fund the other Minneapolis schoolbased health centers. By November 22, 1993, these managed care providers will 

announce their contributions to this effort. In the interim, Medics is providing an 

additional $110,000 to keep the school-based health centers operating. 

11

After thisschoolyear, Medics and the othermanagedcare providerswill evaluate 

theirexperiencesand collaboratewith school-basedhealthcentersto decidewhich 

healthsewices shouldbe deliveredin school-basedhealthcentersand whichsemices 

shouldbe deliveredelsewhere. 

12

Public entitiesthatadministerboth school-basedhealthcentersand managed care 

plans 

We visited three communities where federally funded community health centers 

operate school-based health centers as well as managed care plans. To illustrate this 

example, we will discuss one of these community health centers, the Sunset Park 

Family Health Center of Lutheran Medical Center in Southwest Brooklyn, New York. 

Sunset Park Family Health Center is a federally funded community health center that 

operates 10 school-based health centers in elementary and middle schools in the 

Brooklyn area. They also provide an array of community-based outreach and 

education programs, a mental health and substance abuse program, and two satellite 

health centers in Brooklyn. They have incorporated their school-based health centers 

into the overall system at Sunset Park. 

The school-based health centers serve large numbers of Medicaid eligible children. 

Sunset Park Family Health Center bills about 41 percent of the visits to the schoolbased health centers to Medicaid. Sunset Park recently started Health Care Plus, a 

managed care plan for Medicaid clients, and students enrolled in Health Care Plus 

may choose a school-based health center as a primaxy care provider. 

When school-based health centers are the primary care providers for students, they 

need no authorization to treat patients enrolled in Health Care Plus, and they will be 

reimbursed through Sunset Park for the services provided. Because the school-based 

health centers are part of the managed care network continuity of care is not an issue 

for these students. 

Until recently, Sunset Park faced barriers to integrating the school-based health 

centers into their managed care network. One problem Sunset Park had to address 

was how to ensure that other providers in the Family Health Center network could 

access patient information when necessary. Sunset Park has created a database system 

that should address this issue. An Active Patient Identification System contains 

demographic information and visit histories on all patients using any of the Sunset 

Park Family Health Center facilities, including the School Health Program. The 

school-based health centers are electronically linked to this system, so that visit 

information is available network-wide. 

While this arrangement has potential benefits for children enrolled in Health Care 

Plus, Sunset Park still faces many obstacles to treating children at school-based health 

centers. For example, parents may not understand that they can choose their child’s 

school-based health center as the primary care provider in Health Care Plus. If 

parents do not choose the school-based health centers as a primary care provider for 

13

their children,and the childrenreceivecare at the school-basedhealthcenter, 

reimbursementis not provided and coordinationof care becomesmore difficult. 

Another drawback to this arrangement is that it does not address how or whether the 

school-based health centers treat students enrolled in other managed care plans. 

Because Sunset Park runs a managed care program, other managed care providers see 

Sunset Park as a competitor for patients. This impedes coordination with other 

managed care providers whose enrolled patients receive services at the school-based 

health centers. 

14

Hillsborowh County. Florida 

Managed care providersauthorizeschool-basedhealthcentersto provide care and bill 

Medicaid directlyfor seMce 

Several States told us that some managed care providers authorize school-based health 

centers to provide services to children enrolled with managed care providers. One site 

we visited, the Hillsborough County Public Health Unit in Tampa, Florida, sponsors 

several school-based health centers that serve many children enrolled with managed 

care providers. The Hillsborough County Public Health Unit recently began to seek 

authorization to perform EPSDT screening and limited sexvices on managed care 

enrolled students who are registered at their health centers. 

The State of Florida’s Department of Health and Rehabilitation Semites awards over 

$9 million in Supplemental School Health Grants to 192 schools throughout Florida. 

This grant program provides funds for school health projects at nine Hillsborough 

county schools at the elementary, middle, and high school level. Four of these 

schools deliver services through on-site school-based health centers. This program, 

called the Healthy Student and Healthy Young Student program sexves two high 

schools, one middle school, and one alternative school for pregnant teenagers. The 

Hillsborough County Health Department manages the project with close cooperation 

from the Hillsborough County School System. 

The schools involved in this program share three mental health therapists, a clinic 

nurse, a nurse practitioner, a community health nurse, a nutritionist, health aides, a 

program manager, and a physician. These professionals deliver a range of services, 

including: triage for medical injuries and illness, health education and counseling, 

mental health assessment and counseling, injury prevention, pregnancy counseling 

semices, and baby and mother semices. The alternative school for pregnant teenagers 

provides all pre-natal and post-partem care for its enrolled students and their newborn 

babies up to 6 weeks following the birth. 

The project is funded primarily through the Supplemental School Health Grants, but 

school-based health centers also receive in-kind contributions of staff from the County 

Health department. The County Public Health Unit bills for Medicaid services 

provided at the school-based health centers. The County Public Health Unit has set a 

goal for school-based health centers to provide EPSDT screenings to all Medicaid 

eligible students in these schools. 

To ensure that all children are screened, the school-based health centers are trying to 

obtain authorization to screen those children enrolled with Medicaid managed care 

providers. Without an authorization number, however, any service the school-based 

health centers provide to Medicaid children enrolled in managed care plans will not be 

reimbursed by Medicaid. Due to time constraints and the priority of screening eligible 

15

students, 

services. 

Students 

eligible. 

the school-based health centers are focusing authorization efforts on EPSDT 

registering for school-based health centers must indicate if they are Medicaid 

If eligible, the school-based health centers ask students to supply their 

Medicaid identification number. Using the Medicaid identification number, or in some 

cases the child’s name and supporting information, the county public health unit 

generates printouts of the Medicaid eligible children and their primary care providers. 

The school-based health centers then separate out those who are assigned to a 

Medipass provider (Florida’s managed care Medicaid plan for individual physicians to 

become primary care providers), or to a managed care health plan. 

When a student assigned to a managed care provider needs an EPSDT screening, staff 

from the Hillsborough county school-based health centers call the primary care 

provider for that student. They explain that the health center will perform the 

screening and request an authorization number so that they may bill Medicaid for the 

service. If the physician agrees, the county public health unit receives an authorization 

number for that particular service and performs the screening. The school-based 

health centers can then bill Medicaid for the service through the county public health 

unit and be reimbursed at the regular Medicaid rate for EPSDT. 

Sometimes, the county public health unit does not have time to receive preauthorization for screenings. In these cases, they perform screenings on children who 

need them and bill Medicaid for the sexvice. These Medicaid bills will be rejected or 

accepted based on whether the managed care provider authorizes the sexvice.1 

The county public health unit also has billed Medicaid for pregnancy related semices 

provided at the alternative school. Using the same process as with the EPSDT 

screening, the school-based health center calls the primary care provider to authorize 

care. Usually, the primary care provider will authorize the school to provide 

pregnancy related services to this hard to reach population. In this case, the schoolbased health centers are reimbursed at the regular Medicaid rate for a pregnancy. 

The biggest barriers tothistypeofcoordination havebeen overcoming
the


competitive natureofmanaged care, and theschool-based healthcenters’
 lackoftime


toobtainauthorization toprovideservice. For providers
 tomake money,theymust


providesetices.By authorizing someoneelsetodeliver service totheir patients,
 they


potentially losesome income,and theymay feelthatinthelongrun,theywill
lose 

patients. This issue makes some primary care providers reluctant to authorize the 

school-based health centers to provide care. The other barrier is that calling for 

4 

I 

Since Hilfaborough County started requesting authorization for EPSDT screening, obtaining authorization haa 

beeome more difficult beeauae the State Medieaid agency no longer accepts authorization for aeMcea after they have been 

provided. This need to pre-authorize aemieea will delay a child’s screening or force the school-baaed health centers to perform 

screening without reimbursement when there is no time to obtain authorization numbers before delivering amvkes. 

16

authorization of care is time-consuming, particularly in schools where only a few staff 

members run the school-based health centers. 

Hillsborough county says they have been able to build the trust of managed care 

providers in many cases because the physician who works at the school-based health 

centers is well-known and respected in the community. 

The issue of time constraints continues to be a problem, but Hillsborough county tries 

to address this by prioritizing their calls to managed care providers. The County 

Public Health Unit calls physicians they have worked with before, or physicians who 

will be more likely to authorize service first. They still screen all the students who 

need it, regardless of insurance status. But, by prioritizing their calls, school-based 

health centers maximize the reimbursement they will receive for performing EPSDT. 

The arrangement is helpful because it allows the schools to serve students enrolled in 

managed care conveniently, and the school-based health centers are reimbursed for 

services that have gone uncompensated in the past. 

17

San Francisco. California 

Managed care givesexpeditedpatientcare on school-basedhealthcenter referrals 

Balboa Teen Health Center was established in 1986 in cooperation with the 

Department of Public Health and the San Francisco Unified School District. Since 

opening, Balboa’s Teen Health Center has provided a full range of primary care, 

including routine examinations, acute care, mental health programs, health education, 

and other semices. All services are provided confidentially and at no charge to Balboa 

High School students, regardless of their insurance status. The only requirement for 

treatment is that parents sign a blanket waiver consenting to services when enrolling 

children at the school-based health center. 

As part of a baseline budget for children’s programs established by proposition J, 

California’s Children’s Budget Initiative, Balboa Teen Health Center receives funding 

from the local health department. This funding was intended to cover Balboa Teen 

Health Center’s financial needs for 10 years; however, recent budget difficulties have 

threatened the stability of this funding source. In addition to these funds, the State of 

California recently authorized Balboa Teen Health Center to bill for services provided 

to students enrolled in Medi-Cal, California’s Medicaid program. However, none of 

the San Francisco area managed care providers authorize Medi-Cal to reimburse 

Balboa Teen Health Center for services it provides to their patients. 

Many ofthestudents atBalboaHighSchoolareinsured
withKaiserPermanence,


either privately orthroughtheMedi-Calprogram.Inan effort
 tosupplementits


healthcarecapabilities and toguarantee continuity ofcare,
BalboaTeen Health


Centerhasestablishedan expedited referral process
withKaiserPermanenceforall


students
 coveredby thatprovider.


For students covered by Kaiser Permanence, whether Medi-Cal recipients or not, the


Balboa Teen Health Center performs a triage function. Balboa provides basic primary


or acute care to students who register for the health center. If follow-up or treatment


beyond the capabilities of the Balboa Teen Health Center is necessaV, the health


center immediately refers the student to Kaiser Perrnanente. Balboa Teen Health


Center telephones the physician contact at Kaiser Perrnanente, explains the problem,


and schedules an appointment for the patient. For these students, continuity of care is


ensured.


Balboa Teen Health Center shares patient information with Kaiser only when


referring students for emergency care, follow-up visits, or additional services not


available at Balboa. Although information is usually shared informally by telephone or


facsimile machine, all information shared outside the school-based health center with


facilities other than the San Francisco Department of Public Health recluires specific


patient release of information.


18

There is no formal contract between the two providers. However, Balboa Teen


Health Center recently drafted a letter to the physician contact at Kaiser Teen Clinic


in San Francisco to create a more formal structure for their working relationship.


Kaiser has agreed to and followed the terms of this letter. While this agreement helps


ensure continuity of care for Kaiser Permanence patients, it does not address the


funding issues raised when school-based health centers provide uncompensated care to


students enrolled in managed care plans.


19

APPENDIX A 

OREGON SENATE BILL 760 

A-1 
. .... . ...

-.. . . 

. . 

, 66th OREGON LEGISLATIVEASSEMBLY-1991 Regular
 3esskn

Enrolled 

Senate Bill 760 

Sponsored by SenatorKENNEMER; Senators BRENNEMAN, CEASE, COHEN, GOLD, HAMBY, 

McCOY, TROW, Re resentatives BARNES,BAUMAN, CARTER,CLARK,HAYDEN,MASON, 

McTEAGUE, MEE&, MILLER,SHIPRACK,SOWA, STEIN (at the requestofClackamm 

County, Coalition of Local HealthOflieiald


.

. . Z37 

CHAPTER...-.
.. ....—-”...

Relating topoverty level
 medical programs. 

Be It Enacted by the People oftheState
of Oregosx

SECI’ION 1. h is the purpose of this Act to take advan~ge of opportunities tcx


(1) Enhance the state �nd local public health partnership


(2) Improve the access to care �nd health status of women and childrem �nd


(3) Strengthen public health programs and semices at the county health department level.


SECI’ION Z The Adult and Family Services Division, the Oflice of Mtilcal Assistance Pro-


grams and the Health Division shall endeavor to develop �greements with local governments to facilitate the enrollment of poverty level me&cal assistance program clients. Subject to the 

availability of funds therefor, the �greement shall be structured to allow flexibility by the state and 

local governments and may allow �ny of the following options for enrolling clients in poverty level 

medical assistance progrm. 

(1) Initial processing shall be done at the county health department by employees of the county, 

with eligibility determination completed at the local orlce of the Adult and Family Services Division; 

(2) Initial processing and eligibility determination shall be done �t the county health department 

by employees of the Adult and Family Services Division: or 

(3) Application forms shaJl be made �vailable �t the county health department with initial 

processing and eligibility determination shall be done at the local off~ce of the Adult and Family 

Services Dlviaion. 

SECTION S. To capitalize on the successful public health programs provided by county health 

department �nd the sizable investment by state and local governments inthe public health system. 

state agencies shallencourage agreements that allow county health departments and other publicly 

supported programs to continue to be the providers of those prevention and health promotion services now �vailable, plus other maternal �nd child health services such �s prenatal outreach and 

care, child health services �nd family planning services to women �nd children who become eligible 

for poverty level medical assistance program benefits pursuant to section 4 of this Act. 

SECI’ION 4. [n order to make advantageous use of the system of public health services avail­

�ble through county health departments and other publicly supported programs �nd to insure access 

to public heaith services through contract under ORS chapter 414, the state shall: 

(1)
Unless cause can be shown why such �n agreement is not feasible, require and approve 

agreements between prepaid health plans and publicly funded providers for authorization of payment 

for point of contact services in the following categories: 

A-2 
.............

...........c......... .

...........................................

. 

(8) hnmuniz4tionq


(b) Sexually transmitted diseaseq �nd


(c) Other communicable diseases;


(2) Continue to811owenrollees in prepaid health plans to receive family planning aervicea from 

fee-for-service providem, 

(3) Encoura~e �d ammove . . �greements between prepaid health plans �nd publicly funded providem for �uthoridon of �nd payment for services in the following ‘categories: 

(a) Maternity case management; 

(b) Well-child care; �nd “ 

(c) Prenatal care; �nd 

(4)
Recognize the social value of partnerships between county health departments �nd other 

publicly supported programs �nd other health providers, �nd take �ppropriate measures to involve 

publicly supported health care �nd service programs in the development �nd implementation of 

managed health care programs in their �reaa of responsibility. 

Passed by Senate May s 19Dl 

4d%z9’a%?& ..—”. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

-----p~%: 

Passed by House %e 4, lWl 

.

Speaker of Housa

. 3—

Enrolled Senate Bill 760 

Ree8ived by tkvo~ 

Pii by OKI of Secmtmy of StatQ: 

../.f:&i.&.M . ...J2i.2d5 . . .._-. ,*1 

.. . ./L4 ? ...._?& . Secretary0[ St 

Page 2 

A-3

APPENDIX B 

CONTRACT BETWEEN MULTNOMAH COUNTY AND GOOD HEALTH PLAN 

B-1 
Letter of Agreement 

1.	 Sewices will be provided by the Multnomah County Department of Health, hereinafter 

referred to as “Provider”, to Good Health Plan of Oregon Medicaid-sponsored 

members, who are Office of Medical Assistance Programs (OMAF’) eligible recipients 

who have enrolled with the Good Health Plan, hereinafter referred to as “Members”, or 

“Membet’. Sewices will be provided for immunizations, sexually transmitted diseases, 

and other communicable diseases of public health concern. Good Health Plan of 

Oregon will hereinafter be referred to as “Health Plan”. 

2.	 Health Plan will furnish Provider each month with a current roster of enrolled Members, 

which will indicate all existing Primary Care Physician designations. 

3.	 Services will be provided within the scope and guidelines of S6 760 with the intent to 

involve publicly supported health care and service programs in the development and 

implementation of managed health care programs in their areas of responsibility. 

4.	 Provider agrees to bill services to Health Plan, not to Members. Provider will make 

every effort to bill in a timely manner. Bills will be submitted beginning 14 days after 

date of service, but they may be submitted up to one year from date of sewice. Any 

bill submitted more than one year after the date of seMce will not be payable by either 

Health Plan or Member. Provider will submit bills on standard HCFA 1500 forms, using 

CPT codes and [CD-9 codes. Services for individual Members will be billed separately, 

and Provider will bill for all services provided to Member regardless of whether services 

are covered by this Agreement. Health Plan will pay only for those sewices covered 

by this Agreement. Clean claims will be paid within 30 working days. Provider must 

appeal any claims adjudications or other matters within 90 days of the date of payment 

and if Provider fails to do so, Provider will be deemed to have waived any appeals 

rights. 

5.	 Provider agrees to accept Health Plan’s payment as payment in full for covered 

services. Health Plan’s payment will be as listed in Attachment A. Appropriate 

services covered by this Agreement that are not listed specifically in Attachment A will 

be reimbursed at the Health Plan allowable for the service. Payments will be 

considered payment in full for applicable charges. Provider agrees that no copay ;,lent 

will be charged at time of service. 

6.	 Provider agrees to provide Members with the same quality and timeliness of care as 

other patients. Quality of care will be commensurate with the professional standards 

of the community. 

7.	 Provider through the state of Oregon, is self-insured under provisions of ORS 30.260 

through 30.300 (as now or hereafter amended) for its tort liabilities. Pursuant to ORS 

30.260 through 30.300, Provider and its employees are insured against any claim or 

claims for damages arising by reason of personal injuries or death occasioned directly 

or indirectly in connection with the performance of, or failure to perform, any Provider 

service provided hereunder, the use of any property and facilities provided by Provider, 

and activities performed by Provider in connection with this Agreement. A letter 

certifying Provider’s insurance shall be provided to Health Plan upon request. 

B-2 
8. 

9. 

10.


11. 

12. 

13. 

14. 

15. 

The patiies hereto mutually agree to indemnify, defend, and hold each other (including 

their officers, agents, and employees) harmless against any and all claims, demands, 

damages, liabilities, and costs incurred by the other party, including reasonable 

attorneys’ fees, arising out of or in connection with, either directly or indirectly, the 

performance of any setice, or any other actor omission by or under the direction of 

the indemnifying patty, its officers, agents, or employees. 

Provider hereby agrees that in no event, including but not limited to non-payment by 

Health Plan, insolvency of Health Plan, or breach of this Letter of Agreement, shall 

Provider bill, charge, collect a deposit from, seek compensation, remuneration, or 

reimbursement from, or have any recourse against Member, or other persons acting 

on their behalf, other than Health Plan, for covered services provided pursuant to this 

Letter of Agreement. ““~is is further dictated by the Federal Medicaid Act and 

applicable Oregon Statutes and Oregon Administrative Rules concerning the provision 

of Medical Services under prepaid capitated health plans. 

Provider further agrees that this provision shall survive termination of this Letter of 

Agreement regardless of the cause giving rise to termination and shall be construed 

to be for the benefit of Health Plan’s Member; and that this provision supersedes any 

oral or written contra~ agreement now existing or hereafter entered into between 

Provider and Member, or persons acting on their behalf. This provision applies to 

services provided during a time period for which Member premiums have been paid. 

Provider agrees to maintain all required licenses, certificates, and/or registrations as 

issued by the appropriate State, Federal, and local governmental agencies to provide 

the health care services which Provider undertakes to provide to Members under this 

Letter of Agreement. 

Provider agrees, except in accordance with provisions, spirit and intent of this 

Agreement not to differentiate or discriminate in its provision of services to Members 

because of race, color, national origin, ancestry, religion, sex, marital status, sexual 

orientation, or age. 

Attachment B lists current service locations. Provider will notify Health Plan of service 

location changes as theyoccur. 

Provider will make every reasonable effort to direct the Member to Member’s primary 

care physician for services not included in this contract. Members may be billed only 

for those services not covered by Medicaid. 

Provider and Health Plan may agree to contract for certain services not included in this 

Agreement on an as-needed basis. Provider and Health Plan will agree at time of 

service on rates and charges associated with such services. Services will include but 

are not limited to obstetrical case management and specialized programs sponsored 

by Provider. 

In the event of any dispute arising out of or relating to this Agreement, the parties shall 

attempt in good faith to mutually resolve the dispute. Any appeals on decisions 

related to treatment or services will be mediated between Health Plan and Provider. 

B-3

----

16.	 - This Letter of Agreement may be terminated at any time without cause by either party 

upon sixty (60) days advance written notice to the other party. 

17. The term of this Letter of Agreement shall commence on Janua~ 1, 1993 and shall 

1993 and thereafter until December 31 of continue in effect through December 31, 

each following year unless terminated by either party pursuant to the terms stated 

herein.	 The fee schedule as listed in Attachment A may be revised concurrent with 

renewal. 

AGREED AND ACCEPTED: 

Multnomah CounWf 0re90n Sisters of Providence 

Health Plans in Oregon Department of Health 

“Provider” Good Health Plan of Oregon HMO 

‘Health Plan” 

.-

.- 7 

/“.. ; 

By:=-” ?’:”~~’ A - ~~ “4“‘~ 

Ted von Glahn 

Chief Operating Officer 

?3 -086307) >: 

Employer I.D. Number 

By: 

BilllOdegaard, Direct8r, Health Dept. 

By-:” Progra Manager, Health Department

Date: 

REVIEWED: 

IJ+URENCE B. KRESSEL, County Counsel 

-

0.,. 

B-4 
Addendum A 

This Addendum to the Letter of Agreement seines to establish operational protocol and procedures to 

help ensure coordinated delive~ of the health services specified in the Letter of Agreement, which 

Medicaid-s~nsored, Managed Care Program enrollees may receive from both County health department 

personnel and their Good Health Plan of Oregon (Plan) providers. 

(1)	 Primary Care Physician (PCP) Coordination: Plan PCPS are to be informed of Planreimbursad, optional health care services received by their members at County health clinics. 

�	 The respective County wifl b~l the Plan for each service encounter in a format that 

identifies the date, member mme,diagnostic code(s), and procedure code(s) enabling 

the Plan to generate a report for entry by the PCP in the member’s medical record. 

(2) Protocol to Support Compliance with Recommended Immunization Schedules -

The involved PCP and County clinic wUI adhere to the fallowing procedures: 

�	 During the initial offiie v&it, the PCP is expected to discuss the immunizations deliv~ 

option and help the member determine where they wifl most readily compfy with 

immunization schedules, at their PCP’S office or at a County clinic. 

�	 If a member selfdirects to the County for immunization services, she wifl be encouraged 

to remain with the County provider to completion of the immediate immunization 

schedule. 

� The Plan will assist PCPS with a tracking and recall system. 

(3)	 Protocol Related to Sexually Transmitted Diseases: Routine screening, treatment, and 

monitoring for recurrence of STDS will be providd exclusively by the PCP in the course of 

providing the member’s primaty care. 

�	 Both the invofved County and the PCP will screen and treat sexually transmitted 

diseases when a member presents episodically. 

�	 The Plan expects the County to proceed with treatment and all immediate 

foflowup to assure that this episodic treatment was effective. 

�	 Members will be directed to their PCPS for annual gynecological examinations, 

which include routine STD screening, and ongoing monitoring of conditions 

previously treated by the County. 

� The point-of-sewice contact mayarisedirectly from STO concerns or from the delivery 

of family pfanning services, which routinely involve a PAP test and, secondarily, may 

detect the presence of a STD. 

Continued 

B-5 
Addendum A - page 2 

(4)	 Protocol Related to Other Communicable Diseases: The County will provide necessqf 

diagnostic testing and counseling when a member contact presents the opportunity to screen 

for a communicable disease of public health concern (i.e., TB, HIV/AIDS, and viral hepatitis). 

The County will refer the member to the PCP for treatment and concurrently notify the member’s 

PCP of the referral, to facilitate PCP follow up, as soon as the member is informed of an 

HIV/AIDS diagnosis or TB diagnosis (services typically invdve skin test/chest x-ray/lNH). 

� The PCP, in providing primary c-are, routinely will screen for communicable diseases 

�	 When the PCP makes a TB diagnosis, she/he may refer the member to the County for 

treatment if justified by the County’s capabii”~ to treat more effectively; otherwise, 

treatment will be provided routinely by the PCP or referred to a Plan specialist. 

�	 The County will be asked to furnish the Plan with informational material about its 

communicable disease prevention and treatment sewices, which may be used to inform 

PCPS more fully about this treatment option. 

(5)	 Referral to Plan Pharmacies: To ensure efficient dispensing, prescriptions for members should 

be called in or taken to a Plan pharmacy (see listing provided as Addendum B). 

� The Plan will supply all County clinics with updated Plan Pharmacies listings as issued. 

�	 The rationale for this restriction is the likelihood that a non-Plan pharmacy will deny 

service to a Medical Card holder designated as an enrollee of the Good Health Plan. 

(6)	 Access to Family Planning Sewices: Members may obtain OMAP-coverecffamify pfanning 

services from the County or any other licensed, enrolled OMAP provider. Counseling on 

methods of family planning is the only service covered by the Good Health Plan. However, the 

member’s PCP, as an individually-enrdled OMAP provider, can provide OMAP-covered family 

planning medical services and prescriptionson a fee-for-servicereimbursementbasis. 

�	 When the County provides covered family planning services to a GHPO-Medicaid 

member, the County will bill OMAP for these sewices on a fee-for-service basis. 

Therefore, neither the Plan nor the member’s PCP will be notified of County-provided 

family planning services. 

�	 To ensure access to provider options for family planning services, member materials will 

promote the publicly-funded 1-800 -SAFEN= telephone information and referral service, 

which can direct the member to her County heaith department and community providers 

of all-options family planning. Plan Providers will be furnished SafeNet promotional 

materials for additional distribution to members. 

B-6 
APPENDIX C 

CONTRACT BETWEEN HEALTH START AND RAMSEYCARE 

c-1 
PREPAID MEDICAL ASSISTANCE PROGRAM


PRIMARY CARE PROVIDER AGREEMENT


This Agreement, made and entered into this ‘irst day of ‘cc* 

t 199<, by and between the party executing this Agreement on t 

Signature and Declaration Page attached hereto (“ProviderZ) and NW 

HEALTH NETWORK, INC. (“Health Plan”) 

SECTION 1 PARTIES AND PURPOSE


Section 1.1 Parties. The Health Plan is a Minneso 

nonprofit corporation licensed and organized as a health maintenan 

organization to arrange to provide health care services to residen 

of Minnesota on a prepaid basis. The Health Plan has been du 

approved and designated by the State of Minnesota as a vendor 

health care services for the Prepaid Medical Assistance Progr 

(“PMAP”) for eligible Medical Assistance (“MA”) recipients whc] enro 

in the Health Plan. Provider is a community health care clinic a 

is duly licensed by the State of Minnesota. 

Section 1.2 PurDose. The Health Plan wishes to contract wi 

Provider to provide Primary Health Care Services under PMAP to 

recipients enrolled in the Health Plan. Provider agrees to work wi 

the Health Plan in the delivery of health care services to M 

eligible persons participating in PMAP who are enrolled in the Heal 

Plan. Provider is willing to provide such persons with Prima 

Health Care Services as provided under federal and Minnesota law a 

regulations governing PMAP and the Health Plan, and to receive 

payment in full the payment specified h this Agreement. 

c-2 
SECTION II: DEFINITIONS


. The following definitions shall apply to this Agreement and t

all exhibits and addenda attached hereto:


Section 2.1 ~Care Coordination-. The initial and periodi 

assessment of each Enrollee~s health and social situation and th 

development, implementation and monitoring of care plans for ea 

Enrollee. 

Section 2.2 “Care Coordinator”. The nurse, social worker


other appropriate professional person who is designated by Provider

selected Primary Care Site medical staff to perform Care Coordinati

for assigned Enrollees.


Section 2.3 ‘Clinic Professional-. All medical doctors a

other duly qualified licensed or registered health care professiona

who are members, partners, shareholders, owners, agents, or employe

of Provider or are otherwise affiliated with Provider.


Section 2.4 “Covered Services”. Those health care produc

and services included in the PMAP benefit package and described


the Health Plan’s Description of Benefits.


Section 2.5 “Emeraencv Care-. The provision of medically 

necessary Covered Services which are required to treat an immediat 

medical emergency. 

Section 2.6 ‘Enrollee”. An MA-eligible individual who 

enrollment in the Health Plan under PMAP has been entered into t 

State Client Information File. 

Section 2.7 ‘Enrolle ~. A contract, certifica

or other evidence of coverage issued to an Enrollee that describ 

c-3 
the Covered Services available to the Enrollee under PMAP and th 

Health PlanJs Description of Benefits. 

Section 2.8 “Health P1an Qua li. t v ASsu rance Protocol_ # � Th 

standards and operating procedures adopted from time to thue by th 

Health Plan as necessary to maintain the Health Plan’s quality 

assurance program i.n accordance with Minnesota law and acceptable 

the United States Departxtent of Health and Human Services (DHHS). 

Section 2.9 am Care Protocol”. The utilization and quali 

assurance standards and procedures identified and developed from ti

to time by the Health Plan to be used in the care of Enrollees. T

MA Care Protocol includes specific penalties for non-compliance wi

established standards and provides an appeals process for a

participating providers affected by the Protocol. The MA Ca

Protocol is subject to the Quality Assurance Plan and is contained


the MA Care Manual maintained by the Health Plan and is incorporat

herein by reference.


Section 2.10 ~. “
 A physician appointed


the Health Plan to oversee the quality of Covered Services deliver

to Enrollees and to review cases of excessive utilization of Cover

Services. The MA Medical Director shall have the authority to ma

determinations in accordance with the MA Care Protocol.


Section 2.11 ~
W a Prov*der&. A “provider


{Uovered Services under PMAP who is a Primary care Providerr


Referral Provider or other provider under contract with the Heal

Plan to provide such health services.


Section 2.12 ‘Medical Emera encv Servicesm. Covered Servic

provided as Emergency Care. For purposes of this contract, ‘Medic

c-4 
Emergency~ shall mean a condition that if not treated immediately


could cause a person serious physical or mental disability the


continuation of severe pain or death. Labor and delivery is a medical


emergency if it meets this definition.


Section 2.13 “Out-of-Plan Care”. Health care provided to an


Enrollee by providers who are not under contract with the Health Plan


to provide health services under PMAP.


Section 2.14 ~ Screeni aive roclram”.


The State program mandated by Minnesota Statutes, Section 256B=69


(1990), section 256B.0915 (Supp. 1991), and Minnesota Rules, parts


9505.2390 to 9505.2500.


Section 2.15 ~Pre~aid Medical Assistance PrOCfram(PMAP)#* The


program authorized under Minnesota Statutes, Section 256B.091 (1990),


Section 256B.0915 (1992) and Minnesota Rules, parts 9500.1450 to


9500.1464.


Section 2.16 ‘Primarv CareU. A type of medical care 

emphasizing first contact care and the assumption of ongoing 

responsibility for the patient in both health maintenance and therapy 

for illness or injury. It is comprehensive in scope and involves the


overall coordination of care of the patient~s health problems whether


biological, behavioral or social.


Section 2.17 “Primarv Care Providerm. A piimary care


physician or other provider of health care who has entered into a


contract with and who is authorized by the Health Plan to provide


Primary Care Covered Services to Enrollees and to authorize Covered


Services to be performed by Referral Providers.


Section 2.18 “Primarv Care Site”. A medical clinic location


c-5

whose medical staff agrees to serve as the primary control point for 

an.Enrollee’s medical care needs. 

Section 2.19 “Provider Manual#. The official Minnesota


Department of Human Services’ publication, entitled ~Medical


Assistance and General Assistance Medical Care Provider Manual,”


which is issued to providers by the State to clarify policy,


procedures, or definitions of Covered Services under PMAP.


Section 2.20 ~eferral Provider”. A provider of health care 

who delivers Covered Services to Enrollees as requested by a duly 

authorized Primary Care Provider and who has entered into a Referral 

Provider contract with the Health Plan to deliver such Covered 

Services. 

Section 2.21 ~ @. Covered Services provided 

to Enrollees by Referral Providers as requested by a Primary Care 

Provider. 

Section 2.22 “re ~.
 Covered medical services which

are medically necessary in order to prevent a serious deterioration


of the health of an Enrollee who is temporarily outside the service


area, Ramsey County of the State of Minnesota, when the need for care 

arises. 

SECTION 111$ PROVISION OF SERVICES . 

Section 3.1 Ob lIU ‘ at”o I n to Provide Covered Services. Provider

is a Primary Care Provider and shall provide, or arrange for the 

provision by MA Participating Providers designated by the Health Plan 

pursuant to the MA Care Protocol, to Enrollees who choose to obtain 

services from Provider, all medically necessary and appropriate 

C-6 
Covered Services “including those services in Appendix I to this 

Agreement, attached and incorporated herein. Provider shall, to the 

maximum extent possible, provide Care Coordination for each Enrollee 

who chooses to obtain services from Provider, including all Covered 

Services rendered to such Enrollee by providers not affiliated with 

Provider. The Health Plan may make deletions from or additions to’ 

the Covered Services as nay be required from time to time by federal 

or state law subject to approval by the Minnesota Department of 

Health. The Health Plan shall give written notice of any such 

deletions or additions to Provider within seven (7) days of being so 

notified by appropriate persons responsible for the PMAP. 

Section 3.2 C.L.I.A. Requirements. All laboratory testing


sites providing services for PMAP pursuant to arrangements under this


Agreement shall have either a Clinical Laboratory Improvement


Amendments (CLIA) certificate of waiver or a certificate of


registration along with a CLIA identification number. Those


laboratories with certificates of waiver will provide only the eight


types of tests permitted under the terms of their waiver.


Laboratories with certificates of registration may perform a full


range of laboratory tests.


Section 3.2 s~ ervic . Provider is responsible for 

and agrees to provide Covered Services to Enrollees i“n accordance 

with the professional standards of the community and h accordance 

with the Health Plan Quality Assurance Protocol and the MA Care


Protocol. All Covered Services provided in accordance with this


Agreement shall be at least equal in quality, completeness and


promptness to services provided by Provider to other persons not


c-7

covered by this Agreement.


. Section 3.4 Jnformation Reaardina Services* Provider shall


furnish to the Health Plan without charge reports and data concerning


Covered Services provided by Provider to Enrollees in such form and


at such times as may be reasonably required by the Health Plan, the


State of Minnesota, or the United States Department of Health and


Human Services (@DHHS~).


Section 3.5 Control of Operations. The operation and


maintenance of the offices, facilities and equipment of Provider


shall be solely and exclusively under the control and supervision of


Provider. The Health Plan shall have no right, authority or control


over the selection of staff or the supervision of personnel of


Provider. Each Clinic Professional sha11 maintain the same


doctor/patient relationship as would arise in the absence of this


Agreement, and no provision of this Agreement shall have the effect


of infringing upon a Clinic Professional/s professional relationship


with each Enrollee.


Section 3.6 Enrollee Identification. Based on information


made available to the Health Plan by the State of Minnesota, the


Health Plan shall maintain such lists as are needed for the purpose


of enabling Provider to establish procedures for identification of


eligible Enrollees. The Health Plan shall also issue an


identification card to each Enrollee, promptly after his or h=


enrollment, bearing the name of the Enrollee, Enrollee numb=, and


effective date of coverage. Provider agrees to use reasonable


efforts to verify the current status of an Enrolleets eligibility for


Covered Services.


C-8

Section 3.7 primarv Care Sites. At the time of enrollment,


Enrollees shall be notified of the names of MA Participating


Providers who have been designated by the Health Plan to serve as


Primary Care Sites. Enrollees shall be notified that they are to seek


Covered Services exclusively from those Primary Care Sites or from


Referral Providers to whom Enrollees are referred in writing by a


Primary Care Provider. Provider agrees to make the Primary Care Site


as designated by Provider available t.o each Enrollee. Provider will


furnish the Health Plan with a current list of all Clinic


Professionals who will be providing Covered Services and shall


provide the Health Plan with an amended list within ten (10) working


days of any changes.


Section 3.8 site Designation Enrollees. Enrollees will also 

be notified that the Health Plan retains the right to designate a 

specific Primary Care Site for each Enrollee and will do so when it 

is judged appropriate by the Health Plan. If an Enrollee is informed 

that he or she has been assigned to receive Covered Services from a 

specific Primary Care Site, then all subsequent Covered Services for 

that Enrollee must be provided or arranged for by such Site. Only 

Covered Services authorized by Enrollees designated Primary Care 

Site will be covered by the Health Plan, except for Medical Emergency 

Services and ‘out-of-plan~ Urgent Care servicesf as de-finedherein 

and in the Enrollee Certificate. 

Section 3.9 Other Providers. Except in cases of Medical 

Emergency or as provided otherwise in PMAP or as expressly specified 

by the Health Plan in writing from time to time, if Provider is 

unable for any reason to render a necessary Covered Service to an


c-9

Enrollee, Provider shall arrange to have such Covered Services


rendered to Enrollee by another HA Participating Provider if


possible. The Health Plan will make available to Provider a list of


all XA Participating Providers, as modified from time to time=


Providers shall obtain prior authorization from the Health Plan for


any such arrangement to have Covered Services rendered by a provider


that is not a Primary Care Provider under contract with the Health


Plan to provide services under PMAP.


SECTION IV PAYMENT FOR SERVICES


Section 4.1 Pavment Procedure. The Health Plan shall pay


Provider for the provision of Covered Services to Enrollees and the


other responsibilities assumed by Provider under this Agreement, as


provided in Exhibit A attached hereto and incorporated herein.


Provider shall send all invoices for Covered Services provided to


Enrollees to the Health Plan’s Claim Department as specified by the


Health Plan. Information required to be submitted in such invoices


by Provider includes, but is not necessarily limited to the


following:


a) primary and secondary diagnosis codes using ICD-9 coding;


b) procedure codes including modifiers;


c) unit of service and date of service;


d)	 place of service (e.g. inpatient hospital; outpatient


hospital, outpatient clinic, physician office, etc.); and,


e) MA identification number.


Provider must file all such invoices within sixty (60) days following


the close of the calendar quarter in which the services invoiced were


provided.


c-lo

Section 4.2 EXcJusive Pavment. Provider agrees that the


pa’yment for Covered Services specified in this Section constitutes


the entire payment for the Covered Services provided and


responsibilities assumed by Provider under this Agreement, and that


Provider shall not charge Enrollees for additional amounts for said


Covered Services. If payment for any Covered Service is denied due


to non-compliance with the MA Care Protocol or the Health Plan


Quality Assurance Protocol, Provider agrees not to bill the Health


Plan or the Enrollee for such Covered Services.


Provider shall accept as payment in full for Covered Services


rendered to Enrollees such amounts as are paid pursuant to this


Agreement. PROVIDER AGREES NOT TO BILL, CHARGE, COLLECT A DEPOSIT


FROM , SEEK REMUNERATION FROM, OR HAVE ANY RECOURSE AGAINST AN


ENROLLEE OR PERSONS ACTING ON THEIR BEHALF FOR SERVICES PROVIDED


UNDER THIS AGREEMENT. THIS PROVISION APPLIES TO BUT IS NOT LIMITED


TO THE FOLLOWING EVENTS: (1) NONPAYMENT BY THE HEALTH MAINTENANCE


ORGANIZATION OR (2) BREACH OF THIS AGREEMENT. THIS PROVISION DOES


NOT PROHIBIT THE PROVIDER FROM COLLECTING COPAYMENTS OR FEES FOR


UNCOVERED SERVICES.


THIS PROVISION SURVIVES THE TERMINATION OF THIS AGREEMENT FOR


AUTHORIZED SERVICES PROVIDED BEFORE THIS AGREEMENT “ TERMINATES,


REGARDLESS OF THE REASON FOR TERMINATION. THIS PROVISION IS FOR THE


BENEFIT OF THE HEALTH MAINTENANCE ENROLLEES. THIS PROVISION DOES NOT


APPLY TO SERVICES PROVIDED AFTER THIS AGREEMENT TERMINATES.


C-11

THIS PROVISION SUPERSEDES ANY CONTRARY OIU.L OR WRITTEN AGREEMENT


EXISTING NOW OR ENTERED INTO IN THE F’UTURE BETWEEN THE PROVIDER AND


THE ENROLLEE OR PERSONS ACTING ON THEIR BEHALF REGARDING LIABILITY


FOR PAYMENT FOR SERVICES PROVIDED UNDER THIS AGREEMENT.


SECTION v: -CASE MANAGEMENT AND UTILIZATION PROTOCOLS 

Provider agrees to cooperate and comply with all protocols 

established from time to time by the Health Plan with respect to the 

provision by Provider of Covered services to Enrollees under this 

Agreement, including, without limitation, protocols related to 

hospital admissions, length of stays, referrals, and medical Case 

management. Provider understands that failure to obtain necessary 

prior authorization from the Health Plan may result in a financial 

penalty to Provider. 

SECTION VI QUALITY REVIEW AND EVALUATION 

Section 6.1 Performance of Duties. Provider agrees to comply


with any and all quality evaluation, quality assurance, and quality


control responsibilities, including the Clinic Professional


credentialing and recredentialing process, which may be established


by the Health Plan from time to time or to which the Health Plan may 

be subject under local, state or federal law with respect to PMAP. 

Provider agrees to abide by the decisions of the MA Medical Director 

and the Health Plan during the term of this Agreement. 

All Clinic Professionals retain their right to make independent


decisions affecting individual patient care and to advocate the needs


of patients. Clinic Professionals’ primary consideration shall be


the quality of services rendered to Enrollee.


C-12

Section 6.2 Evaluatiorl. Provider shall participate as


reasonably requested in the Health Plan’s ongoing evaluation of the 

delivery of Covered Services and shall provide such information at no 

charge as may be reasonably requested to enable the Health Plan to 

impleInent the Health Plan Quality Assurance Protocol and MA Care 

Protocol. 

Section 6.3 Audit. Inspection. Provider shall make available 

during normal business hours all records pertaining to MA Enrollees 

that are relevant to this Agreement to authorized representatives of 

the State and DHHS and at such times, places, and in such manner as 

such a-uthorizedrepresentatives may reasonably request for purpose of 

audit, inspection, and examination of the quality, appropriateness~ 

and timeliness of services performed by Provider pursuant to this 

Agreement. 

SECTION VII CONSUMER COMPLAINT PROCEDURES


Section 7.1 ~do~tion of Procedure. Provider shall adopt and 

implement the Health Plants consumer complaint system and procedures 

with respect to PMAP as modified from time to time. Such procedures 

shall comply with all applicable statutes, rules and regulations. 

Section 7.2 J?ole of the Health Plan. The Health Plan shall


make available written procedures for the handling and resolving of


complaints, inquiries and opinions with respect to PMAP in a fair and


reasonable manner.


Section 7.3 Designation of Representative. Provider shall


designate a person with appropriate authority who shall be


responsible for the handling and resolving of all such complaints,


inquiries and opinions.


C-13 
Section 7.4 Coo~eratio~. Provider shall inform the Health


plan of all written complaints, inquiries and opinions filed with


Provider by Enrollees and shall cooperate and assist the Health Plan


in resolving such matters. Pursuant to the requirements of Minnesota


Statutes Chapter 256, Provider shall inform the State Ombudsman


within three (3) working days of its receipt of a formal complaint,


provide the Health Plan with copies of correspondence with the State


Ombudsman, and provide the Enrollee complaining with the name and


number of the State Ombudsman.


Section 7.5 Arbitration. My complaint which the Enrollee, 

Provider or the Health Plan determines has not been satisfactorily 

resolved shall be settled by arbitration in accordance with Minnesota 

Statutes, Chapter 572, provided that the arbitration is not required 

when an Enrollee elects to litigate his or her complaint prior to 

submission to arbitration or a medical malpractice damage claim is 

involved. 

SECTION VIII BOOKS AND RECORDS


Section 8.1 Access by Plan. The Health Plan shall have


access to Provider’s books, Enrollee patient records, records of


accounts and any other relevant documents at reasonable hours and


upon reasonable notice for examination and inspection as may be


necessary for the administration of this Agreement or to meet federal


or state requirements under PMAP.


Section 8.2 Release of Information. The Health Plan shall be


authorized publicly to release aggregate cost, utilization and other


information concerning PMAP. Specific information that identifies


C-14

Provider shall not be released without Provider’s written


authorization except as a part of reports required by the State of


Minnesota or I)HHS. The Health Plan is authorized to release


information in its possession or obtained under this Agreement


pertaining to providers or Enrollees, necessary to comply with


federal and state statutes applicable to the Health Plan.


Section 8.3 Data Privacy. Provider agrees to comply with all


the requirements of the Minnesota Government Data Practices Act in


providing services under this Agreement. In accordance with Minn.


Stat., Section 13.46, subd. 10 (1990) , Provider accepts


responsibility for providing adequate supervision and training to its


agents and employees to ensure compliance with the Act. No private


or confidential data collected, maintained, or used in the course of


performance of this Agreement shall be disseminated except as


authorized by statute, either during the period of this contract or


thereafter. Provider agrees to indemnify and save and hold the


Health Plan, its agents and employees, harmless from all claims


arising out of, resulting from, or in any manner attributable to any


violation by Provider of any provision of the Minnesota Government


Data Practices Act, including legal fees and disbursements paid or


incurred to enforce the provisions of this Agreement.


Section 8.4 &fedi.calRecords. Provider shall provide for the


development of a medical record-keeping system through which all


pertinent information relating to rnedi,calservices and management of


Enrollees provided by Provider is accumulated and readily available


to appropriate health professionals.


Section 8.5 Encounter Data. Provider must maintain


C-15

sufficient patient encounter data to identify the PhYs~Cian who


delivers services to Enrollees, as required by section


1902 (In)(2)(A) (xi) Of the Social Security Act (42 U.s.c. s


1396b(m) (2)(A) (xi)).


Section 8.6 Other Reau i.red Records% Provider agrees to


furnish information from its records to the HEALTH ~JJ~ to be 

provided to the STATE or its agents which the STATE may reasonably 

require to administer PMAP including, but not necessarily limited to, 

the information in the Provider Manual, as defined in Section 2.20 of 

this Agreement. 

Section 8.7 Becord ~ rer3aratio All

records collected, used, dissexainated and stored by the Provider 

pertaining to MA Enrollees shall be maintained in accordance with 

Minn. Stat. Ch. 13 (1990) and Minn. Stat. ~ 144.335 (1990), 

safeguarded in accordance with the requirements of 42 CFR 431 Subpart 

F and retained in accordance with the record retention requirements 

of 45 CFR Part 74. Provider agrees to maintain such records and 

prepare such reports and statistical data as may be deemed necessary 

by the Health Plan. Provider agrees to furnish or make available 

without cost all records to authorized representatives of the Health 

Plan, the State and DHHS during normal business hours and in such


form as shall redesignated. Provider agrees to maintain and make


available to the HEALTH PLAH, the STATE, and DHHS all records related


to Enrollees and required under this Agreement for a period of six


(6) years after the termination date of this Agreement. Records to


be retained include but are not limited to medical, claims, case


management, and prior-authorization records.


C-16

Upon termination of the contract, or at such time as individual


MA .Enrollees terminate enrollment, Provider shall~ ~Pon request bY


the HEALTH PLAN and at Provider’s expense provide to the HEALTH PLAN


copies of all records pertaining to medical services provided MA


Enrollee(s).


SECTION IX ADVERTISING AND PROMOTION


Section 9.1 Use of Names. Each party to this Agreement


reserves the right to, and control of the use of, its names and all


symbols, trademarks and service marks presently existing or hereafter


established with respect to it, except that Provider hereby


authorizes the Health Plan to use the names, addresses, and phone


numbers, for purposes of promotion and advertising by the Health


Plan. Such authorization is limited to listing the name of Provider,


including clinic or institution names, individual physician names,


addresses and phone numbers, in an ethical and reasonable manner for


purposes of promotion and advertising.


Section 9.2 Prohibition Acrai.nstUnauthorized Use. Except as


authorized above, each party agrees that it will not use the names,


symbols , trademarks, or service marks of any other party in


advertising or promotion or otherwise without the prior written


consent of such other party and will cease any and all use


immediately upon termi.nati.on.


Section 9.3 RamseyCare The Health Plan shall have sole


responsibility for all advertising and promotion and for solicitation


of Enrollees under the MA RamseyCare program.


C-17

SECTION X DURATION AND TERMINATION


Section 10.1 XEX3!* The term of this Agreement shall commence


on the date first above written and continue through June 30, 1994,


unless otherwise terminated as provided under this Agreement.


Section 10.2 ~erminatio~


a. This Agreement may be terminated by Provider or Plan at any 

time upon at least one hundred twenty-five (125) days prior written 

notice to the other party provided that the effective date of 

termination under this Section 10.2.a. shall not occur prior to June 

30, 1994. 

b: If Provider violates the Health Plan Quality Assurance


Protocol or the MA Care Protocol, as amended from time to time,


including the failure of the any Clinic Professional to satisfy the


credentialing or recredentialing requirements, the Health Plan may


terminate this Agreement immediately upon notice to Provider. In any


event, any Clinic Professional who does not satisfy the credentialing


or recredentialing process or laboratory testing site that does not


meet federal and state requirements will not be permitted to provide


Covered Services to Enrollees.


c. This Agreement further may be terminated at the option of 

any non-breaching party, upon a material breach of any party in 

substantial performance of any term or covenant in this Agreement, 

after thirty (30) days prior written notice of such breach is given 

to the breaching party; provided however that such termination will 

not limit or otherwise affect any rights or remedies of any nonbreaching party otherwise available at law or in equity for such 

breach. 

c-18

d. In the event that the Health Plan’s arrangement with the


State of Minnesota regarding PMAP terminates, this Agr@ement maY be


terminated by the Health Plan upon at least thirty (30) days prior


written notice to Provider.


Section 10.3 Termination of Obligations. The rights and


obligations of each party to this Agreement shall continue until


termination of this Agreement. Upon termination, the rights and


obligations of each party shall cease; provided, however, that


termination shall not relieve the Health Plan or provider of


obligations with respect to Covered Services furnished prior to


*


termination.


Section 10.4 CooDeratioq. Upon notice of termination of this 

Agreement, the Health Plan and Provider shall cooperate with each 

other in giving notice of termination to all Enrollees and Provider 

shall cooperate with the Health Plan in transferring to other ~ 

Primary Care Providers all Enrollees then under Provider’s Care. 

SECTION XI MISCELLANEOUS 

Section 11.1 Independent Parties. Each party to this 

Agreement is and shall continue to be an independent entity, and no 

party is an agent or representative of any other. 

Section 11.2 Insurance and Licensing. Provider shall provide 

<and maintain policies of malpractice insurance as shall “be ‘necessary 

to insure Provider and its employees or agents against any claim or 

claims for damages arising by reason of personal injuries or death 

incurred directly or indirectly in connection with the performance of


any service provided by Provider, and shall provide the Health Plan


with evidence that such coverage is in effect. Unless such policies


C-19

are ‘occurrence policies,U Provider will maintain such coverage for 

at L least thirty-six (36) months following te~ination of this 

Agreement. Provider and each Clinical Professional providing Covered 

Services hereunder shall maintain all federal, state, and local 

licenses, permits, and association memberships required to operate a 

medical or--dental. clinic :in the tState.-of--Mhnesota8 as applicable, 

and shall comply with all applicable state and federal statutes and 

regulations. Provider shall notify the Health Plan as soon as 

reasonably possible of any actions brought against Provider or any 

Clinic Professionals by any federal or state agency restricting, 

suspending, or terminating Provider’s authority to operate a clinic 

or the Clinic Professional/s license to practice. 

Section 11.3 J401d Harmless bv Provider. Provider shall hold


the Health Plan harmless from any claims, demands, and expenses of


any kind by reason of any act or omission caused or alleged to have


been caused by Provider, or any agent or employee thereof, or any


person or group to whom referral is made by Provider.


Section 11.4 Hold Harmless bv the Health Plan. The Health 

Plan shall hold Provider harmless from any claims, demands, and 

expenses of any kind by reason of any act “or omission caused or 

alleged to have been caused by the Health Plan, or any agent or


employee thereof, in the discharge of its responsibil~ities to an


Enrollee under this Agreement.


Section 11.5 Confidential Information. Provider shall keep


all quality assurance and utilization review information of the


Health Plan (including but not limited to all statistical data,


reports and standards), and all financial information relating to


C-20

this Agreement confidential, and shall use its best efforts to


prevent and protect such information from unauthorized disclosure by 

its agents or employees. Provider shall not use or allow its agents 

or employees to use any such information to the competitive 

disadvantage or detriment of the Health Plan. Provider shall comply 

with all applicable confidentiality laws and regulations. 

Section 11.6 Amendment and InterDretatioq. This Agreement may


be amended by mutual written agreement of the parties hereto at any


time. In addition, the Health Plan may inform Provider in writing of


reasonable interpretations, clarifications and guidelines which do


not materially alter the terms of this Agreement.


Section 11.7 No Assignment. This Agreement and the rights and


obligations of the parties hereto shall not be assigned or


transferred without the written consent of all parties hereto, except


that the Health plan may assign any or all of its rights and


responsibilities to any corporation that is a subsidiary or affiliate


of the Health Plan as allowed by federal or state law.


Section 11.8 Severability. The provisions of this Agreement


are intended to be severable. In the event any provision of this


Agreement shall be held invalid or unenforceable by any court of


competent jurisdiction, such holding shall not validate or render


unenforceable any other provision hereof.


Section 11.9 No Waiver The failure of either party to insist


upon the strict observation or performance of any provision of this


Agreement or to exercise any right or remedy shall not impair or


~’aiveany such right or remedy.


Section 11.10 P~n Aqainst Discrimination. In the


C-21

performance of obligations under this contract, Provider


comply with provisions of: the Constitution of the United


the State of Minnesota; the Civil Rights Acts of 1964;


agrees to 

States and


Executive


Order 11246, Equal Employment Opportunity, dated September 24, 1965,


42 CFR 434.25; Minn. Stat. 363.073 (1990); and any other laws,


regulations, or orders which prohibit discrimination on grounds of


race, sex, color, age, religion, health status, disability national


origin or public assistance status.


Section 11.11 Comnliance with Environmental Laws. In the


performance of obligations under this contract, Provider shall comply


with all applicable standards, orders or requirements issued under


section 306 of the Clean Air Act, 42 U.S.C. 1857 (h), Section 5.08 of


the Clean Water Act, 33 U.S.C. 1368, Executive Order 11738, and


Environmental Protection Agency regulations (40 C.F.R. Part 15) which


prohibit the use of


Facilities.


Section 11.12


facilities included on the EPA List of Violating


Conmliance with Enerm Policv and Conservation


Laws. In the performance of obligations under this contract, 

Provider agrees to comply with Public Law 94-165 and the provisions 

of the State Energy Conservation Plan.


Section 11.13 ~. Provider


shall comply with state and federal law in their perfofiance of its


obligations under this contract, including but not limited to Minn.


Stat. , section 256B.69, Minn. Rules, parts 9500.1450 to 9500.1464,


Title XIX of the Social Security Act (42 U.S.C. s 1396 et. sea.), and


the applicable provisions of 42 C.F.R. section 431.200 et. sea.


Minn. Rules, parts 9500.1450 to 9500.1464 are attached as Appendix


c-22

III and incorporated herein. If any terms of this agreement are 

determined to be inconsistent with rule or law, the applicable rule 

or law provision shall govern. 

Section 11.14 Affirmative Action. Provider certifies that it


has received a certificate of compliance from the Co)~ission@r of


Human Rights pursuant to Minn. Stat., section 363.073 (1990).


Section 11.15 Voter Registration. Provider certifies that it 

will comply with Minnesota Statutes, section 201.162 (Iggo) . 

Section 11.16 Lobbvinu Disclosure. Provider certifies that, to 

the best


(i) 

of its knowledge, understanding, and belief~ that:


No Federal appropriated funds have been paid or will be


paid in what the Provider believes to be a violation of


section 1352, title 31, U.S. Code, by or on behalf of


Provider to any person for influencing or att@mPtin9 to


influence an officer or employee of an agency, a Member of


Congress, an officer or employee of Congress, or an


employee of a Member of Congress in connection with the


awarding of any Federal contract, the making of any Federal


grant, the making of any Federal loan, the entering into of


any cooperative agreement, and the extension, continuation~


renewal, amendment, or modification of any Federal


contract, grant, loan, or cooperative agreement”.


(2)	 If any funds other than Federal appropriated funds have


been paid or will be paid to any person for influencing or


attempting to influence an officer or employee of any


agency, a Member of Congress, an officer or employee of


Congress, or an employee of a Member of Congress in


C-23

connection with any Federal contract, grant, loan, or


cooperative agreement, provider shall complete and submit


Standard Form-LLL, “Disclosure Form to Report Lobbying~m in


accordance with its instructions.


(3) Provider will require that the language of this


certification be included in the award documents for all


subawards at all tiers (including subcontracts, subgrantsl


and contracts under grants, loans, and cooperative


agreements) and will require that all subrecipients certify


and disclose accordingly.


This certification is a material representation of facts upon


which reliance was placed when this transaction was made or entered


into. Submission of this certification is a prerequisite for making


or entering this transaction imposed by section 1352, title 31, V.S.


Code. Any person who fails to file the required certification shall


be subject to a civil penalty of not less than $10,000 and not more


than $100,000 for each such failure.


Section 11.17 Mediation. If either party requests that the


Commissioner of Health order that a dispute pertaining to the terms


of renewal or maintenance of this Agreement be submitted to mediation


in accordance with Minnesota law, then the Health Plan “and Provider


agree that the party requesting the mediation will bear the cost of


the mediation.


Section 11.18 Entire Aqreement. This Agreement, including the


exhibits and any addenda attached hereto, and any separate agreement


made a part hereof, constitute the entire understanding between the


c-2d

parties hereto concerning the subject matter hereof. This Agreement 

supersedes all prior agreements and any amendments thereto concerning 

such subject matter with respect to all obligations and rights 

hereunder arising as of the effective date of this Agreement.


IN WITNESS WHEREOF, the parties hereto have caused this 

Agreement to be executed on the day and year first written above. 

See Sianature and Declaration Paue


C-25

Exhibit A 

. Fee for Service pavme nt forServices 

I. General Terms for Payment 

1.	 MA Provider shall submit directly to NWNL Health Network, 

on forms approved by the Plan, all statements for Covered 

Sendces rendered by MA Provider to Enrollees, and shall 

contain complete statistical and descriptive medical and 

patient data. 

2.	 For all Covered Services eligible for payment, NWNL Health 

Network shall pay GAMC Provider an amount equal to the 

lesser of 

~ne hundred fifteen Dercen~ (l 150/0~of the Maximum

;ee for Health Services, as set forth in the NWNL Health 

Network RamseyCare MA Fee Schedule, or 

b. GAMC Provider billed charges. 

3.	 The NWNL Health Network RamseyCare MA Fee Schedule will 

be based on the State of Minnesota’s Medical Assistance Rates, 

as maybe modified horn time to time by NWNL Health Network. 

Changes to the NWNL Health Network RamseyCare MA Fee 

Schedule will be communicated in writing to the MA Provider 

thirty (30) days prior to the effective date of such changes. 

C-26

SERVICE DELIVERY REQUIREMENTS


The Provider shall provide to Enrollees all Covered Services set


forth in section 3.o1 of the contract, and as clarified in this


appendix.


A. Service Requirements


1. prenatal Care Services


As a means of reducing the number of low birth weight and 

preterm births occurring in the population eligible for MA, 

the Minnesota Department of Human Services (“DHSHI has 

instituted a special prenatal care initiative. This prenatal 

care initiative is designed to identify women who are at risk 

of having a low birth weight/preterm baby, assure increased 

access to prenatal care and provide additional services 

tailored to the special prenatal care needs of high risk 

pregnant women. Consistent with the fee-for-service


requirements, Provider must perform the following tasks:


a.	 All pregnant women must be screened during their initial


prenatal care office visit to determine their risk of


poor pregnancy outcome. A referral to the Women,


Infants, Children Supplemental Food and Nutrition


Program (WIC) should be made at this time.


b.	 The DHS Prenatal Risk Assessment Form DHS-3060, or an


alternative form approved by DHS, must be completed at


this initial visit and forwarded to DHS within thirty 

(30) days of the assessment, unless directed other~’ise 

by the Health Plan, and maintained in Provider’s medical 

records for the Enrollee. 

c. Those women who are identified at high risk (a score of 

10 or more points on the DHS Risk Assessment Form) must


be offered enhanced perinatal services. Enhanced


perinatal services include: high risk antepartum


management, prenatal health education, prenatal


nutrition education, childbirth education, and a high


risk follow-up home visit.


2.	 Earlv and Periodic Screenin~, Diaanosis and Treatment (EPSDTL 

Services/Child and Teen Checkups 

EPSDT is a comprehensive screening program provided to a 

recipient under the age of 21 to identify a potentially 

handicapping condition and to provide for diagnosis and 

treatment of specific medical conditions. The intent of the 

EPSDT Program is to provide the standards by which children 

receive preventive health care and early interventive 

C-27

services. DHS recommends that the provision of EPS

services become a regular part of ongoing well child car

physical exams. The following EPSDT services are currentl

covered by MA when performed in accordance with EPSDT progra

standards:


Q Health history 

� Assessment of physical growth 

� Physical examination 

� Oral examination 

� Vision evaluation 

. Hearing evaluation 

� Developmental screening 

. Sexual development 

. Nutritional assessment 

� Immunizations 

. Laboratory tests 

. Health education 

The obligations of the Provider with regard to EPSDT services a 

described below. 

a.	 The Provider must notify Enrollees under the age of 21 of t

availability of EPSDT services.


b.	 The Provider must provide all of the required scre~~n

components according to the EPSDT standards and perlod~cl

schedule as directed by the Health Plan. The Provider m

offer additional preventive services beyond these minim

standards.


c.	 The Provider must record the results of the EPSDT heal

screening on the EPSDT Child Screening Form (DHS-1973) a

forward the top copy of the form to DHS within thirty (

days of the assessment.


3. Mental Health and Chemical De~endencv (MH/CD) Services


The Provider i.sresponsible for referring MH/CD services as need

by Enrollees to MA Participating Providers who are MH/CD provide

as determined by the Health Plan.


4. Servinq Minority and S~ecial Needs Populations “


The Provider must provide or arrange to provide appropri

services for the following special needs groups when required


requested. If the Provider already provides specialized servi

to the following populations as described in this section, th

the Provider agrees to make these services available to Enroll


served pursuant to this Agreement. If the Provider does n

provide such specialized services, the Provider will ma

arrangements with the Health plan to assure that appropri

services are delivered.


c-2a

a. 

b.


c.


d.


e.


f.


9“


h.


i.


j. 

Seriouslv and Persistently Mentallv ill fSPMI)L ong

medications review and monitoring day treatment and o

‘milieu” alternatives to conventional therapy,


coordination with the individual~s case manager to as

appropriate utilization of all needed psychosocial servic

Elderlv. ~hvsicallv handicam ed and chronically ill: in


services, neurological assessments.


Abused children and adults, abusive individu

comprehensive assessment and diagnostic services


specialized treatment techniques for victims and perpetra

of maltreatment (physical, sexual, emotional).


Southeast Asians and other ~rou?m with langua~e barri

interpreter services, bilingual staff, culturally appropr

assessment and treatment. Whenever an individual reques


interpreter in order to obtain health care services,

individual must be provided with access to an interprete

Cultural and racial minorities: culturally approp

services rendered by Clinic Professionals with sp

expertise in the delivery of health care services to

various cultural and racial minority groups.


Dual M’H/WVelODEIent?!llV Disabled (DD1. or /CD clie 

comprehensive assessment, diagnostic and treatment serv 

provided by staff who are trained to work with clients


multiple disabilities and complex needs.


Lesbians and aav men: sensitivity to critical social

family issues unique to these clients.


Hearinq im~aired: access to TDD and hearing imp 

interpreter services. 

~ eed o end snecific c treatm 

Enrollees must be provided with an opportunity to re 

MH/CD services from the same sex therapist and the optio 

participating in an all male/all female group th 

program. 

Children and adolescents. i.ncludinu severelv and emotion

disturbed (SED) children and children involved in the


protection svstem: services specific to the needs of


groups, including day treatment, home-based mental h

services, and inpatient services. The services which

Provider delivers must be provided in the least restri


clinical setting, individualized to meet the specific


of each child, and designed to insure early identific

and treatment of mental illness. Services mus

coordinated with the child’s county case manager.


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� k. Pevelornn entallv Dlsabled (DD] ti specialized mental health and 

habilitative services and other appropriate services covered 

by MA. Such services may include: family planning services 

adapted to the special needs of the developmentally disabled


population, behavior management, rehabilitative and


therapeutic services, pain management, or genetic counseling.


After an initial assessment, a written treatment plan must be


developed for the Enrollee when appropriate. As required,


the treatment plans should provide access to a coordinated


outpatient rehabilitation team, independent living skills


training, ongoing medical skill rechecks, and services


designed to maintain or increase function and prevent.further


deterioration or dependency. The treatment plan should be


coordinated with available community resources and support


systems, including the individual’s county DD case manager.


The treatment plan must identify the persons responsible for


providing services and a case manager. For those Enrollees


with multiple handicaps, a multidisciplinary provider


consultation should be arranged. Although continuity of care


should be a major consideration in the treatment planning


process, referrals to specialists and subspecialists must be


made when medically indicated.


B. ~
Enrollee


The Provider must insure proper MA Enrollee access to services and must


comply with all of the requirements listed below:


1.	 Provider must agree to accept all eligible MA Enrollees who


select or who are assigned to the Health Plan without regard


to current or previous medical condition.


2.	 Provider agrees to not set any enrollment limits on the 

number of MA recipients which it will serve unless other 

arrangements are made with the Health Plan. 

3.	 MA Enrollees in the Health Plan may not be charged any


deductible costs or be asked to make any copayments for


covered services under PMAP.


4.	 Provider may not discriminate against any MA Enrollee on the


basis of: race, sex, color, religion, health ,status, a9e,


handicap, national origin, public assistance status, or


sexual orientation.


5.	 Provider must insure that its services are accessible to


handicapped MA Enrollees. A barrier-free service delivery


access point must be available for Enrollees who use


wheelchairs.


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6.� Provider services must be available to MA Enrollees to the 

same extent that such services are available to the general 

population. Some walk-in or unscheduled clinic hours must be 

available each week to accommodate MA Enrollees who are ill. 

7.� The Provider must have available a 24 hour/day number for


Enrollees to call in case of an emergency.


a.	 Upon request, Provider must arrange with the Health Plan for


any Enrollee to obtain a second medical opinion by a MA


Participating Provider, and an out of plan second medical 

opinion for MH/CD services, when the Provider determines 

through the initial assessment process that no structured


treatment is required.


9. Provider must insure Enrollee confidentiality, as required by


Minnesota	 Statutes Chapter 13 (1986), the Minnesota


Government Data Practices Act.


10. Provider must safeguard the confidentiality of certain


services (i.e. family planning, diagnosis of pregnancy,


diagnosis and treatment of sexually transmittable diseases,


and MH/CD services) provided to Enrollees who are minors


(under-age 21), to the-extent allowable by law.


c. Case Management


Providerts case management system must be designed to coordinate the


provision of services- to Enrollees and must promote and assure service 

accessibility, attention to individual needs, continuity of care, 

comprehensive -and coordinated service delivery, the provision of 

culturally appropriate care and fiscal and professional accountability. 

At a minimum, the. Providerts case management system must incorporate 

the following elements: 

a.	 Procedures for the provision of an individual needs


assessment, the development of an individual treatment plan,


the establishment of treatment objectives, the monitoring of


outcomes, and a process to insure that treatment plans are


revised as necessary. These procedures must be designed to


accommodate the specific cultural and linguistic needs of the


Enrollees.


b.	 A strategy to ensure that all Enrollees and/or authorized


family members or guardians are involved in treatment


planning and consent to the medical treatment.


c.	 A method for coordinating the medical needs of an Enrollee 

with his/her social service needs. This may involve working 

with county social service staff or with the various 

community resources in the county. Coordination with the 

county social service staff will be required when the 

Enrollee is in need of the following services: case 

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. -. 

d.


e. 

f.


management for serious and persistent mental illness or


seriously emotionally disturbed children, prepetition


screening, preadmission screening or elderly waiver servicesl 

extended care or halfway house services through the 

Consolidated Chemical Dependency Treatment Fund, child 

protection, court ordered treatment, or a state medical


review team or social security disability determination.


Procedures and criteria for making referrals to specialists


and subspecialists.


Capacity to implement; when indicated, case management


functions such as: individual needs assessment, including


screening for special needs (e.g. mental health/chemical


dependency problems, mental reta~dation~ high risk health 

problems, difficulty living independently, functional 

problems, language or comprehension barriers); individual 

treatment plan development; establishment of treatment 

objectives; treatment follow-up; monitoring of outcones; 

revision of treatment plan. 

Procedures for insuring that appropriate Clinic Professionals


interact with the school districts and participate in


developing individualized education plans (IEPs) or


individualized family service plans (IFSP) for school age


Enrollees, and providing for transportation, if services in


the IEP or IFSP are provided outside of the child’s school.


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