exhibit10-7.htm


    
      

    

    
      
        Back
          to Form 10-Q

      

      
        Exhibit
          10.7

      

      
        


      

      
        STATE
          OF CONNECTICUT

      

      
        DEPARTMENT
          OF SOCIAL SERVICES

      

      
        


      

      
        	
                Amendment
                  Number:

              	
                1

              
	
                Contract
                  #:

              	
                093-HUS-WCC-2

              
	
                Contract
                  Period:

              	
                07/01/2005
                  - 06/30/2007

              
	
                Contractor
                  Name:

              	
                WELLCARE
                  OF CONNECTICUT, INC.

              
	
                Contractor
                  Address:

              	
                127
                  Washington Avenue, North Haven, CT
                  06473

              


      

      
        


      

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


      

      
         

        
          	
                  1.

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

                


        

      

      
         

        
          	
                  2.

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

                


        

      

      
        


         

        A. HUSKY
          B Covered Services

      

      
        B. DELETED

      

      
        C. HUSKY
          Plus

      

      
        D. Provider
          Credentialing and Enrollment Requirements

      

      
        E.  American
          Academy of Pediatrics - Recommendations for Preventative Pediatric Health
          Care

      

      
        F.  DSS
          Marketing Guidelines

      

      
        G. 
          Standards for Internal Quality Assurance Programs for Health
          Plans

      

      
        H. 
          Claims Inventory, Aging and Unaudited Quarterly Financial
          Reports

      

      
        I.   Capitation
          Payment Amount

      

      
        J.   Inpatient/Eligibility
          Recategorization Chart

      

      
        K. Abortion
          Reporting

      

      
        L.
           BLANK - RESERVED FOR POSSIBLE FUTURE USE

      

      
        M.BLANK
          -
          RESERVED FOR POSSIBLE FUTURE USE

      

      
        
          N.  HUSKY
            Behavioral Health Carve-Out Coverage and Coordination of Medical and
            Behavioral
            Services

        

        O.  CTBHP
          Master Covered Services Table


      

      
         

        
          	
                  3.

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

                


        

      

      
        


         

        Page
          1 of
          2

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      
        
          	
                  4.

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

                


        

      

      
         

        
          	
                  5.

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

                


        

      

      
        


         

        ACCEPTANCES
          AND APPROVALS

         

      

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

      

      
        


      

      
        	
                WELLCARE
                  of CONNECTICUT, Inc.

                 

              	
                Department
                  of Social Services

              
	
                /s/  Todd
                  Farha

              	
                5/30/2007

              	
                /s/  Michael
                  P. Starkowski

              	
                5/31/2007

              
	
                Signature
                  (Authorized Official)

              	
                Date

              	
                Signature
                  (Authorized Official)

              	
                Date

                 

              
	
                Todd
                  Farha

              	
                President
                  & CEO

              	
                Michael
                  P. Starkowski

              	
                Commissioner

              
	
                Typed
                  Name (Authorized Official)

              	
                Title

              	
                Typed
                  Name (Authorized Official)

              	
                Title

              


      

      
        


      

      
        


      

      
        Attorney
          General (as to
          form)                                                                                                                        Date

      

      
        


         

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

      

      
         

      

      
         

        Page
          2 of
          2

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      
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          HUSKY B Final

      

      
        


      

      
        


      

      
        PART
          I:   STANDARD CONNECTICUT
          CONTRACT TERMS

      

      
        PART  II: GENERAL
          CONTRACT TERMS FOR MCOS


      

      
         

        1.      DEFINITIONS

         

      

      
        2.      DELEGATIONS
          OF AUTHORITY

      

      
         

        3.      FUNCTIONS
          AND DUTIES OF THE MCO


      

      
        3.01  Provision
          of Services

      

      
        3.02  Non-Discrimination

      

      
        3.03  Gag
          Rules/Integrity of Professional Advice to Members

      

      
        3.04  Coordination
          and Continuation of Care

      

      
        3.05  Emergency
          Services

      

      
        3.06  Geographic
          Coverage

      

      
        3.07  Choice
          of Health Professional

      

      
        3.08  Provider
          Network

      

      
        3.09  Network
          Adequacy and Maximum Enrollment Levels

      

      
        3.10  Provider
          Contracts

      

      
        3.11  Provider
          Credentialing and Enrollment

      

      
        3.12  Specialist
          Providers and the Referral Process

      

      
        3.13  PCP
          and Specialist Selection, Scheduling and Capacity

      

      
        3.14  Family
          Planning Access and Confidentiality

      

      
        3.15  Pharmacy
          Access

      

      
        3.16  Mental
          Health and Substance Abuse Access

      

      
        3.17  Children's
          Issues and Preventive Care and Services

      

      
        3.18  Well-Care
          Services for Adolescents

      

      
        3.19  HUSKY
          Plus Physical

      

      
        3.20  Prenatal
          Care

      

      
        3.21  Dental
          Care

      

      
        3.22  Pre-Existing
          Conditions

      

      
        3.23  Prior
          Authorization

      

      
        3.24  Newborn
          Enrollment and Minimum Hospital Stays

      

      
        3.25  Acute
          Care Hospitalization at Time of Enrollment or Disenrollment

      

      
        3.26  Open
          Enrollment

      

      
        3.27  Special
          Disenrollment

      

      
        3.28  Linguistic
          Access

      

      
        3.29  Services
          to Members

      

      
        3.30  Information
          to Potential Members

      

      
        3.31  DSS
          Marketing Guidelines

      

      
        3.32  Health
          Education

      

      
        3.33  Quality
          Assessment and Performance Improvement

      

      
        3.34  Inspection
          of Facilities

      

      
        3.35  Examination
          of Records

      

      
        3.36  Medical
          Records

      

      
        3.37  Audit
          Liabilities

      

      
        3.38  Clinical
          Data Reporting

      

      
        


         

        10

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      
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          HUSKY B Final


      

      
         

        3.39   Utilization
          Management

      

      
        3.40   Financial
          Records

      

      
        3.41   Insurance

      

      
        3.42   Subcontracting
          for Services

      

      
        3.43   Timely
          Payment of Claims

      

      
        3.44   Insolvency
          Protection

      

      
        3.45   Fraud
          and Abuse


      

      
         

        4.  MCO
          Responsibility Concerning Payments Made On Behalf Of The
          Member

      

      
         

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

      

      
        4.2     Payments
          for Noncovered Services

      

      
        4.3     Cost-Sharing
          Exemption for American Indian/Native American Children

      

      
        4.4     Copayments

      

      
        4.5     Copayments
          Prohibited

      

      
        4.6     Maximum
          Annual Limits for Copayments

      

      
        4.7     Tracking
          Copayments

      

      
        4.8     Amount
          of Premium Paid

      

      
        4.9     Billing
          and Collecting the Premium Payments

      

      
        4.10   Notification
          of Premium Payments Due

      

      
        4.11   Notification
          of Non-payment of the Premium Payments

      

      
        4.12   Past
          Due Premium Payments Paid

      

      
        4.13   Resumption
          of Services if the Child is Re-enrolled

      

      
        4.14   Overpayment
          of Premium

      

      
        4.15   Member
          Premium Share Paid by Another Entity

      

      
        4.16   Tracking
          Premium Payments

      

      
        4.17   Behavioral
          Health Payment Adjustment


      

      
         

        5.
          LIMITED COVERAGE OF SOME GOODS AND SERVICES AND
          ALLOWANCES

      

      
        5.01    Limited
          Coverage of Some Goods and Services


      

      
         

        6.      FUNCTIONS
          AND DUTIES OF THE DEPARTMENT

      

      
        6.1    Eligibility
          Determinations

      

      
        6.2    Ineligibility
          Determinations

      

      
        6.3    Enrollment
          / Disenrollment

      

      
        6.4    Lock-In
          / Open Enrollment

      

      
        6.5    Capitation
          Payments to the MCO

      

      
        6.6    Newborn
          Retroactive Adjustments

      

      
        6.7    Information

      

      
         

        7.      DECLARATIONS
          AND MISCELLANEOUS PROVISIONS

      

      
        7.01  Competition
          not Restricted

      

      
        7.02  Nonsegregated
          Facilities

      

      
        


         

        11

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      
        05
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          HUSKY B Final

      

      
        


        7.03   Offer
          of Gratuities

      

      
        7.04   Employment/Affirmative
          Action Clause

      

      
        7.05   Confidentiality

      

      
        7.06   Independent
          Capacity

      

      
        7.07   Liaison

      

      
        7.08   Freedom
          of Information

      

      
        7.09   Waivers

      

      
        7.10   Force
          Majeure

      

      
        7.11   Financial
          Responsibilities of the MCO

      

      
        7.12   Captilization
          and Reserves

      

      
        7.13   Members
          Held Harmless

      

      
        7.14   Compliance
          with Applicable Laws, Rules and Policies

      

      
        7.15   Federal
          Requirements and Assurances

      

      
        7.16   Civil
          Rights

      

      
        7.17   Statutory
          Requirements

      

      
        7.18   Disclosure
          of Interlocking Relationships

      

      
        7.19   DEPARTMENT'S
          Data Files

      

      
        7.20   Hold
          Harmless

      

      
        7.21   Executive
          Order Number 16


      

      
         

        8.      MCO
          RESPONSIBILITIES CONCERNING INTERNAL AND
          EXTERNAL APPEALS

      

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

      

      
        8.2    Internal
          Appeal Process Required

      

      
        8.3    Denial
          Notice

      

      
        8.4    Internal
          Appeal Process

      

      
        8.5    Written
          Appeal Decision

      

      
        8.6    Expedited
          Review

      

      
        8.7    External
          Appeal Process through the DOI

      

      
        8.8    Provider
          Appeal Process


      

      
         

        9.      CORRECTION
          ACTION AND CONTRACT TERMINATION

      

      
        9.1     Performance
          Review

      

      
        9.2     Settlement
          of Disputes

      

      
        9.3     Administrative
          Errors

      

      
        9.4     Suspension
          of New Enrollment

      

      
        9.5     Sanctions

      

      
        9.6     Payment
          Withhold, Class C Sanctions

      

      
        9.7     Emergency
          Services Denials

      

      
        9.8     Termination
          for Default

      

      
        9.9     Termination
          for Mutual Convenience

      

      
        9.10   Termination
          for Financial Instability of the MCO

      

      
        9.11   Termination
          for Unavailability of Funds

      

      
        9.12   Termination
          for Collusion in Price Determination

      

      
        9.13    Termination
          Obligations of Contracting Parties

      

      
        
          9.14    Waiver
            of Default



         

        12

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      
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          HUSKY B Final

      

      
        


        10.     OTHER
          PROVISIONS

      

      
        10.1    Severability

      

      
        10.2    Effective
          Date

      

      
        10.3    Order
          of Precedence

      

      
        10.4    Correction
          of Deficiencies

      

      
        10.5    This
          is not a Public Works Contract


      

      
         

        11.        APPENDICES

      

      
        
          	
                  
                    Appendix
                      A  HUSKY B Covered Services

                  

                	
                   

                


        

      

      
        
          	
                  
                    Appendix
                      B   HUSKY Plus-Behavioral Deleted

                  

                	
                   

                


        

      

      
        
          	
                  
                    Appendix
                      C  HUSKY Plus

                  

                	
                   

                


        

      

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

                  

                	
                   

                


        

      

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

                  

                	
                   

                


        

      

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

                  

                	
                   

                


        

      

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

                  

                	
                   

                


        

      

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

                  

                	
                   

                


        

      

      
        
          	
                  
                    Appendix
                      I  Capitation Payment Amount

                  

                	
                   

                


        

      

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

                  

                	
                   

                


        

      

      
        
          	
                  
                    Appendix
                      K Abortion Reporting.

                  

                	
                   

                


        

      

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

                  

                	
                   

                


        

      

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

                  

                	
                   

                


        

      

      
        


        12.        SIGNATURES

      

      
        


        
 

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      
        
          
            05
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              HUSKY B Final

          

          
            


            PART
              II:
              GENERAL CONTRACT TERMS  FOR MCOs

          

          
            


            1.        DEFINITIONS

          

          
            


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

          

          
            


            Abuse:

          

          
            


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

          

          
            


            Administrative
              Services Organization (ASO):

          

          
            


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

          

          
            


            Allowance:

          

          
            


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

          

          
            


            American
              Indian/Alaska Native (Al):

          

          
             

          

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

                       

                    


              	
                      2)

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

                    


            

          

          
            


            
              	
                      3)

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

                    


            

          

          
            


            Applicant:

          

          
            


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

          

          
            


            
              	
                      1)

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

                    


            

          

          
            


            
              	
                      2)

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

                    


            

          

          
            


            
              	
                      3)

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

                    


            

          

          
            


            
              	
                      4)

                    	
                      A
                        child who is emancipated in accordance with the provisions
                        of
                        Sections 46b-150 to 46b-150e, inclusive, of the Connecticut General
                        Statutes, who is applying on his or her own behalf or on
                        behalf of a minor
                        dependent with whom he or she lives.

                       

                      A
                        child is an applicant until the child receives coverage under
                        HUSKY
                        B.

                    


            

          

          
            


            14

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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              HUSKY B Final

          

          
             

            Behavioral
              Health Partnership ("Partnership" or "BHP"):

          

          
            


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

          

          
            


            Behavioral
              Health Services:

          

          
            


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

          

          
            


            Capitation
              Rate:

          

          
            


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

          

          
            


            Capitation
              Payment:

          

          
            


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

          

          
            


            Child:

          

          
            


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

          

          
            


            Child
              Health Assistance:

          

          
            


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

          

          
            


            Child
              Preventive Care:

          

          
            


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

          

          
            


            Children
              with Special Health Care Needs:

          

          
            


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

          

          
            


            Clean
              Claim:

          

          
            


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

          

          
            


            15

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
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              HUSKY B Final

          

          
            


            CMS:

          

          
            


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

          

          
            


            Coinsurance:

          

          
            


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

          

          
            


            Commissioner:

          

          
            


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

          

          
            


            Complaint:

          

          
            


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

          

          
            


            Consultant:

          

          
            


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

          

          
            


            Contract
              Administrator:

          

          
            


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

          

          
            


            Contract
              Services:

          

          
            


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

          

          
            


            Co-payment:

          

          
            


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

          

          
            


            Cost-sharing:

          

          
            


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

          

          
            


            CPT
              Codes or Current Procedure Terminology:

          

          
            


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

          

          
            


            Date
              of Application:

          

          
            


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

          

          
            


            16

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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              HUSKY B Final

          

          
            


            Day:

          

          
            


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

          

          
            


            Deductible:

          

          
            


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

          

          
            


            DEPARTMENT:

          

          
            


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

          

          
            


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

          

          
            


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

          

          
            


            Durable
              Medical Equipment (DME):

          

          
            Equipment
              furnished by a supplier or a home health agency that:

          

          
            1)    Can
              withstand repeated use;

          

          
            2)    Is
              primarily and customarily used to serve a medical purpose;

          

          
            
              3)   
                Generally is not useful to an individual in the absence of an illness
                or injury; and

            

          

          
            4)    Is
              appropriate for use in the home.

          

          
            


            Emergency
              or Emergency Medical Condition:

          

          
            


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

          

          
            


            Emergency
              Services:

          

          
            


            Covered
              inpatient and outpatient services that are:

          

          
            1)      Furnished
              by a qualified provider and

          

          
            2)      Needed
              to evaluate or stabilize an emergency medical condition.

          

          
            


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

          

          
            


            External
              Quality Review Organization (EQRO):

          

          
            


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

          

          
            


          

          
            


            17

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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              HUSKY B Final

          

          
            
               

              Family:



            For
              the
              purposes of this contract, the family is defined as the household that
              includes
              the child and the following individuals who live with the
              child:

          

          
            
              1) 
                All
                of the child's siblings who are under nineteen (19) years of age, including
                full and half, and siblings who are HUSKY A
                Members;

            

          

          
            2)  Natural
              and adoptive parents of the child;

            3)  The
              spouse of the child; and

          

          
            
              4) 
                Stepparent
                and stepsiblings of the child, except when the inclusion of the stepparent
                and stepsiblings in the filing unit make the child ineligible for HUSKY
                B.

               

            

            Federal
              Poverty Level (FPL):

          

          
            


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

          

          
            


            Formulary:

          

          
            
 

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

          

          
            


            FQHC-Sponsored
              MCO:

          

          
            


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

          

          
            


            Fraud:

          

          
            


            
              	
                       

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

                    


            

          

          
            


            Free-look
              Period:

          

          
            


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

          

          
            


            Global
              Plan of Care:

          

          
            


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

          

          
            


            Health
              Plan Employer Data and Information Set (HEDIS):

          

          
            


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

          

          
            


            18

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
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HHS:

          

          
            


            The
              United States Department of Health and Human Services.

          

          
            


            HUSKY,
              Part A, or HUSKY A:

          

          
            


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

          

          
            


            HUSKY
              Plan, Part B or HUSKY B:

          

          
            


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

          

          
            


            HUSKY
              Plus Physical Programs:

          

          
            


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

          

          
            


            ICD9-CM:

          

          
            


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

          

          
            


            Immigrant:

          

          
            


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

          

          
            


            Income:

          

          
            


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

          

          
            


            Income
              Band 1:

          

          
            


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

          

          
            


            Income
              Band 2:

          

          
            


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

          

          
            
 

            federal
              poverty level.

          

          
            


            Income
              Band 3:

          

          
            


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

          

          
            


            In-network
              providers or network providers:

          

          
            


            19

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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              HUSKY B Final

          

          
            


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

          

          
            


            Institution:

          

          
            


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

          

          
            


            Limited
              Benefits:

          

          
            


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

          

          
            


            Lock-in:

          

          
            


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

          

          
            


            Lock-out:

          

          
            


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

          

          
            


            Managed
              Care Organization (MCO):

          

          
            


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

          

          
            


            Marketing:

          

          
            


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

          

          
            


            Maximum
              Annual Aggregate Cost-sharing:

          

          
            


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

          

          
            


            Medicaid:

          

          
            


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

          

          
            


            Medical
              Appropriateness or Medically Appropriate:

          

          
            


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

          

          
            


            Medically
              Necessary or Medical Necessity:

          

          
            


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

          

          
            


            20

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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              HUSKY B Final

          

          
            


            Member:

          

          
            


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

          

          
            


            National
              Committee on Quality Assurance (NCQA):

          

          
            


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

          

          
            


            Non-citizen:

          

          
            


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

          

          
            


            Open
              Enrollment Period:

          

          
            


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

          

          
            


            Out-of-network Provider:

          

          
            


            A
              provider that has not contracted with the MCO.

          

          
            


            Passive
              Billing:

          

          
            


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

          

          
            


            Post-Stabilization
              Services:

          

          
            


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

          

          
            


            Premium:

          

          
            


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

          

          
            


            Preventive
              Care and Services:

          

          
            


            
              	
                      1)

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

                    


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


              	
                      3)

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

                    


              	4) 	WIC
                      evaluations as applicable


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

                    


              	6)	 Preventive
                      dental care for children; and


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

                    


            

          

          
             

          

          
            21

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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              HUSKY B Final

          

          
             

          

          
            Primary
              and Preventive Health Care Services:

          

          
            


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

          

          
            


            Primary
              Care Provider (PCP):

          

          
            


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

          

          
            


            Prior
              Authorization:

          

          
            


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

          

          
            


            Redetermination:

          

          
            


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

          

          
            


            Risk:

          

          
            


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

          

          
            


            Routine
              Cases:

          

          
            


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

          

          
            


            State
              Children's Health Insurance Program (SCHIP):

          

          
            


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

          

          
            


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

          

          
            


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

          

          
            


            Subcontract:

          

          
            


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

          

          
            


            Subcontractor:

          

          
            


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

          

          
            


            22

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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              HUSKY B Final

          

          
            


            Title
              V:

          

          
            


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

          

          
            


            Title
              XXI:

          

          
            


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

          

          
            


            Urgent
              Cases:

          

          
            


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

          

          
            


            Vendor:

          

          
            


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

          

          
            


            Well-Care
              Visits:

          

          
            


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

          

          
            


            WIC:

          

          
            


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

          

          
            


            23

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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            2.            DELEGATIONS
              OF AUTHORITY

          

          
            


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

          

          
            


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

          

          
            


            3.01           Provision
              of Services

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            24

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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            separate
              financial arrangement with the MCO, which may include reimbursement
              to the MCO
              directly. The DEPARTMENT may opt to reimburse the MCO directly based
              on claims
              paid by the MCO. The rate of reimbursement will be negotiated between
              the
              DEPARTMENT and the MCO. If SCHIP covered services were changed to exclude
              services, the DEPARTMENT may determine that such services will no longer
              be
              covered under HUSKY B and the DEPARTMENT will propose a contract amendment
              to
              reduce the capitation rate accordingly.

          

          
            


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

          

          
            


            3.02           Non-Discrimination

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


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

          

          
            


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

          

          
            


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

          

          
            


            25

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            0501
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              HUSKY B Final

          

          
            


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

          

          
            


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

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            3.03        Gag
              Rules/Integrity of Professional Advice to Members

          

          
            


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

          

          
            


            3.04         Coordination
              and Continuation of Care

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            26

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
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                      4.

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

                    


            

          

          
            


            
              	
                      5.

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

                    


            

          

          
            


            
              	
                      6.

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

                    


            

          

          
            


            
              	
                      7.

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

                    


            

          

          
            


            
              	
                      8.

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

                    


            

          

          
            


            3.05        Emergency
              Services

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


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

          

          
            


            27

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
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                      e.

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

                    


            

          

          
            


            
              	
                      f.

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

                    


            

          

          
            


            
              	
                      g.

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

                    


            

          

          
            


            
              	
                      h.

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

                    


            

          

          
            


            
              	
                      i.

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

                    


            

          

          
            


            
              	
                      j.

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

                    


            

          

          
            


            
              	
                      k.

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

                    


            

          

          
            


            
              	
                      I.

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

                    


            

          

          
            


            
              	
                      m.

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

                    


            

          

          
            


            
              	
                      n.

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

                    


            

          

          
            


            28

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


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

          

          
            


            
              	
                      o.

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

                    


            

          

          
            


            
              	
                      p.

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

                    


            

          

          
            


            
              	
                      q.

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

                    


            

          

          
            


            
              	
                      r.

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

                    


            

          

          
            


            3.06   Geographic
              Coverage

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


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

          

          
            


            29

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
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            3.07            Choice
              of Health Professional

          

          
            


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

          

          
            


            3.08            Provider
              Network

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            3.09            Network
              Adequacy and Maximum Enrollment Levels

          

          
            


            Primary
              Care Providers and Dentists

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


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                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            Specialists

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


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                      a)

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

                    


            

          

          
            


            
              	
                      b)

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

                    


            

          

          
            


            
              	
                      c)

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

                    


            

          

           

          
            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

           

          
            
              	
                      a)

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

                    


            

          

          
            


            
              	
                      b)

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

                    


            

          

          
            


            
              	
                      c)

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

                    


            

          

           

          
            
              	
                      1)

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

                       

                    


              	2) 	The
                      severity of the Member's condition;


            

          

          
             

          

          
            
              	
                      3)

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

                    


            

          

          
            


            
              	
                      4)

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

                    


            

          

          
            


            
              	
                      5)

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

                    


            

          

          
            


            32

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


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

                    


            

          

          
            


            Sanctions:

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

           

          
            
              	
                      a)

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

                    


            

          

          
            


            
              	
                      b)

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

                    


            

          

           

          
            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            3.10    Provider
              Contracts

          

          
            


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

          

          
            


            33

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
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                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

                    	
                      Providers
                        must provide evidence of and maintain adequate
                        malpractice insurance.

                       

                      For
                        physicians, the minimum malpractice coverage requirements
                        are $1 million
                        per individual episode and $3 million in the
                        aggregate;

                    


            

          

          
             

          

          
            
              	
                      d.

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

                       

                    


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


            

          

          
             

          

          
            
              	
                      f.

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

                    


            

          

          
            


            
              	
                      g.

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

                    


            

          

          
            


            
              	
                      h.

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

                    


            

          

          
            


            3.11           Provider
              Credentialing and Enrollment

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
             

          

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


              	
                      2.

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

                    


            

          

          
            
              	
                      3.

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

                    


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


              	5.	Board
                      certification or eligibility, as
                      appropriate;


            

          

           

          
            34

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
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            6.           A
              current statement from the provider addressing:     


          

          
            
              	 	 


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


              	b)	Physical
                      and mental health status;


              	
                      c)

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

                    


              	d)	Revocation
                      and suspension of hospital privileges; and


              	e)	A
                      history of malpractice claims.


            

          

          
             

          

          
            
              	
                      7.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


              	
                       

                      4.

                    	
                       

                      Continuing
                        medical education credits;

                       

                    


              	5.	A
                      valid DEA certification; and


            

          

          
             

          

          
            
              	
                      6.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


            
              	
                      f.

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

                    


            

          

          
            


            35

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


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

          

          
            


            
              	
                      g.

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

                    


            

          

          
            


            3.12            Specialist
              Providers and the Referral Process

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            3.13            PCP
              and Specialist Selection, Scheduling and Capacity

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            36

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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                      5.

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

                       

                    


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


            

          

          
             

          

          
            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


            
              	
                      f.

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

                    


            

          

          
            


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

          

          
            


            3.14    Family
              Planning Access and Confidentiality

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            37

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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                      d.

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

                    


            

          

          
            


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

          

          
            


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

          

          
            


            3.15           Pharmacy
              Access

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

                    	
                      Have
                        established protocols to respond to urgent requests
                        for medications;

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            
              	
                      5.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            38

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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            MCO
              may
              have a drug management program that includes a prescription drug formulary.
              If
              the MCO has a drug formulary, the MCO shall have a prior authorization
              process
              to permit access at a minimum to all medically necessary and appropriate
              drugs
              covered for the Medicaid fee-for-service population. The MCO drug formulary
              must
              include only Food and Drug Administration approved drug products and
              be
              sufficiently broad enough in scope to meet the needs of the MCO's Members.
              The
              MCO drug formulary shall consist of a reasonable selection of drugs
              which do not
              require prior approval for each specific therapeutic drug
              class.

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


            3.16    Mental
              Health and Substance Abuse Access

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            39

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            0501
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              HUSKY B Final

          

          
            


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

          

          
             

          

          
            
              	d.	
                      Ancillary
                        Services

                       

                    


              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


              	
                       

                      e.

                    	
                       

                      Co-Occuring
                        Medical and Behavioral Health
                        Conditions

                    


            

          

          
             

          

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

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                       

                    


              	3.	Coordinate
                      with the BMP ASO, upon request.


            

          

          
             

          

          
            
              	
                      4.

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

                    


            

          

          
            


            
              	
                      5.

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

                    


              	 	 


            

          

          
            


            f.            Freestanding
              Primary Care Clinics

          

          
            


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

          

          
            


            g.            Home
              Health Services

          

          
            


            40

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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              HUSKY B Final

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


              	
                       

                      h.

                    	
                       

                      Hospital
                        Inpatient Services.

                    


            

          

          
             

          

          
            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            
              	
                      5.

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

                       

                    


              	i.	
                      Hospital
                        Outpatient Clinic Services

                       

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

                    


              	j.  	
                      Long
                        Term Care

                       

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

                    


            

          

           

          
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            k.           Primary
              Care Behavioral Health Services

          

          
            


            
              	
                      1.

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

                    


            

          

          
             

          

          
            
              	a)	Behavioral
                      health related prevention and anticipatory
                      guidance;


              	b) 	Screening
                      for behavioral health disorders;


              	
                      c)

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

                    


            

          

          
            
              	
                      d)

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

                    


            

          

          
            
              	
                      e)

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            I.           
              School Based Health Center Services

          

          
            


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

          

          
            


            3.17           Children's
              Issues and Preventive Care and Services

          

          
            


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

          

          
            


            42

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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                      a.

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

                    


            

          

          
            


            1.           Child
              preventive care consisting of:

          

          
            


            
              	
                      a).
                        

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

                    


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


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


              	d).	Health
                      screenings; and


              	e).	Routine
                      laboratory tests.


            

          

          
             

          

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

                       

                    


              	
                      3.

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

                       

                    


              	4.	WIC
                      evaluations, as applicable;


            

          

          
             

          

          
            
              	
                      5.

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

                    


            

          

          
            


            
              	
                      6.

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

                    


            

          

          
            


            a).
              Oral
              exams and prophylaxis; 

            b).
              Fluoride treatments; 

            c).
              Sealants, and 

            d).
              X-rays

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            43

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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                      1.

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

                       

                    


              	2.	A
                      comprehensive unclothed or partially draped physical
                      exam;


            

          

          
             

          

          
            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            
              	
                      5.

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

                    


            

          

          
            


            
              	
                      6.

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

                       

                    


              	7. 	 Health
                      education, including anticipatory
                      guidance.


            

          

          
             

          

          
            
              	
                      d.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


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

          

          
            


            3.18   Well-Care
              Services for Adolescents

          

          
            


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

          

          
            


            44

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
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            3.19           HUSKY
              PLUS: Physical

          

          
            


            a.           Overview

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            
              	
                      5.

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

                    


            

          

          
            


            
              	
                      b.

                    	
                      MCO's
                        Responsibility to Maximize HUSKY Plus Physical
                        Services

                    


            

          

          
            


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

          

          
            


            c.           HUSKY
              B MCO Case Management Responsibilities

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            45

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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              HUSKY B Final

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            d.            Disenrollment

          

          
            


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

          

          
            


            e.            Quality
              Assurance

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            f.            Payment

          

          
            


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

          

          
            


            3.20           Prenatal
              Care

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                       

                    


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


            

          

          
             

          

          
            
              	
                      4.

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

                    


            

          

          
            


            
              	
                      5.

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

                    


            

          

          
            


            46

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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                      6.

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

                    


            

          

          
            


            
              	
                      7.

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

                    


            

          

          
            


            
              	
                      8.

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

                    


            

          

          
            


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

          

          
            


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

          

          
            


            3.21           Dental
              Care

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            
              	
                      5.

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

                    


            

          

          
            


            47

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
              01 07
              HUSKY B Final

          

          
            


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

          

          
            


            
              	
                      6.

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

                    


            

          

          
            


            
              	
                      7.

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

                    


            

          

          
            


            
              	
                      8.

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

                    


            

          

          
            


            3.22            Pre-Existing
              Conditions

          

          
            


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

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            3.23            Prior
              Authorization

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            1     Preventive
              care, including:

          

          
            a)      Periodic
              and well-child visits;

          

          
            b)      Immunizations;
              and

          

          
            c)      Prenatal
              care;

          

          
             

            2       Preventive
              family planning services including:

          

          
            a)      Reproductive
              health exams;

          

          
            b)      Member
              counseling;

          

          
            c)      Member
              education;

          

          
            


            
              	
                      d)

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

                    


            

          

          
            


            
              	
                      e)

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

                    


            

          

          
            


            f)      Emergency
              ambulance services or emergency care.

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            3.24        Newborn
              Enrollment and Minimum Hospital Stays

          

          
            


            48

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      3.25

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

                    


            

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


            
              	
                      f.

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

                    


            

          

          
            


            
              	
                      g.

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

                    


            

          

          
            


            49

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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            of
              the
              effective date of the individual's enrollment into the MCO as a HUSKY
              A Member.
              In the instances where the inpatient stay qualifies for HUSKY A reinsurance,
              the
              reinsurance day count starts with the individual's effective date of
              enrollment
              as a HUSKY A Member.

          

          
            


            3.26           Open
              Enrollment

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            3.27           Special
              Disenrollment

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


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

          

          
            


            
              	
                      1.

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

                    


            

          

          
            
              	
                      2.

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

                    


            

          

          
            


            c.           The
              following shall not constitute good cause:

          

          
             

            1.           Extensive
              or expensive health care needs;

          

          
            2.           A
              change in the member's health status;

          

          
            


            50

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            05
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            3.           The
              Member's diminished mental capacity; or

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            3.28           Linguistic
              Access

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


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

          

          
            


            3.29           Services
              to Members

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            51

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
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              	1.  	Covered
                      services;


              	
                      2.

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

                    


              	3.	Prior
                      authorization process;


            

          

          
            
              	
                      4.

                    	
                      Definition
                        of and distinction between emergency care and
                        urgent care;

                    


            

          

          
            
              	
                      5.

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

                    


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


              	7.	Assistance
                      locating an appropriate provider;


              	8.	Member
                      rights and responsibilities;


              	9.	Member
                      services, including hours of operation;


              	10. 	Enrollment,
                      disenrollment and plan changes;


              	11.	Procedures
                      for selecting and changing PCP;


              	12.	Availability
                      of provider network directory and updates;


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


              	14.	Access
                      and availability standards;


            

          

          
            
              	
                      15.

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

                    


              	16.	Family
                      planning services;


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


              	18.	Copayments;


              	19. 	Allowances;


              	20.	Maximum
                      annual aggregate cost-sharing;


              	21.	Premiums;


              	22.	Involuntary
                      disenrollments;


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


              	24.	Preventive
                      health guidelines; and


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


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




          

          
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                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


            
              	
                      f.

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

                    


            

          

          
            


            
              	
                      g.

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

                    


            

          

          
            


            
              	
                      h.

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

                    


            

          

          
            


            
              	
                      i.

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

                    


            

          

          
            


            
              	
                      j.

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

                    


            

          

          
            


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

          

          
            


            
              	
                      k.

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

                    


            

          

          
            


            
              	
                      l.

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

                       

                      The
                        MCO's CAHPS survey shall continue to include behavioral health
                        questions.

                    


            

          

          
             

          

          
            
              	
                      m.

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

                    


            

          

          
            


            
              	
                      n.

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

                    


            

          

          
            


            3.30           Information
              to Potential Members

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


              	2.	Rights
                      and responsibilities of Members;


              	3.	Appeal
                      procedures; and


            

          

          
            
              	
                      4.

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

                    


            

          

          
            


            3.31           DSS
              Marketing Guidelines

          

          
            


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

          

          
            


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              	 a. 	
                       Prohibited
                        Marketing Activities:

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

                       

                    


              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                       

                    


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


            

          

          
             

          

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

          

          
            


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

          

          
            


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

          

          
            


            3.32        Health
              Education

          

          
            


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

          

          
            


            3.33        Quality
              Assessment and Performance Improvement

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


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

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

                    	
                      Provides
                        for systematic data collection of performance and participant
                        results;

                       

                    


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

                       

                    


              	4.	Provides
                      for making needed changes;


            

          

          
             

          

          
            
              	
                      5.

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

                    


            

          

          
            


            
              	
                      6.

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

                    


            

          

          
            


            
              	
                      7.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


            
              	
                      1.

                    	
                      A
                        quality assessment and performance improvement
                        assurance plan;

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


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

          

          
            


            
              	
                      a)

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

                    


            

          

          
            


            b)     Board
              of Directors of the MCO.


          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            
              	
                      5.

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

                    


            

          

          
            


            
              	
                      6.

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

                    


            

          

          
            


            
              	
                      7.

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

                    


            

          

          
            


            
              	
                      8.

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

                    


            

          

          
            


            
              	
                      9.

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

                    


            

          

          
            


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                      10.

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

                    


            

          

          
            


            
              	
                      11.

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

                    


            

          

          
            


            
              	
                      12.

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

                    


            

          

          
            


            
              	
                      13.

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

                    


            

          

          
            


            
              	
                      14.

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

                    


            

          

          
            


            
              	
                      15.

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

                    


            

          

          
            


            a)
              The
              project shall focus upon at one of the following areas:

          

          
            1)      Prevention
              and care of acute and chronic conditions;

          

          
            2)      High
              volume services;

          

          
            3)      Continuity
              and coordination of care;

          

          
            4)      Appeals
              and complaints; and

          

          
            5)      Access
              to and availability of services.

          

          
             

            b).
              Measurement of performance using quality indicators that are:

          

          
            1)  Objective;

          

          
            2)  Clearly
              and unambiguously defined;

          

          
            
              
                3) 
                  Based on current clinical knowledge or health
                  services research;

              

            

            4)  Valid
              and reliable;

          

          
            5)  Systematically
              collected; and

          

          
            


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

                    


            

          

          
            


            
              	
                      c)

                    	
                      Implementation
                        of system interventions to achieve quality improvement;

                       

                    


              	d)	Evaluation
                      of the effectiveness of the
                      interventions;


            

          

          
             

          

          
            
              	
                      e)

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

                    


            

          

          
            


            
              	
                      f)

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

                    


            

          

           

          
            
              	
                      16.

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

                    


            

          

          
            


            
              	
                      17.

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

                    


            

          

          
            


            3.34            Inspection
              of Facilities

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            3.35            Examination
              of Records

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


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

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


            
              	
                      f.

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

                    


            

          

          
            


            
              	
                      g.

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

                    


            

          

          
            


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                      h.

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

                    


            

          

          
            


            3.36           Medical
              Records

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            3.37           Audit
              Liabilities

          

          
            


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

          

          
            


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

          

          
            


            3.38           Clinical
              Data Reporting

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            b.        Utilization
              reports shall cover, but not be limited to, the following
              areas:

          

          
                1.           Well-child
              visits;

          

          
                2.           Immunizations;


          

          
                3.           Maternal
              and prenatal care;

          

          
                4.           Preventive
              care;

          

          
                5.           Inpatient
              and outpatient services;

          

          
                6.           Dental
              services;

          

          
                7.           HEDIS/CAHPS;
              and

          

          
            8.           Other
              services.

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


            
              	
                      f.

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

                    


            

          

          
            


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            g.           Daily
              and Monthly Reports

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            a)      Behavioral
              health emergency department visits;

          

          
            b)      Behavioral
              health emergency room recidivism;

          

          
            c)      Substance
              abuse and neonatal withdrawal;

          

          
            d)      Child
              and adolescent obesity and/or type II diabetes;

          

          
            e)      Sickle
              cell;

          

          
            f)      Eating
              disorders; and

          

          
            g)      Medical
              detox.

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


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

          

          
            


            3.39         Utilization
              Management

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


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                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            3.40        Financial
              Records

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      1.

                    	
                      Audited
                        financial reports per MCO HUSKY line of business. If the
                        MCO is licensed
                        as a health care center or insurance company, both the annual
                        audited
                        financial reports for the MCO and the audited financial reports
                        per MCO
                        HUSKY line of business shall be conducted and reported in
                        accordance with
                        C.G.S. Section 38a-54. If the MCO is not licensed as a health
                        care center
                        or insurance company, the annual audited financial reports
                        for the MCO and
                        the audited financial reports per MCO line of business shall
                        be completed
                        in accordance with generally accepted auditing principles.

                       

                      The
                        MCO may elect to combine HUSKY A and HUSKY B in the audited
                        financial
                        statement. If this election is made, the MCO shall also submit
                        the
                        following: a separate unaudited income statement for HUSKY
                        A and HUSKY B,
                        which will be compared to the audited financial
                        statement.

                    


            

          

          
             

          

          
            


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                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            
              	
                      5.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


             

          

          
            


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            3.41           Insurance

             

            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                       

                    


              	3. 	
                      Workers
                        compensation; and

                       

                    


              	4.	Unemployment
                      insurance.


            

          

          
             

          

          
            
              	
                      b.

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

                    


            

          

          
            


            3.42           Subcontracting
              for Services

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


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                      d.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


            
              	
                      f.

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

                    


            

          

          
            


            
              	
                      g.

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

                    


            

          

          
            


            
              	
                      h.

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

                    


            

          

          
            


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                      i.

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

                    


            

          

          
            


            
              	
                      j.

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

                    


            

          

          
            


            3.43           Timely
              Payment of Claims

          

          
            


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

          

          
            


            3.44           Insolvency
              Protection

          

          
            


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

          

          
            


            3.45           Fraud and
              Abuse

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


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                      d.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


            
              	
                      f.

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

                    


            

          

          
            


            
              	
                      g.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            
              	
                      5.

                    	
                      Establishing
                        procedures to process fraud and abuse
                        complaints; and

                    


            

          

          
            


            
              	
                      6.

                    	
                      Establishing
                        procedures for reporting information to
                        the DEPARTMENT.

                    


            

          

          
            


            
              	
                      h.

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

                    


            

          

          
            


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

          

          
            


            
              	
                      i.

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

                    


            

          

          
            


            
              	
                      j.

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

                    


            

          

          
            


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

          

          
            


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                      4.

                    	
                      MCO
                        RESPONSIBILITY CONCERNING PAYMENTS MADE ON BEHALF OF THE
                        MEMBER

                    


            

          

          
            


            
              	
                      4.01

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

                    


            

          

          
            


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

          

          
            


            4.02        Payments
              for Non-covered Services

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      4.03

                    	
                      Cost-Sharing
                        Exemption for American Indian/Alaskan
                        Native Children

                    


            

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


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

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


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

          

          
            


            4.04         Co-payments

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            1.  Outpatient
              physician visits, except for well child visits;

          

          
            2.  Powered
              wheelchairs;

          

          
            3.  Hearing
              examinations;

          

          
            4.  Nurse
              midwife visits;

          

          
            5.  Nurse
              practitioner visits;

          

          
            6.  Podiatrist
              visits;

          

          
            7.  Chiropractor
              visits;

          

          
            8.  Naturopathic
              visits;

          

          
            9.  Eye
              care exams;

          

          
            10. Oral
              contraceptives;

          

          
            11. Generic
              and brand name prescriptions; and

            
              12.
Non-emergency
                care provided in a hospital emergency department or urgent care facility,
                except for a condition such that a prudent

            

          

          
             

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            layperson,
              acting reasonably, would have believed that emergency medical treatment
              is
              needed.

          

          
            


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

          

          
            


            4.05      Co-payments
              Prohibited No co-payment shall be charged
              for:

          

          
            1. Ambulance
              for emergency medical conditions;

          

          
            2. Durable
              medical equipment other than powered wheelchairs;

          

          
            3. Emergency
              medical conditions; and

          

          
            4.  Family
              planning services, excluding oral contraceptives;

          

          
            5.  Home
              health services;

          

          
            6.  Hospice
              and short-term rehabilitation;

          

          
            7.  Inpatient
              hospital services;

          

          
            8.  Inpatient
              physician services;

            
              9. 
                Laboratory
                and x-ray services, including diagnostic and treatment radiology and
                ultrasound treatment;
10. Occupational
              therapy;

          

          
            11. Outpatient
              surgical visits;

          

          
            12. Physical
              therapy,

          

          
            13. Preadmission
              testing;

            
              14.
Preventive
                care and services, including all well-baby and well-child services as
                described in 42 CFR 457.520;
15.  Prosthetic
              devices;

          

          
            16.  Skilled
              nursing;

          

          
            17.  Speech
              therapy;

          

          
            
              18. 
                The
                following dental services: oral exams, prophylaxis, x-rays, fillings,
                fluoride treatments, sealants, and oral surgery.

            

          

          
             

            4.06            Maximum
              Annual Limits for Co-payments

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


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                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


            
              	
                      f.

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

                    


            

          

          
            


            
              	
                      g.

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

                    


            

          

          
            


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

          

          
            


            4.07           Tracking
              Co-payments

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


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

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


            
              	
                      f.

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

                    


            

          

          
            


            
              	
                      g.

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

                    


            

          

          
            


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

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            4.08        Amount
              of Premium Payment

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


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                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      d. 
                        

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

                    


            

          

          
            


            4.09        Billing
              and Collecting the Premium Payments

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            4.10         Notification
              of Premium Payments Due

          

          
            


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

          

          
            


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

          

          
            


            4.11          Notification
              of Non-payment of the Premium Payments

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


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            b. The
              notice shall contain:

          

          
            1.  The
              amount of the premium that is due;

          

          
            2.  The
              date the premium was due;

          

          
            3.  The
              effective date of disenrollment for failure to pay the
              premium;

          

          
            4.  Information
              concerning lock-out;

          

          
            
              5. 
                An
                instruction for the applicant to immediately contact the DEPARTMENT or its
                agent if the applicant cannot pay the premium by the due date because of a
                decrease in income or other change in family circumstances;
                and

            

          

          
            
              6.
Any
                additional information required to be included in the notice by the
                DEPARTMENT.

               

            

          

          
            
              	
                      b.

                    	
                      The
                        MCO shall collaborate with the DEPARTMENT and its agent to
                        establish
                        billing and collection procedures. The MCO shall notify the
                        Department or
                        its agent pursuant to the agreed upon procedures if a premium
                        is not
                        received by the due date.

                    


            

          

          
            


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

          

          
            


            4.12           Past
              Due Premium Payments Paid

          

          
            


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

          

          
            


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

          

          
            


            4.13           Resumption
              of Services if the Child is Re-enrolled

          

          
            


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

          

          
            


            4.14       Overpayment
              of Premium

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


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

          

          
            


            4.15        Member
              Premium Share Paid by Another Entity

          

          
            


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

          

          
            


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

          

          
            


            4.16        Tracking
              Premium Payments

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


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

          

          
            


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

          

          
            


            4.17       Behavioral
              Health Payment Adjustment

          

           

          
            
              	a. 	
                      placeholder
                        for the amount.

                       

                    


              	
                      b.

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

                    


            

          

          
            


            
              	
                      1)

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

                    


            

          

          
            


            
              	
                      2)

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

                    


            

          

          
            


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                      5.

                    	
                      LIMITED
                        COVERAGE OF SOME GOODS AND SERVICES AND
                        ALLOWANCES

                    


            

          

          
            


          

          
            5.01           Limited
              Coverage of Some Benefits

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


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            6.           FUNCTIONS
              AND DUTIES OF THE DEPARTMENT

          

          
            


            6.01       Eligibility
              Determinations

          

          
            


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

          

          
            


            6.02       Ineligibility
              Determinations

          

          
            


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

          

          
            


            6.03       Enrollment/Disenrollment

          

          
            


            
              	
                      a.

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

                    


            

          

          
             

          

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

                       

                    


              	
                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            
              	
                      5.

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

                    


            

          

          
            


            
              	
                      6.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


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            6.04        Lock-In/Open
              Enrollment

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            a) Documented
              long waiting times for appointments;

          

          
            
              b)
                More
                than a forty-five (45) day wait for scheduling a
                well-care visit; 

            

            
              c)
                More than a two (2) business day wait for non-urgent, symptomatic
                office
                visit; 

            

          

          
            
              d) Unavailability
                of same day office visit or same day referral to an emergency provider for
                emergency care services;

            

            e)  Documented
              inaccessibility of MCO by phone or mail;

          

          
            f)  Phone
              calls not answered promptly;

          

          
            g) Caller
              placed on hold for extended periods of time;

          

          
            h)
              Phone
              messages and letters not responded to promptly; and i)   Rude and
              demeaning treatment by MCO staff.

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


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                      a)

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

                    


            

          

          
            


            
              	
                      b)

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

                    


            

          

          
            


            
              	
                      c)

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

                    


            

          

          
            


            6.05           Capitation
              Payments to the MCO

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


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            6.06        Newborn
              Retroactive Adjustments

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            6.07        Information

          

          
            


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

          

          
            


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            7.           DECLARATIONS
              AND MISCELLANEOUS PROVISIONS

          

          
            


            7.01       Competition
              Not Restricted

          

          
            


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

          

          
            


            7.02       Non-segregated
              Facilities

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            7.03       Offer
              of Gratuities

          

          
            


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

          

          
            


            7.04            Employment/Affirmative
              Action Clause

          

          
            


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

          

          
            


            7.05        Confidentiality

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            7.06        Independent
              Capacity

          

          
            


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

          

          
            


            7.07         Liaison

          

          
            


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

          

          
            


            7.08         Freedom
              of Information

          

          
            


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

          

          
            


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

          

          
            


            7.09        Waivers

          

          
            


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

          

          
            


            7.10        Force
              Majeure

          

          
            


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

          

          
            


            7.11        Financial
              Responsibilities of the MCO

          

          
            


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

          

          
            


            7.12        Capitalization
              and Reserves

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


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                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            7.13        Members
              Held Harmless

          

          
             

            The
              MCO
              shall not hold a Member liable for:

          

          
             

          

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

                       

                    


              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            7.14        Compliance
              with Applicable Laws, Rules And Policies

          

          
            


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

          

          
            


            7.15        Federal
              Requirements and Assurances

          

          
            


            a.           
              General

          

          
            


            
              	
                      1.

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

                    


            

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


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

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            b.           Lobbying

          

          
            


            
              	
                      1. 

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

                    


            

          

          
            


            
              	
                      2. 

                    	
                      The
                        MCO shall submit to the DEPARTMENT a disclosure form as provided in
                        45 CFR 93.110 and Appendix B to 45 CFR Pt. 93, if any funds other
                        than federally appropriated funds have been paid or will be paid to
                        any person for influencing or attempting to influence an officer or
                        employee of any agency, a Member of the U.S. Congress, an officer or
                        employee of the U.S. Congress or an employee of a Member of the U.S.
                        Congress in connection with this
                        contract.

                    


            

          

          
            


            c.           Title
              XXI and SCHIP Regulations

          

          
            


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

          

          
            


            d.           Clean
              Air and Water Acts

          

          
            


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

          

          
            


            e.           Energy
              Standards

          

          
            


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

          

          
            


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

          

          
            


            f.           Maternity
              Access and Mental Health Parity

          

          
            


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

          

          
            


            7.16      Civil
              Rights

          

          
            


            a.           Federal
              Authority

          

          
            


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

          

          
            


            b.           Discrimination

          

          
            


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

          

          
            


            c.           Merit
              Qualifications

          

          
            


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

          

          
            


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            d.           Confidentiality

          

          
            


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

          

          
            


            7.17      Statutory
              Requirements

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            7.18      Disclosure
              of Interlocking Relationships

          

          
            


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

          

          
            


            7.19      DEPARTMENT'S
              Data Files

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


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                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            7.20        Hold
              Harmless

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            7.21        Executive
              Order Number 16

          

          
            


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

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


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

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


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            8.           MCO
              RESPONSIBILITIES CONCERNING INTERNAL AND
              EXTERNAL APPEALS

          

          
            


            
              	
                      8.01

                    	
                      MCO
                        Responsibilities Concerning Internal and External Appeals
                        and Notices of
                        Denial

                    


            

          

          
            


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

          

          
            


            8.02           Internal
              Appeal Process Required

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            8.03           Denial
              Notice

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            b.          All
              denial notices shall clearly state or explain:

          

          
            1.           What
              goods and/or services are being denied;

          

          
            2.           The
              reasons for the denial;

          

          
            3.           The
              contract section that supports the denial;

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


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                      5.

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

                    


            

          

          
            


            
              	
                      6.

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

                       

                    


              	7.	
                      The
                        availability of expedited internal appeal;

                       

                    


              	8.	The
                      external appeal process available through the
                      DOI;


            

          

          
             

          

          
            
              	
                      9.

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

                    


            

          

          
            


            
              	
                      10.

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

                    


            

          

          
            


            
              	
                      11.

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

                    


            

          

          
            


            
              	
                      12.

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

                    


            

          

          
            


            
              	
                      13.

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

                    


            

          

          
            


            
              	
                      14.

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

                    


            

          

          
            


            8.04     
              Internal Appeal Process

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


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                      d.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


            
              	
                      f.

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

                    


            

          

          
            


            
              	
                      g.

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

                    


            

          

          
            


            
              	
                      h.

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

                    


            

          

          
            


            
              	
                      i.

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

                    


            

          

          
            


            
              	
                      j.

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

                    


            

          

          
            


            8.05        Written
              Decision

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


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

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            8.06         Expedited
              Review

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            8.07         External
              Appeal Process through the DOI

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


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

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            
              	
                      4.

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

                    


            

          

          
            


            
              	
                      5.

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

                    


            

          

          
            


            
              	
                      6.

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

                    


            

          

          
            


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

          

          
            


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

          

          
            


            8.08       Provider
              Appeal Process

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


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            9.           CORRECTIVE
              ACTION AND CONTRACT TERMINATION

          

          
            


            9.01           Performance
              Review

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            9.02           Settlement
              of Disputes

          

          
            


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

          

          
            


            9.03           Administrative
              Errors

          

          
            


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

          

          
            


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            9.04           Suspension
              of New Enrollment

          

          
            


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

          

          
            


            9.05           Sanctions

          

          
            


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

          

          
            


            a.           Sanctions
              for Noncompliance

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


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

          

          
            


            
              	
                      a)

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

                    


            

          

          
            


            
              	
                      b)

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

                    


            

          

          
            


            
              	
                      c)

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

                    


            

          

          
            


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

          

          
            


            
              	
                      2.

                    	
                      Class
                        B Sanctions. Sanctions Warranted Upon
                        Single Occurrence.

                    


            

          

          
            


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

          

          
            


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

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      a)

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

                    


            

          

          
            


            
              	
                      b)

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

                    


            

          

          
            


            
              	
                      c)

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

                    


            

          

          
            


            101

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
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                      d)

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

                    


            

          

          
            


            
              	
                      e)

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      a)

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

                       

                    


              	          
                      b)	Assessment
                      of liquidated damages:


            

          

          
             

          

          
            
              	
                      1)

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

                    


            

          

          
            


            
              	
                      2)

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

                    


            

          

          
            


            
              	
                      3)

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

                    


            

          

           

          
            
              	
                      c)

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

                    


            

          

          
            


            
              	
                      d)

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

                    


            

          

          
            


            102

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
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              HUSKY B Final

          

          
            


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

          

          
            


            
              	
                      3.

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

                    


            

          

          
            


            c.           Other
              Remedies

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            9.06         Payment
              Withhold, Class C Sanctions

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      1.

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

                    


            

          

          
            


            
              	
                      2.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            103

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


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

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            9.07        Emergency
              Services Denials

          

          
            


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

          

          
            


            9.08       Termination
              For Default

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            
              	
                      b.

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

                    


            

          

          
            


            
              	
                      c.

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

                    


            

          

          
            


            104

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


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

          

          
            


            
              	
                      d.

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

                    


            

          

          
            


            
              	
                      e.

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

                    


            

          

          
            


            
              	
                      f.

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

                    


            

          

          
            


            9.09         Termination
              for Mutual Convenience

          

          
            


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

          

          
            


            9.10         Termination
              for Financial Instability of the MCO

          

          
            


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

          

          
            


            9.11         Termination
              for Unavailability of Funds

          

          
            


            
              	
                      a.

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

                    


            

          

          
            


            105

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
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            contract.
              Whenever possible, the MCO will be given thirty (30) days notification
              of
              termination.

          

          
            


            
              	
                      b,

                    	
                      In
                        the event of a reduction in the appropriation from the state
                        or
                        federal budget for the Division of Health Care Financing of the
                        Department of Social Services or an across-the-board budget reduction
                        affecting the Department of Social Services, the DEPARTMENT may
                        either re­ negotiate this contract or terminate with thirty (30)
                        days' written notice. Any reduction in the capitation rates that is
                        agreed upon by the parties or any subsequent termination of this
                        contract by the DEPARTMENT in accordance with this provision shall
                        only affect capitation payments or portions thereof for covered
                        services purchased on or after the effective date of any such
                        reduction or termination. Should the DEPARTMENT elect to renegotiate
                        the contract, the DEPARTMENT will provide the MCO with those contract
                        modifications, including capitation rate revisions, it would deem
                        acceptable.

                    


            

          

          
            


            
              	
                      c.

                    	
                      The
                        MCO shall have the right not to extend the contract if the
                        new
                        contract terms are deemed to be insufficient notwithstanding any
                        other provision of this contract. The MCO shall have a minimum of
                        sixty (60) days to notify the DEPARTMENT regarding its desire to
                        accept new terms. If the new capitation rates and any other contract
                        modifications are not established at least sixty (60) days prior to
                        the expiration of the initial or extension agreement, the DEPARTMENT
                        will reimburse the MCO at the higher of the new or current capitation
                        rates for that period during which the new contract period had
                        commenced and the MCO's 60-day determination and notification period
                        had not been completed, and the MCO will be held to the terms of the
                        executed contract.

                    


            

          

          
            


            9.12       Termination
              for Collusion in Price Determination

          

          
            


            
              	
                      a.

                    	
                      In
                        competitive bidding markets, the MCO has previously certified
                        that
                        the prices presented in its proposal were arrived at independently,
                        without consultation, communication, or agreement with any other
                        bidder for the purpose of restricting competition; that, unless
                        otherwise required by law, the prices quoted have not been knowingly
                        disclosed by the MCO, prior to bid opening, directly or indirectly to
                        any other bidder or to any competitor; and that no attempt has been
                        made by the MCO to induce any other person or firm to submit or not
                        to submit a proposal for the purpose of restricting
                        competition.

                    


            

          

          
            


            
              	
                      b.

                    	
                      In
                        the event that such action is proven, the DEPARTMENT shall
                        have
                        the right to terminate this contract upon the same terms and
                        conditions as a Termination for
                        Default.

                    


            

          

          
            


            9.13       Termination
              Obligations of Contracting
              Parties

          

          
            


            
              	
                      A

                    	
                      The
                        MCO shall be provided the opportunity for a hearing prior
                        to
                        any termination of this contract pursuant to any provision of
                        this
                        contact. The

                    


            

          

          
            


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            DEPARTMENT
              may notify Members of the MCO and permit such Members to disenroll
              immediately
              without cause during the hearing process.

          

          
            


            
              	
                      b.

                    	
                      Upon
                        contract termination, the MCO shall allow the DEPARTMENT,
                        its agents
                        and representatives full access to the MCO's facilities and
                        records to arrange the orderly transfer of the contracted activities.
                        These records include the information necessary for the reimbursement
                        of any outstanding HUSKY B claims.

                       

                    


              	c. 	If
                      this contract is terminated for any reason other than default
                      by the
                      MCO:


            

          

          
             

          

          
            
              	
                      1.

                    	
                      The
                        MCO shall ensure that an adequate provider network will be maintained
                        at all times during the transition period and that continuity of care
                        is maintained for all
                        Members;

                    


            

          

          
            


            
              	
                      2.

                    	
                      The
                        MCO shall submit a written transition plan to the DEPARTMENT sixty
                        (60) days in advance of the scheduled
                        termination;

                    


            

          

          
            


            
              	
                      3.

                    	
                      The
                        DEPARTMENT shall be responsible for notifying all Members
                        of the date
                        of termination and process by which the Members will continue to
                        receive services;

                    


            

          

          
            


            
              	
                      4.

                    	
                      The
                        DEPARTMENT shall be responsible for all expenses relating
                        to said
                        notification;

                    


            

          

          
            


            
              	
                      5.

                    	
                      The
                        MCO shall notify all providers and be responsible for all expenses
                        related to such notification;
                        and

                    


            

          

          
            


            
              	
                      6.

                    	
                      The
                        DEPARTMENT shall withhold a portion, not to exceed $100,000, of the
                        last month's capitation payment as a surety bond for a six (6) month
                        period to ensure compliance under the
                        contract.

                    


            

          

          
            


            9.14     Waiver
              of Default

          

          
            


            Waiver
              of
              any default shall not be deemed to be a waiver of any subsequent default.
              Waiver
              of breach of any provision of the contract shall not be deemed to be
              a waiver of
              any other or subsequent breach and shall not be construed to be a modification
              of the terms of the contract unless stated to be such in writing, signed
              by an
              authorized representative of the DEPARTMENT, and attached to the original
              contract.

          

          
            


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            10.       OTHER
              PROVISIONS

          

          
            


            10.01  Severability

          

          
            


            If
              any
              provision of this procurement or the resultant contract is declared
              or found to
              be illegal, unenforceable, or void, then both parties shall be relieved
              of all
              obligations under that provision. The remainder of this procurement
              or the
              resultant contract shall be enforced to the fullest extent permitted
              by
              law.

          

          
            


            10.02  Effective
              Date

          

          
            


            This
              contract is subject to review for form and substance by and will not
              become
              effective until it is approved by the DEPARTMENT.

          

          
            


            10.03  Order
              of Precedence

          

          
            


            This
              contract shall be read together to achieve one harmonious whole. However,
              should
              any irreconcilable conflict arise between Part I and Part II of this
              contract,
              Part II shall prevail.

          

          
            


            10.04  Correction
              of Deficiencies

          

          
            


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

          

          
            


            10.05  This
              is not a Public Works Contract

          

          
            


            The
              DEPARTMENT and the MCO as parties to this purchase of service Contract
              mutually
              covenant, acknowledge and agree that this contract does not constitute
              and shall
              not be construed to constitute a public works contract. The DEPARTMENT
              and the
              MCO's mutual agreement that this contract is not a public works contract
              shall
              have full force and effect on Part I Section 32 and other Sections
              of this
              contract as applicable.

          

          
            


            108

          

        

      

    

     

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

    

    


    HUSKY
      B - APPENDIX A: Covered Benefits

     

    
      	
              Benefit
                Features

            	
              HUSKY
                Coverage

            	 
	
              Outpatient
                Physician Visits

            	
              $5
                co-pay

            	
              *

            
	
              Preventive
                Care

            	
              No
                co-pay

              Periodic
                and well child visits, immunizations, WIC evaluations as applicable,
                and
                prenatal care covered in full with $5 co-pay on other visits.

              Periodicity
                schedule and reporting based on the American Academy of
                Pediatrics (AAP) as amended from time to time:

              Age
                Category  # of Exams

              Birth
                to Age 1  6 exams

              Ages
                1-5           6
                exams

              Ages
                6-10         1 exam every 2
                years

              Ages
                11-19       1 exam every
                year.

              Immunization
                schedule per the Advisory Committee on Immunization Practices
                (ACIP), as amended from time to time. As of January 1, 2001, the
                schedule
                is as follows:

              Age
                CategoryVaccine Type

              BirthHepatitis
                B-1st
                dose

              1-4
                monthsHepatitis B-2nd
                dose

              2
                monthsDiphtheria, Tetanus, Pertussis (DTP) 1st
                dose;
                Haemophilus Influenza Type B (hib)-1st
                dose; Polio
                (OVP)-1st
                dose

              4
                monthsDiphtheria, Tetanus, Pertussis (DTP) 2nd
                dose;
                Haemophilus Influenza Type B (hib)- 2nd
                dose; Polio
                (OVP)- 2nd
                dose

              6
                monthsDiphtheria, Tetanus, Pertussis (DTP) 3rd
                dose;
                Haemophilus Influenza Type B (hib)-3rd
                dose

              6-12
                monthsHepatitis B-3rd
                dose; Polio
                (OVP)-3rd
                dose

              12-15
                monthsHaemophilus Influenza Type B (hib)-3rd
                dose;
                Measles, Mumps, Rubella (MMR)-1st
                dose

              12-18
                monthsChicken Pox (Var)-single dose; Diphtheria, Tetanus, Pertussis
                (DTP)
                4th
                dose

              4-6
                yearsDiphtheria, Tetanus, Pertussis (DTP) 5th
                dose;
                Measles, Mumps, Rubella (MMR)-2nd
                dose; Polio
                (OVP)-4th
                dose

              11-12
                yearsTetanus Diphtheria (Td)

              Influenza:
                Every year beginning at 6 months for children who have serious long-term
                health problems such as heart disease, lung disease, kidney disease,
                metabolic disease, diabetes, asthma, anemia, and/or are on long term
                aspirin treatment

              Pneumococcal:
                Vaccinate children 2 years and older who are at risk of pneumococcal
                disease or its complications

            	
              *

            
	
              Family
                Planning

            	
              100%

              Family
                Planning Services include:

              Reproductive
                health exams;

              Patient
                Counseling;

              Patient
                Education;

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

              Screening,
                testing and treatment;

              Pre
                and post-test counseling for sexually transmitted diseases and
                HIV;

              Abortions
                that are necessary to save the life of the mother or if the pregnancy
                resulted from rape or incest or if pregnancy resulted from rape or
                incest
                and other medically necessary abortions as defined in Section 3.14
                of the
                contract.

            	 
	
              Preventative
                Family Planning Services

            	
              100%

            	
              *

            
	
              Oral
                Contraceptives

            	
              $5
                co-pay (included in prescription drugs)

            	
              *

            
	
              Inpatient
                Physician

            	
              100%

            	
              *

            
	
              Inpatient
                Hospital

            	
              100%

            	 
	
              Outpatient
                Surgical Facility

            	
              100%

            	 
	
              Ambulance

            	
              100%
                if determined to be an emergency in accordance with state
                law

            	 
	
              Pre-Admission
                /Continued Stay

            	
              Arranged
                through provider.

            	 
	
              Prescription
                Drug

            	
              $3
                co-pay on generics

              $5
                co-pay on oral contraceptives

              $6
                co-pay on brand-name formularies

            	
              *

            
	
              Short
                Term Rehabilitation

            	
              100%

              For
                conditions where significant improvement is expected within 60 days
                including:

              Physical
                Therapy;

              Speech
                Therapy;

              Occupational
                Therapy; and

              Skilled
                Nursing Care (excludes private duty nursing)

            	 
	
              Home
                Health Care

            	
              100%

              Includes                    Disposable
                medical supplies for homebound members

              Excludes:                      Custodial
                care, homemaker care or care that may be provided in a medical office,
                hospital or skilled nursing facility and offered to the member is
                such
                setting.

            	 
	
              Hospice

            	
              100%
                provided to members who are diagnosed as having a terminal illness
                with a
                life expectancy of six months or less.  Covered care
                includes

              Nursing
                care;

              Physical
                therapy, Speech therapy, and Occupational therapy;

              Medical
                social services;

              Home
                health aides and homemakers;

              Medical
                supplies;

              Drugs;

              Appliances;

              DME;

              Physician
                services;

              Short-term
                inpatient care, including respite care and care for pain control
                and acute
                and chronic symptom management; services of volunteers and other
                benefits
                when ordered by a physician.

              Limitations
                on short-term therapies do not apply.

            	 
	
              Long
                Term: Rehabilitation; Physical Therapy; Skilled Nursing
                Care

            	
              Not
                covered under HUSKY B.

              Supplemental
                coverage available under HUSKY Plus Physical for medically eligible
                children.

            	 
	
              Lab
                and X-Ray

            	
              100%

            	 
	
              Pre-Admission
                Testing

            	
              100%

            	 
	
              Emergency
                Care

            	
              100%
                if determined to be an emergency in accordance with state
                law.  $25 co-pay if determined a non-emergency. $25 co-pay
                waived if the patient is admitted.

            	
              *

            
	
              Durable
                Medical Equipment (DME)

            	
              DME
                means equipment that is furnished by a supplier or home health agency
                that:

              1.can
                withstand repeated use;

              2.is
                primarily and customarily used to serve a medical purpose;

              3.is
                generally not useful to an individual in the absence of an illness
                or
                injury; and

              4.is
                appropriate for use in the home

              100
                % covered except DME does not include:

              ·
Power
                wheelchairs for members who are eligible for HUSKY Plus
                Physical;

              ·
Devices
                not
                medical in natures such as:

              ·
                whirlpools,

              ·
                saunas,

              ·
                elevators,

              ·
                vans,

              ·
van
                lifts,

              ·
home
                convenience items (e.g., air cleaners, filtration units and related
                apparatus, exercise bicycles and other types of exercise
                equipment),

              ·
insulin
                injectors,

              ·
non-rigid
                appliances and supplies, such as, sheets, self-help devices, experimental
                or investigational research equipment, and

              ·
items
                for
                personal comfort and or usefulness to the member’s household.

              Supplemental
                coverage available under HUSKY Plus Physical for medically eligible
                children.

            	 
	
              Hearing
                Aids

               

            	
              Hearing
                aids for children twelve years of age or younger, limited to $1,000.00
                within a 24-month period.

              Supplemental
                coverage available under HUSKY Plus for medically eligible
                children

            	 
	
              Prosthetics

            	
              100%

              Includes:                      Devices
                whether worn anatomically or surgically implanted, which replace
                all or
                part of a body organ or structure and which correct, strengthen or
                provide
                necessary support to the body will be covered when medically
                necessary.

              Excludes:                      Orthopedic
                shoes, foot orthotics, wigs or hairpieces.

              Supplemental
                coverage available under HUSKY Plus Physical for medically eligible
                children

            	 
	
              Eye
                Care

              Eye
                Exams

            	
               

              5$
                co-pay

            	
              *

            
	
              Hearing
                Exam

            	
              $5
                co-pay

            	
              *

            
	
              Nurse
                Midwives

            	
              $5
                co-pay (except for preventative services)

            	
              *

            
	
              Nurse
                Practitioners

            	
              $5
                co-pay (except for preventative services)

            	
              *

            
	
              Podiatrists

            	
              $5
                co-pay

            	
              *

            
	
              Chiropractors

            	
              $5
                co-pay

            	
              *

            
	
              Naturopaths

            	
              $5
                co-pay

            	
              *

            
	
              Dental

            	
              100%

              Dental
                Services include:

              Exams,
                1 every 6 months;

              X-rays,

              Fillings;

              Fluoride
                Treatments;

              Oral
                Surgery

            	
              *

            


    

    


    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
                  

          

        

      

    

    


    Limited
      Benefits

    
      	
              Benefit
                Features

            	
              HUSKY
                Coverage

            	 
	
              Eye
                Care

              Eyeglass
                frames and lenses or contact lenses

            	
              Once
                every 2 consecutive eligibility periods with an allowance of $100
                toward
                the purchase of these goods.  The optical hardware must be
                provided without charge under the following conditions:

              (i)One
                pair of contact lenses every 2 consecutive eligibility periods when
                such
                lenses are determined to be the primary and the best method for aiding
                the
                member vision and the lenses are not needed solely for the correction
                of
                vision;

              (ii)Eyeglass
                frames and lenses and contact lenses that are determined to be medically
                necessary after eye surgery, the initial pair only; and

              (iii)Contact
                lenses, as needed, for the treatment of Keratonconus.

            	 
	
              Dental

              Orthodontia

            	
               

              $725
                allowance per orthodontia case.

            	 
	
              Bridges
                or crowns; root canals; full or partial dentures; or
                extractions

            	
              $50
                allowance per procedure, per member but no more than an aggregate
                allowance for all such procedures of $250 per eligibility
                period.

            	 
	
              Contraceptives

              Intruterine
                Devices (IUD) and insertion of the IUD

            	
               

              $50
                allowance per member

            	
               

              *

            
	
              Internally
                implantable time-release devices and their insertion

            	
              $50
                allowance per member

            	
              *

            
	
              Time-released
                contraceptive injections

            	
              $15
                allowance per member per injection

            	
              *

            
	
              Nutritional
                Formulas

            	
              100%

              Limited
                to medically necessary amino acid modified preparations and low protein
                modified food products for the treatment of inherited metabolic diseases
                when ordered by a participating physician

            	
              *

            


    

    


    Annual
      co-payments cannot exceed $760/$1350 (Income Band 1/Income Band 2) including
      premiums, per year.

    


    
      
        
          `Note:
            Prior authorization may be required by the MCO unless otherwise noted
            by an
            asterisk (*).  Co-payment not required for preventive
            services.           

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    


    EXCLUSIONS
      AND LIMITATIONS

    
      	
              1.

            	
              Services
                and/or procedures considered to be of an unproven, experimental,
                or
                research nature or cosmetic, social, habilitative, vocational,
                recreational, or educational.

            


    

    
      	
              2.

            	
              Services
                in excess of those deemed medically necessary to treat the patient’s
                condition.

            


    

    
      	
              3.

            	
              Services
                for a condition that is not medical in
                nature.

            


    

    
      	
              4.

            	
              Devices
                required by third parties, such as school or employment physicals,
                physicals for summer camp, enrollment in health, athletic, or similar
                clubs, premarital blood work or physicals, or physicals required
                by
                insurance companies or court ordered alcohol or drug abuse
                course.

            


    

    
      	
              5.

            	
              Cosmetic
                and reconstructive surgery is excluded, except when surgery is required
                for:

            


    

    
      	
              a) 
                

            	
              reconstructive
                surgery in connection with the treatment of malignant tumors or other
                destructive pathology that causes
                dysfunction;

            


    

    
      	
              b) 
                

            	
              reduction
                mammoplasty in females when Medically Necessary and breast surgery
                in
                males only in cases of suspected malignancy. Surgery must be necessary
                to
                achieve normal physical or bodily
                function.

            


    

    
      	
              6.

            	
              Routine
                foot care rendered:

            


    

    
      	
              a)  

            	
              in
                the examination, treatment or removal of all or part of corns,
                callosities, hypertrophy or hyperplasia of the skin or subcutaneous
                tissues of the foot.

            


    

    
      	
              b) 
                

            	
              in
                the cutting, trimming or other non-operative partial removal of toenails,
                except when Medically Necessary in the treatment of neuro-circulatory
                conditions.

            


    

    
      	
              7.

            	
              Evaluation,
                treatment and procedures related to, and performance of, sex-change
                operations.

            


    

    
      	
              8.

            	
              Surgical
                treatment or hospitalization for the treatment of morbid obesity
                except
                where prior authorized Medically
                Necessary.

            


    

    
      	
              9.

            	
              Care,
                treatment, procedures, services or supplies that are primarily for
                dietary
                control including, but not limited to, any exercise weight reduction
                programs, whether formal or informal, and whether or not recommended
                by an
                In-network Physician or Out-of-Network
                Physician.

            


    

    
      	
              10.

            	
              Acupuncture,
                biofeedback, or hypnosis.

            


    

    
      	
              11.

            	
              Treatment
                at pain clinics unless determined to be Medically
                Necessary.

            


    

    
      	
              12.

            	
              Ambulatory
                blood pressure monitoring.

            


    

    
      	
              13.

            	
              Any
                court order for testing, diagnosis, care, or treatment deemed not
                Medically Necessary.

            


    

    


    
      
        
          `Note:
            Prior authorization may be required by the MCO unless otherwise noted
            by an
            asterisk (*).  Co-payment not required for preventive
            services.           

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
Appendix
      B

    Husky
      Plus Behavioral - Deleted

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

    Appendix
      C

    HUSKY
      Plus


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

        
             

        

      

    


    HUSKY
      PLUS

    SUPPLEMENTAL
      INSURANCE COVERAGE

     

    On
      October 29, 1997, the Connecticut legislature authorized the establishment
      of
      the HUSKY, Part B and HUSKY Plus insurance programs to provide health care
      coverage for uninsured children pursuant to Title XXI of the Social Security
      Act. HUSKY, Part A is the program for children’s coverage under Title XIX of the
      Social Security Act. The HUSKY Plus program was originally comprised of two
      supplemental health insurance programs to provide services to children whose
      intensive medical and/or behavioral health needs cannot be accommodated within
      the basic benefit package offered under HUSKY, Part B.  Effective
      January 1, 2006 the supplemental health insurance program that covered children
      with intensive behavioral health needs, HUSKY Plus Behavioral (HPB) was
      eliminated. Emergency mobile, case management, and rehabilitative services
      previously covered under HPB are now covered under the core HUSKY B benefit
      package (see Sec. 6.2 and Appendix 6.1). This appendix only addresses the HUSKY
      Plus Physical program, the program designed to provide coverage to children
      with
      intensive physical health needs.  General Features of the HUSKY Plus
      Physical Program

     

    The
      HUSKY
      Plus Physical (HPP) Plan is a supplemental benefit package for children who
      are
      eligible for and enrolled in HUSKY, Part B, with household incomes under 300%
      of
      the federal poverty limit (Income bands 1 and 2 only). Children may not apply
      for coverage under HUSKY Plus unless they have already been determined to be
      eligible under HUSKY, Part B, and have enrolled in HUSKY, Part B.

    Children
      who are eligible under HPP will be dually eligible. That
      is, children who are determined to be eligible under HPP will continue to
      receive benefits under HUSKY, Part B, including those physical health services
      for their special needs diagnoses or conditions that are covered under Part
      B.

     

    As
      described below, these services will be coordinated by a case
      management/treatment team composed of case managers from both HUSKY, Part B
      and
      one or both of the HUSKY Plus Physical plan, which will maximize the
      coordination of benefits under both plans and other sources of coverage through
      federal, state and private support. The case management/treatment team will
      need
      to coordinate the development of the Global Plan of Care (GPC) so that services
      included do not replicate special education services authorized under an
      Individual Education Plan (I.E.P.) or Individualized Family Service Plan
      (I.F.S.P.).

    In
      the
      event that the child is eligible for HUSKY, Part B and HPP, the case management
      team leader of HPP will need to coordinate with the HUSKY, Part B case manager
      to assure that the HPP GPC’s complements services provided under HUSKY, Part
      B.

     

    However,
      ultimate utilization management decisions will rest with the utilization
      managers of the plan that is financially at risk; i.e., HUSKY, Part B
      utilization managers will have final decision making authority for those
      services for which they are at risk and HPP utilization managers will have
      the
      decision making authority for those supplemental services included in their
      benefit package.

    In
      the
      event there is a dispute between the participating HUSKY, Part B managed care
      plan and the HPP concerning the responsibility for reimbursement of a service
      authorized under the treatment plan, the dispute will be referred to the
      Commissioner (or his/her designee) for resolution.

     

    Eligible
      children will be able to receive services under both the basic and one or both
      supplemental benefit package simultaneously in order to allow both plans to
      provide services to the child to the fullest extent possible in the least
      restrictive setting.

     

    HPP
      services may supplement HUSKY, Part B services once a child has exhausted his
      or
      her annual benefit limits under Part B. However, HPP will always be the payer
      of
      last resort. The case management/treatment team will always look to exhaust
      all
      medically necessary coverage benefits under HUSKY, Part B, including conversion
      options when appropriate, before these services are supplanted or replaced
      by
      services available under HPP .

     

    II.  HUSKY
      Plus Plan for Children with Special Physical Health Care
      Needs

     

    Program
      Administration

    The
      HUSKY
      Plus Plan for Children with Special Physical Health Care Needs (HPP) will be
      administered by the Connecticut Children’s Medical Center. The advisory
      committee established by the Department of Public Health for Title V of the
      Social Security Act will be the Steering Committee for the HPP plan along with
      representatives from the Departments of Social Services (DSS) and Children
      and
      Families (DCF). The Steering Committee shall be named the Steering and Advisory
      Committee for Children with Special Health Care Needs and HUSKY Plus Physical
      (SASH).

     

    Eligibility

    Children
      enrolled in HUSKY, Part B, Income Bands 1 and 2, who have intensive physical
      health needs that cannot be met within the Part B benefit package will be
      eligible for supplemental services under the HPP plan if they meet the clinical
      eligibility standard. The clinical eligibility standard is based on diagnostic
      and/or acuity criteria and shall be the same as those for the Title V program
      currently operating in the state.

    Clinical
      eligibility will be determined:

     

    
      	
              1.  

            	
              By
                documentation of clinical information which meets the “Medical Eligibility
                Criteria” of the Department of Public Health Title V Program;
                or

            


    

     

    
      	
              2.  

            	
              By
                meeting the approved definition of Children with Special Health Needs
                with
                documentation of clinical evidence. The definition adopted by the
                Steering
                Committee but subject to change is as
                follows:

            


    

     

     “Children
      with Special Health Care Needs are those who have or are at elevated risk for
      (biologic or acquired) chronic physical or developmental conditions and who
      also
      require health and related (not educational and not recreational) services
      of a
      type and amount not usually required by children of the same age (beyond
      Connecticut’s EPSDT periodicity schedule). The age of eligibility is birth to 18
      years, but may include those to age 21 (for those determined eligible before
      age
      18) for purposes of transition to adult services.” . In addition, eligibility
      for HPP will end at age 19, when eligibility for HUSKY, Part B also
      ends.

    For
      the
      purposes of determining acuity of a child who meets the Medical Eligibility
      Criteria or who may qualify as a Child with Special Health Care Needs, the
      HPP
      Center will use the Children with Special Health Care Needs Screening Tool,
      or
      others as approved by the Department (See attached).

     

    Referral
      and Application Process

    Children
      who may be at risk may be identified by their parents, their primary care
      provider, or another provider in the HUSKY, Part B Plan in which the child
      is
      enrolled. Referral made by made in writing or by telephone by any of the above
      parties. However, the application process for HPP will be coordinated by the
      HUSKY, Part B Plan.

    Children
      will be assessed for eligibility consistent with the practices and procedures
      currently in place under the Title V Program.

     

    Covered
      Services

    All
      children determined eligible for HPP will receive care coordination, advocacy,
      family support and case management services as well as comprehensive
      multidisciplinary evaluation once a year and up to 3 follow-up visits per year
      with members of the multidisciplinary group as needed. In addition, the range
      of
      services will include the following to the extent that they are not covered
      under the HUSKY, Part B benefit package:

     

    
      	
              ·  

            	
              Adaptive
                Seating,
                Specialized:   One
                evaluation, fabrication and completion per year. Fees are inclusive
                of one
                adjustment every 2 weeks until family is
                satisfied.

            


    

     

    
      	
              ·  

            	
              Audiometry:
                 Includes BAER, OAE; two per
                year.

            


    

     

    
      	
              ·  

            	
              Cast
                Room:  Cast room visits
                as necessary to maintain integrity of cast or to implement treatment
                plan.

            


    

     

    
      	
              ·  

            	
              Diagnostic
                Imaging (i.e., MRI,
                CT):

            


    

     

    
      	
              ·  

            	
              Durable
                Medical Equipment:   Exclusive of the basic
                HUSKY B plan and include items that assist in the activities of daily
                living

            


    

     

    
      	
              ·  

            	
              EEG/telemetry: Two
                per year.

            


    

     

    
      	
              ·  

            	
              EKG/Holter:  Two
                per year.

            


    

     

    
      	
              ·  

            	
              Emergency
                Care: Exclusive of the
                basic plan; directly related to condition that qualifies child for
                HPP.

            


    

     

    
      	
              ·  

            	
              Gait
                Analysis: One per
                year.

            


    

     

    
      	
              ·  

            	
              General
                Dental, Orthodontic: Only for children who have
                malocclusive disorders or periodontal disease resulting from their
                underlying qualifying condition or related
                treatment.

            


    

     

    
      	
              ·  

            	
              Hearing
                Aids:  One (or one pair) analog hearing aid(s)
                as prescribed per year; One (or one pair) digital hearing aid(s)
                as
                prescribed every 5 years

            


    

     

    
      	
              ·  

            	
              Home
                Health
                Aide:   Total
                of ten hours/week

            


    

     

    
      	
              ·  

            	
              Laboratory

            


    

     

    
      	
              ·  

            	
              Medical
                and Surgical
                Supplies

            


    

     

    
      	
              ·  

            	
              Medical
                Nutrition
                Services

            


    

     

    
      	
              ·  

            	
              Medical
                23 Hour and Day
                Surgery

            


    

     

    
      	
              ·  

            	
              Occupational,
                Physical and Speech
                Therapies

            


    

     

    
      	
              ·  

            	
              Orthotic
                Devices:   No more
                than one a year or one pair per year per prescribed type, including
                all
                delivery fees, fittings and
                adjustments.

            


    

     

    
      	
              ·  

            	
              Pharmacy: Over
                the Counter medications will be covered if medically necessary and
                directly related to the condition that qualifies the child for the
                program. Prior authorization by DSS
                required.

            


    

     

    
      	
              ·  

            	
              Physician
                Fees for Inpatient
                Care: Visits must be
                requested as consultations by the admitting physician and be specifically
                related to the qualifying
                condition.

            


    

     

    
      	
              ·  

            	
              Physician
                Fees for Outpatient
                Care: Covered as per care
                plan.

            


    

     

    
      	
              ·  

            	
              Prosthetics/Prosthetic
                Devices: No more than one
                per year including all delivery fees, fittings and adjustments/repairs.
                Excludes myoelectric devices.

            


    

     

    
      	
              ·  

            	
              Pulmonary
                Function Testing:  One per
                year.

            


    

     

    
      	
              ·  

            	
              Radiology

            


    

     

    
      	
              ·  

            	
              Skilled
                Intermittent Nursing:  One visit per day for
                evaluation, treatment, and education. Must be provided by a licensed
                home
                health
                agency.

            


    

     

    
      	
              ·  

            	
              Sleep
                Study/Polysomography:  One per
                year.

            


    

     

    
      	
              ·  

            	
              Special
                Nutritional Formulas or Supplements/ PKU
                Foods: Nutritional habilitative and/or
                rehabilitative sustenance of a type or amount not usually required
                by
                children. Prescribed by an authorized professional within acceptable
                standards of the American Dietetic
                Association.

            


    

     

    
      	
              · 

            	
              Transportation:  2
                round trips per year to any health care appointment by ambulance,
                chair-vans and/or other licensed medical transportation for non-emergent
                visits.

            


    

     

    
      	
              ·  

            	
              Wheelchairs:  One
                new manual wheelchair no more than every three years. One new motorized
                wheelchair no more than every five
                years.

            


    

     

    This
      list
      may be revised from time to time as recommended by the Steering Committee and
      approved by the Department.

     

    Service
      Providers

    The
      Connecticut Children’s Medical Center will serve as the coordinating
      organization. but services will be provided by the entities under contract
      to
      provide Title V services.

     

    Service
      Utilization Management

    Service
      utilization will be managed through a clear definition of medical necessity.
      “Medical Necessity” or “medically necessary” is defined as health
      care provided to correct or diminish the adverse effects of a medical condition
      or mental illness; to assist an individual in attaining or maintaining an
      optimal level of health; to diagnose a condition; or prevent a medical condition
      from occurring.

    All
      services will be subject to prior authorization by the utilization management
      staff at the Connecticut Children’s Medical Center. These decisions will be
      subject to the process for Grievances and Appeals (see below).

     

    Coordination
      of HPP Services with HUSKY, Part B

    In
      order
      to ensure that HPP will be the documented payer of last resort, the HPP Center
      shall assign each enrollee with a case manager and provide care coordination
      services. The HPP case manager shall coordinate with the HUSKY, Part B case
      manager to ensure that all medically necessary HPP covered services identified
      in the global plan of care (GPC), which are also covered in the HUSKY, Part
      B
      basic benefit package, are exhausted first under HUSKY, Part B.

    The
      HPP
      Center shall designate a Lead Case Manager who will be responsible for convening
      a case management/treatment team that will develop an individualized
      GPC for each enrollee. The case
      management/treatment team may be composed of, but not limited to, the enrollee
      or enrollee’s parent(s), treating clinicians and/or providers, the HUSKY, Part B
      Case Manager, and the Lead Case Manager. The case management/treatment team
      will
      coordinate the development of the GPC so that covered services included in
      the
      GPC do not replicate special education services authorized under an I.E.P.
      or
      I.F.S.P.

    In
      the
      event that the enrollee is also eligible for HPB, the case management/treatment
      team shall include the case manager from HPB. The case management/treatment
      team
      shall develop a GPC that integrates services from HUSKY, Part B, HPP and HPB
      as
      appropriate.

     

    Global
      Plan of Care (GPC)

    HPP
      will
      ensure that the case management/treatment team completes the GPC for each
      enrollee within 30 days of the date of eligibility determination. The case
      management/treatment team on at least a semi-annual basis will reassess the
      GPC.
      The GPC will be based on the comprehensive need assessment, periodic
      reassessments, and treatment plans from the HUSKY, Part B Plan and HPP
      Contractor providing services to the child. The GPC will include medical
      management recommendations reflecting the level of involvement of the HPP staff
      and the scope of clinical practice of the clinical staff, estimates of the
      need
      and frequency of specific clinical services and a designation of who is
      responsible for the specific elements of the GPC.

     

    The
      GPC
      will be mailed or faxed to the enrollee’s HUSKY, Part B Plan and to the child’s
      primary care physician.  A written copy of the GPC will be kept on
      file at HPP, as part of the child’s case file.

     

    Program
      Quality

    Both
      HPP
      will be reviewed annually by an external quality review organization (EQRO)
      pursuant to the goals identified in the Title XXI State Plan. Pursuant to this
      review, the Commissioner will submit a report to the Governor and the General
      Assembly on the HUSKY Plus Programs which will include an evaluation of the
      special health outcome and access measures identified for HUSKY Plus
      enrollees.

    In
      addition, the Department will review the HPP Center at least annually. Based
      on
      the EQRO report and the Department review, recommendations for program quality
      improvement will be identified. Corrective action plans and quality improvement
      projects will be initiated by the Centers in conjunction with the
      Department.

     

    Grievance
      and Appeals Process

    In
      accordance with 42 CFR 457 part(s) 1120 – 1180, a HUSKY Plus applicant has the
      right to request an administrative review regarding a decision made on their
      HUSKY Plus application. Whenever possible, HPP will attempt to resolve
      grievances informally. However, parents and providers will be encouraged and
      supported in the filing of appeals without fear of compromised service. A copy
      of the appeals procedure, written in a manner easily understood by the lay
      public, will be distributed to every family at the time of their application
      to
      HPP.

     

    The
      state
      ensures that all enrollees and applicants receive timely written notice of
      any
      determinations required to be subject to review, as outlined
      below.  Written notices at each level include the reasons for the
      determination, an explanation of applicable rights to review of that
      determination, the standard and expedited time frames for review, the manner
      in
      which a review can be requested, and the circumstances under which enrollment
      may continue pending review.  However, the State will not provide
      an opportunity for review of a matter if the sole basis for the decision is
      a
      provision in this plan or in federal or State law requiring automatic change
      in
      eligibility, enrollment, or a change in coverage under the health benefits
      package that affects all applicants or enrollees or a group of applicants or
      enrollees without regard to their individual circumstances.

    The
      following decisions can be appealed through the grievance process:

     

    
      	
              ·  

            	
              Denial
                of eligibility for Income Bands One and Two
                only;

            


    

     

    
      	
              ·  

            	
              Failure
                to make a determination of eligibility within 21 days of
                application;

            


    

     

    
      	
              ·  

            	
              Suspension
                or termination of enrollment in HPP for enrollees enrolled in Income
                Band
                One or Income Band Two of HUSKY B;

            


    

     

    
      	
              ·  

            	
              Delay,
                denial, reduction, suspension or termination of goods or services,
                including determination regarding level of
                services;

            


    

     

    
      	
              ·  

            	
              Failure
                to approve, furnish or provide payment for services in a timely
                manner;

            


    

     

    
      	
              ·  

            	
              Medical
                necessity of a type of service or setting;
                and

            


    

     

    
      	
              ·  

            	
              Choice
                of provider

            


    

     

    While
      an
      appeal regarding suspension or termination of eligibility or enrollment is
      being
      considered, the enrollee will remain eligible for HPP and their goods and/or
      services will be continued until the grievance is decided, so long as the
      enrollee remains in Income Band 1 and 2. An enrollee who has been enrolled
      in
      Income Band 3 of the HUSKY B program shall be disenrolled from HPP.

    While
      an
      appeal regarding delay, denial, reduction, suspension or termination of goods
      and/or services is being considered, the enrollee will continue to receive
      such
      goods and/or services until the appeal is decided, so long as the child remains
      in Income Band 1 or 2.

     

    Applicants
      or enrollees requesting to review their files or other information relevant
      to
      the appeal review will be provided access to their files at a mutually
      convenient date and time, but no later than four days prior to the decision
      being issued. Additionally, the State will ensure that applicants or
      enrollees have opportunities to represent themselves or have representatives
      of
      their choosing in the review process, and to fully participate in the review
      process.

    The
      grievance and appeals process will have three levels of appeal: the first to
      HPP’s medical director (who was not involved in the prior decision), the second
      to a sub-group of the Steering Committee, and the third to the
      Commissioner.

     

    Whenever
      a decision is made regarding an enrollee’s eligibility, enrollment or goods
      and/or services, a letter is sent from the HPP Center to the parent describing
      the decision. Letters, which deny, reduce, suspend or terminate eligibility
      or
      enrollment, or goods and/or services (as listed above), will also include a
      one
      page Appeal Form and a copy of the Appeals Procedure Summary. To begin the
      appeals process, the parent or provider should complete the Appeals Form. The
      form should be mailed or delivered to the HPP Center but must be received by
      the
      Center within 45 days of the date of the letter describing the decision that
      is
      being appealed.

     

    Level
      One Appeal:

    The
      HPP
      Center will send a letter that acknowledges receipt of the appeal form to the
      parent or provider. The letter will identify a HPP staff member as the Appeals
      Manager. The Appeals Manager will track the appeal, act as the contact person
      for questions and updates, and will attempt to resolve the appeal within ten
      days. If the appeal is resolved to the satisfaction of the parent or provider
      by
      the Appeals Manager, a letter will be sent describing the resolution, and there
      will be no further action. If the appeal cannot be resolved at this level,
      the
      Appeals Subcommittee will review the appeal.

     

    Level
      Two Appeal:

    The
      Appeals Subcommittee of the Steering and Advisory Committee for Children with
      Special Health Care Needs and HUSKY Plus Physical (SASH) for HPP has three
      members, one each from:

     

    
      	
              ·  

            	
              The
                Department of Social Services (DSS)

            


    

     

    
      	
              ·  

            	
              The
                Department of Public Health (DPH)
                and

            


    

     

    
      	
              ·  

            	
              The
                Connecticut Children’s Medical
                Center

            


    

     

    No
      one
      directly involved in the decision being appealed will be a member of this
      subcommittee. The Appeals Manager is not a member of this subcommittee but
      will
      attend to provide needed information.

    A
      letter
      will be sent to the parent or provider that gives the time and date of the
      Appeals Subcommittee meeting. The meeting will be scheduled to occur within
      ten
      business days of receipt of the written appeal. The parent or provider may
      reschedule this meeting, for any reason, once. However, the Appeals Committee
      meeting must occur within 25 business days of the receipt of the
      appeal.

    The
      parent or provider may bring support persons to the Appeals Subcommittee
      meeting, including legal counsel, a person with special knowledge or training
      with respect to the problems of the enrollee, and one or two individuals for
      support.

     

    In
      the
      Appeals Subcommittee, the Appeals Manager will present the appeal; along with
      any documents involved in the initial decision. The Appeals Manager will also
      present a summary of the efforts to this point to resolve the appeal. The
      parent, provider or accompanying support persons may also present arguments
      and
      documents, which support the appeal. Once all appeal arguments are completed,
      the Appeals Subcommittee will either make a decision regarding the appeal,
      or if
      necessary, continue the case until more information is obtained or until
      documents are reviewed. The Appeals Subcommittee must render a final decision
      no
      later than 30 days from the date of the Appeals Subcommittee meeting. The
      Appeals Subcommittee chairperson will send the parent or provider a letter
      describing the Appeal Committee’s decision no later than 30 days from the date
      of the Appeals Subcommittee meeting.

     

    Level
      Three Appeal:

    If
      the
      parent or provider does not agree with the Appeal Subcommittee’s decision,
      he/she may continue the appeal process by writing a letter to the Commissioner
      of the Department of Social Services (DSS) or designee. In this case, the parent
      or provider must send a copy of the original Appeal Form, the Appeals
      Subcommittee letter and any other pertinent documents to the Commissioner or
      designee within ten business days of the date of the Appeals Subcommittee
      letter. The Appeals Manager will continue to help the parent or provider with
      this next step. The DSS Commissioner or designee shall make a determination
      and
      provide a written decision to the parent no later than 90 days from the initial
      request date.

    If
      the
      enrollee has been enrolled in the HPP program and is found to be ineligible
      for
      HPP, and this decision is appealed, the enrollee will continue to be eligible
      for HPP services so long as the child remains eligible for and enrolled in
      HUSKY, Part B, Income Bands 1 and 2, until the appeal process is completed.
      Enrollees of HUSKY, Part B who are in Income Band 3 are not eligible for the
      HUSKY Plus Program and shall be immediately disenrolled from HPP

     

    Expedited
      Appeal:

    Pursuant
      to 42 CFR 457.1160, the appeal process for HPP must allow for expedited review.
      This process applies to both eligibility and enrollment matters as well as
      for
      goods and/or services. If an enrollee requests an expedited review, HPP must
      determine within one business day of receipt of the request, whether to expedite
      the review or whether to perform the review according to the standard
      timeframes. The review may be expedited if the Medical Director of HPP
      determines that the standard time frame could seriously jeopardize life or
      health or ability to attain, maintain or regain maximum function. If the Medical
      Director of HPP determines that the appeal should be expedited, the Level One
      review must be completed within 72 hours of receipt of the appeal request by
      HPP. A Level Two review of an expedited appeal must be completed within 72
      hours
      after completion of the Level One review. An expedited Level Three review must
      be completed within 72 hours after completion of the Level Two expedited review.
      The above timeframe may be extended upon request of the parent up to a maximum
      of 14 days.

    



    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Appenndix
      D

     

    Provider
      Credentialing and Enrollment
      Requirements

    



    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

                

      

    

    


    HUSKY
      B

    PROVIDER
      CREDENTIALING AND ENROLLMENT REQUIREMENTS

    1. Provider
      Credentialing, and Enrollment Distinction

    Provider
      Credentialing and provider enrollment are separate and distinct processes in
      the
      HUSKY Programs. However, credentialing and enrollment are linked in that these
      requirements affect direct service providers as well as the manner in which
      MCOs
      submit provider network information to the Department of Social
      Services.

     

    2. Credentialing
      Definition

    For
      the
      purpose of the HUSKY programs, the term credentialing means the requirements
      for
      provider participation specified in the contracts between the Department of
      Social Services (DSS or the Department) and the MCO (Part II, 3.11, Provider
      Credentialing and Enrollment). In this section of the contract, the Department
      specifies the minimum criteria that the MCOs must require for provider
      participation in a health plan. The MCOs must ensure that their providers
      meet the Department's credentialing requirements.

     

    3. Other
      Sources Credentialing

    Credentialing
      is sometimes used to refer to a variety of requirements or entities, which
      issue
      credentialing standards. Examples include: the MCO's individual credentialing
      requirements; the managed care subcontractor's credentialing requirements;
      an
      accreditation organization requirements, such as the National Committee on
      Quality Assurance (NCQA); the licensure process; a trade organization or
      association such as the Joint Commission on Accreditation of Health
      Organizations (JCAHO).

     

    4. DSS
      Requirements and Other Credentialing Sources

    DSS
      credentialing requirements represent the minimum criteria for provider
      participation in a health plan. The Department will allow flexibility to the
      MCOs to use more stringent criteria, particularly as it concerns quality level
      of care for clients. While the MCOs may require additional, more stringent
      criteria, the Department is concerned with the impact on access to care.
      Therefore, DSS expects the MCOs to balance the need for stringent credentialing
      standards with the need to assure accessibility and continuity of
      care.

     

    5. Delegated
      Credentialing

    The
      contract between the Department and the MCOs permits the plan to delegate
      credentialing of individual providers to a facility. However, the MCO is
      ultimately responsible and accountable to DSS for compliance with the
      Department's credentialing requirements.

    For
      the
      purpose of HUSKY, delegated credentialing means that the MCO entrusts the
      Department's credentialing requirements to another entity. MCOs delegate
      credentialing to a variety of entities depending on the nature of the services
      and the type of provider.

    In
      delegated credentialing, the MCO remains responsible to DSS to verify and
      monitor compliance with the Department's credentialing requirements. The
      Department views delegated credentialing as a form of subcontract, therefore,
      similar oversight issues arise in the performance of the credentialing
      requirements. The Department requires the plans to demonstrate and document
      to
      DSS the plan's strong oversight of its delegated credentialing facilities.
      (Part
      II, Section 3.41 in B 3.44 in A, Subcontracting for Services).

     

    6. Implications
      of Delegated Credentialing

    In
      some
      instances, the MCO credentials the individual provider directly or delegates
      credentialing of the providers to the following entities:

     

    
      	
              ·  

            	
              A
                subcontractor providing specific services (e.g., dental
                care);

            


    

     

    
      	
              ·  

            	
              A
                credentialing subcontractor; or

            


    

     

    
      	
              ·  

            	
              A
                facility (e.g., a freestanding clinic or
                hospital)

            


    

    The
      relationship between the MCO and the delegated entity as well as the interplay
      with various credentialing requirements may take any number of configurations.
      Currently, the Department reiterates that the MCO may delegate credentialing
      of
      individual providers to a facility (e.g., a school based health center,
      freestanding clinic or hospital). However, the Department emphasizes that the
      MCO is ultimately responsible and accountable to DSS for compliance with all
      of
      the Department's credentialing requirements.

     

    7.  Oversight
      of Delegated Credentialing

    The
      Department requires the MCO to demonstrate strong oversight of their delegated
      credentialing facilities, as with any subcontract. - Therefore, the Department
      reiterates that these arrangements are subject to the Department's review and
      approval. For the purpose of delegated credentialing, the MCOs must provide
      assurances to DSS at a minimum of the following:

     

    
      	
              •

            	
              The
                MCO and the delegated entity should clearly identify in detail each
                party's responsibility for credentialing of
                providers.

            


    

    
      	
              •

            	
              The
                Department's credentialing requirements should be clearly identified
                as
                well as each party's role in adhering to these
                requirements.

            


    

    
      	
              •

            	
              The
                *credentialing files must be available to the plan in order to perform
                its
                oversight of the credentialing requirements. The Department must
                also have
                adequate access to credentialing files for the purposes of administering
                the managed care contracts.

            


    

    (DSS/MCO
      HUSKY A Contract, Part II, Section 3.45 “Subcontracting for Services” and in
      HUSKY B Section 3.42 “Subcontracting for Services”.)

     

    8.  Provider
      Enrollment Clarifications

    For
      the
      purpose of HUSKY, the Department refers to provider enrollment as the process
      of
      capturing information on providers participating with MCOs contracted by DSS
      to
      provide services to clients. This process results in a profile of an MCO's
      provider network.    The MCOs submit the provider network
      information to DSS via the Department's agent on a continuous basis. The
      Department utilizes the provider network information to facilitate the
      administration of managed care contracts and- the Medicaid program.

     

    Provider
      enrollment information serves the following purposes:

     

    
      	
              a)

            	
              To
                evaluate each MCO's service area and access to services which areused
                to
                establish enrollment ceiling or cap (currently summarized by plan
                submittals of provider tables);

            


    

    
      	
              b)

            	
              To
                provide accurate infori-nation to clients for the purpose of client
                enrollment in an MCO; and

            


    

    
      	
              c)

            	
              To
                maintain each plan's provider network information consistent with
                the
                provider directory.

            


    

     

    Based
      on
      the previous discussion of credentialing, the Department clarifies the
      relationship between credentialing or delegated credentialing and provider
      enrollment as follows:

    
      	
              a)

            	
              Enrollment
                for purposes of cap determination.

            


    

    
      	
               

            	
              •

            	
              The
                MCO must credential and enroll individual providers when the providers
                are
                counted towards the member enrollment
                ceiling.

            


    

    
      	
               

            	
              •

            	
              DSS
                credentialing requirements and provider enrollment processes also
                apply to
                individual providers in a facility when the individual provider is
                included in the count for cap
                determination.

            


    

    
      	
               

            	
              •

            	
              The
                MCO may delegate credentialing of individual providers to a facility
                (e.g., a clinic or hospital) and enroll the facility as such. In
                this
                case, -neither the facility nor the individual providers are provided
                in
                the count for cap determination.

            


    

    b)           Enrollment
      for purposes of accurate information to clients

    
      	
              ·  

            	
              The
                MCO must enroll and credential individual providers as well as facilities
                in order to maintain accurate and updated information on the providers
                participating with a health plan. The provider network information
                is used
                by the Department's enrollment broker during
                enrollment.

            


    

    
      	
              ·  

            	
              The
                Department stresses the importance of maintaining provider network
                information accurate and up-to-date. It is crucial that clients should
                have access to provider network information during the MCO select-ion
                process.

            


    

    c)           Enrollment
      for purposes of inclusion in the provider network directory.

    
      	
               

            	
              •

            	
              The
                MCO must credential and enroll individual providers when the providers
                are
                included and listed as individual providers in the health plan's
                provider
                directory.

            


    

    
      	
               

            	
              •

            	
              DSS
                credentialing requirements and provider enrollment processes also
                apply to
                individual providers in a facility when the individual provider is
                included and listed in the provider
                directory.

            


    

    
      	
               

            	
              •

            	
              If
                the 14CO delegates credeintialing of individual providers to
                a       facility and enrolls the
                facility, the facility is included and listed in the provider directory.
                The facility's individual providers are listed in the provider directory.
                The facility's providers are not listed in the provider
                directory.

            


    

     

    
      	
              9.  

            	
              Specific
                Issues and DSS Credentialing
                Requirements

            


    

     

    
      	
              a)

            	
              Medicaid
                participation

            


    

    The
      MCO
      or the delegated credentialing entity is responsible for the determination
      and
      verification that the provider meets the minimum requirements for Medicaid
      participation. The MCO or its -subcontractors may not delegate this provision
      to
      the Department nor require providers to enroll or participate in fee-for-service
      Medicaid to fulfill the requirement. While the Department encourages the MCO
      to
      contract with traditional and existing Medicaid providers, Medicaid
      participation in itself is not a requirement of the HUSKY
      contracts.

     

    
      	
              b)

            	
              Allied
                Health Professional Licensed Clinics or
                Hospitals

            


    

    The
      Department pays freestanding clinics participating in the Medicaid program
      for a
      variety of services. In Connecticut, clinic services include for example,
      medical services, well-child care, dental care, mental health and substance
      abuse services, rehabilitation services and other services. Clinic providers
      must meet federal and state requirements for participation in the Medicaid
      program. In accordance with Title 42 of the Code of Federal Regulations, Part
      440.90 and Section 171 of the Medical Services Policy of the Connecticut Medical
      Assistance Program, clinic services are provided by or under the direction
      or a
      physician, dentist or psychiatrist.

     

    The
      physician direction requirement means that the free-standing clinic's services
      may be provided by the clinic's allied health professionals whether or not
      the
      physician is physically present at the time that the services are provided.
      An
      allied health professional is further defined as an individual, employed in
      a
      clinic, who is qualified by special education and training, skills, and
      experience in providing care and treatment. The clinic is staffed by physicians
      and allied health professionals who are directly involved in the facility's
      programs. The allied health professionals provide services under the direction
      of a physician who is a licensed practitioner performing within the scope of
      his/her practice.

     

    Based
      on
      the Department's definition of clinic services, the services provided by allied
      health professionals are included under the terms of the contracts between
      the
      Department and the MCOs.

    As
      with
      all services, clinic services must be properly credentialed according to the
      Department's requirements, including licensure and certification standards.
      Allied health professionals may have licensure or certification requirements,
      such as Certified Addition Counselors or Licensed Social Workers. In accordance
      with the Department's definition, other allied health professions may qualify
      by
      virtue of their skills or experience and must function under the direction
      of a
      physician. In this case- the directing physician, as opposed to the allied
      health professional, is subject to the credentialing requirements as well as
      provider enrollment. The MCO may credential the physician directly or may
      delegate credentialing.

     

    The
      Department's provisions for credentialing, delegated and provider enrollment
      would remain in effect for the directing physician (please refer to Section
      8,
      Provider Enrollment Clarifications).

     

    
      	
              c)

            	
              NCQA
                Standards and DSS requirements

            


    

     

    While
      NCQA standards do not address credentialing of allied health professionals,
      services provided by allied health professionals may qualify for reimbursement
      by virtue of their skills or experience, however, the allied health
      professionals must function under the direction of a physician. In this case,
      the directing physician is subject to the credentialing
      requirements.

    



    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Appendix
      E

     

    American
      Academy of Pediatrics - Recommendations for
      Preventive Pediatric Health Care

    



    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

            

      

    


    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
Appendix
      F

     

    DSS
      Marketing Guidelines

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

                

        

      

    

    


    Appendix
      F

     

    Detailed
      Marketing Guidelines

    1)  General
      HUSKY marketing materials

     

    Marketing
      materials are defined as all media, including brochures and leaflets; newspaper,
      magazine, radio, television, billboard and yellow pages advertisements; and
      presentation materials used by MCO representatives.

    The
      DEPARTMENT will not restrict the MCO's general communications to the public.
      However, the MCO must obtain prior approval from the DEPARTMENT prior to any
      written material or advertisement that is mailed to, distributed to, or aimed
      at
      HUSKY recipients or individuals potentially eligible for HUSKY, specifically,
      material that mentions Medicaid, Medical Assistance, Title XIX, Title XXI State
      Children's Health Insurance Program (SCHIP) or HUSKY. Examples of HUSKY-specific
      materials would be those which are in any way targeted to HUSKY populations
      (such as billboards or bus posters disproportionately located in low-income
      neighborhoods); those that mention the MCO's HUSKY product name; or those that
      contain language or information specifically designed to attract HUSKY
      enrollment.

     

    2)  General
      MCO marketing/advertising

    All
      MCO-specific marketing activities for the HUSKY population, as defined above,
      and all marketing materials /advertising put forth by HUSKY-only MCO require
      DEPARTMENT prior approval.

    In
      determining whether to approve a particular marketing activity, the DEPARTMENT
      will apply a variety of criteria, including, but not limited to:

     

    
      	
              a)

            	
              Accuracy:
                The content of the material must be accurate. Any information that
                is
                deemed inaccurate will be
                disallowed.

            


    

    
      	
              b)

            	
              Misleading
                references to the MCO's positive attributes: Misleading information
                will
                be disallowed even if it is accurate. For example, the MCO may seek
                to
                advertise that its health care services are free to its Medicaid
                (HUSKY A)
                Members. In this situation, DEPARTMENT would disallow the language
                since
                this could be construed by Members as being a particular advantage
                of the
                plan (e.g. they might believe they would have to pay for health services
                if they chose another MCO or remained in
                fee-for-service).

            


    

    
      	
              c)

            	
              Threatening
                Messages: MCOs shall not imply that the managed care program or the
                failure to join a particular MCO would endanger the Member's health
                status, personal dignity, or the opportunity to succeed in various
                aspects
                of their lives. MCOs are strictly prohibited from creating threatening
                implications about the State's mandatory assignment process for HUSKY
                A
                Members or other aspects of the HUSKY A or HUSKY B
                programs.

            


    

    
      	
              d)

            	
              MCO's
                Legitimate Strengths: MCOs may differentiate themselves by promoting
                their
                legitimate positive attributes.

            


    

     

    3) MCO
      advertising at provider care sites

    Promotional
      and health education materials at care delivery sites (including patient waiting
      areas) are permitted, subject to prior DEPARTMENT content approval. MCO member
      services staff may provide member services (e.g. face-to-face member education)
      at provider care sites, however, face-to-face meetings, for purposes of
      marketing, at care delivery sites between individual Members and MCO staff
      are
      not permitted.

     

    4)  MCO
      advertising in DEPARTMENT eligibility offices

     

    MCOs
      may
      make their materials available at DEPARTMENT offices only through the DEPARTMENT
      or its agent. This restriction applies to all eligibility offices, including
      those based in hospitals. MCO marketing staff and provider staff are not
      permitted to solicit Member enrollment by positioning themselves at or near
      eligibility offices. Note that the only face-to-face marketing activities
      allowed are those directly permitted under items #5, #7, #11 and #12 of these
      guidelines. All other face-to-face marketing activities are
      prohibited.

     

    5) Provider
      communications with HUSKY patients about MCO options

     

    DEPARTMENT
      marketing restrictions apply to the MCO's participating providers as well as
      to
      the MCOs. MCOs must notify all of their participating providers of the
      DEPARTMENT marketing restrictions and provide them with a copy of this
      document.

     

    Each
      provider entity is allowed to notify its patients of the HUSKY-certified MCOs
      it
      participates in, and to explain that the patients must enroll in one of these
      MCOs if they wish to preserve their existing relationship. This must be done
      through written materials prior-approved by DEPARTMENT, and must be distributed
      to HUSKY patients without regard to health status. Providers must not indicate
      a
      preference between the MCOs in which they participate.

     

    6) Member-initiated
      telephone conversations with MCOS and providers

     

    These
      conversations are permitted and do not require prior approval by the DEPARTMENT,
      but information given to potential Members, during such telephone conversation
      must be in accordance with the DEPARTMENT's marketing guidelines. However,
      telephone conversations must be initiated by the potential Member, not by the
      MCO staff (or provider staff). MCOs and providers may return calls to Members
      and potential Members when Members and potential Members leave a message
      requesting that this occur.

     

    7)  Member-initiated
      one-on-one meetings with MCO staff prior to enrollment

    Such
      meetings, when requested by the Member, are permitted but may not occur at
      a
      participating provider's care delivery site or at the Member's residence. These
      meetings must occur at the MCO's offices or another mutually-agreed upon public
      location. All verbal interaction with the Member must be in compliance with
      the
      DEPARTMENT's marketing guidelines.

     

    8) Mailings
      by MCO in response to Member requests

     

    MCO
      mailings are permitted in response to Member verbal or written requests for
      information. The content of such mailings must be prior-approved by the
      DEPARTMENT. MCOs may include gifts of nominal value (unit cost less than $2,
      e.g. magnets, pens, bags, jar grippers, etc.) in these mailings.

     

    9) Unsolicited
      MCO mailings

     

    MCOs
      are
      permitted to send unsolicited mailings. The content of such mailings must be
      prior-approved by DEPARTMENT. In addition, the target audiences must be
      prior-approved by DEPARTMENT, and the MCOs must explain how they obtained the
      list of names, addresses and phone numbers.

     

    10) 
      Telemarketing

     

    Telemarketing
      is not a permitted marketing activity

     

    11) MCO
      group meetings held at MCO

     

    These
      meetings must be prior approved by the DEPARTMENT. The MCO may not notify
      prospective Members until DEPARTMENT prior approval has been
      obtained

    
       

      12)
        MCO
        group meetings held in public facilities, churches, health fairs, or other
        community sites

    

     

    These
      are
      permitted activities as long as DEPARTMENT approved materials are utilized
      in
      the presentations and the DEPARTMENT's marketing guidelines are followed. The
      DEPARTMENT reserves the right to monitor such meetings on an ad hoc basis.
      MCOs
      are required to notify the DEPARTMENT sufficiently in advance to allow
      DEPARTMENT representatives to attend such meetings in order to monitor MCO
      activities if desired. As soon as the MCO has scheduled these activities, the
      DEPARTMENT should be notified.

     

    13)  MCO
      group meetings held in private clubs or homes

     

    These
      activities are prohibited. The only permitted group meetings are those described
      under items #11 and #12.

     

    14)   Individual
      solicitation, residences

     

    MCO
      (and
      provider) staff are not permitted to visit potential Members at their places
      of
      residence for purposes of explaining MCO features and promoting enrollment.
      This
      prohibition is absolute, and applies even in situations where 

    the
      potential Member desires and/or requests a home visit. MCO staff can visit
      Member homes after enrollment becomes effective, as part of their
      orientation/education efforts.

     

    15) Gifts,
      cash incentives, or rebates to potential Members and
      members.

     

    MCOs
      (and
      their providers) are prohibited from disseminating gift items, except those
      of a
      nominal value (pens, key chains, magnets, etc.), to potential Members.
      DEPARTMENT-approved written materials may also be disseminated to prospective
      Members along with similar nominal value gifts. MCOs may give items of nominal
      value (unit cost less than $2), with their logo on it, to persons (potential
      Members and others) attending health fairs, presentations at community forums
      organized through or other sanctioned events, with DEPARTMENT approval. Such
      items would include magnets, pens, bags, plastic band-aid dispensers, etc.
      Pre-approved nominal value items may also be included with new Member
      information packets.

     

    16)  Gifts
      to Members for specific health-related events

     

    Gifts
      to
      Members are allowed for medically "good" behavior (e.g. baby T-shirt showing
      immunization schedule once a woman completes targeted series of prenatal
      visits). All such gifts, including any written materials included with them
      (or
      on them), must be prior-approved by the DEPARTMENT. The criteria for providing
      such gifts must also be prior-approved by DEPARTMENT. MCOs must not provide
      gifts in any situations other than those that have been prior-approved by
      DEPARTMENT. Additional DEPARTMENT prior approval is required for all additional
      uses of the gift items or for new gifts.

     

    The
      DEPARTMENT may approve magnets, phone labels, and other nominal items that
      reinforce a MCO's care coordination programs (e.g. through advertising the
      Member Services hotline and/or the PCP office phone number). All such items
      must
      be prior-approved by the DEPARTMENT. The criteria for disseminating this
      information must also be prior-approved, although the DEPARTMENT is likely
      to be
      amenable to the MCOs' inclusion of this information in "welcome" packets sent
      to
      new Members.

     

    Health
      education videos are also allowed, but must be prior-approved by
      DEPARTMENT.

     

    17)           Phoning
      by Members from health care provider locations

     

    Providers
      may provide the use of a phone to potential HUSKY Members or HUSKY Members
      subject to the following restrictions:

     

    
      	
              a)

            	
              MCO
                or provider staff may not coach or instruct the
                caller;

            


    

    
      	
              b)

            	
              Privacy
                must be given to the MEMBER during their phone conversation with
                the HUSKY
                application and enrollment center.

            


    

     

    
      	
              18)

            	
              Non-alcoholic
                beverages and light refreshments for potential Members at
                meetings

            


    

    Non-alcoholic
      beverages and light refreshments are permitted at DEPARTMENT approved group
      meetings.

     

    
      	
              19.

            	
              Use
                of HUSKY Name; HUSKY Logo and Mandatory Language
                Requirements

            


    

     

    MCOs
      will
      be allowed use of the HUSKY logo and name for use in their marketing materials,
      subject to the following:

    
      	
              a)

            	
              must
                be used in conjunction with the following language unless alternative
                language has been prior approved by the DEPARTMENT.

               

              HUSKY
                gives families the freedom of choice to enroll in one of several
                participating health plans. Toll-free information:
                1-877-CT-HUSKY;

            


    

    
      	
              b)

            	
              the
                above mandatory language must be placed in the vicinity of the HUSKY
                logo;
                and

            


    

    
      	
              c)

            	
              the
                font size for the HUSKY phone number cannot be smaller than the MCOs
                member services phone number.

            


    

    


    
      	 	
              Type
                of Marketing Activity

            	
              Permitted

            	
              Not
                Permitted

            	
              Permitted
                With DEPARTMENT Approval

            
	
              1

            	
              General
                HUSKY marketing materials

            	 	 	
              X

            
	
              2

            	
              General,
                MCO advertising/marketing

            	 	 	
              X

            
	
              3

            	
              MCO
                advertising in provider care sites

            	 	 	
              X

            
	
              4

            	
              MCO
                advertising in all DEPARTMENT- eligibility offices, including
                hospital-based (Must be made available only through the DEPARTMENT
                or its
                agent)

            	 	 	
              X

            
	
              5

            	
              Provider
                communications with Medicaid patients about MCO options

            	 	 	
              X

            
	
              6

            	
              Member-initiated
                telephone conversations with MCO and Provider staff

            	
              X

            	 	 
	
              7

            	
              Member-initiated
                one-on-one meetings with MCO staff prior to enrollment

            	
              X

            	 	 
	
              8

            	
              Mailings
                by MCO in response to Member requests

            	 	 	
              X

            
	
              9

            	
              Unsolicited
                MCO mailings to Members

            	 	 	
              X

            
	
              10

            	
              Telemarketing

            	 	
              X

            	 
	
              11

            	
              MCO
                group meetings, held at MCO

            	 	 	
              X

            
	
              12

            	
              MCO
                group meetings held in public facilities such as churches, health
                fairs,
                WIC program or other community sites

            	 	 	
              X

            
	
              13

            	
              MCO
                group meetings held in private clubs or homes

            	 	
              X

            	 
	
              14

            	
              Individual
                solicitation at residences

            	 	
              X

            	 
	
              15

            	
              Items
                of nominal value along with written information about the MCO or
                general
                health education information to potential Members (given at such
                places as
                health fairs, community forums or other events approved by the Department)
                or included in new Member information packets.

            	 	 	
              X

            
	
              16

            	
              Gifts
                to Members (e.g. baby T-shirt showing immunization schedule) based
                on
                specific health events unrelated to enrollment

            	 	 	
              X

            
	
              17

            	
              Phoning
                by Members from health care provider locations

            	
              X

            	 	 
	
              18

            	
              Non-alcoholic
                beverages and light refreshments (e.g. fruit, cookies) for potential
                Members at meetings (may not mention refreshments in advertisements
                for
                meetings)

            	
              X

            	 	 


    

    


    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

Appendix
      G

     

    Standards
      for Internal Quality Assurance Programs for
      Health Plans

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

       

      STANDARDS
        FOR INTERNAL QUALITY ASSURANCE PROGRAMS FOR HEALTH PLANS

       

      
        	
                Standard
                  I:

              	
                Written
                  QAP Description

              


      

       

      The
        organization has a written description of its Quality Assurance Program
        (QAP).  This written description meets the following
        criteria:

      
        	
                A.

              	
                Goals
                  and objectives - There is a written description of the QA program
                  with detailed goals and annually developed objectives that outline
                  the
                  program structure and design and include a timetable for implementation
                  and accomplishment.

              


      

      B.           Scope

      
        	
                 

              	
                1.

              	
                The
                  scope of the QAP is comprehensive, addressing both the quality
                  of clinical
                  care and quality of non-clinical aspects of services, such as and
                  including: availability, accessibility, coordination, and continuity
                  of
                  care.

              


      

      
        	
                 

              	
                2.

              	
                The
                  QAP methodology provides for review of the entire range of care
                  provided
                  by the organization, by assuring that all demographic groups, care
                  settings (e.g. inpatient, ambulatory, [including care provided
                  in private
                  practice offices] and home care), and types of services (e.g. preventive,
                  primary, specialty care and ancillary) are included in the scope
                  of the
                  review.  This review should be carried out over multiple review
                  periods and not on just a concurrent
                  basis.

              


      

      
        	
                C.

              	
                Specific
                  activities - The written description specifies quality of care
                  studies and other activities to be undertaken over a prescribed
                  period of
                  time, and methodologies and organizational arrangements to be used
                  to
                  accomplish them.  Individuals responsible for the studies and
                  other activities are clearly identified and are
                  appropriate.

              


      

      
        	
                D.

              	
                Continuous
                  activity - The written description provides for continuous
                  performance of the activities, including tracking of issues over
                  time.

              


        	E. 	 Provider
                review - The QAP provides:

        

      
        	
                 

              	
                1.

              	
                Review
                  by physicians and other health professionals of the process followed
                  in
                  the provision of health services;

              


      

      
        	
                 

              	
                2.

              	
                Feedback
                  to health professionals and health plan staff regarding performance
                  and
                  patient results.

              


      

      
        	
                F.

              	
                Focus
                  on health outcomes - The QAP methodology addresses health outcomes to
                  the extent consistent with existing
                  technology.

              


      

      


      
        	
                Standard
                  II:

              	
                Systematic
                  Process of Quality Assessment and
                  Improvement

              


      

       

      The
        QAP
        objectively and systematically monitors and evaluates the quality and
        appropriateness of care and service provided members, through quality of
        care
        studies and related activities, and pursues opportunities for improvement
        on an
        ongoing basis.

       

      
        	
                A.

              	
                Specification
                  of clinical or health services delivery areas to be
                  monitored

              


      

      
        	
                 

              	
                1.

              	
                Monitoring
                  and evaluation of clinical issues reflects the population served
                  by the
                  health plan, in terms of age groups, disease categories, and special
                  risk
                  status.

              


      

      
        	
                 

              	
                2.

              	
                For
                  the Medicaid population, the QAP monitors and evaluates at a minimum,
                  care
                  and services in certain priority areas of concern selected by the
                  State.  It is recommended that these be taken from among those
                  identified by the Health

              	
                Care
                  Financing Administration's (HCFA's) Medicaid Bureau and jointly
                  determined
                  by the State and the Managed Care Organization
                  (MCO).

              


      

      
        	
                 

              	
                3.

              	
                At
                  its discretion and/or as required by the State Medicaid agency,
                  the MCO's
                  QAP also monitors and evaluates other aspects of care and
                  service.

              


      

       

      B.           Use
        of quality indicators 

      Quality
        indicators are measurable variables relating to a specified clinical or health
        services delivery area, which are reviewed over a period of time to monitor
        the
        process of outcomes of care delivered in that area.

      
        	
                 

              	
                1.

              	
                The
                  MCO identifies and uses quality indicators that are measurable,
                  objective,
                  and based on current knowledge and clinical
                  experiences.

              


      

      
        	
                 

              	
                2.

              	
                For
                  the priority area selected by the State from the HCFA Medicaid
                  Bureau's
                  list of priority clinical and health service delivery areas of
                  concern,
                  the MCO monitors and evaluates quality of care through studies,
                  which
                  include, but are not limited to, the quality indicators also specified
                  by
                  the HCFA Medicaid Bureau.

              


      

      
        	
                 

              	
                3.

              	
                Methods
                  and frequency of data collection are appropriate and sufficient
                  to detect
                  need for program change.

              


      

       

      C.           Use
        of clinical care standards/practice guidelines

      
        	
                 

              	
                1.

              	
                The
                  QAP studies and other activities monitor quality of care against
                  clinical
                  care or health services delivery standards or practice guidelines
                  specified for each area identified.

              


      

      
        	
                 

              	
                2.

              	
                The
                  clinical standards/practice guidelines are based on reasonable
                  scientific
                  evidence and are developed or reviewed by plan
                  providers.

              


      

      
        	
                 

              	
                3.

              	
                The
                  clinical standards/practice guidelines focus on the process and
                  outcomes
                  of health care delivery, as well as access to
                  care.

              


      

      
        	
                 

              	
                4.

              	
                A
                  mechanism is in place for continuously updating the standards/practice
                  guidelines.

              


      

      
        	
                 

              	
                5.

              	
                The
                  clinical standards/practice guidelines shall be included in provider
                  manuals developed for use by  HMO providers or otherwise
                  disseminated to the providers as they are
                  adopted.

              


      

      
        	
                 

              	
                6.

              	
                The
                  clinical standards/practice guidelines address preventive health
                  services.

              


      

      
        	
                 

              	
                7.

              	
                The
                  clinical standards/practice guidelines are developed for the full
                  spectrum
                  of populations enrolled in the
                  plan.

              


      

      
        	
                 

              	
                8.

              	
                The
                  QAP shall use these clinical standards/practice guidelines to evaluate
                  the
                  quality of care provided by the MCO's providers, whether the providers
                  are
                  organized in groups, as individuals, as IPAs, or in a combination
                  thereof.

              


      

      
        	
                 

                D.

              	
                 

                Analysis
                  of clinical care and related
                  services

              


      

      
        	
                 

              	
                1.

              	
                Appropriate
                  clinicians monitor and evaluate quality through review of individual
                  cases
                  where there are questions about care and through studies analyzing
                  patterns of clinical care and related service.  For quality
                  issues identified in the QAP's targeted clinical areas, the analysis
                  includes the identified quality indicators and uses clinical care
                  standards or practice guidelines.

              


      

      
        	
                 

              	
                2.

              	
                Mulitdisciplinary
                  teams are used, where indicated, to analyze and address system
                  issues.

              


      

      
        	
                 

              	
                3.

              	
                For
                  the D.1. and D.2. above, clinical and related services requiring
                  improvement are identified.

                 

              


        	 E.  	 	Implementation
                of remedial/corrective actions


        	 	 	The
                QAP includes written procedures for taking appropriate remedial action
                whenever, as determined under the QAP, inappropriate or substandard
                services are furnished, or services that should have been furnished
                were
                not. 
                These
                  written remedial/corrective action procedures
                  include:

              


      

               

      
        	
                 

              	
                1.

              	
                Specification
                  of the types of problems requiring remedial/corrective
                  action.

              


      

      
        	
                 

              	
                2.

              	
                Specification
                  of the person(s) or body responsible for making the final determinations
                  regarding quality problems.

              


      

      
        	
                 

              	
                3.

              	
                Specific
                  actions to be taken.

              


      

      
        	
                 

              	
                4.

              	
                Provision
                  of feedback to appropriate health professionals, providers
                  and  staff.

              


      

      
        	
                 

              	
                5.

              	
                The
                  schedule and accountability for implementing corrective
                  actions.

              


      

      
        	
                 

              	
                6.

              	
                The
                  approach to modify the corrective action if improvements do not
                  occur.

              


      

      
        	
                 

              	
                7.

              	
                Procedures
                  for terminating the affiliation with the physician, or other health
                  professional or provider.

                 

              


      

      
        	
                F.

              	
                Assessment
                  of effectiveness of corrective
                  actions

              


      

      
        	
                 

              	
                1.

              	
                As
                  actions are taken to improve care, there is monitoring and evaluation
                  of
                  corrective actions to assure that appropriate changes have been
                  made.  In addition,
                  changes in practice patterns are tracked.

              	
                 

              


      

      
        	
                 

              	
                2.

              	
                The
                  MCO assures follow-up on identified issues to ensure that actions
                  for
                  improvement
                  have been effective.

                 

              	
                 

              


      

      
        	
                G.

              	
                Evaluation
                  of continuity and effectiveness of the
                  QAP

              


      

      
        	
                 

              	
                1.

              	
                The
                  MCO conducts a regular and periodic examination of the scope and
content
                  of the QAP to ensure that it covers all types of services in all
settings,
                  as specified in standard I-B-2.

              	
                 

              	
                 

              


      

      
        	
                 

              	
                2.

              	
                At
                  the end of each year, a written report on the QAP is prepared which
                  addresses: QA studies and other activities completed, trending
                  of clinical
                  and services indicators and other performance data; demonstrated
                  improvements in quality; areas of deficiency and recommendations
                  for
                  corrective action; and an evaluation of the overall effectiveness
                  of the
                  QAP

              


      

      
        	
                 

              	
                3.

              	
                There
                  is evidence that QA activities have contributed to significant
                  improvements in the care and services delivered to
                  members.

              


      

       

      
        	
                Standard
                  III:

              	
                Accountability
                  to the Governing Body

              


      

       

      The
        QA
        committee is accountable to the governing body of the managed care
        organization.  The governing body should be the board of directors, or
        a committee of senior management may be designated in instances in which
        the
        board's participation with QA issues is not direct.  There is evidence
        of a formally designated structure, accountability at the highest levels
        of the
        organization, and ongoing and/or continuous oversight of the QA
        program.  Responsibilities of the Governing Board for monitoring,
        evaluating, and making improvements to care include:

       

      
        	
                A.

              	
                Oversight
                  of the  QAP - There is documentation that the governing
                  body has approved the overall QAP and  the annual
                  QAP.

              


      

      
        	
                B.

              	
                Oversight
                  of entity - The Governing Body has formally designated an accountable
                  entity or entities within the organization to provide oversight
                  of QA, or
                  has formally decided to provide such oversight as a committee of
                  the
                  whole.

              


      

      
        	
                C.

              	
                QAP
                  progress reports - The Governing body routinely receives written
                  reports from the QAP describing actions taken, progress in meeting
                  QA
                  objectives, and improvements made.

              


      

      
        	
                D.

              	
                Annual
                  QAP review - The Governing Body formally reviews on a periodic basis
                  (but no less frequently than annually) a written report on the
                  QAP which
                  includes: studies undertaken, results, subsequent actions, and
                  aggregate
                  data on utilization and quality of services rendered, to assess
                  the QAP's
                  continuity, effectiveness and current
                  acceptability.

              


      

      
        	
                E.

              	
                Program
                  modification - Upon receipt of regular written reports from the QAP
                  delineating actions taken and improvements made, the Governing
                  Body takes
                  actions when appropriate and directs that the operational QAP be
                  modified
                  on an ongoing basis to accommodate review findings and issues of
                  concern
                  within the MCO.  Minutes of the meetings of the Governing Board
                  demonstrate that the Board has directed and followed up on necessary
                  actions pertaining to QA.

              


      

       

      
        	
                Standard
                  IV:

              	
                Active
                  QA Committee

              


      

       

      The
        QAP
        delineates an identifiable structure responsible for performing QA functions
        within the MCO.  The committee or other structure has:

       

      
        	
                A.

              	
                Regular
                  meetings - The structure/committee meets on a regular basis with
                  specified frequency to oversee QAP activities.  This frequency
                  is sufficient to demonstrate that the structure/committee is following
                  up
                  on all findings and required actions, but in no case are such meetings
                  less frequent than quarterly.

              


      

      
        	
                B.

              	
                Established
                  parameters for operating -The role, structure and function of the
                  structure/committee are specified.

              


      

      
        	
                C.

              	
                Documentation
                  - There are contemporaneous records documenting the
                  structure's/committee's activities, findings, recommendations and
                  actions.

              


      

      
        	
                D.

              	
                Accountability
                  - The QAP committee is accountable to the Governing Body and
                  reports
                  to it (or its designee) on a scheduled basis on activities, findings,
                  recommendations and actions.

              


      

      
        	
                E.

              	
                Membership
                  - There is active participation in the QA committee from health
                  plan
                  providers, who are representative of the composition of the health
                  plan's
                  providers.

              


      

       

      
        	
                Standard
                  V:

              	
                QAP
                  Supervision

              


      

       

      There
        is
        a designated senior executive who is responsible for program implementation.
        The
        organization's Medical Director has substantial involvement in QA
        activities.

       

      
        	
                Standard
                  VI:

              	
                Adequate
                  Resources

              


      

       

      The
        QAP
        has sufficient material resources, and staff with the necessary education,
        experience, or training; to effectively carry out its specified
        activities.

       

      
        	
                Standard
                  VII:

              	
                Provider
                  Participation in the
                  QAP

              


      

      
        	
                A.

              	
                Participating
                  physicians and other providers are kept informed about the written
                  QA
                  plan.

              


      

      
        	
                B.

              	
                The
                  MCO includes in all its provider contracts and employment agreements,
                  for
                  both physicians and nonphysician providers, a requirement securing
                  cooperation with the QAP.

              


      

      
        	
                C.

              	
                Contracts
                  specify that hospitals, physicians, and other contractors will
                  allow the
                  MCO access to the medical records of their
                  members.

              


      

       

      
        	
                Standard
                  VIII:

              	
                Delegation
                  of QAP Activities

              


      

      The
        MCO
        remains accountable for all QAP functions, even if certain functions are
        delegated to other entities.  If the MCO delegates any QA activities
        to contractors.

      
        	
                A.

              	
                There
                  is a written description of delegated activities; the delegate's
                  accountability for these activities; and the frequency of reporting
                  to the
                  MCO.

              


      

      
        	
                B.

              	
                The
                  MCO has written procedures for monitoring the implementation of
                  the
                  delegated functions and for verifying the actual quality of care
                  being
                  provided.

              


      

      
        	
                C.

              	
                There
                  is evidence of continuous and ongoing evaluation of delegated activities,
                  including approval of quality improvement plans and regular specified
                  reports.

              


      

       

      
        	
                Standard
                  IX:

              	
                Enrollee
                  Rights and
                  Responsibilities

              


      

      The
        MCO
        demonstrates a commitment to treating members in a manner that acknowledges
        their rights and responsibilities.

       

                 

      
        	 A.	 	 Written
                policy on enrollee rights


        	 	 	The
                MCO has a written policy that recognizes the following rights of
                members:
                 

              


        	
                 

              	
                1.

              	
                To
                  be treated with respect, and recognition of their dignity and need
                  for
                  privacy;

              


      

      
        	
                 

              	
                2.

              	
                To
                  be provided with information about the MCO, its services, the
                  practitioners providing care, and members' rights and
                  responsibilities;

              


      

      
        	
                 

              	
                3.

              	
                To
                  be able to choose primary care practitioners, within the limits
                  of the
                  plan network, including the right to refuse care from specific
                  practitioners;

              


      

      
        	
                 

              	
                4.

              	
                To
                  participate in decision-making regarding their health
                  care;

              


      

      
        	
                 

              	
                5.

              	
                To
                  voice grievances about the MCO or care
                  provided;

              


      

      
        	
                 

              	
                6.

              	
                To
                  formulate advance directives; and

              


      

      
        	
                 

              	
                7.

              	
                To
                  have access to his/her medical records on accordance with applicable
                  Federal and State laws.

                 

              


      

      
        	
                B.

              	
                Written
                  policy enrollee responsibilities - The MCO has a written policy that
                  addresses members' responsibility for cooperating with those providing
                  health care services. This written policy addresses members'
                  responsibility for:

              


      

      
        	
                 

              	
                1.

              	
                Providing,
                  to the extent possible, information needed by professional staff
                  in caring
                  for the member; and

              


      

      
        	
                 

              	
                2.

              	
                Following
                  instructions and guidelines given by those providing health care
                  services.

                 

              


      

      
        	
                C.

              	
                Communication
                  of policies to providers - A copy of the organization's policies on
                  members' rights and responsibilities is provided to all participating
                  providers.

                 

              


      

      
        	
                D.

              	
                Communication
                  of policies to enrollees/members - Upon enrollment, members are
                  provided a written statement that includes information on the
                  following:

              


      

      
        	
                 

              	
                1.

              	
                Rights
                  and responsibilities of members;

              


      

      
        	
                 

              	
                2.

              	
                Benefits
                  and services included and excluded as a condition of memberships,
                  and how
                  to obtain them, including a description
                  of:

              


      

      
        	
                 

              	
                a.

              	
                Any
                  special benefit provisions (example, co-payment, higher deductibles,
                  rejection of claim) that may apply to service obtained outside
                  the system;
                  and

              


      

      
        	
                 

              	
                b.

              	
                The
                  procedures for obtaining out-of-area
                  coverage;

              


      

      
        	
                 

              	
                3.

              	
                Provisions
                  for after-hours and emergency
                  coverage;

              


      

      
        	
                 

              	
                4.

              	
                The
                  organization's policy on referrals for specialty
                  care;

              


      

      
        	
                 

              	
                5.

              	
                Charges
                  to members, if applicable,
                  including:

              


      

      
        	
                 

              	
                a.

              	
                Policy
                  on payment of charges; and

              


      

      
        	
                 

              	
                b.

              	
                Co-payment
                  and fees for which the member is
                  responsible.

              


      

      
        	
                 

              	
                6.

              	
                Procedures
                  for notifying those members affected by the termination or change
                  in any
                  benefit services, or service delivery
                  office/site;

              


      

      
        	
                 

              	
                7.

              	
                Procedures
                  for appealing decisions adversely affecting the members' coverage,
                  benefits, or relationship with the
                  organization;

              


      

      
        	
                 

              	
                8.

              	
                Procedures
                  for changing practitioners;

              


      

      
        	
                 

              	
                9.

              	
                Procedures
                  for disenrollment; and

              


      

      
        	
                 

              	
                10.

              	
                Procedures
                  for voicing complaints and/or grievances and for recommending changes
                  in
                  policies and services.

                 

              


      

      
        	
                E.

              	
                Enrollee/member
                  grievance procedures - The organization has a system(s) linked to the
                  QAP, for resolving members' complaints and formal grievances. This
                  system
                  includes:

              


      

      
        	
                 

              	
                1.

              	
                Procedures
                  for registering and responding to complaints and grievances in
a
                  timely fashion (organizations should establish and monitor standards
                  for
                  timeliness);

              	
                 

              


      

      
        	
                 

              	
                2.

              	
                Documentation
                  of the substance of the complaint or grievances, and actions
                  taken;

              


      

      
        	
                 

              	
                3.

              	
                Procedures
                  to ensure a resolution of the compliant or
                  grievance;

              


      

      
        	
                 

              	
                4.

              	
                Aggregation
                  and analysis of complaint and grievance data and use of the data
                  for
                  quality improvement; and

              


      

      
        	
                 

              	
                5.

              	
                An
                  appeal process for grievances.

                 

              


      

      
        	
                F.

              	
                Enrollee/member
                  suggestions - Opportunity is provided for members to offer
                  suggestions for changes in policies and procedures.

                 

              


      

      
        	
                G.

              	
                Steps
                  to assure accessibility of services - The MCO takes steps to promote
                  accessibility of services offered to members. These steps
                  include:

              


      

      
        	
                 

              	
                1.

              	
                The
                  points of access to primary care, specialty care and hospital services
                  are
                  identified for members;

              


      

      
        	
                 

              	
                2.

              	
                At
                  a minimum, members are given information
                  about:

              


      

      
        	
                 

              	
                a.

              	
                How
                  to obtain services during regularly hours of
                  operation

              


      

      
        	
                 

              	
                b.

              	
                How
                  to obtain emergency and after-hours care;
                  and

              


      

      
        	
                 

              	
                c.

              	
                How
                  to obtain the names, qualifications, and titles of the professionals
                  providing and/or responsible for their care.

                 

              


      

      
        	
                H.

              	
                Written
                  information for members

              


      

      
        	
                 

              	
                1.

              	
                Member
                  information is written in prose that is readable and easily understood;
                  and

              


      

      
        	
                 

              	
                2.

              	
                Written
                  information is available, as needed, in the languages of the major
                  population groups served.  A "major" population group is one
                  which represents at least 10% of plan's membership.

                 

              


      

      
        	
                I.

              	
                Confidentiality
                  of patient information - The MCO acts to ensure that the
                  confidentiality of the specified patient information and records
                  is
                  protected.

              


      

      
        	
                 

              	
                1.

              	
                The
                  MCO has established in writing, and enforced, policies and procedures
                  on
                  confidentiality of medical records.

              


      

      
        	
                 

              	
                2.

              	
                The
                  MCO ensures that patient care offices/sites have implemented mechanisms
                  that guard against the unauthorized or inadvertent disclosure of
                  confidential information to persons outside of the medical care
                  organization.

              


      

      
        	
                 

              	
                3.

              	
                The
                  MCO shall hold confidential information obtained by its personnel
                  about
                  enrollees related to their examination, care and treatment and
                  shall not
                  divulge it without the enrollee's authorization,
                  unless:

              


      

      
        	
                 

              	
                a.

              	
                it
                  is required by law;

              


      

      
        	
                 

              	
                b.

              	
                it
                  is necessary to coordinate the patient's care with physicians,
                  hospitals,
                  or other health care entities, or to coordinate insurance or other
                  matters
                  pertaining to payment; or

              


      

      
        	
                 

              	
                c.

              	
                it
                  is necessary in compelling circumstances to protect the health
                  or safety
                  of an individual.

              


      

      
        	
                 

              	
                4.

              	
                Any
                  release of information in response to a court order is reported
                  to the
                  patient in a timely manner; and

              


      

      
        	
                 

              	
                5.

              	
                Enrollee
                  records may be disclosed, whether or not authorized by the enrollee,
                  to
                  qualified personnel for the purpose of conducting scientific research,
                  but
                  these personnel may not identify, directly or indirectly, any individual
                  enrollee in any report of the research or otherwise disclose participant
                  identity in any manner.

                 

              


      

      
        	
                J.

              	
                Treatment
                  of minors - The MCO has written policies regarding the appropriate
                  treatment of minors.

                 

              


      

      
        	
                K.

              	
                Assessment
                  of member satisfaction - The MCO conducts periodic surveys of member
                  satisfaction with its services.

              


      

      
        	
                 

              	
                1.

              	
                The
                  surveys include content on perceived problems in the quality,
                  accessibility and availability of
                  care.

              


      

      
        	
                 

              	
                2.

              	
                The
                  surveys assess at least a sample
                  of:

              


      

      
        	
                 

              	
                a.

              	
                All
                  Medicaid members;

              


      

      
        	
                 

              	
                b.

              	
                Medicaid
                  member requests to change practitioners and/or facilities;
                  and

              


      

      
        	
                 

              	
                c.

              	
                Disenrollment
                  by Medicaid members.

              


      

      
        	
                 

              	
                3.

              	
                As
                  a results of the surveys, the
                  organization:

              


      

      
        	
                 

              	
                a.

              	
                Identifies
                  and investigates sources of
                  dissatisfaction;

              


      

      
        	
                 

              	
                b.

              	
                Outlines
                  action steps to follow-up on the findings;
                  and

              


      

      
        	
                 

              	
                c.

              	
                Informs
                  practitioners and providers of assessment
                  results.

              


      

      
        	
                 

              	
                4.

              	
                The
                  MCO reevaluates the effects of the above
                  activities.

              


      

       

      
        	
                Standard
                  X:

              	
                Standards
                  for Availability and
                  Accessibility

              


      

      The
        MCO
        has established standards for access (e.g. to routine, urgent and emergency
        care; telephone appointments; advice; and member service
        lines).  Performance on these on these dimensions of access are
        assessed against the standards.

       

      
        	
                Standard
                  XI:

              	
                Medical
                  Records Standards

              


      

      
        	
                A.

              	
                Accessibility
                  and availability of medical records - The MCO shall include provision
                  in provider contracts for appropriate access to the medical records
                  of its
                  enrollees for purposes of quality reviews conducted by the Secretary,
                  State Medicaid agencies, or agents thereof.

                 

              


      

      
        	
                B.

              	
                Record
                  keeping - Medical records may be on paper or electronic. The plan
                  takes steps to promote maintenance of medical records in a legible,
                  current, detailed, organized and comprehensive manner that permits
                  effective patient care and quality review as follows:

                 

              


      

      
        	
                 

              	
                1.

              	
                Medical
                  records standards- The MCO sets standards for medical records.
                  The records
                  reflect all aspects of patient care, including ancillary services.
                  These
                  standards shall at a minimum, include requirements
                  for:

              


      

      
        	
                 

              	
                a.

              	
                Patient
                  identification information - Each page or electronic file in the
                  record
                  contains the patient's name or patient ID
                  number.

              


      

      
        	
                 

              	
                b.

              	
                Personal/biographical
                  data - Personal/biographical data includes: age, sex, address;
                  employer;
                  home and work telephone numbers; and martial
                  status.

              


      

      
        	
                 

              	
                c.

              	
                Entry
                  date - All entries are dated.

              


      

      
        	
                 

              	
                d.

              	
                Provider
                  identification - All entries are identified as to
                  author.

              


      

      
        	
                 

              	
                e.

              	
                Legibility
                  - The record is legible to someone other than the writer.  Any
                  record judged illegible by one physician reviewer should be evaluated
                  by a
                  second reviewer.

              


      

      
        	
                 

              	
                f.

              	
                Allergies
                  - Medication allergies and adverse reactions are prominently noted
                  on the
                  record.  Absence of allergies (no known allergies-NKA) is noted
                  in an easily recognizable location.

              


      

      
        	
                 

              	
                g.

              	
                Past
                  medical history - (for patients seen 3 or more times) Past medical
                  history
                  is easily identified including serious accidents, operations,
                  illnesses.  For children, past medical history relates to
                  prenatal care and birth.

              


      

      
        	
                 

              	
                h.

              	
                Immunizations-
                  For pediatric records (ages 12 and under) there is a completed
                  immunization record or a notation that immunizations are
                  up-to-date.

              


      

      
        	
                 

              	
                i.

              	
                Diagnostic
                  information

              


      

      
        	
                 

              	
                j

              	
                Medication
                  information

              


      

      
        	
                 

              	
                k.

              	
                Identification
                  of current problems - Significant illness, medical conditions and
                  health
                  maintenance concerns are identified in the medical
                  record.

              


      

      
        	
                 

              	
                l.

              	
                Smoking/ETOH/substance
                  abuse - Notation concerning cigarettes and alcohol use and substance
                  abuse
                  is present (for patients 12 years and over and seen three or more
                  times).  Abbreviations and symbols may be
                  appropriate.

              


      

      
        	
                 

              	
                m.

              	
                Consultations,
                  referral and specialist reports - Notes from consultations are
                  in the
                  record. Consultation, lab, and x-ray reports filed in the chart
                  have the
                  ordering physicians initials or other documentation signifying
                  review.  Consultation and significantly abnormal lab and imaging
                  study results have an explicit notation in the record and follow-up
                  plans.

              


      

      
        	
                 

              	
                n.

              	
                Emergency
                  care

              


      

      
        	
                 

              	
                o.

              	
                Hospital
                  discharge summaries - Discharge summaries are included as part
                  of the
                  medical record for (1) all hospital admissions which occur while
                  the
                  patient is enrolled in the MCO and (2) prior admissions as
                  necessary.

              


      

      
        	
                 

              	
                p.

              	
                Advance
                  directives - For medical records of adults, the medical record
                  documents
                  whether or not the individual has executed an advance
                  directive.  An advance directive is a written instruction such
                  as a living will or durable power of attorney for health care relating
                  to
                  the provision of health care when the individual is
                  incapacitated.

              


      

      
        	
                 

              	
                2.

              	
                Patient
                  visit data - Documentation of individual encounters must provide
                  adequate
                  evidence of, at a minimum;

              


      

      
        	
                 

              	
                a.

              	
                History
                  and physical examination - Appropriate subjective and objective
                  information is obtained for the presenting
                  complaints.

              


      

      
        	
                 

              	
                b.

              	
                Plan
                  of treatment

              


      

      
        	
                 

              	
                c.

              	
                Diagnostic
                  tests

              


      

      
        	
                 

              	
                d.

              	
                Therapies
                  and other prescribed regimens; and

              


      

      
        	
                 

              	
                e.

              	
                Follow-up
                  - Encounter forms or notes have a notation, when indicated, concerning
                  follow-up care, call, or visit.  Specific time to return is
                  noted in weeks, months, or PRN. Unresolved problems from previous
                  visits
                  are addressed in subsequent visits.

              


      

      
        	
                 

              	
                f.

              	
                Referrals
                  and results thereof; and

              


      

      
        	
                 

              	
                g.

              	
                All
                  other aspects of patient care, including ancillary
                  services.

              


      

      
        	
                 

              	
                3.

              	
                Record
                  review process-

              


      

      
        	
                 

              	
                1.

              	
                The
                  MCO has a system (record review process) to assess the content
                  of medical
                  records for legibility, organization, completion and conformance
                  to its
                  standards.

              


      

      
        	
                 

              	
                2.

              	
                The
                  record assessment system addresses documentation of the items listed
                  in B,
                  above.

              


      

      


      
        	
                Standard
                  XII:

              	
                Utilization
                  Review

                 

              


      

      
        	
                A.

              	
                Written
                  program description- The MCO has a written utilization management
                  program
                  description which includes, at a minimum, procedures to evaluate
                  medical
                  necessity, criteria used, and approve the provision of medical
                  information
                  sources and the process used to review services

              	
                .

              


      

      
        	
                B.

              	
                Scope
                  - The program has mechanisms to detect underutilization as well
                  as
                  overutilization.

              


      

      
        	
                C.

              	
                Preauthorization
                  and concurrent review - For MCO with preauthorization or concurrent
                  review
                  programs:

              


      

      
        	
                 

              	
                1.

              	
                Preauthorization
                  and concurrent review decisions are supervised by qualified medical
                  professionals;

              


      

      
        	
                 

              	
                2.

              	
                Efforts
                  are made to obtain all necessary information, including pertinent
                  clinical
                  information, and consult with the treating physician as
                  appropriate;

              


      

      
        	
                 

              	
                3.

              	
                The
                  reasons for decisions are clearly documented and available to the
                  member.

              


      

      
        	
                 

              	
                4.

              	
                There
                  are well-publicized and readily available appeals mechanisms for
                  both
                  providers and patients. Notification of a denial includes a description
                  of
                  how file an appeal;

              


      

      
        	
                 

              	
                5.

              	
                Decisions
                  and appeals are made in a timely manner as required by the exigencies
                  of
                  the situation;

              


      

      
        	
                 

              	
                6.

              	
                There
                  are mechanisms to evaluate the effects of the program using data
                  on member
                  satisfaction, provider satisfaction or other appropriate;
                  and

              


      

      
        	
                 

              	
                7.

              	
                If
                  the MCO delegates responsibilities for utilization management,
                  it has
                  mechanisms to ensure that these standards are met by the
                  delegate.

              


      

       

      
        	
                Standard
                  XIII:

              	
                Continuity
                  of Care System

                 

              


      

      The
        MCO
        has put a basic system in place which promotes continuity of care and case
        management.

       

      
        	
                Standard
                  XIV:

              	
                QAP
                  Documentation

                 

              


      

      
        	
                A.

              	
                Scope
                  - The MCO shall document that it is monitoring the quality
                  of care
                  across all services and all treatment modalities, according to
                  its written
                  QAP.

              


      

      
        	
                B.

              	
                Maintenance
                  and availability of documentation - The MCO must maintain and make
                  available to the State, and upon request to the Secretary of HHS,
                  studies,
                  reports, appropriate, concerning the activities and corrective
                  actions.

              


      

       

      
        	
                Standard
                  XV:

              	
                Coordination
                  of QA Activity with other Management Activity

                 

              


      

      The
        findings, conclusions, recommendations, actions taken, and results of actions
        taken as a result of QA activity, are documented and reported to appropriate
        individuals within the MCO and through established QA channels.

      
        	
                A.

              	
                QA
                  information is used in recredentialing, recontracting, and/or annual
                  performance evaluations.

              	
                 

              


      

      
        	
                B.

              	
                QA
                  activities are coordinated with other performance monitoring activities,
                  including utilization management, risk management, and resolution
                  and
                  monitoring of member complaints and
                  grievances.

              


      

      
        	
                C.

              	
                There
                  is a linkage between QA and other management functions of the MCO,
                  such
                  as: network changes, benefit redesign, medical management systems,
                  practice feedback to providers, patient education and member
                  services.

              


      

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
Appendix
        H

       

      Claims
        Inventory, Aging and Unaudited Quarterly Financial
        Reports

       

    

    

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      HUSKY
        B
        Appendix H

      (document
        1 of 5)

      Report
        #1

      HUSKY
        A & B Unprocessed Claims in Dollars

       

      
        	
                Plan
                  Name

              	 	 	 	 	 	 	 
	
                Qtr.
                  Ending:

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Claims
                  In Process During Qtr. (In Dollars) (1)

              	 	 	 
	 	
                1-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	
                Total
                  Claims Outstanding At The End Of The Qtr.

              
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Unpaid
                  Adjudicated Claims (In Dollars) (2)

              	 	 	 	 
	 	
                1-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	
                Total
                  Unpaid Adjudicated Claims (In Dollars) At The End Of The
                  Qtr.

              
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                1.   Claims
                  in process-all claims that are in a pending status (data,
                  medical, COB edits) and require review by a claim examiner prior
                  to being
                  released for adjudication.  Because the final pay amount is
                  unknown, the amounts are recorded at the billed amount

              
	
                2.  Unpaid
                  adjudicated claims-claims which have been adjudicated and have a
                  known pay amount, however, a check has not been issued for these
                  claims.  Because the final pay amount is known, the amounts are
                  recorded using net amount + withhold.

              
	 	 	 	 	 	 	 	 
	
                UB92
                  - In general these claim forms represent hospital based claims
                  (inpatient
                  and outpatient).

              	 	 	 
	
                HCFA
                  1500 - These claim forms are used for outpatient services provided
                  by
                  non-hospital facilities.

              	 	 	 
	 	 	 	 	 	 	 	 
	
                Other
                  items to note about report #1 and #2:

              	 	 	 	 	 	 
	
                *  If
                  a claim does not include the information specified in Bulletin
                  HC-56 it is
                  rejected.  This claim would not appear in the
                  inventory

                after
                  it was rejected.

              
	
                *   A
                  claim could contain all of the information specified by Bulletin
                  HC-56,
                  but it is incorrect.  In this instance it could have been
                  included in the pending claims prior to identifying it as a claim
                  with
                  incorrect data.  Examples of incorrect data would be using a
                  discontinued code.

              
	
                *  If
                  a claim is submitted for a service which requires prior authorization,
                  but
                  none if found by the MCO, it is denied.

              	 	 
	
                    At
                  the point of denial the claim would be excluded from the
                  report.

              	 	 	 	 	 
	
                *  The
                  pending claims could include duplicates which have not been identified
                  by
                  the MCO.  If a duplicate is identified, one is paid
                  and

              	 
	
                     all
                  of the duplicates are rejected.

              	 	 	 	 	 	 	 
	
                *   The
                  pending category may include claims which have been pended for
                  a medical
                  records review.  As per the guidelines in Bulleting
                  HC-56,

                if
                  additional information is needed from the provider, the MCO has
                  30 days to
                  request additional information. After the information is received,
                  the MCO
                  has 30 days to pay the claim without interest.

              
	
                *   If
                  a claim is denied and subsequently reversed on appeal,
                  the  clock would start on the date of the appeal
                  determination.

              	 	 
	
                *  If
                  a credit balance exists for a provider, the time to process the
                  claim is
                  still measured.  To the extent that processing exceeds 45
                  days

                it
                  would accrue interest as any other claim would.

              
	
                If
                  a rejected or denied claim is subsequently resubmitted, it would
                  take on a
                  new claim number.  The clock would begin from the date of
                  re-submissions.

              	 
	
                The
                  only time a processed claim is re-opened is for an adjustment to
                  amount
                  paid.

              	 	 	 	 	 


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      HUSKY
        B Appendix H

      document
        2 of 5)

      Report
        #2

      HUSKY
        A & B Volume of Unprocessed Claims


      
        	
                Plan
                  Name

              	 	 	 	 	 	 	 
	
                Qtr.  Ending:

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Claims
                  In Process During Qtr. (# of claims) (1)

              	 	 	
                Total
                  Claims In Process During Qtr.

              
	 	
                01-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	 
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Unpaid
                  Adjudicated Claims (# of claims) (2)

              	 	 	
                Total
                  Unpaid Adjudicated Claims (# of claims) At The End Of The
                  Qtr.

              
	 	
                01-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	 
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Total
                  Unprocessed And Unpaid Adjudicated Claims (3)

              	 	 	
                Total
                  Unprocessed & Unpaid Adjudicated Claims

              
	 	
                01-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	 
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 


      

       

      
        
          	
                  
                    Claims
                      Inventory

                  

                	
                  EQUAL
                    OR Less than 45 Days

                	
                  Greater
                    than 45 Days

                
	 	 	 
	
                  MCO
                    Claims

                	
                  %

                	
                  %

                
	
                  Pharmacy

                	
                  %

                	
                  %

                
	
                  Dental

                	
                  %

                	
                  %

                
	
                  Vision

                	
                  %

                	
                  %

                
	
                  Mental
                    Health

                	
                  %

                	
                  %

                
	
                  Total

                	
                  %

                	
                  %

                


        

         

      

      
        	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Estimated
                  Claims Received but not in system (# of claims)
                  (4)

              	 	 
	 	
                01-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	
                Total
                  Claims Received But Not In System

              
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Mental
                  Health

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Tick
                  Mark Legend:

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                1.   Claims
                  in process-all claims that are in a pending status (data,
                  medical, COB edits) and require review by a claim examiner
                  prior to being released for adjudication.

              
	
                 

              	 	 	 	 	 
	
                2.
                  Unpaid adjudicated claims-claims which have been
                  adjudicated and have a known pay amount, however, a
                  check has not been issued for these claims.

              	 
	
                 

              	 	 	 	 	 
	
                3.  Total
                  of estimated claims in process, and unpaid adjudicated
                  claims.

                 

              	 	 	 
	
                4.  Estimated
                  claims received but not in system-includes any claim that has been
                  received and not input in the system(I.e.
                  claims in the mailroom).

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      HUSKY
        B Appendix H

      (document
        3 of 5)

      Report
        #3

      HUSKY
        A & B Turn Around Time - Claims Processed


      
        	
                Plan
                  Name

              	 	 	 	 	 	 	 
	
                Qtr.
                  Ending:

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Paper
                  Claims Processed During Qtr.

              	 	 	 	 	 
	 	
                01-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	
                Total
                  Paper Claims Processed During Qtr.

              
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Electronic
                  Claims Processed During Qtr.

              	 	 	 	 	 
	 	
                01-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	
                Total
                  Electronic Claims Processed During Qtr.

              
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	
                Claim
                  Type

              	
                Total
                  Paper and Electronic Claims Processed During Qtr.

              	 	 	 	 
	 	
                01-30
                  Days

              	
                31-45
                  Days

              	
                46-60
                  Days

              	
                61-90
                  Days

              	
                91-120
                  Days

              	
                >120
                  Days

              	
                Total
                  Paper & Electronic Claims Processed During
                  Qtr.

              
	
                UB92
                  Claims

              	 	 	 	 	 	 	 
	
                HCFA
                  1500 Claims

              	 	 	 	 	 	 	 
	
                Subtotal
                  MCO Claims

              	 	 	 	 	 	 	 
	
                Pharmacy

              	 	 	 	 	 	 	 
	
                Dental

              	 	 	 	 	 	 	 
	
                Vision

              	 	 	 	 	 	 	 
	
                Subtotal
                  Vendor Claims

              	 	 	 	 	 	 	 
	
                Total

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 


      

       

      
        	
                Turn
                  Around Statistics

              	
                EQUAL
                  OR Less than 45 Days

              	
                Greater
                  than 45 Days

              
	 	 	 
	
                MCO
                  Claims

              	
                %

              	
                %

              
	
                Pharmacy

              	
                %

              	
                %

              
	
                Dental

              	
                %

              	
                %

              
	
                Vision

              	
                %

              	
                %

              
	
                Mental
                  Health

              	
                %

              	
                %

              
	
                Total

              	
                %

              	
                %

              


      

       

      Note:  This
        report includes only paid claims,
        therefore it excludes denied claims.

      
 

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

       

      (document
        5 of 6)

      Appendix
        H

      Unaudited
        Quarterly Financial Reports


    

    
      	 	
              Current
                Assets:

            	
              Current
                Year

            	
              Previous
                Year

            
	
              1

            	
              Cash
                and Cash Equivalents

            	 	 
	
              2

            	
              Short-Term
                Investments

            	 	 
	
              3

            	
              Premiums
                Receivable

            	 	 
	
              4

            	
              Investment
                Income Receivables

            	 	 
	
              5

            	
              Health
                Care receivables

            	 	 
	
              6

            	
              Amounts
                Due from Affiliates

            	 	 
	
              7

            	
              Aggregate
                Write-Ins for Current Assets

            	 	 
	
              8

            	
              TOTAL
                CURRENT ASSETS (items 1-7)

            	 	 
	 	 	 	 
	 	
              Other
                Assets

            	 	 
	
              9

            	
              Restricted
                Cash and Other Assets

            	 	 
	
              10

            	
              Long
                Term Investments

            	 	 
	
              11

            	
              Amounts
                Due from Affiliates

            	 	 
	
              12

            	
              Aggregate
                Write-Ins for Other Assets

            	 	 
	
              13

            	
              TOTAL
                OTHER ASSETS (items 9-12)

            	 	 
	 	 	 	 
	 	
              Property
                and Equipment

            	 	 
	
              14

            	
              Land,
                building and Improvements

            	 	 
	
              15

            	
              Furniture
                and Equipment

            	 	 
	
              16

            	
              Leasehold
                Improvements

            	 	 
	
              17

            	
              Aggreate
                Write-Ins for Other Equipment

            	 	 
	
              18

            	
              TOTAL
                PROPERTY (items 7-14)

            	 	 
	
              19

            	
              TOTAL
                ASSETS 9items 8, 13, and 18)

            	 	 
	 	 	 	 
	 	
              Details
                of Write-Ins Aggregated at item 7 for Current Assets

            	 	 
	
              701

            	 	 	 
	
              702

            	 	 	 
	
              703

            	 	 	 
	
              704

            	 	 	 
	
              705

            	 	 	 
	
              798

            	
              Summary
                of remaining write-ins for item 7 from overflow page

            	 	 
	
              799

            	
              TOTALS:
                (items 701 through 705 plus 798 page 2, item 7)

            	 	 
	 	 	 	 
	 	
              Details
                of Write-Ins Aggregated at item 12 for Other Assets

            	 	 
	
              1201

            	 	 	 
	
              1202

            	 	 	 
	
              1203

            	 	 	 
	
              1204

            	 	 	 
	
              1205

            	 	 	 
	
              1298

            	
              Summary
                of remaining write-ins for item 12 from overflow page

            	 
	
              1299

            	
              TOTALS:
                (items 1201 through 1205 plus 1298 page 2, item 12)

            	 
	 	 	 	 
	 	
              Details
                of Write-Ins Aggregated at item 17 for Other Equipment

            	 
	
              1701

            	 	 	 
	
              1702

            	 	 	 
	
              1703

            	 	 	 
	
              1704

            	 	 	 
	
              1705

            	 	 	 


    

     

     

    
      (document
        5 of 6)

      Appendix
        H

      Unaudited
        Quarterly Financial Reports

       

    

    
      	
              1798

            	
              Summary
                of remaining write-ins for item 17 from overflow page

            	 
	
              1799

            	
              TOTALS:
                (items 1701 through 1705 plus 1798 page 2, item 17)

            	 
	 	 	 	 
	 	
              Current
                Liabilities

            	 	 
	
              1

            	
              Accounts
                Payable (Schedule G)

            	 	 
	
              2

            	
              Claims
                Payable (Reported and Unreported) (Schedule H)

            	 	 
	
              3

            	
              Accrued
                Medical Incentive Pool (Schedule H)

            	 	 
	
              4

            	
              Unearned
                Premiums

            	 	 
	
              5

            	
              Amounts
                Due to Affiliates (Schedule J)

            	 	 
	
              6

            	 	 	 
	
              7

            	
              Aggregate
                Write-Ins for Current Liabilities

            	 	 
	
              8

            	
              TOTAL
                CURRENT LIABILITIES (items 1-7)

            	 	 
	 	 	 	 
	 	
              Other
                Liabilities

            	 	 
	
              9

            	
              Loans
                and Notes Payable (Schedule I)

            	 	 
	
              10

            	
              Amounts
                Due to Affiliates (Schedule J)

            	 	 
	
              11

            	
              Aggregate
                Write-Ins for Other Liabilities

            	 	 
	
              12

            	
              TOTAL
                OTHER LIABILITIES (items 9-11)

            	 	 
	
              13

            	
              TOTAL
                LIABILITIES (items 8 and 12)

            	 	 
	 	 	 	 
	 	
              Net
                Worth

            	 	 
	
              14

            	
              Common
                Stock

            	 	 
	
              15

            	
              Preferred
                Stock

            	 	 
	
              16

            	
              Paid
                in Surplus

            	 	 
	
              17

            	
              Contributed
                Capital

            	 	 
	
              18

            	
              Surplus
                Notes (Schedule K)

            	 	 
	
              19

            	
              Contingency
                Reserves

            	 	 
	
              20

            	
              Retained
                Earnings/Fund Balance

            	 	 
	
              21

            	
              Aggregate
                Write-Ins for Other Net Worth Items

            	 	 
	
              22

            	
              TOTAL
                NET WORTH (items 13 and 22)

            	 	 
	
              23

            	
              TOTAL
                LIABILITIES AND NET WORTH (items 13 and 22)

            	 	 
	 	 	 	 
	 	
              Details
                of Write-Ins Aggregated at item 7 for Current Liabilities

            	 
	
              701

            	
              Payroll
                and Related Liabilities

            	 	 
	
              702

            	
              Accrued
                Audit and Actuarial Fees

            	 	 
	
              703

            	 	 	 
	
              704

            	 	 	 
	
              705

            	 	 	 
	
              798

            	
              Summary
                of Remaining Write-Ins for item 7 from overflow page

            	 
	
              799

            	
              TOTALS
                (items 0701 through 0705 plus 0798 Page 3, item 7)

            	 	 
	 	 	 	 
	 	
              Details
                of Write-Ins Aggregated at item 11 for Other Liabilities

            	 	 
	
              1101

            	 	 	 
	
              1102

            	 	 	 
	
              1103

            	 	 	 
	
              1104

            	 	 	 
	
              1105

            	 	 	 
	
              1198

            	
              Summary
                of remaining write-ins for item 11 from overflow page

            	 
	
              1199

            	
              TOTALS:
                (items 1101 through 1105 plus 1198 page 3, item 11)

            	 
	 	 	 	 
	 	
              Details
                of Write-Ins Aggregated at item 21 for Other Net Worth
                Items

            	 
	
              2101

            	 	 	 


    

     

     

    
      (document
        5 of 6)

      Appendix
        H

      Unaudited
        Quarterly Financial Reports

       

    

    
      	
              2102

            	 	 	 
	
              2103

            	 	 	 
	
              2104

            	 	 	 
	
              2105

            	 	 	 
	
              2198

            	
              Summary
                of remaining write-ins for item 21 from overflow page

            	 
	
              2199

            	
              TOTALS:
                (items 2101 through 2105 plus 2198 page 3, item 21)

            	 
	 	 	 	 
	 	
              Member
                months

            	 	 
	 	
              Revenues

            	 	 
	
              1

            	
              Premium

            	 	 
	
              2

            	
              Fee-For-Service

            	 	 
	
              3

            	
              Title
                XVIII - Medicare

            	 	 
	
              4

            	
              Title
                XIX - Medicaid

            	 	 
	
              5

            	
              Investment

            	 	 
	
              6

            	
              Aggregate
                Write-Ins for Other Revenues

            	 	 
	
              7

            	
              TOTAL
                REVENUES (items 1-6)

            	 	 
	 	 	 	 
	 	
              Expenses

            	 	 
	
              8

            	
              Medical
                and Hospital

            	 	 
	
              9

            	
              Other
                Professional Services

            	 	 
	
              10

            	
              Outside
                Referrals

            	 	 
	
              11

            	
              Emergency
                Room and Out-of-Area

            	 	 
	
              12

            	
              Occupancy,
                Depreciation and Amortization

            	 	 
	
              13

            	
              Inpatient

            	 	 
	
              14

            	
              Incentive
                Pool and Withhold Adjustments

            	 	 
	
              15

            	
              Aggregate
                Write-Ins for other Medical and Hospital Expenses

            	 	 
	
              16

            	
              Subtotal
                (items 8-15)

            	 	 
	
              17

            	
              Reinsurance
                Expenses of Net of Recoveries

            	 	 
	 	 	 	 
	 	
              Less

            	 	 
	
              18

            	
              Copayments

            	 	 
	
              19

            	
              COB
                and Subrogation

            	 	 
	
              20

            	
              Subtotal
                (items 18 and 19)

            	 	 
	
              21

            	
              Total
                Medical and Hospital (items 16 and 17 less 20)

            	 	 
	 	 	 	 
	 	
              Administration

            	 	 
	
              22

            	
              Compensation

            	 	 
	
              23

            	
              Interest
                Expense

            	 	 
	
              24

            	
              Occupancy,
                Depreciation and Amortization

            	 	 
	
              25

            	
              Marketing

            	 	 
	
              26

            	
              Aggregate
                Write-Ins for Other Administration Expenses

            	 	 
	
              27

            	
              TOTAL
                ADMINISTRATION (items 22-26)

            	 	 
	
              28

            	
              TOTAL
                EXPENSES (items 21 and 27)

            	 	 
	
              29

            	
              Income
                (LOSS) (item 21 and 27)

            	 	 
	
              30

            	
              Cumulative
                Effect of Accountin Change)

            	 	 
	
              31

            	
              Provision
                for Federal Income Taxes

            	 	 
	
              32

            	
              NET
                INCOME (item 29, less items 30 and 31)

            	 	 
	 	 	 	 
	 	
              Details
                or Write-Ins Aggregated at item 6 for other Revenues

            	 	 
	
              601

            	
              Other
                Income

            	 	 
	
              602

            	 	 	 
	
              603

            	 	 	 


    

    
       

      (document
        5 of 6)

      Appendix
        H

      Unaudited
        Quarterly Financial Reports

       

      
        	 




    

    
      	
              604

            	 	 	 
	
              605

            	 	 	 
	
              698

            	
              Summary
                of remaining write-ins for item 6 from overflow page

            	 	 
	
              699

            	
              TOTALS:
                (items 601 through 605 plus 698 page 4, item 6)

            	 	 
	 	 	 	 
	 	
              Member
                months

            	 	 
	 	
              Details
                of Write-Ins Aggregated at Item 6 for Other Revenues

            	 	 
	
              1501

            	
              Drugs

            	 	 
	
              1502

            	
              Outpatient

            	 	 
	
              1503

            	 	 	 
	
              1504

            	 	 	 
	
              1505

            	 	 	 
	
              1598

            	
              Summary
                of remaining write-ins for item 15 from overflow page

            	 
	 	 	 	 
	 	
              Details
                of Write-Ins Aggregated at Item 26 for Other Administration
                Expenses

            	 
	
              2601

            	
              MGMT
                Fee Income - SWWA

            	 	 
	
              2602

            	
              MGMTFee
                Expense GOHS

            	 	 
	
              2603

            	
              Other
                Administration Expense

            	 	 
	
              2604

            	
              MGMT
                Fee Expense Corp.

            	 	 
	
              2605

            	
              Accrued
                Audit and Actuarial Expense

            	 	 
	
              2698

            	
              Summary
                of remaining write-Ins for item 26 from ovrflow page

            	 	 
	
              2699

            	
              TOTALS
                (items 2601 through 2605 plus 2698) (page 4, item 26)

            	 


    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
Appendix
      I

     

    Capitation
      Payment Amount

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    SFY
      2007 Rates for Husky B Band 1 & 2

     

    Includes
      BHP Carve out, 3.88% Rate Increase, Hosp Adjustment and Dental
      Adjustment

     

     

    
      	 	
               (Hardcoded)

              SFY
                2007
                Rate

            
	
               FirstChoice

            	
               $155.73

            


    

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Appendix
      J

     

    Inpatient
      / Eligibility Recategorization
      Chart

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
      	
              HUSKY
                B - Appendix J

              HUSKY
                A & B

              Medical
                Acute Care Primary Inpatient/Eligibility Recategorization
                Changes

            
	 	 	 	 	 
	
              Description

            	
              Admitting
                MCO

            	
              New/Continued
                MCO

            	
              Responsible
                Entity

            
	
              HUSKY
                A, different MCO

            	
              A1

            	
              A2

            	
              A1

            	 
	
              HUSKY
                A to FFS

            	
              A1

            	
              FFS

            	
              FFS

            	 
	
              HUSKY
                A to HUSKY B, same MCO

            	
              A1

            	
              B1

            	
              A1

            	 
	
              HUSKY
                A to HUSKY B, different MCO

            	
              A1

            	
              B2

            	
              A1

            	 
	
              HUSKY
                B, different MCO

            	
              B1

            	
              B2

            	
              B1

            	 
	
              HUSKY
                A to disenrolled due to loss

              of
                eligibility (Out of Program)

            	
              A1

            	
              x

            	
              A1

            	 
	
              HUSKY
                B to disenrolled due to loss

              of
                eligibility (Out of Program)

            	
              B1

            	
              x

            	
              B1

            	 
	
              HUSKY
                B to A (Same MCO,

              different
                coverage)

            	
              B1

            	
              A1

            	
              A1

            	 
	
              HUSKY
                B to A (different MCO,

              different
                coverage)

            	
              B1

            	
              A2

            	
              A2

            	 
	
              HUSKY
                B to FFS

            	
              B1

            	
              FFS

            	
              FFS

            	 


    

     

    
      	
              Code

            	 	 	 	 
	
              A1
                = HUSKY A, MCO #1

            	 	 	 	 
	
              A2
                = HUSKY A, MCO #2

            	 	 	 	 
	
              B1
                = HUSKY B, MCO #1

            	 	 	 	 
	
              B2
                = HUSKY B, MCO #2

            	 	 	 	 
	
              FFS
                = Fee-for-service

            	 	 	 	 
	
              x=
                Disenrolled due to loss of eligibility

            	 	 	 	 


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
Appendix
      K

     

    Abortion
      Reporting

     

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      



    HUSKY
      B Non-Hyde Amendment Abortions

     

    Name
      of
      MCO: ___________________________

    Quarter
      Ended: ___________________________ 

                                                                                     

    This
      report shall include all abortions that do not meet the HYDE Amendment criteria,
      and that are paid by the MCO during the quarter (e.g. July 1 - September 30).
      These reports shall be submitted by the 15th of the month following the end
      of
      the quarter (e.g. October 15). The reports shall be submitted in hard copy,
      as
      well as electronically to Lee Voghel, Division of Fiscal Analysis.

    


    
      	
              Date
                of Service

            	
              CPT
                Code

            	
              Medicaid
                Recipient ID#

            	
              Provider
                ID#

            	
              Provider
                Name

            	
              Date
                Paid

            	
              Amount
                Paid

            
	 	 	 	
               

               

              Total

            	 	 	 


    

    


    


    I
      hereby
      certify that to the best of my knowledge the information contained herein is
      true and accurate.

     

    Signature:                                                                                     

    Printed
      Name:                                                                                     

    Title:                                                                                     

    Date:                                                                                     

     

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    Appendix
      L

     

    Blank

     

    Reserved
      for Possible Future Use

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
Appendix
      M

     

    Blank

     

    Reserved
      for Possible Future Use

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      


      APPENDIX
        N

      


      HUSKY
        BEHAVIORAL HEALTH CARE-OUT COVERAGE

      AND
        COORDINATION OF MEDICAL AND BEHAVIORAL SERVICES

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        HUSKY
          A -
          05/07 - Appendix N

      

      
        


      

      
        


      

      
        


      

      
        HUSKY
          BEHAVIORAL

      

      
        


      

      
        


      

      
        Health
          Carve-Out

      

      
        


      

      
        


      

      
        Coverage
          and Coordination of Medical and Behavioral
          Services

      

      
        


      

      
        


      

      
        


      

      
        


      

      
        DEPARTMENT
          OF SOCIAL SERVICES DEPARTMENT OF CHILDREN AND FAMILIES

      

      
        


        Updated
          January 26, 2006

      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      
        Contents

      

      
        


      

      
        	
                
                  Introduction

                

              	
                
                  3

                

              
	
                
                  Ancillary
                    Services

                

              	
                
                  3

                

              
	
                
                  Co-Occurring
                    Medical and Behavioral Health Conditions - Screening, Referral,
                    and
                    Coordination

                

              	
                
                  4

                

              
	
                
                  Freestanding
                    Medical/Primary Care Clinics

                

              	
                
                  5

                

              
	
                
                  Home
                    Health Services

                

              	
                
                  5

                

              
	
                
                  Hospital
                    Emergency Department

                

              	
                
                  7

                

              
	
                
                  Hospital
                    Inpatient Services

                

              	
                
                  8

                

              
	
                
                  Hospital
                    Outpatient Clinic Services

                

              	
                
                  9

                

              
	
                
                  HUSKY
                    Plus Behavioral

                

              	
                
                  9

                

              
	
                
                  Long
                    Term Care

                

              	
                
                  9

                

              
	
                
                  Member
                    Services

                

              	
                
                  10

                

              
	
                
                  Mental
                    Health Clinics

                

              	
                
                  10

                

              
	
                
                  Methadone
                    Maintenance

                

              	
                
                  11

                

              
	
                
                  Multi-Disciplinary
                    Examinations

                

              	
                
                  11

                

              
	
                
                  Notice
                    of Action

                

              	
                
                  11

                

              
	
                
                  Operations

                

              	
                
                  12

                

              
	
                
                  Outreach

                

              	
                
                  12

                

              
	
                
                  Pharmacy

                

              	
                
                  12

                

              
	
                
                  Primary
                    Care Behavioral Health Services

                

              	
                
                  13

                

              
	
                
                  Quality
                    Management

                

              	
                
                  14

                

              
	
                
                  Reports

                

              	
                
                  14

                

              
	
                
                  School-Based
                    Health Center Services

                

              	
                
                  15

                

              
	
                
                  Transportation

                

              	
                
                  16

                

              


      

       

      State
        of
        Connecticut                                                             Page
        2                                                           01/26/06

      
 

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      
        Introduction

      

      
        


        The
          purpose of this document is to outline the policies according to which
          the HUSKY
          MCOs and the Behavioral Health Partnership (BHP) will share responsibility
          for
          providing covered services to HUSKY A and B enrollees after HUSKY behavioral
          health benefits are carved out and administered under a contract with the
          BHP
          Administrative Service Organization ("BHP ASO"). After the carve-out, the
          Managed Care Organizations that participate in HUSKY A and B ("HUSKY MCOs")
          will
          be responsible for providing services for medical conditions and BHP will
          be
          responsible for providing services for behavioral health conditions. The
          BHP ASO
          will provide member services, provider relations services, utilization
          management, intensive care management, quality management and other management
          services to facilitate the provision of timely, effective, and coordinated
          services under the BHP. The BHP ASO will not be responsible for contracting
          with
          providers or maintaining a provider network. Behavioral health providers
          will be
          required to enroll in the Department of Social Services' Connecticut Medical
          Assistance Program Network (CMAP). With the exception of DCF funded residential
          services, claims will be processed by the Department of Social Services'
          Medicaid vendor, Electronic Data Systems (EDS).

      

      
        This
          document is intended to summarize the coverage responsibilities and coordination
          responsibilities for each of the major service areas as established by
          the HUSKY
          BH carve-out transition planning workgroup. In addition to this document,
          which
          is intended for use as an amendment or attachment to the ASO and MCO contracts,
          each of the HUSKY MCOs will develop a coordination agreement with the BHP
          ASO.
          The coordination agreements will further elaborate the coordination protocols
          with special attention to the areas noted below and to the key contacts
          and
          workflows particular to each MCO.

      

      
        


        Ancillary
          Services

      

      
        


        HUSKY
          MCOs will retain responsibility for all ancillary services such as laboratory,
          radiology, and medical equipment, devices and supplies regardless of diagnosis.
          However, laboratory costs for methadone chemistry (quantitative analysis)
          will
          be covered under the BHP when they are part of the bundled reimbursement
          for
          methadone maintenance providers. The HUSKY MCOs may track and trend laboratory
          utilization as part of coordination with the BHP ASO. In addition, the
          MCOs will
          address any increases in the utilization trend with The Department of Social
          Services.

      

      
        


        State
          of
          Connecticut                                                              Page
          3                                                           01/26/06

      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      
        Co-Occurring
          Medical and Behavioral Health Conditions - Screening, Referral, and
          Coordination

      

      
        


        The
          HUSKY
          MCOs currently have programs and procedures designed to support the
          identification of untreated behavioral health disorders in medical patients
          at
          risk for such disorders. Such procedures may be carried out by medical
          service
          providers or by the MCO through the utilization management, case management
          and
          quality management processes. The MCOs will be expected to continue such
          activities in order to foster early and effective treatment of behavioral
          health
          disorders, including those disorders that could affect compliance with
          and the
          effectiveness of medical interventions.

      

      
        


        Both
          the
          HUSKY MCOs and the BHP ASO will be required to communicate and coordinate
          as
          necessary to ensure the effective coordination of medical and behavioral
          health
          benefits. The HUSKY MCOs will contact the BHP ASO when co-management is
          indicated (including BH hospital emergency department visits), such as
          for
          persons with special physical health and behavioral health needs; will
          respond
          to inquiries by the BHP ASO regarding the presence of medical co-morbidities;
          and will coordinate with the BHP ASO when invited to do so. Conversely,
          the BHP
          ASO will contact the HUSKY MCOs when co-management is indicated; will respond
          to
          inquiries by the HUSKY MCOs regarding the presence of behavioral co-morbidities;
          and will coordinate with the HUSKY MCOs when invited to do
          so.

      

      
        


        Both
          the
          BHP ASO and the MCOs will assign key contacts in order to facilitate timely
          coordination. In addition, it is anticipated that the BHP ASO's intensive
          care
          management department will be able to accept warm-line transfers as necessary
          from the HUSKY MCO case management departments to facilitate timely
          co-management.

      

      
        


        The
          BHP
          ASO will convene Medical/Behavioral Co-Management meetings at least once
          a month
          with each HUSKY MCO. The frequency of the meetings will be by agreement
          between
          the BHP ASO and each HUSKY MCO. The purpose of the meeting will be to ensure
          appropriate management of clients with co-occurring medical and behavioral
          health conditions. Cases discussed between the BHP ASO and the MCO will
          include
          all levels of behavioral health and medical care. Furthermore, the BHP
          ASO and
          the HUSKY MCOs shall provide reports in advance of the meetings on the
          cases to
          be reviewed.

      

      
        


        The
          HUSKY
          MCOs and the BHP ASO will from time to time make a determination as to
          whether a
          client's medical or behavioral health condition is primary. If there is
          a
          conflicting determination as to whether medical or behavioral health is
          primary,
          the respective medical directors will work together toward a timely and
          mutually
          agreeable resolution. At the request of either party, the Department of
          Social
          Services will make a determination as to the whether medical or behavioral
          health is primary and that determination shall be binding.

      

      
        


        State
          of
          Connecticut                                                             Page
          4                                                           01/26/06

      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      
        Freestanding
          Medical/Primary Care Clinics

      

      
        


        The
          HUSKY
          MCOs will be responsible for primary care and other medical services provided
          by
          freestanding primary care/medical clinics regardless of diagnosis except
          for
          behavioral health evaluation and treatment services billed under CPT codes
          90801-90806, 90853, 90846, 90847, and 90862 with a primary behavioral health
          diagnosis and only when provided by a licensed behavioral health
          professional.

      

      
        


        Home
          Health Services

      

      
        


        HUSKY
          MCOs and BHP will share responsibility for covering home health services.
          The
          coordination agreements will include language that details procedures for
          resolving coverage responsibility issues. Home health coordination will
          be based
          on the following guidelines:

      

      
        


        The
          HUSKY
          MCOs will be responsible for management and payment of claims when home
          health
          services are required for the treatment of medical diagnoses alone and
          when home
          health services are required to treat both medical and behavioral diagnoses,
          but
          the medical diagnosis is primary. If the individual's behavioral health
          treatment needs cannot be safely and effectively managed by the medical
          nurse
          and/or aide, the home care agency will be required to provide psychiatric
          nursing and/or aide services separately authorized and paid for under the
          BHP.

      

      
        


        BHP
          will
          be responsible for management and payment of claims when home health services
          are required for the treatment of behavioral diagnoses alone (ICD 9: 291-316)
          and when home health services are required to treat both medical and behavioral
          diagnoses, but the behavioral diagnosis is primary. If the individual's
          medical
          treatment needs cannot be safely and effectively managed by the psychiatric
          nurse and/or aide, then the home care agency will be required to provide
          medical
          nursing and/or aide services separately authorized and paid for by the
          HUSKY
          MCOs.

      

      
        


        The
          following table summarizes this policy:

      

      


      
        	
                
                  HUSKY
                    MCOs

                

              	
                
                  BHP
                    ASO

                

              
	
                
                  Medical
                    diagnosis only

                

              	
                
                  Behavioral
                    diagnosis only

                

              
	
                
                  Medical
                    and behavioral diagnoses, Med primary

                

              	
                
                  Behavioral
                    and medical diagnoses, Behavioral primary

                

              
	
                
                  Medical
                    component only, when medical and behavioral diagnoses are present
                    and
                    behavioral health needs cannot be effectively managed by the
                    medical nurse
                    and/or aide.

                

              	
                
                  Behavioral
                    component only, when behavioral and medical diagnoses are present
                    and
                    medical needs cannot be effectively managed by the medical nurse
                    and/or
                    aide.

                

              


      

      
        


        In
          addition, HUSKY MCOs will manage and pay claims for home health physical
          therapy, occupational therapy, and speech therapy services regardless of
          diagnosis.

      

      
        


        State
          of
          Connecticut                                          
Page
          5             
                  
01/26/06

      

      



      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      
        When
          physical therapy, occupational therapy, and speech therapy services occur
          alongside home health behavioral health services, the home health care
          agency
          will be required to get authorization from and submit claims to the both
          the
          HUSKY MCO and to Electronic Data Systems (EDS), the claims vendor for the
          BHP.

      

      
        


        The
          above
          policy will require that providers and management entities make decisions
          as to
          whether a medical or behavioral diagnosis is primary. This determination
          will be
          made at the time the service is presented for authorization. The determination
          will be based on the diagnosis that is the principal focus of the services
—
typically the one that requires the most time and/or expertise. A rebuttable
          presumption shall be made that the primary diagnosis is psychiatric if
          a
          psychiatrist makes the referral. The following examples should help in
          determining the issue of primary diagnosis:

      

      
        


        
          	
                  • 

                	
                  In
                    general, if a recipient is receiving home health behavioral health
                    services and at some point requires home health services for
                    a medical
                    condition, the behavioral health diagnosis remains primary if
                    the medical
                    treatment needs can be safely and effectively managed by the
                    nurse that is
                    providing the behavioral health services. If the medical condition
                    requires treatment by a medical nurse, and the medical nurse
                    is able to
                    safely assume responsibility for the behavioral condition, then
                    the
                    medical diagnosis becomes
                    primary.

                


        

      

      
        


        
          	
                  •  

                	
                  Similarly,
                    if a recipient is receiving home health medical services and
                    at some point
                    requires home health behavioral services for a behavioral condition,
                    the
                    medical diagnosis remains primary if the behavioral health treatment
                    needs
                    can be safely and effectively managed by the nurse that is providing
                    the
                    medical services. If the behavioral condition requires treatment
                    by a
                    psychiatric nurse, and the psychiatric nurse is able to safely
                    assume
                    responsibility for the medical condition, then the behavioral
                    diagnosis
                    becomes primary.

                


        

      

      
        


        If,
          at
          some point, separate nurses or aides are required to provide the behavioral
          and
          medical services, then the nurse and/or aide treating the medical condition
          must
          obtain authorization and payment from the HUSKY MCO and the nurse and/or
          aide
          treating the behavioral health condition must obtain authorization and
          payment
          under the BHP.

      

      
        


        In
          some
          cases, a recipient will not require treatment for both a medical and behavioral
          condition at every visit. For example, a recipient may require two visits
          per
          day for his or her medical condition, but only one visit per day for the
          behavioral health condition, hi this case, the medical condition ought
          to be
          billed as primary for both visits. Conversely, if a recipient requires
          two
          visits per day for his or her behavioral condition, but only one visit
          per day
          for the medical condition, the behavioral condition ought to be billed
          as
          primary for both visits.

      

      
        


        Finally,
          the primary reason for a visit may change from medical to behavioral or
          visa
          versa in the course of home health treatment. If this change occurs at
          the time
          of re-authorization, the home health care agency should pursue a new
          authorization from the entity with responsibility for the new condition
          for
          which home health care is required. If

      

      
        


        State
          of
          Connecticut                                                             Page
          6                                                           01/26/06

      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      
        the
          change in primary diagnosis occurs during an authorized episode of care,
          the
          home health care agency should discontinue services under the preceding
          authorization and pursue a new authorization from the entity with responsibility
          for the services going forward. If the HUSKY MCO reviews a request for
          authorization and believes that the primary has changed from medical to
          behavioral health, the MCO should direct the home care agency to pursue
          authorization through the BHP ASO.   The converse is also true.
          If the primary is not apparent, the clinical reviewers from the BHP ASO
          and the
          MCO should confer and come to agreement.

      

      
        


        Data
          provided by the HUSKY MCOs suggests that there are a modest number of clients
          with diagnoses of autism or mental retardation receiving home health services
          and that more than half of these clients have mixed diagnoses that could
          complicate management and billing. BHP will be responsible for the management
          and payment of claims when home health services are required for the treatment
          of autism, whether on its own or co-morbid with mental retardation. For
          those
          members with these dual diagnoses, providers will be directed to obtain
          authorization from the BHP ASO and to bill EDS with autism primary. The
          HUSKY
          MCOs will retain responsibility for mental retardation alone. BHP will
          also be
          responsible for management and payment of claims when home health services
          are
          required for the treatment of both autism and medical disorders, when the
          medical disorder can be safely and effectively managed by the psychiatric
          nurse
          and/or aide. If the individual's medical treatment needs are so significant
          that
          they cannot be safely and effectively managed by the psychiatric nurse
          and/or
          aide, then the home care agency will be required to provide medical nursing
          and/or aide services separately authorized and paid for by the HUSKY
          MCOs.

      

      
        


        All
          home
          health care agencies operating in Connecticut are enrolled in the Connecticut
          Medical Assistance Program (CMAP) network and may, at their discretion,
          provide
          behavioral health home health services to HUSKY recipients. In contrast,
          the
          HUSKY MCOs may contract with only a subset of the CMAP providers. This
          means
          that there may be times when a client is in treatment for a behavioral
          health
          condition with a CMAP provider that is not participating with a HUSKY MCO.
          If
          this client develops a co-occurring medical disorder that is secondary
          and can
          be managed by the psychiatric home care nurse, BHP will continue to be
          responsible for management and payment of claims. If, however, the patient's
          medical disorder becomes primary and thus the responsibility of the HUSKY
          MCO,
          the HUSKY MCO can elect to continue to use the home care provider as an
          out of
          network provider, or the HUSKY MCO can, at its discretion, transition the
          care
          to a participating home care provider. The client's best interest will
          be a
          factor in this determination. The MCOs and BHP ASO will be expected to
          create
          coordination agreements to expedite the proper handling of such
          cases.

      

      
        


        Hospital
          Emergency Department

      

      
        


        The
          HUSKY
          MCOs will assume responsibility for emergency department services, including
          emergent and urgent visits and all associated charges billed by the facility,
          regardless of diagnosis. Professional psychiatric services rendered in
          an
          emergency department by a community psychiatrist will be reimbursed by
          the BHP
          if the psychiatrist

      

      
        


        State
          of
          Connecticut                                                             Page
          7                                                           01/26/06

      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      
        is
          enrolled in CMAP as an independent solo or group practitioner and bills
          under
          the solo or group practice ID. The BHP will be responsible for observation
          stays
          of 23 hours or less (RCC 762) with a primary behavioral health diagnosis.
          The
          HUSKY MCOs and the Department will implement audit procedures to ensure
          that
          hospitals do not bill HUSKY MCOs for emergency department services when
          patients
          are admitted to the hospital and behavioral health is primary. The HUSKY
          MCOs
          may track and trend Emergency Department utilization for behavioral health.
          The
          MCOs will address any increase in the utilization trend with the
          Departments.

      

      
        


        Hospital
          Inpatient Services

      

      
        


        In
          order
          to assure appropriate coordination and communication, the coordination
          agreements will include specific language detailing processes and procedures
          for
          concurrent communication and the process for handling co-occurring medical
          and
          behavioral health hospital inpatient conditions. In addition, the agreements
          will include specific language on the procedures for resolving coverage
          related
          issues when the ASO and MCOs disagree. Coordination will be based on the
          following guidelines:

      

      
        


        Psychiatric
          Hospitals

      

      
        


        BHP
          will
          be responsible for all psychiatric hospital services and all associated
          charges
          billed by a psychiatric hospital, regardless of diagnosis. The rate is
          all-inclusive so there will be no reimbursement for professional services
          rendered by community-based consulting physicians.

      

      
        


        General
          Hospitals

      

      
        


        HUSKY
          MCOs and BHP will share responsibility for covering inpatient general hospital
          services. The HUSKY MCOs will be responsible for management and payment
          of
          claims for inpatient general hospital services when the medical diagnosis
          is
          primary. Medical would be considered primary when the billed RCC and the
          primary
          diagnosis are both medical.

      

      
        


        During
          a
          medical stay, BHP will be responsible for professional services associated
          with
          behavioral health diagnoses. The admitting physician will be responsible
          for
          coordinating medical orders for any necessary behavioral health services
          with
          the BHP ASO. Other ancillary charges associated with non-primary behavioral
          health diagnoses shall remain the responsibility of the HUSKY MCOs, as
          described
          in the ancillary services section of this document.

      

      
        


        BHP
          will
          be responsible for management and payment of claims for inpatient general
          hospital services when the behavioral diagnosis is primary. The behavioral
          diagnosis will be considered primary when the billed RCC and the primary
          diagnosis are both behavioral or when the billed RCC is medical, but the
          primary
          diagnosis on the claim form is behavioral. During a behavioral stay, the
          HUSKY
          MCOs will be responsible for professional services and other charges associated
          with primary medical diagnoses.

      

      
        


        State
          of
          Connecticut                                                             Page
          8                                                           01/26/06

      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      
        
          	
                   

                	
                  o   When
                    an admission to a general hospital is initially medical, but
                    the reason
                    for continued admission becomes behavioral, responsibility for
                    management
                    and payment of claims will transition to BHP. When the hospital
                    admission
                    is no longer medically necessary for the medical diagnosis, the
                    HUSKY MCO
                    ceases to be responsible for management and payment. The BHP
                    ASO will
                    monitor the timeliness of transfer from a medical unit to a psychiatric
                    unit when the primary diagnosis changes from medical to behavioral
                    health.

                


        

      

      
        


        The
          following table summarizes this policy:

      

      


      
        	
                
                  Inpatient
                    Payment for Primary Diagnosis

                

              	 	
                
                  Professional
                    Services Paid for Secondary Diagnosis

                

              
	
                
                  Inpatient
                    Type

                

              	
                
                  Revenue
                    Codes

                

              	
                
                  Diagnosis

                

              	
                
                  Assignment

                

              	 	
                
                  HCPCS

                

              	
                
                  Diagnosis

                

              	
                
                  Assignment

                

              
	
                
                  General
                    Hospital

                

              	
                
                  BH

                

              	
                
                  BH

                

              	
                
                  BHP

                

              	 	
                
                  BH

                

              	
                
                  BH

                

              	
                
                  BHP

                

              
	
                
                  General
                    Hospital

                

              	
                
                  BH

                

              	
                
                  BH

                

              	
                
                  BHP

                

              	 	
                
                  Med

                

              	
                
                  Med

                

              	
                
                  MCO

                

              
	
                
                  General
                    Hospital

                

              	
                
                  Med

                

              	
                
                  BH

                

              	
                
                  BHP

                

              	 	
                
                  BH

                

              	
                
                  BH

                

              	
                
                  BHP

                

              
	
                
                  General
                    Hospital

                

              	
                
                  Med

                

              	
                
                  BH

                

              	
                
                  BHP

                

              	 	
                
                  Med

                

              	
                
                  Med

                

              	
                
                  MCO

                

              
	
                
                  General
                    Hospital

                

              	
                
                  Med

                

              	
                
                  Med

                

              	
                
                  MCO

                

              	 	
                
                  Med

                

              	
                
                  Med

                

              	
                
                  MCO

                

              
	
                
                  General
                    Hospital

                

              	
                
                  Med

                

              	
                
                  Med

                

              	
                
                  MCO

                

              	 	
                
                  BH

                

              	
                
                  BH

                

              	
                
                  BHP

                

              


      

      
        


        Hospital
          Outpatient Clinic Services

      

      
        


        BHP
          will
          be responsible for all outpatient psychiatric clinic, intensive outpatient,
          extended day treatment, and partial hospitalization services provided by
          general
          and psychiatric hospitals for the evaluation and treatment of behavioral
          health
          disorders. BHP will also cover evaluation and treatment services related
          to a
          non-behavioral health diagnosis if the billing code is psychiatric as outlined
          in the covered services grid.

      

      
        


        The
          HUSKY
          MCOs will be responsible for all primary care and other medical services
          provided by hospital medical clinics regardless of diagnosis including
          all
          medical specialty services and all ancillary services.

      

      
        


        HUSKY
          Plus Behavioral

      

      
        


        HUSKY
          Plus Behavioral services (intensive in-home psychiatric services) will
          be
          included in the HUSKY B benefit package. The ASO will manage access to
          these
          services under the carve-out.

      

      
        


        Long
          Term
          Care

      

      
        


        The
          HUSKY
          MCOs will be responsible for all long term care services (i.e., nursing
          homes,
          chronic disease hospitals) regardless of diagnosis. These services are
          seldom

        


      

      
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          of
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Page
          9                    
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        required
          for the treatment of clients with primary behavioral health disorders under
          the
          HUSKY program. The admission of a client with a primary behavioral health
          disorder must be by mutual agreement of the BHP ASO and the HUSKY MCO in
          which
          the client is enrolled.

      

      
        


        DSS
          currently exempts any long-term care client from managed care the first
          of the
          month in which the client's stay exceeds 90 days. DSS will consider early
          exemption for clients with a primary behavioral health diagnosis if DSS
          were
          provided with adequate notice when such clients are admitted to long-term
          care.

      

      
        


        Member
          Services

      

      
        


        The
          BHP
          ASO will have its own member services department with a dedicated toll
          free
          phone number. The member services staff will provide non-clinical information
          to
          recipients and when appropriate provide immediate access to clinical staff
          for
          care related assistance. The member services staff will respond to all
          calls
          directed to the member services line and it is expected will have the ability
          to
          accept warm-line transfers from the HUSKY MCOs. The HUSKY MCOs will replace
          references to existing BH subcontractors on member materials with the new
          BHP
          ASO name and member services phone number, wherever such references occur.
          Branch logic for the DSS' 1-877-CTHUSKY number will be modified to incorporate
          the ASO member services line as an option for callers that require BHP
          related
          assistance.

      

      
        


        The
          MCOs
          will continue to conduct welcome calls to new members. At the time of the
          welcome call, the HUSKY MCO member services representative will provide
          the
          member with information on how to access the BHP ASO.

      

      
        


        HUSKY
          MCO
          member services departments will occasionally receive calls from members
          who are
          requesting BH services. In addition, BH issues may emerge in the course
          of a
          welcoming call. The member may screen positive for behavioral health issues
          and
          express an interest in discussing further or have clear behavioral health
          issues
          and need a referral. In either case, the member service representative
          can
          affect a warm-line transfer to the ASO member services department, take
          the
          member's information and fax this information to the ASO for follow-up,
          or
          provide the member with the telephone number for the BHP ASO.

      

      
        


        If
          the
          client is in crisis, the MCO member services representative should follow
          the
          MCO's protocols for handling crisis calls. The BHP ASO will have the capacity
          to
          accept warm-line transfer of such crisis calls when, at the discretion
          of the
          MCO, such transfer is appropriate.

      

      
        


        Mental
          Health Clinics

      

      
        


        BHP
          will
          be responsible for all Mental Health Clinic Services regardless of diagnosis
          including routine outpatient services and all diagnostic and treatment
          services
          billed as intensive outpatient treatment, extended day treatment, and partial
          hospitalization

      

      
        


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          of
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        treatment.
          BHP will also cover evaluation and treatment services related to a medical
          diagnosis such as psychological testing for a client with traumatic brain
          injury.

      

      
        


        Methadone
          Maintenance

      

      
        


        BHP
          will
          be responsible for reimbursing methadone clinics for methadone maintenance
          services provided to HUSKY enrollees. All methadone maintenance services
          for
          which the source of service is the methadone maintenance clinic are included
          in
          the Department's bundled rate with methadone maintenance
          clinics.   The MCOs will cover all methadone maintenance
          laboratory services when billed by an independent laboratory

      

      
        


        Multi-Disciplinary
          Examinations

      

      
        


        The
          MCOs
          will be responsible for contracting with DCF certified Multi-Disciplinary
          Examination providers and for covering all components of the DCF
          Multi-Disciplinary Examinations including behavioral health evaluation
          services
          (e.g., 90801, 96110). .

      

      
        


        Notice
          of
          Action

      

      
        


        The
          HUSKY
          MCOs will be responsible for issuing notices of action for medical review
          decisions and the BHP ASO will be responsible for issuing notices of action
          for
          behavioral health review decisions. The HUSKY MCOs will issue notices of
          action
          to the client and the provider, but will not issue a notice to the BHP
          ASO.
          Similarly, the BHP ASO will issue notices of action to the client and the
          provider, but will not issue a notice to the HUSKY MCO.

      

      
        


        In
          preparation for a fair hearing, the Department of Social Services will
          work with
          the Department's contractor that issued the notice to prepare the Department's
          case. Typically, the ASO will not be involved in an MCO related fair hearing
          and
          the MCO will not be involved in an ASO related fair hearing. However, when
          a
          client has co-morbid medical and behavioral health conditions and the action
          affects both conditions, then both the MCO and the ASO may be involved
          in
          preparation for the fair hearing.

      

      
        


        If
          a
          HUSKY MCO or one of its providers disagrees with a clinical management
          decision
          made by the BHP ASO, the HUSKY MCO is encouraged to raise the issue with
          the ASO
          on behalf of the client and to resolve the issue informally prior to the
          scheduled fair hearing. The converse is also true. If the issue remains
          unresolved, DSS will review the issue with the HUSKY MCO and the ASO and
          make a
          determination as to whether DSS supports the decision of the contractor
          that
          issued the notice. If DSS supports the contractor that issued the notice,
          the
          matter will proceed to fair hearing.

      

      
        


        The
          HUSKY
          MCOs may at times refer a client or provider to the BHP ASO because the
          primary
          presenting condition is behavioral health rather than medical. The HUSKY
          MCO's
          determination that a condition is behavioral health rather than medical
          shall
          not constitute grounds for issuing a notice of action. The converse is
          true for
          the BHP ASO.

      

      
        


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          of
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          11                                                            01/26/06

      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      
        The
          HUSKY
          MCO may at times issue a notice of action for a prescription written by
          a CMAP
          enrolled behavioral health prescribing provider. In such instances, the
          HUSKY
          MCO will be expected to send notice of action to the client and to the
          prescribing provider.

      

      
        


        Operations

      

      
        


        In
          order
          to support coordination and communication regarding operational issues
          such as
          claims payment, the Departments will host a monthly meeting with the BHP
          ASO and
          the HUSKY MCOs.

      

      
        


        Outreach

      

      
        


        The
          HUSKY
          MCOs currently provide outreach to members to assist them with accessing
          necessary services. The MCOs will continue to provide outreach to members
          to
          assist them with accessing medical services. For example, they may reach
          out to
          members to connect them to a primary care provider or to ensure necessary
          follow-up after a medical hospitalization. If an MCO's outreach worker
          identifies a member with a behavioral health issue, the worker may, at
          the MCO's
          discretion, provide information to the member on how to access behavioral
          health
          services via the ASO or facilitate a direct referral.

      

      
        


        The
          BHP
          ASO will conduct extensive outreach focused on connecting clients to behavioral
          health care when clients are experiencing barriers to care. They will also
          make
          efforts to ensure a connection to care after discharge from a hospital
          or
          residential treatment center. If in the course of outreach the BHP ASO
          identifies a member with a significant medical issue, the ASO may provide
          information to the member on how to access necessary medical services through
          the MCO or the member's primary care provider or facilitate a direct
          referral.

      

      
        


        Pharmacy

      

      
        


        The
          HUSKY
          MCOs will assume responsibility for all pharmacy services and all associated
          charges, regardless of diagnosis. However, methadone costs that are part
          of the
          bundled reimbursement for methadone maintenance and ambulatory detox providers
          will be covered under BHP. Methadone maintenance providers and ambulatory
          detox
          providers are responsible for supplying and dispensing methadone and these
          costs
          are covered by the BHP as part of an all-inclusive rate.

      

      
        


        Each
          HUSKY MCO maintains its own pharmacy program with distinct formularies,
          drug
          utilization review requirements, and prior authorization requirements.
          Under
          BHP, the Departments will have contracts with prescribing behavioral health
          providers and these providers will be required to follow the pharmacy program
          requirements of the HUSKY MCO in which the member is enrolled as well as
          other
          applicable Medicaid program

      

      
        


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          of
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        requirements.
          BHP prescribing providers include psychiatrists, psychiatric nurses,
          freestanding behavioral health clinics, and hospitals.

      

      
        


        DSS
          disseminates all policy transmittals and provider bulletins for CMAP providers
          through EDS. The ASO will not have a role in communications of this type.
          DSS
          will issue a provider bulletin to all enrolled prescribing providers prior
          to
          the carve-out date in order to apprise the providers of the pharmacy program
          requirements of each MCO and remind providers of the HUSKY program's temporary
          supply rules. DSS will require that providers adhere to each MCOs pharmacy
          program requirements and provide MCOs with any clinical information necessary
          to
          support requests for authorization or the preparation of clinical summaries
          for
          the purpose of fair hearings.

      

      
        


        Subsequently,
          the MCOs must notify DSS of changes to its pharmacy program requirements.
          DSS
          will in turn use the provider bulletin process to notify CMAP providers
          of such
          changes within 30 days of the effective date. The Departments prefer that
          DSS
          manage such pharmacy program communications since it will have a complete
          and
          up-to-date file of enrolled prescribing providers. This new communication
          process should resolve some of the pharmacy program communication issues
          that
          currently exist in the HUSKY program. Specifically, among some HUSKY MCOs,
          certain providers such as freestanding behavioral health clinics are not
          included in routine pharmacy program communications issued by the MCO.
          Under the
          carve-out, all providers will be apprised of the requirements of all HUSKY
          MCOs.
          The initial provider bulletin pertaining to pharmacy will provide each
          MCO's web
          address where pharmacy program requirements are available.

      

      
        The
          BHP
          ASO will fully cooperate with the MCOs and work closely with the MCOs to
          ensure
          compliance with the pharmacy programs of the individual MCOs. The BHP ASO
          will
          work closely with the MCOs to monitor pharmacy utilization and, if necessary,
          cooperate with the MCOs in conducting targeted provider education or training
          related to prescribing. DSS will require that its prescribing providers
          participate in quality initiatives and targeted pharmacy education and
          training
          conducted by the HUSKY MCOs for the purpose of improving prescribing practices
          and/or adherence to pharmacy program requirements. If the HUSKY MCOs encounter
          a
          behavioral health provider who engages in persistent misconduct related
          to
          psychiatric prescribing, the matter should be referred to DSS for
          investigation.

      

      
        


        The
          HUSKY
          MCOs may track and trend behavioral health pharmacy utilization and address
          any
          increase in the utilization trend with the Departments. DSS will continue
          to
          review each MCO's compliance with pharmacy contract provisions and new
          DSS staff
          will meet with each MCO to familiarize themselves with each MCO
          formulary/pharmacy process and available data in order to be prepared to
          work
          with the MCOs on reporting specs.

      

      
        


        Primary
          Care Behavioral Health Services

      

      
        


        The
          HUSKY
          MCOs will retain responsibility for all primary care services and all associated
          charges, regardless of diagnosis. These responsibilities
          include:

      

      
        


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        1.      behavioral
          health related prevention and anticipatory guidance;

      

      
        2.      screening
          for behavioral health disorders;

      

      
        
          	
                  3.

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

                


        

      

      
        
          	
                  4.

                	
                  management
                    of psychotropic medications, when the primary care
                    physician concludes it is safe and appropriate to do so, in
                    conjunction with treatment by a BHP non-medical behavioral health
                    specialist when necessary;
                    and

                


        

      

      
        
          	
                  5.

                	
                  referral
                    to a behavioral health specialist when the primary care
                    physician concludes that it is safe and appropriate to do
                    so.

                


        

      

      
        


        The
          BHP
          ASO will develop education and guidance for primary care physicians related
          to
          the provision of behavioral health services in primary care settings. At
          their
          discretion, the HUSKY MCOs can collaborate with the ASO in the development
          of
          education and guidance or they will be provided the opportunity to review
          and
          comment. The education and guidance will address PCP prescribing with support
          and guidance from the ASO or referring clinic, in circumstances when the
          PCP is
          comfortable with this responsibility. The BHP ASO will make telephonic
          psychiatric consultation services available to primary care providers.
          Consultation may be initiated by any primary care provider that is seeking
          guidance on psychotropic prescribing for a HUSKY A, HUSKY B, or Voluntary
          Services enrollee.

      

      
        


        To
          promote effective coordination and collaboration, the BHP ASO will work
          with
          interested HUSKY MCOs and provider organizations to sponsor opportunities
          for
          joint training. HUSKY MCO policies and provider contracts must permit the
          provision of behavioral health services by primary care providers; however,
          the
          MCOs will not be expected to provide education and training to improve
          ability
          of primary care providers to provide these services.

      

      
        


        The
          HUSKY
          MCOs may track and trend primary care behavioral health utilization. The
          MCOs
          will address any increase in the utilization trend with the
          Departments.

      

      
        


        Quality
          Management

      

      
        


        The
          BHP
          ASO will be required to conduct at least three quality improvement initiatives
          each year. For the second year of the contract, the ASO will invite the
          HUSKY
          MCOs to participate in a joint quality improvement initiative focused on
          an area
          of mutual concern. Each MCO may participate at its discretion. The Departments
          will determine during the second year of the project whether to ask the
          BHP ASO
          to propose an additional joint quality improvement initiative with the
          MCOs
          during the third year of its contract.

      

      
        


        Reports

      

      
        


        The
          BHP
          ASO will provide a weekly census report on all behavioral health inpatient
          stays
          identifying those with co-occurring medical and behavioral health conditions.
          In

      

      
        


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          of
          Connecticut                                                            Page
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        addition,
          the reports in Exhibit E of the BHP ASO contract will also be made available
          to
          the MCOs upon request.

      

      
        


        The
          MCOs
          will provide daily and monthly reports and/or data as mutually agreed upon
          to
          the BHP ASO regarding i) behavioral health emergency department visits,
          ii)
          behavioral health emergency room recidivism, iii) substance abuse & neonatal
          withdrawal, iv) child/adolescent obesity and/or type II diabetes, v) sickle
          cell
          report, vi) eating disorders report, and vii) medical detox.

      

      
        


        The
          Departments will also make MCO specific behavioral health encounter data
          available to the MCOs upon request to support quality management activities
          and
          coordination. The format of the data extract will be consistent with the
          encounter data reporting format, or other format mutually agreed upon by
          the
          Departments and the MCO.

      

      
        


        The
          HUSKY
          MCOs will identify BH NEMT data versus medical NEMT data in their NEMT
          reporting
          to DSS. In addition, the HUSKY MCOs will track and trend NEMT complaints
          related
          to BH visits separately from NEMT complaints related to medical visits.
          The BHP
          ASO will also compile NEMT related complaints, although these complaints
          will be
          forwarded to the HUSKY MCOs for resolution.

      

      
        


        The
          MCOs
          will continue to include behavioral health access in their CAHPS survey
          and
          report this information to the Departments.

      

      
        


        School-Based
          Health Center Services

      

      
        


        In
          general, BHP will be responsible for reimbursing school-based health centers
          for
          behavioral health diagnostic and treatment services (CPT 90801-90807, 90853,
          90846, and 90847) provided to students with a behavioral health diagnosis.
          The
          HUSKY MCOs will be responsible for primary care services provided by
          school-based health centers, regardless of diagnosis, but they will not
          be
          responsible for behavioral health assessment and treatment services billed
          under
          CPT codes 90801-90807, 90853, 90846, and 90847. The following narrative
          provides
          additional background and a rationale for this arrangement.

      

      
        


        School-based
          health centers currently provide a range of general health and behavioral
          health
          services that are reimbursable under the HUSKY program. All of these
          school-based health centers are licensed by the Department of Public Health,
          either as freestanding outpatient clinics or as satellites under a hospital
          license. Under these licenses, clinics can provide general medical services
          as
          well as behavioral health services.

      

      
        


        School-based
          health centers vary in their degree of expertise in the provision of behavioral
          health services. Some school-based health centers provide prevention and
          counseling for students with emotional or behavioral issues and bill for
          those
          services using general primary care prevention and counseling codes, often
          without a behavioral

      

      
        


        State
          of
          Connecticut                                                             Page
          15                                                            01/26/06

      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      
        health
          diagnosis. Those primary care and preventive counseling services that are
          currently covered under the MCO contracts with individual School-Based
          Health
          Centers will continue to be the responsibility of the HUSKY
          MCOs.

      

      
        


        Other
          school-based health centers have taken steps to develop their behavioral
          health
          services including relying on licensed behavioral health practitioners
          and/or
          affiliation agreements with local outpatient child psychiatric clinic that
          provide clinical staff, consultation, or oversight. If the school-based
          health
          center provides behavioral health diagnostic and treatment services, these
          services will be the responsibility of the BHP ASO. The school-based health
          center must enroll as a CMAP provider in order to be reimbursed for those
          services under BHP.

      

      
        


        In
          some
          cases, the behavioral health component of the school-based health center's
          services is provided under the license of an outpatient child psychiatric
          clinic. In this case, the outpatient child psychiatric clinic will be enrolled
          as a CMAP provider and the services provided will be reimbursable as behavioral
          health clinic services under BHP.

      

      
        


        Transportation

      

      
        


        All
          of
          the HUSKY MCOs will continue to provide transportation for HUSKY A enrollees
          with behavioral health disorders for behavioral health services that are
          covered
          under Medicaid. Specifically, the MCOs will continue to be responsible
          for
          transportation to hospitals, clinics, and independent professionals for
          routine
          outpatient, extended day treatment, intensive outpatient, partial
          hospitalization, detoxification, methadone maintenance, and inpatient
          psychiatric services. The MCOs will also be responsible for services that
          might
          be covered under EPSDT. For example, case management services are not included
          in the Connecticut Medicaid state plan, but they are covered under EPSDT
          when
          medically necessary. Although case management does not necessarily require
          transportation to a facility, if transportation to a facility were necessary
          for
          a case management encounter, the MCOs would be responsible for providing
          it.
          These policies under BHP are simply a continuation of current HUSKY A program
          policies.

      

      
        


        The
          MCOs
          will not be responsible for transportation for non-Medicaid services such
          as
          respite, or DCF funded services that are designed to come to the client
          including care coordination, emergency mobile psychiatric services, home-based
          services, and therapeutic mentoring.

      

      
        


        The
          transportation benefit for behavioral health visits will continue to be
          subject
          to the same policies and procedures applicable to other HUSKY A covered
          services. The Departments will issue a member services handbook that indicates
          that transportation services are covered for HUSKY A enrollees and that
          such
          services will be covered by the HUSKY MCO with which the member is enrolled.
          The
          handbook will indicate that the MCO specific transportation policies apply,
          that
          HUSKY MCO recipients should refer to their HUSKY member handbook for details,
          and arrange for transportation directly with their HUSKY MCO transportation
          broker.

      

      
        


        State
          of
          Connecticut                                                            Page
          16                                                            01/26/06


      

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      
        The
          ASO
          will make referrals to the closest appropriate providers (typically 3 names
          will
          be given upon request) and avoid referrals to facilities and offices outside
          of
          a 25-30 mile radius unless circumstances require otherwise. The ASO is
          not
          required to review provider distance from the member when responding to
          requests
          for authorization. The transportation brokers will assess all requests
          for
          transportation when contacted by the member and it will be up to the
          transportation broker and the MCO to apply coverage limitations as appropriate
          when contacted by the member. In most cases, the transportation broker
          and/or
          the MCO will be able to make decisions about whether to authorize transportation
          to the non-closest provider or to a provider that is outside of the 25-30
          mile
          radius by working directly with the member.   However, the ASO
          will be required to respond to inquiries from the MCO or transportation
          broker
          if additional information is needed to support authorization of a transportation
          request.

      

      
        


        The
          HUSKY
          MCOs will also retain responsibility for all Emergency Medical Transportation
          and associated charges, regardless of diagnosis, and hospital-to-hospital
          ambulance transportation of members with a behavioral health
          condition.

      

      
        


        The
          BHP
          ASO is expected to work closely with the MCOs to monitor transportation
          utilization and, if necessary, cooperate with the MCOs in conducting targeted
          provider education or training related to the appropriate use of transportation
          services. The HUSKY MCOs may track and trend utilization of transportation
          to
          behavioral health facilities. Any increases in the utilization trend will
          be
          addressed with the Departments.

      

      
        


        State
          of
          Connecticut                                                             Page
          17                                                            01/26/06

      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      
        APPENDIX
          O

      

      
        


      

      
        CTBHP
          Master Covered Services Table

      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

       

      
        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July
                      31,2006

                  


          

        

        
          


          0507

        

        


        
          	
                  
                    HUSKY
                      A and B Appendix O - CT BHP Master Covered Services Table -
                      September
                      2006

                  

                
	
                  
                    Coverage

                  

                	
                  
                    1
                      =
                      HUSKY MCO - All diagnoses

                  

                
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BHP -All diagnoses

                  

                
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                
	 	
                  
                    4=
                      Not covered

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    General
                      Hospital Inpatient

                  

                	
                  
                    Coverage

                  

                
	
                  
                    110

                  

                	
                  
                    Room
                      & Board- Private

                  

                	
                  
                    3

                  

                
	
                  
                    111

                  

                	
                  
                    Room
                      & Board- Private -Med/Surg/Gyn

                  

                	
                  
                    3

                  

                
	
                  
                    112

                  

                	
                  
                    Room
                      & Board- Private -OB

                  

                	
                  
                    3

                  

                
	
                  
                    113

                  

                	
                  
                    Room
                      & Board- Private -Pediatric

                  

                	
                  
                    3

                  

                
	
                  
                    114

                  

                	
                  
                    Room
                      & Board - Private - Psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    115

                  

                	
                  
                    Room
                      & Board- Private -Hospice

                  

                	
                  
                    3

                  

                
	
                  
                    116

                  

                	
                  
                    Room
                      & Board - Private - Detox

                  

                	
                  
                    2

                  

                
	
                  
                    117

                  

                	
                  
                    Room
                      & Board- Private -Oncology

                  

                	
                  
                    3

                  

                
	
                  
                    118

                  

                	
                  
                    Room
                      & Board- Private -Rehab

                  

                	
                  
                    3

                  

                
	
                  
                    119

                  

                	
                  
                    Room
                      & Board- Private -Other

                  

                	
                  
                    3

                  

                
	
                  
                    120

                  

                	
                  
                    Room
                      & Board-Semi-Private/2 Bed

                  

                	
                  
                    3

                  

                
	
                  
                    121

                  

                	
                  
                    Room
                      & Board-Semi-Private/ 2 Bed- Med/Surg/Gyn

                  

                	
                  
                    3

                  

                
	
                  
                    122

                  

                	
                  
                    Room
                      & Board-Semi-Private/ 2 Bed -OB

                  

                	
                  
                    3

                  

                
	
                  
                    123

                  

                	
                  
                    Room
                      & Board-Semi-Private/ 2 Bed-Pediatric

                  

                	
                  
                    3

                  

                
	
                  
                    124

                  

                	
                  
                    Room
                      & Board - Semi-Private/2 Bed - Psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    125

                  

                	
                  
                    Room
                      & Board-Semi-Private/ 2 Bed-Hospice

                  

                	
                  
                    3

                  

                
	
                  
                    126

                  

                	
                  
                    Room
                      & Board - Semi-Private/2 Bed - Detox

                  

                	
                  
                    2

                  

                
	
                  
                    127

                  

                	
                  
                    Room
                      & Board-Semi-Private/ 2 Bed-Oncology

                  

                	
                  
                    3

                  

                
	
                  
                    128

                  

                	
                  
                    Room
                      & Board-Semi-Private/ 2 Bed-Rehab

                  

                	
                  
                    3

                  

                
	
                  
                    129

                  

                	
                  
                    Room
                      & Board-Semi-Private/ 2 Bed-Other

                  

                	
                  
                    3

                  

                
	
                  
                    130

                  

                	
                  
                    Room
                      & Board-Semi-Private/3-4 Bed

                  

                	
                  
                    3

                  

                
	
                  
                    131

                  

                	
                  
                    Room
                      & Board-Semi-Private/3-4 Bed- Med/Surg/Gyn

                  

                	
                  
                    3

                  

                
	
                  
                    132

                  

                	
                  
                    Room
                      & Board-Semi-Private/3-4 Bed-OB

                  

                	
                  
                    3

                  

                
	
                  
                    133

                  

                	
                  
                    Room
                      & Board-Semi-Private/3-4 Bed-Pediatric

                  

                	
                  
                    3

                  

                
	
                  
                    134

                  

                	
                  
                    Room
                      & Board - Semi-Private/3-4 Bed - Psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    135

                  

                	
                  
                    Room
                      & Board-Semi-Private/3-4 Bed-Hospice

                  

                	
                  
                    3

                  

                
	
                  
                    136

                  

                	
                  
                    Room
                      & Board - Semi-Private/3-4 Bed - Detox

                  

                	
                  
                    2

                  

                
	
                  
                    137

                  

                	
                  
                    Room
                      & Board-Semi-Private/3-4 Bed-Oncology

                  

                	
                  
                    3

                  

                
	
                  
                    138

                  

                	
                  
                    Room
                      & Board-Semi-Private/3-4 Bed-Rehab

                  

                	
                  
                    3

                  

                
	
                  
                    139

                  

                	
                  
                    Room
                      & Board-Semi-Private/3-4 Bed-Other

                  

                	
                  
                    3

                  

                
	
                  
                    140

                  

                	
                  
                    Room
                      & Board-Private-Deluxe

                  

                	
                  
                    3

                  

                
	
                  
                    141

                  

                	
                  
                    Room
                      & Board-Private-Deluxe- Med/Surg/Gyn

                  

                	
                  
                    3

                  

                
	
                  
                    142

                  

                	
                  
                    Room
                      & Board-Private - Deluxe-OB

                  

                	
                  
                    3

                  

                
	
                  
                    143

                  

                	
                  
                    Room
                      & Board-Private - Deluxe-Pediatric

                  

                	
                  
                    3

                  

                
	
                  
                    144

                  

                	
                  
                    Room
                      & Board - Private - Deluxe - Psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    145

                  

                	
                  
                    Room
                      & Board-Private - Deluxe-Hospice

                  

                	
                  
                    3

                  

                
	
                  
                    146

                  

                	
                  
                    Room
                      & Board - Private - Deluxe - Detox

                  

                	
                  
                    2

                  

                
	
                  
                    147

                  

                	
                  
                    Room
                      & Board-Private - Deluxe-Oncology

                  

                	
                  
                    3

                  

                
	
                  
                    148

                  

                	
                  
                    Room
                      & Board-Private - Deluxe-Rehab

                  

                	
                  
                    3

                  

                
	
                  
                    149

                  

                	
                  
                    Room
                      & Board-Private - Deluxe-Other

                  

                	
                  
                    3

                  

                
	
                  
                    150

                  

                	
                  
                    Room
                      & Board - Ward

                  

                	
                  
                    3

                  

                
	
                  
                    151

                  

                	
                  
                    Room
                      & Board - Ward - Med/Surg/ Gyn

                  

                	
                  
                    3

                  

                
	
                  
                    152

                  

                	
                  
                    Room
                      & Board - Ward - OB

                  

                	
                  
                    3

                  

                
	
                  
                    153

                  

                	
                  
                    Room
                      & Board - Ward - Pediatric

                  

                	
                  
                    3

                  

                
	
                  
                    154

                  

                	
                  
                    Room
                      & Board - Ward - Psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    155

                  

                	
                  
                    Room
                      & Board - Ward - Hospice

                  

                	
                  
                    3

                  

                
	
                  
                    156

                  

                	
                  
                    Room
                      & Board - Ward - Detox

                  

                	
                  
                    2

                  

                
	
                  
                    157

                  

                	
                  
                    Room
                      & Board - Ward - Oncology

                  

                	
                  
                    3

                  

                
	
                  
                    158

                  

                	
                  
                    Room
                      & Board - Ward - Rehab

                  

                	
                  
                    3

                  

                
	
                  
                    159

                  

                	
                  
                    Room
                      & Board - Ward - Other

                  

                	
                  
                    3

                  

                
	
                  
                    160

                  

                	
                  
                    Other
                      Room & Board

                  

                	
                  
                    3

                  

                
	
                  
                    164

                  

                	
                  
                    Other
                      Room & Board - Sterile Environment

                  

                	
                  
                    3

                  

                
	
                  
                    167

                  

                	
                  
                    Other
                      Room & Board - Self Care

                  

                	
                  
                    3

                  

                
	
                  
                    169

                  

                	
                  
                    Other
                      Room & Board - Other

                  

                	
                  
                    3

                  

                
	
                  
                    170

                  

                	
                  
                    Room
                      & Board- Nursery

                  

                	
                  
                    3

                  

                
	
                  
                    171

                  

                	
                  
                    Room
                      & Board- Nursery - Newborn

                  

                	
                  
                    3

                  

                
	
                  
                    172

                  

                	
                  
                    Room
                      & Board- Nursery - Premature

                  

                	
                  
                    3

                  

                
	
                  
                    175

                  

                	
                  
                    Room
                      & Board- Nursery - Neonatal ICU

                  

                	
                  
                    3

                  

                
	
                  
                    179

                  

                	
                  
                    Room
                      & Board- Nursery - Other

                  

                	
                  
                    3

                  

                


        

         

        
          5/1/2007


        

        
          1
            of 11
            HUSKY A B Appendix O - BHP Master Covered Services Table
            05/01/07]

        



        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July 31,
                      2006

                  


          

        

        
          


          0507

        

        


        
          	 	
                  
                    HUSKY
                      A and B Appendix 0 - CT BHP Master Covered Services Table -
                      September
                      2006

                  

                	 
	
                  
                    Coverage

                  

                	
                  
                    1=
                      HUSKY MCO - All diagnoses

                  

                	 
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BHP - All diagnoses

                  

                	 
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                	 
	 	
                  
                    4=
                      Not covered

                  

                	 
	
                  
                    190

                  

                	
                  
                    Subacute
                      Care

                  

                	
                  
                    3

                  

                
	
                  
                    200

                  

                	
                  
                    Intensive
                      Care

                  

                	
                  
                    3

                  

                
	
                  
                    201

                  

                	
                  
                    Intensive
                      Care - Surgical

                  

                	
                  
                    3

                  

                
	
                  
                    202

                  

                	
                  
                    Intensive
                      Care - Medical

                  

                	
                  
                    3

                  

                
	
                  
                    203

                  

                	
                  
                    Intensive
                      Care - Pediatric

                  

                	
                  
                    3

                  

                
	
                  
                    204

                  

                	
                  
                    Intensive
                      Care - Psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    205

                  

                	
                  
                    Intensive
                      Care - Post ICU

                  

                	
                  
                    3

                  

                
	
                  
                    207

                  

                	
                  
                    Intensive
                      Care - Burn Treatment

                  

                	
                  
                    3

                  

                
	
                  
                    208

                  

                	
                  
                    Intensive
                      Care - Trauma

                  

                	
                  
                    3

                  

                
	
                  
                    209

                  

                	
                  
                    Intensive
                      Care - Other

                  

                	
                  
                    3

                  

                
	
                  
                    210

                  

                	
                  
                    Coronary
                      Care

                  

                	
                  
                    3

                  

                
	
                  
                    211

                  

                	
                  
                    Coronary
                      Care - Myocardial Infarction

                  

                	
                  
                    3

                  

                
	
                  
                    212

                  

                	
                  
                    Coronary
                      Care - Pulmonary

                  

                	
                  
                    3

                  

                
	
                  
                    213

                  

                	
                  
                    Coronary
                      Care - Heart Transplant

                  

                	
                  
                    3

                  

                
	
                  
                    214

                  

                	
                  
                    Coronary
                      Care - Post CCU

                  

                	
                  
                    3

                  

                
	
                  
                    219

                  

                	
                  
                    Coronary
                      Care - Other

                  

                	
                  
                    3

                  

                
	
                  
                    224

                  

                	
                  
                    Late
                      discharge/Medically necessary

                  

                	
                  
                    4

                  

                
	 	
                  
                    Note:
                      MCOs cover alcohol detoxification on a medical
                      floor.

                  

                	 
	
                  
                    Code

                  

                	
                  
                    General
                      Hospital Emergency Department

                  

                	
                  
                    Coverage

                  

                
	
                  
                    450

                  

                	
                  
                    Emergency
                      Room General Classification

                  

                	
                  
                    1

                  

                
	
                  
                    451

                  

                	
                  
                    EMTALA
                      Emergency Medical Screening Services

                  

                	
                  
                    1

                  

                
	
                  
                    452

                  

                	
                  
                    Emergency
                      Room Beyond EMTALA Screening

                  

                	
                  
                    1

                  

                
	
                  
                    456

                  

                	
                  
                    Urgent
                      Care

                  

                	
                  
                    1

                  

                
	
                  
                    459

                  

                	
                  
                    Other
                      Emergency Room

                  

                	
                  
                    1

                  

                
	
                  
                    762

                  

                	
                  
                    Observation
                      room

                  

                	
                  
                    3

                  

                
	
                  
                    981

                  

                	
                  
                    Professional
                      Fee - Emergency Department

                  

                	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    General
                      Hospital Outpatient

                  

                	
                  
                    Coverage

                  

                
	
                  
                    490

                  

                	
                  
                    Ambulatory
                      Surgery**

                  

                	
                  
                    3

                  

                
	
                  
                    762

                  

                	
                  
                    Observation
                      room

                  

                	
                  
                    3

                  

                
	
                  
                    900

                  

                	
                  
                    Psychiatric
                      Services General (Evaluation)

                  

                	
                  
                    2

                  

                
	
                  
                    901

                  

                	
                  
                    Electroconvulsive
                      Therapy**

                  

                	
                  
                    2

                  

                
	
                  
                    905

                  

                	
                  
                    Intensive
                      Outpatient Services - Psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    906

                  

                	
                  
                    Intensive
                      Outpatient Services - Chemical Dependency

                  

                	
                  
                    2

                  

                
	
                  
                    907

                  

                	
                  
                    Community
                      Behavioral Health Program (Day Treatment)

                  

                	
                  
                    2

                  

                
	
                  
                    913

                  

                	
                  
                    Partial
                      Hospital

                  

                	
                  
                    2

                  

                
	
                  
                    914

                  

                	
                  
                    Individual
                      Therapy

                  

                	
                  
                    2

                  

                
	
                  
                    915

                  

                	
                  
                    Group
                      Therapy

                  

                	
                  
                    2

                  

                
	
                  
                    916

                  

                	
                  
                    Family
                      Therapy

                  

                	
                  
                    2

                  

                
	
                  
                    918

                  

                	
                  
                    Psychiatric
                      Service - Testing

                  

                	
                  
                    3

                  

                
	
                  
                    919

                  

                	
                  
                    Other
                      - Med Admin

                  

                	
                  
                    2

                  

                
	
                  
                    961

                  

                	
                  
                    Professional
                      Fees-Psychiatric

                  

                	
                  
                    4

                  

                
	
                  
                    All
                      others

                  

                	 	
                  
                    1

                  

                
	 	
                  
                    Note:
                      Includes outpatient provided by special care hospitals (e.g.,
                      Gaylord)

                  

                	 
	 	
                  
                    "MCOs
                      pay for all professional services charges (e.g., anesthesiologist)
                      regardless of diagnosis, except psychiatrist
                      charges.

                  

                	 
	
                  
                    Code

                  

                	
                  
                    Psychiatric
                      Hospital Inpatient (includes Riverview, CVH)

                  

                	
                  
                    Coverage

                  

                
	
                  
                    100

                  

                	
                  
                    All
                      inclusive room and board plus ancillary

                  

                	
                  
                    4

                  

                
	
                  
                    124

                  

                	
                  
                    Room
                      and Board-Psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    126

                  

                	
                  
                    Room
                      & Board - Semi-Private/2 Bed - Detox

                  

                	
                  
                    2

                  

                
	
                  
                    128

                  

                	
                  
                    Room
                      & Board-Semi-Private/ 2 Bed-Rehab

                  

                	
                  
                    4

                  

                
	
                  
                    190

                  

                	
                  
                    Subacute
                      Care

                  

                	
                  
                    2

                  

                
	
                  
                    224

                  

                	
                  
                    Late
                      discharge/Medically necessary

                  

                	
                  
                    4

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Psychiatric
                      Hospital Outpatient

                  

                	
                  
                    Coverage

                  

                
	
                  
                    490

                  

                	
                  
                    Ambulatory
                      Surgery**

                  

                	
                  
                    3

                  

                
	
                  
                    762

                  

                	
                  
                    Observation
                      room

                  

                	
                  
                    2

                  

                
	
                  
                    900

                  

                	
                  
                    Psychiatric
                      Services General (Evaluation)

                  

                	
                  
                    2

                  

                
	
                  
                    901

                  

                	
                  
                    Electroconvulsive
                      Therapy

                  

                	
                  
                    2

                  

                
	
                  
                    905

                  

                	
                  
                    Intensive
                      Outpatient Services ^psychiatric

                  

                	
                  
                    2

                  

                
	
                  
                    906

                  

                	
                  
                    Intensive
                      Outpatient Services - Chemical Dependency

                  

                	
                  
                    2

                  

                


        

        
           

          5/1/2007

        

        
          2
            of 11
            HUSKY A B Appendix 0 - BHP Master Covered Services Table
            05/01/07]

        



        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July 31,
                      2006

                  


          

        

        
          


          0507

        

        


        
          	
                  
                    HUSKY
                      A and B Appendix O - CT BHP Master Covered Services Table -
                      September
                      2006

                  

                
	
                  
                    Coverage

                  

                	
                  
                    1=
                      HUSKY MCO -All diagnoses

                  

                
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BHP -All diagnoses

                  

                
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                
	 	
                  
                    4=
                      Not covered

                  

                
	
                  
                    907

                  

                	
                  
                    Community
                      Behavioral Health Program (Day Treatment)

                  

                	
                  
                    2

                  

                
	
                  
                    913

                  

                	
                  
                    Partial
                      Hospital-More Intensive

                  

                	
                  
                    2

                  

                
	
                  
                    914

                  

                	
                  
                    Psychiatric
                      Service-Individual Therapy

                  

                	
                  
                    2

                  

                
	
                  
                    915

                  

                	
                  
                    Psychiatric
                      Service-Group Therapy

                  

                	
                  
                    2

                  

                
	
                  
                    916

                  

                	
                  
                    Psychiatric
                      Service-Family Therapy

                  

                	
                  
                    2

                  

                
	
                  
                    918

                  

                	
                  
                    Psychiatric
                      Service-Testing

                  

                	
                  
                    2

                  

                
	
                  
                    919

                  

                	
                  
                    Other-
                      Med Admin

                  

                	
                  
                    2

                  

                
	 	
                  
                    "MCOs
                      pay for all professional services charges (e.g., anesthesiologist)
                      regardless of diagnosis, except psychiatrist
                      charges.

                  

                	 
	
                  
                    Code

                  

                	
                  
                    Alcohol
                      and Drug Abuse Center (Non-hospital Inpatient Detox)

                  

                	
                  
                    Coverage

                  

                
	
                  
                    H0011

                  

                	
                  
                    Acute
                      Detoxification (residential program inpatient)

                  

                	
                  
                    2

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Alcohol
                      and Drug Abuse Center (Ambulatory Detoxification)

                  

                	
                  
                    Coverage

                  

                
	
                  
                    H0014

                  

                	
                  
                    Ambulatory
                      Detoxification

                  

                	
                  
                    2

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    PRTF

                  

                	
                  
                    Coverage

                  

                
	
                  
                    T2048

                  

                	
                  
                    Psychiatric
                      health facility service, per diem

                  

                	
                  
                    2

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    DCF
                      Residential

                  

                	
                  
                    Coverage

                  

                
	
                  
                    N/A

                  

                	
                  
                    DCF
                      Funded residential facility

                  

                	
                  
                    2

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Long
                      Term Care Facility

                  

                	
                  
                    Coverage

                  

                
	
                  
                    100

                  

                	
                  
                    Per
                      diem rate

                  

                	
                  
                    1

                  

                
	
                  
                    183

                  

                	
                  
                    Home
                      reserve

                  

                	
                  
                    1

                  

                
	
                  
                    185

                  

                	
                  
                    Inpatient
                      hospital reserve

                  

                	
                  
                    1

                  

                
	
                  
                    189

                  

                	
                  
                    Non-covered
                      reserve

                  

                	
                  
                    4

                  

                
	 	
                  
                    Note:
                      Includes inpatient at special care hospitals.

                  

                	 
	
                  
                    Code

                  

                	
                  
                    MH
                      Clinic

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90801

                  

                	
                  
                    Psychiatric
                      Diagnostic Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90802

                  

                	
                  
                    Interactive
                      Psychiatric Diagnostic Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      Psychotherapy- Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90805

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90807

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90808

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90809

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90810

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90811

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90812

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90813

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90814

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90815

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      Psychotherapy (without the patient present)

                  

                	
                  
                    2

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      Psychotherapy (conjoint psychotherapy) (with the patient
                      present)

                  

                	
                  
                    2

                  

                
	
                  
                    90849

                  

                	
                  
                    Multi-group
                      family psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90857

                  

                	
                  
                    Interactive
                      group psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90862

                  

                	
                  
                    Pharmacologic
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90887

                  

                	
                  
                    Interpretation
                      or explanation of results of psychiatric or other medical examinations
                      and
                      procedures or other accumulated data to family or other responsible
                      persons.

                  

                	
                  
                    2

                  

                
	
                  
                    96101

                  

                	
                  
                    Psychological
                      testing, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    96110

                  

                	
                  
                    Developmental
                      testing and report, limited

                  

                	
                  
                    2

                  

                
	
                  
                    96111

                  

                	
                  
                    Developmental
                      testing and report, extended

                  

                	
                  
                    2

                  

                
	
                  
                    96118

                  

                	
                  
                    Neuropsychological
                      testing battery, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    H0015

                  

                	
                  
                    Intensive
                      Outpatient-Substance Dependence*

                  

                	
                  
                    2

                  

                
	
                  
                    H0035

                  

                	
                  
                    Mental
                      health partial hospitalization, treatment, less than 24 hours
                      (CMHC)*

                  

                	
                  
                    2

                  

                
	
                  
                    H2012

                  

                	
                  
                    Extended
                      Day Treatment

                  

                	
                  
                    p*ft**

                  

                
	
                  
                    H2013

                  

                	
                  
                    Partial
                      Hospitalization (non-CMHC)*

                  

                	
                  
                    2*

                  

                


        

         

        
          5/1/2007


        

        
          3
            of 11
            HUSKY A B Appendix O - BHP Master Covered Services Table
            05/01/07]

        



        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July
                      31,2006

                  


          

        

        
          


          0507

        

        


        
          	
                  
                    HUSKY
                      A and B Appendix O - CT BMP Master Covered Services Table -
                      September
                      2006

                  

                
	
                  
                    Coverage

                  

                	
                  
                    1=
                      HUSKY MCO - All diagnoses

                  

                
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BMP -All diagnoses

                  

                
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                
	 	
                  
                    4=
                      Not covered

                  

                
	
                  
                    H2019

                  

                	
                  
                    Therapeutic
                      Behavioral Services, per 15 minutes (IICAPS, MST, MDFT, FFT,
                      FST, HVS)
                      (Clients under 21 only)

                  

                	
                  
                    2***

                  

                
	
                  
                    T1017

                  

                	
                  
                    Targeted
                      case management, each 15 minutes (part of home-based services
                      only -
                      IICAPS, MST, MDFT, FFT, FST, HVS) (Clients under 21
                      only)

                  

                	
                  
                    2

                  

                
	
                  
                    J1630

                  

                	
                  
                    Jnjection,
                      Haloperidol, up to 5 mg

                  

                	
                  
                    2

                  

                
	
                  
                    J1631

                  

                	
                  
                    Injection,
                      Haloperidol decanoate, per 50 mg^

                  

                	
                  
                    2

                  

                
	
                  
                    J2680

                  

                	
                  
                    Injection,
                      Fluphenazine decanoate, up to 25 mg

                  

                	
                  
                    2

                  

                
	
                  
                    M0064

                  

                	
                  
                    Brief
                      office visit for the sole purpose of monitoring or changing
                      drug
                      prescriptions used in the treatment of mental psychoneurotic
                      and
                      personality disorders

                  

                	
                  
                    2

                  

                
	
                  
                    S9480

                  

                	
                  
                    Intensive
                      Outpatient-Mental Health

                  

                	
                  
                    2

                  

                
	
                  
                    S9484

                  

                	
                  
                    Emergency
                      mobile mental health service, follow-up (Clients under 21
                      only)

                  

                	
                  
                    o***

                  

                
	
                  
                    S9485

                  

                	
                  
                    Emergency
                      mobile mental health service, initial evaluation (Clients under
                      21
                      only)

                  

                	
                  
                    Oft**

                  

                
	
                  
                    T1016

                  

                	
                  
                    Case
                      Management - Coordination of health care services - each 15
                      min.

                  

                	
                  
                    2

                  

                
	
                  
                    H0037

                  

                	
                  
                    Community_psychiatric
                      supportive treatment program, per diem

                  

                	
                  
                    4

                  

                
	
                  
                    S9475

                  

                	
                  
                    Ambulatory
                      setting, substance abuse treatment or detoxification
                      services

                  

                	
                  
                    4

                  

                
	 	
                  
                    'Coverage
                      restricted to providers approved by DSS to provide this
                      service

                  

                	 
	 	
                  
                    ***
                      Coverage restricted to providers certified by DCF to provide
                      this
                      service

                  

                	 
	 	
                  
                    ""Coverage
                      restricted to providers licensed by DCF to provide this
                      service

                  

                	 
	 	 	 
	
                  
                    Code

                  

                	
                  
                    FQHC
                      Mental Health Clinic

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90801

                  

                	
                  
                    Psychiatric
                      Diagnostic Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90802

                  

                	
                  
                    Interactive
                      Psychiatric Diagnostic Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      Psychotherapy- Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90805

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90807

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90808

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90809

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90810

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90811

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90812

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90813

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90814

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90815

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      Psychotherapy (without the patient present)

                  

                	
                  
                    2

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      Psychotherapy (conjoint psychotherapy) (with the patient
                      present)

                  

                	
                  
                    2

                  

                
	
                  
                    90849

                  

                	
                  
                    Multi-group
                      family psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90857

                  

                	
                  
                    Interactive
                      group psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90862

                  

                	
                  
                    Pharmacologic
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90887

                  

                	
                  
                    Interpretation
                      or explanation of results of psychiatric or other medical examinations
                      and
                      procedures or other accumulated data to family or other responsible
                      persons.

                  

                	
                  
                    2

                  

                
	
                  
                    96101

                  

                	
                  
                    Psychological
                      testing, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    96110

                  

                	
                  
                    Developmental
                      testing and report, limited

                  

                	
                  
                    2

                  

                
	
                  
                    96111

                  

                	
                  
                    Developmental
                      testing and report, extended

                  

                	
                  
                    2

                  

                
	
                  
                    96118

                  

                	
                  
                    Neuropsychological
                      testing battery, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    H0015

                  

                	
                  
                    Intensive
                      Outpatient-Substance Dependence*

                  

                	
                  
                    2

                  

                
	
                  
                    H2012

                  

                	
                  
                    Extended
                      Day Treatment

                  

                	
                  
                    n****

                  

                
	
                  
                    H2013

                  

                	
                  
                    Partial
                      Hospitalization (non-CMHC)*

                  

                	
                  
                    2*

                  

                
	
                  
                    J1630

                  

                	
                  
                    Injection,
                      Haloperidol, up to 5 mg

                  

                	
                  
                    2

                  

                
	
                  
                    J1631

                  

                	
                  
                    Injection,
                      Haloperidol decanoate, per 50 mg

                  

                	
                  
                    2

                  

                
	
                  
                    J2680

                  

                	
                  
                    Injection,
                      Fluphenazine decanoate, up to 25 mg

                  

                	
                  
                    2

                  

                
	
                  
                    M0064

                  

                	
                  
                    Brief
                      office visit for the sole purpose of monitoring or changing
                      drug
                      prescriptions used in the treatment of mental psychoneurotic
                      and
                      personality disorders

                  

                	
                  
                    2

                  

                
	
                  
                    S9480

                  

                	
                  
                    Intensive
                      Outpatient-Mental Health

                  

                	
                  
                    2

                  

                
	
                  
                    S9484

                  

                	
                  
                    Emergency
                      mobile mental health service, follow-up (Clients under 21
                      only)

                  

                	
                  
                    2***

                  

                
	
                  
                    S9485

                  

                	
                  
                    Emergency
                      mobile mental health service, initial evaluation (Clients under
                      21
                      only)

                  

                	
                  
                    o***

                  

                
	
                  
                    T1015

                  

                	
                  
                    Clinic
                      visit/encounter all-inclusive (For use by FQHC MH
                      Clinics)

                  

                	
                  
                    2

                  

                


        

        
           

          5/1/2007

        

        
          4
            of 11
            HUSKY A B Appendix O - BHP Master Covered Services Table
            05/01/07]

        



        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July 31,
                      2006

                  


          

        

        
          


          0507

        

        


        
          	 	
                  
                    HUSKY
                      A and B Appendix O - CT BHP Master Covered Services Table -
                      September
                      2006

                  

                	 
	
                  
                    Coverage

                  

                	
                  
                    1=
                      HUSKY MCO - All diagnoses

                  

                	 
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BHP - All diagnoses

                  

                	 
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                	 
	 	
                  
                    4=
                      Not covered

                  

                	 
	
                  
                    H0037

                  

                	
                  
                    Community
                      psychiatric supportive treatment program, per diem

                  

                	
                  
                    4

                  

                
	
                  
                    S9475

                  

                	
                  
                    Ambulatory
                      setting, substance abuse treatment or detoxification
                      services

                  

                	
                  
                    4

                  

                
	 	
                  
                    'Coverage
                      restricted to providers approved by DSS to provide this
                      service

                  

                	 
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Rehabilitation
                      Clinic

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90801

                  

                	
                  
                    Psychiatric
                      Diagnostic Interview

                  

                	
                  
                    3

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      Psychotherapy- Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    3

                  

                
	
                  
                    90805

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min) with medical
                      evaluation and management services

                  

                	
                  
                    3

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    3

                  

                
	
                  
                    90807

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min) with medical
                      evaluation and management services

                  

                	
                  
                    3

                  

                
	
                  
                    90808

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min)

                  

                	
                  
                    3

                  

                
	
                  
                    90809

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min) with medical
                      evaluation and management services

                  

                	
                  
                    3

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      psychotherapy (without the patient present)

                  

                	
                  
                    3

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      psychotherapy (conjoint)

                  

                	
                  
                    3

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      psychotherapy

                  

                	
                  
                    3

                  

                
	
                  
                    90857

                  

                	
                  
                    Interactive
                      Group therapy

                  

                	
                  
                    3

                  

                
	
                  
                    96118

                  

                	
                  
                    Neuropsychological
                      testing battery, per hour

                  

                	
                  
                    3

                  

                
	
                  
                    All
                      others

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    School-Based
                      Health Centers (Freestanding Medical Clinic)

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90782

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; subcutaneous or
                      intramuscular

                  

                	
                  
                    1

                  

                
	
                  
                    90783

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; intra-arterial

                  

                	
                  
                    1

                  

                
	
                  
                    90784

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; intravenous

                  

                	
                  
                    1

                  

                
	
                  
                    90801

                  

                	
                  
                    Psychiatric
                      Diagnostic Interview

                  

                	
                  
                    3

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      psychotherapy (20-30 min)

                  

                	
                  
                    3

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      psychotherapy (without the patient present)

                  

                	
                  
                    3

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      psychotherapy (conjoint psychotherapy w/patient
                      present)

                  

                	
                  
                    3

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      psychotherapy (other than of a multiple-family
                      group)

                  

                	
                  
                    3

                  

                
	
                  
                    99211

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, that may not require the presence of a
                      physician.
                      (Typically 5 minutes)

                  

                	
                  
                    1

                  

                
	
                  
                    99212

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: problem focused history; problem focused examination;
                      straightforward medical decision-making. (Typically 10 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99213

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: expanded problem focused history; expanded problem
                      focused
                      examination; medical decision making of low complexity. (Typically
                      15
                      minutes face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99214

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: detailed history; detailed examination; medical
                      decision
                      making of moderate complexity (Typically 25 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99215

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: comprehensive history; comprehensive examination;
                      medical
                      decision making of high complexity (Typically 40 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    All
                      others

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    School-Based
                      Health Centers (FQHC Medical Clinic)

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90782

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; subcutaneous or
                      intramuscular

                  

                	
                  
                    1

                  

                
	
                  
                    90783

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; intra-arterial

                  

                	
                  
                    1

                  

                
	
                  
                    90784

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; intravenous

                  

                	
                  
                    1

                  

                
	
                  
                    90801

                  

                	
                  
                    Psychiatric
                      Diagnostic Interview

                  

                	
                  
                    3

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      psychotherapy (20-30 min)

                  

                	
                  
                    3

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      psychotherapy (without the patient present)

                  

                	
                  
                    3

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      psychotherapy (conjoint psychotherapy w/patient
                      present)

                  

                	
                  
                    3

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      psychotherapy (other than of a multiple-family
                      group)

                  

                	
                  
                    3

                  

                
	
                  
                    T1015

                  

                	
                  
                    Clinic
                      visit/encounter all-inclusive (For use by FQHC
                      Clinics)

                  

                	
                  
                    2

                  

                
	
                  
                    99211

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, that may not require the presence of a
                      physician.
                      (Typically 5 minutes)

                  

                	
                  
                    1

                  

                


        

        
          5/1/2007

        

        
          


          5
            of 11
            HUSKY A B Appendix O - BHP Master Covered Services Table
            05/01/07]

        



        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July 31,
                      2006

                  


          

        

        
          


          0507

        

        


        
          	
                  
                    HUSKY
                      A and B Appendix O - CT BHP Master Covered Services Table -
                      September
                      2006

                  

                
	
                  
                    Coverage

                  

                	
                  
                    1
                      =
                      HUSKY MCO - All diagnoses

                  

                
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BHP - All diagnoses

                  

                
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                
	 	
                  
                    4=
                      Not covered

                  

                
	
                  
                    99212

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: problem focused history; problem focused examination;
                      straightforward medical decision-making. (Typically 10 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99213

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: expanded problem focused history; expanded problem
                      focused
                      examination; medical decision making of low complexity. (Typically
                      15
                      minutes face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99214

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: detailed history; detailed examination; medical
                      decision
                      making of moderate complexity (Typically 25 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99215

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: comprehensive history; comprehensive examination;
                      medical
                      decision making of high complexity (Typically 40 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    All
                      others

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Methadone
                      Clinic

                  

                	
                  
                    Coverage

                  

                
	
                  
                    H0020

                  

                	
                  
                    Methadone
                      service; rate includes all services for which the source of
                      service is the
                      methadone maintenance clinic.

                  

                	
                  
                    2

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    MD,
                      DO and APRN other than Psychiatrist or Psychiatric
                      APRN

                  

                	
                  
                    Coverage

                  

                
	
                  
                    00104

                  

                	
                  
                    Anesthesia
                      for electroconvulsive therapy

                  

                	
                  
                    1

                  

                
	
                  
                    80100

                  

                	
                  
                    Drug
                      screen, qualitative, chromatographic method, each
                      procedure

                  

                	
                  
                    1

                  

                
	
                  
                    81000

                  

                	
                  
                    Urinalysis,
                      by dip stick or tablet reagent, non-automated, with
                      microscopy

                  

                	
                  
                    1

                  

                
	
                  
                    83840

                  

                	
                  
                    Methadone
                      chemistry (quantitative analysis)

                  

                	
                  
                    1

                  

                
	
                  
                    90782

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; subcutaneous or
                      intramuscular

                  

                	
                  
                    1

                  

                
	
                  
                    90783

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; intra-arterial

                  

                	
                  
                    1

                  

                
	
                  
                    90784

                  

                	
                  
                    Therapeutic
                      or diagnostic injection; intravenous

                  

                	
                  
                    1

                  

                
	
                  
                    908XX

                  

                	
                  
                    Psychotherapy
                      codes

                  

                	
                  
                    4

                  

                
	
                  
                    99211

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, that may not require the presence of a
                      physician.
                      (Typically 5 minutes)

                  

                	
                  
                    1

                  

                
	
                  
                    99212

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: problem focused history; problem focused examination;
                      straightforward medical decision making (Typically 10 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99213

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: expanded problem focused history; expanded problem
                      focused
                      examination; medical decision making of low complexity. (Typically
                      15
                      minutes face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99214

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: detailed history; detailed examination; medical
                      decision
                      making of moderate complexity (Typically 25 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    99215

                  

                	
                  
                    Office
                      or other outpatient visit for the evaluation and management
                      of an
                      established patient, which requires at least two of these three
                      components: comprehensive history; comprehensive examination;
                      medical
                      decision making of high complexity (Typically 40 minutes
                      face-to-face)

                  

                	
                  
                    1

                  

                
	
                  
                    All
                      others

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Psychiatrist
                      (MD or DO)

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90801

                  

                	
                  
                    Diagnostic
                      Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90802

                  

                	
                  
                    Interactive
                      Diagnostic Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90805

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90807

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90808

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90809

                  

                	
                  
                    Individual
                      PsychotherapyjOffice or other Outpatient (75-80 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90810

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90811

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90812

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90813

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90814

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90815

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                


        

        
          5/1/2007

        

        
          


          6
            of 11
            HUSKY A B Appendix O - BHP Master Covered Services Table
            05/01/07]

        



        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July 31,
                      2006

                  


          

        

        
          


          0507

        

        


        
          	 	
                  
                    HUSKY
                      A and B Apjoejrdixjg^CT BMP Master Covered Services Table -
                      September
                      2006

                  

                	 
	
                  
                    Coverage

                  

                	
                  
                    1
                      =
                      HUSKY MCO - All diagnoses

                  

                	 
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BHP- All diagnoses

                  

                	 
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                	 
	 	
                  
                    4=
                      Not covered

                  

                	 
	
                  
                    90816

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90817

                  

                	
                  
                    90816
                      with medical evaluation and management

                  

                	
                  
                    2

                  

                
	
                  
                    90818

                  

                	
                  
                    Individual
                      psychotherapy, insight oriented 45-50 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    90819

                  

                	
                  
                    90818
                      with medical evaluation and management

                  

                	
                  
                    2

                  

                
	
                  
                    90821

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90822

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (75-80 min) with med
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90823

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90824

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (20-30 min) med
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90826

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90827

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (45-50 min) med
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90828

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90829

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (75-80 min) med
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      Psychotherapy (without the patient present)

                  

                	
                  
                    2

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      Psychotherapy (conjoint)

                  

                	
                  
                    2

                  

                
	
                  
                    90849

                  

                	
                  
                    Multi-group
                      family psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      Psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90857

                  

                	
                  
                    Interactive
                      Group psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90862

                  

                	
                  
                    Pharmacological
                      management, including prescription, use, and review of medication
                      with no
                      more than minimal medical psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90865

                  

                	
                  
                    Narcosynthesis
                      for Psychiatric Diagnostic and Therapeutic purposes

                  

                	
                  
                    2

                  

                
	
                  
                    90870

                  

                	
                  
                    Electroconvulsive
                      therapy (including necessary monitoring); single
                      seizure

                  

                	
                  
                    2

                  

                
	
                  
                    90875

                  

                	
                  
                    Individual
                      psychophysiological therapy incorporating biofeedback training
                      (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90876

                  

                	
                  
                    Individual
                      psychophysiological therapy incorporating biofeedback training
                      (45-50
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90880

                  

                	
                  
                    Hypnotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90887

                  

                	
                  
                    Interpretation
                      or explanation of results of psychiatric or other medical examinations
                      and
                      procedures or other accumulated data to family or other responsible
                      persons.

                  

                	
                  
                    2

                  

                
	
                  
                    96101

                  

                	
                  
                    Psychological
                      testing, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    96110

                  

                	
                  
                    Developmental
                      testing with report

                  

                	
                  
                    2

                  

                
	
                  
                    96111

                  

                	
                  
                    Developmental
                      testing, extended

                  

                	
                  
                    2

                  

                
	
                  
                    96118

                  

                	
                  
                    Neuropsychological
                      testing battery, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    99201

                  

                	
                  
                    Office
                      or other outpatient visit, 10 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99202

                  

                	
                  
                    Office
                      or other outpatient visit, 20 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99203

                  

                	
                  
                    Office
                      or other outpatient visit, 30 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99204

                  

                	
                  
                    Office
                      or other outpatient visit, 45 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99205

                  

                	
                  
                    Office
                      or other outpatient visit, 60 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99211

                  

                	
                  
                    Office
                      or other outpatient visit, 5 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99212

                  

                	
                  
                    Office
                      or other outpatient visit, 10 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99213

                  

                	
                  
                    Office
                      or other outpatient visit, 15 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99214

                  

                	
                  
                    Office
                      or other outpatient visit, 25 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99215

                  

                	
                  
                    Office
                      or other outpatient visit, 40 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99217

                  

                	
                  
                    Observation
                      care discharge

                  

                	
                  
                    2

                  

                
	
                  
                    99218

                  

                	
                  
                    Initial
                      observation care, low severity

                  

                	
                  
                    2

                  

                
	
                  
                    99219

                  

                	
                  
                    Initial
                      observation care, moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99220

                  

                	
                  
                    Initial
                      observation care, high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99221

                  

                	
                  
                    Inpatient
                      hospital care, 30 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99222

                  

                	
                  
                    Inpatient
                      hospital care, 50 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99223

                  

                	
                  
                    Inpatient
                      hospital care, 70 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99231

                  

                	
                  
                    Subsequent
                      hospital care, 15 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99232

                  

                	
                  
                    Subsequent
                      hospital care, 25 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99233

                  

                	
                  
                    Subsequent
                      hospital care, 35 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99234

                  

                	
                  
                    Observation
                      of inpatient hospital care, low severity

                  

                	
                  
                    2

                  

                
	
                  
                    99235

                  

                	
                  
                    Observation
                      of inpatient hospital care, moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99236

                  

                	
                  
                    Observation
                      of inpatient hospital care, high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99238

                  

                	
                  
                    Hospital
                      discharge day management 30 minutes or less

                  

                	
                  
                    2

                  

                
	
                  
                    99239

                  

                	
                  
                    Hospital
                      discharge day management more than 30 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99241

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      15
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99242

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      30
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99243

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      40
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99244

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      60
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99245

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      80
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99251

                  

                	
                  
                    Initial
                      inpatient consultation, 20 minutes

                  

                	
                  
                    2

                  

                


        

        


        
          


          5/1/2007

        

        
          


          7
            of 11
            HUSKY A B Appendix O - BHP Master Covered Services Table
            05/01/07]

        



        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July 31,
                      2006

                  


          

        

        
          


          0507

        

        


        
          	 	
                  
                    HUSKY
                      A and B Appendix 0 - CT BHP Master Covered Services Table -
                      September
                      2006

                  

                	 
	
                  
                    Coverage

                  

                	
                  
                    1=
                      HUSKY MCO - All diagnoses

                  

                	 
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BHP - All diagnoses

                  

                	 
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                	 
	 	
                  
                    4=
                      Not covered

                  

                	 
	
                  
                    99252

                  

                	
                  
                    Initial
                      inpatient consultation, 40 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99253

                  

                	
                  
                    Initial
                      inpatient consultation, 55 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99254

                  

                	
                  
                    Initial
                      inpatient consultation, 80 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99255

                  

                	
                  
                    Initial
                      inpatient consultation, 110 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99271

                  

                	
                  
                    Confirmatory
                      consultation, limited or minor

                  

                	
                  
                    2

                  

                
	
                  
                    99272

                  

                	
                  
                    Confirmatory
                      consultation, low severity

                  

                	
                  
                    2

                  

                
	
                  
                    99273

                  

                	
                  
                    Confirmatory
                      consultation, moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99274

                  

                	
                  
                    Confirmatoryjjonsultation,
                      moderate to high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99275

                  

                	
                  
                    Confirmatory
                      consultation, high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99281

                  

                	
                  
                    Emergency
                      department visit, minor severity

                  

                	
                  
                    2

                  

                
	
                  
                    99282

                  

                	
                  
                    Emergency
                      department visit, low to moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99283

                  

                	
                  
                    Emergency
                      department visit, moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99284

                  

                	
                  
                    Emergency
                      department visit, high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99285

                  

                	
                  
                    Emergency
                      department visit, high severity with significant
                      threat

                  

                	
                  
                    2

                  

                
	
                  
                    J1630

                  

                	
                  
                    Injection,
                      Haloperidol, up to 5 mg

                  

                	
                  
                    2

                  

                
	
                  
                    J1631

                  

                	
                  
                    Injection,
                      Haloperidol decanoate, per 50 mg

                  

                	
                  
                    2

                  

                
	
                  
                    J2680

                  

                	
                  
                    Injection,
                      Fluphenazine decanoate, up to 25 mg

                  

                	
                  
                    2

                  

                
	
                  
                    M0064

                  

                	
                  
                    Brief
                      office visit for the sole purpose of monitoring or changing
                      prescriptions
                      used in the treatment of mental psychoneurotic or personality
                      disorders

                  

                	
                  
                    2

                  

                
	
                  
                    T1016

                  

                	
                  
                    Case
                      Management - Coordination of health care services - each 15
                      min.

                  

                	
                  
                    2

                  

                
	
                  
                    All
                      others

                  

                	 	
                  
                    4

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Psychiatric
                      APRN

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90801

                  

                	
                  
                    Diagnostic
                      Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90802

                  

                	
                  
                    Interactive
                      Diagnostic Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90805

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90807

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90808

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90809

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min) with medical
                      evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90810

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90811

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90812

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90813

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90814

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90815

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min) with
                      medical evaluation and management services

                  

                	
                  
                    2

                  

                
	
                  
                    90816

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90817

                  

                	
                  
                    90816
                      with medical evaluation and management

                  

                	
                  
                    2

                  

                
	
                  
                    90818

                  

                	
                  
                    Individual
                      psychotherapy, insight oriented 45-50 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    90819

                  

                	
                  
                    90818
                      with medical evaluation and management

                  

                	
                  
                    2

                  

                
	
                  
                    90821

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90822

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (75-80 min) with med
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90823

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90824

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (20-30 min) med
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90826

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90827

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (45-50 min) med
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90828

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90829

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (75-80 min) med
                      management

                  

                	
                  
                    2

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      Psychotherapy (without the patient present)

                  

                	
                  
                    2

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      Psychotherapy (conjoint)

                  

                	
                  
                    2

                  

                
	
                  
                    90849

                  

                	
                  
                    Multi-group
                      family psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      Psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90857

                  

                	
                  
                    Interactive
                      Group psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90862

                  

                	
                  
                    Pharmacological
                      management, including prescription, use, and review of medication
                      with no
                      more than minimal medical psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90865

                  

                	
                  
                    Narcosynthesis
                      for Psychiatric Diagnostic and Therapeutic purposes

                  

                	
                  
                    2

                  

                


        

        
          5/1/2007

        

        
          


          8
            of 11
            HUSKY A B Appendix 0 - BHP Master Covered Services Table
            05/01/07]

        



        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July
                      31,2006

                  


          

        

        
          


          0507

        

        


        
          	 	
                  
                    HUSKY
                      A and B Appendix O - CT BHP Master Covered Services Table -
                      September
                      2006

                  

                	 
	
                  
                    Coverage

                  

                	
                  
                    1=
                      HUSKY MCO - All diagnoses

                  

                	 
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BHP - All diagnoses

                  

                	 
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BHP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                	 
	 	
                  
                    4=
                      Not covered

                  

                	 
	
                  
                    90870

                  

                	
                  
                    Electroconvulsive
                      therapy (including necessary monitoring); single
                      seizure

                  

                	
                  
                    2

                  

                
	
                  
                    90875

                  

                	
                  
                    Individual
                      psychophysiological therapy incorporating biofeedback training
                      (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90876

                  

                	
                  
                    Individual
                      psychophysiological therapy incorporating biofeedback training
                      (45-50
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90880

                  

                	
                  
                    Hypnotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90887

                  

                	
                  
                    Interpretation
                      or explanation of results of psychiatric or other medical examinations
                      and
                      procedures or other accumulated data to family or other responsible
                      persons.

                  

                	
                  
                    2

                  

                
	
                  
                    96101

                  

                	
                  
                    Psychological
                      testing, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    96110

                  

                	
                  
                    Developmental
                      testing with report

                  

                	
                  
                    2

                  

                
	
                  
                    96111

                  

                	
                  
                    Developmental
                      testing, extended

                  

                	
                  
                    2

                  

                
	
                  
                    96118

                  

                	
                  
                    Neuropsychological
                      testing battery, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    99201

                  

                	
                  
                    Office
                      or other outpatient visit, 10 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99202

                  

                	
                  
                    Office
                      or other outpatient visit, 20 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99203

                  

                	
                  
                    Office
                      or other outpatient visit, 30 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99204

                  

                	
                  
                    Office
                      or other outpatient visit, 45 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99205

                  

                	
                  
                    Office
                      or other outpatient visit, 60 minutes, new patient

                  

                	
                  
                    2

                  

                
	
                  
                    99211

                  

                	
                  
                    Office
                      or other outpatient visit, 5 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99212

                  

                	
                  
                    Office
                      or other outpatient visit, 10 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99213

                  

                	
                  
                    Office
                      or other outpatient visit, 15 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99214

                  

                	
                  
                    Office
                      or other outpatient visit, 25 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99215

                  

                	
                  
                    Office
                      or other outpatient visit, 40 minutes, established
                      patient

                  

                	
                  
                    2

                  

                
	
                  
                    99217

                  

                	
                  
                    Observation
                      care discharge

                  

                	
                  
                    2

                  

                
	
                  
                    99218

                  

                	
                  
                    Initial
                      observation care, low severity

                  

                	
                  
                    2

                  

                
	
                  
                    99219

                  

                	
                  
                    Initial
                      observation care, moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99220

                  

                	
                  
                    Initial
                      observation care, high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99221

                  

                	
                  
                    Inpatient
                      hospital care, 30 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99222

                  

                	
                  
                    Inpatient
                      hospital care, 50 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99223

                  

                	
                  
                    Inpatient
                      hospital care, 70 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99231

                  

                	
                  
                    Subsequent
                      hospital care, 15 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99232

                  

                	
                  
                    Subsequent
                      hospital care, 25 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99233

                  

                	
                  
                    Subsequent
                      hospital care, 35 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99234

                  

                	
                  
                    Observation
                      of inpatient hospital care, low severity

                  

                	
                  
                    2

                  

                
	
                  
                    99235

                  

                	
                  
                    Observation
                      of inpatient hospital care, moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99236

                  

                	
                  
                    Observation
                      of inpatient hospital care, high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99238

                  

                	
                  
                    Hospital
                      discharge day management 30 minutes or less

                  

                	
                  
                    2

                  

                
	
                  
                    99239

                  

                	
                  
                    Hospital
                      discharge day management more than 30 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99241

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      15
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99242

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      30
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99243

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      40
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99244

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      60
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99245

                  

                	
                  
                    Office
                      consultation for a new or established patient, approximately
                      80
                      minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99251

                  

                	
                  
                    Initial
                      inpatient consultation, 20 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99252

                  

                	
                  
                    Initial
                      inpatient consultation, 40 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99253

                  

                	
                  
                    Initial
                      inpatient consultation, 55 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99254

                  

                	
                  
                    Initial
                      inpatient consultation, 80 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99255

                  

                	
                  
                    Initial
                      inpatient consultation, 110 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    99271

                  

                	
                  
                    Confirmatory
                      consultation, limited or minor

                  

                	
                  
                    2

                  

                
	
                  
                    99272

                  

                	
                  
                    Confirmatory
                      consultation, low severity

                  

                	
                  
                    2

                  

                
	
                  
                    99273

                  

                	
                  
                    Confirmatory
                      consultation, moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99274

                  

                	
                  
                    Confirmatory
                      consultation, moderate to high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99275

                  

                	
                  
                    Confirmatory
                      consultation, high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99281

                  

                	
                  
                    Emergency
                      department visit, minor severity

                  

                	
                  
                    2

                  

                
	
                  
                    99282

                  

                	
                  
                    Emergency
                      department visit, low to moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99283

                  

                	
                  
                    Emergency
                      department visit, moderate severity

                  

                	
                  
                    2

                  

                
	
                  
                    99284

                  

                	
                  
                    Emergency
                      department visit, high severity

                  

                	
                  
                    2

                  

                
	
                  
                    99285

                  

                	
                  
                    Emergency
                      department visit, high severity with significant
                      threat

                  

                	
                  
                    2

                  

                
	
                  
                    J1630

                  

                	
                  
                    Injection,
                      Haloperidol, up to 5 mg

                  

                	
                  
                    2

                  

                
	
                  
                    J1631

                  

                	
                  
                    Injection,
                      Haloperidol decanoate, per 50 mg

                  

                	
                  
                    2

                  

                
	
                  
                    J2680

                  

                	
                  
                    Injection,
                      Fluphenazine decanoate, up to 25 mg

                  

                	
                  
                    2

                  

                
	
                  
                    M0064

                  

                	
                  
                    Brief
                      office visit for the sole purpose of monitoring or changing
                      prescriptions
                      used in the treatment of mental psychoneurotic or personality
                      disorders

                  

                	
                  
                    2

                  

                
	
                  
                    T1016

                  

                	
                  
                    Case
                      Management - Coordination of health care services - each 15
                      min.

                  

                	
                  
                    2

                  

                


        

        
          5/1/2007

        

        
          


          9
            of 11
            HUSKY A B Appendix O - BHP Master Covered Services Table
            05/01/07]

        



        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        
          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July 31,
                      2006

                  


          

        

        
          


          0507

        

        


        
          	
                  
                    HUSKY
                      A and B Appendix O;- CT BMP Master Covered Services
                      Table

                  

                	
                  
                    -
                      September 2006

                  

                
	
                  
                    Coverage

                  

                	
                  
                    1=
                      HUSKY MCO - All diagnoses

                  

                
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BMP - All diagnoses

                  

                
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BMP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                	 
	 	
                  
                    4=
                      Not covered

                  

                	 
	
                  
                    All
                      others

                  

                	 	
                  
                    4

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Psychologist
                      and Psychologist Group

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90801

                  

                	
                  
                    Diagnostic
                      Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90802

                  

                	
                  
                    Interactive
                      Diagnostic Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90808

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90810

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90812

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90814

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90816

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90818

                  

                	
                  
                    Individual
                      psychotherapy, insight oriented 45-50 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    90821

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90823

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90826

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90828

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      Psychotherapy (without the patient present)

                  

                	
                  
                    2

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      Psychotherapy (conjoint)

                  

                	
                  
                    2

                  

                
	
                  
                    90849

                  

                	
                  
                    Multi-group
                      family psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      Psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90857

                  

                	
                  
                    Interactive
                      Group psychotherapy

                  

                	 	
                  
                    2

                  

                
	
                  
                    90875

                  

                	
                  
                    Individual
                      psychophysiological therapy incorporating biofeedback training
                      (20-30

                  

                	
                  
                    min)

                  

                	
                  
                    2

                  

                
	
                  
                    90876

                  

                	
                  
                    Individual
                      psychophysiological therapy incorporating biofeedback training
                      (45-50

                  

                	
                  
                    min)

                  

                	
                  
                    2

                  

                
	
                  
                    90880

                  

                	
                  
                    Hypnotherapy

                  

                	 	
                  
                    2

                  

                
	
                  
                    90887

                  

                	
                  
                    Interpretation
                      or explanation of results of psychiatric or other medical examinations
                      and
                      procedures or other accumulated data to family or other responsible
                      persons. .

                  

                	
                  
                    2

                  

                
	
                  
                    96101

                  

                	
                  
                    Psychological
                      testing, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    96110

                  

                	
                  
                    Developmental
                      testing with report

                  

                	
                  
                    2

                  

                
	
                  
                    96111

                  

                	
                  
                    Developmental
                      testing, extended

                  

                	
                  
                    2

                  

                
	
                  
                    96118

                  

                	
                  
                    Neuropsychological
                      testing battery, per hour

                  

                	
                  
                    2

                  

                
	
                  
                    T1016

                  

                	
                  
                    Case
                      Management - Coordination of health care services - each 15
                      min.

                  

                	
                  
                    2

                  

                
	 	 	 
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Independent
                      Practice Behavioral Health Professional (LCSW, LMFT, LPC,
                      LADC)

                  

                	
                  
                    Coverage

                  

                
	
                  
                    90801

                  

                	
                  
                    Diagnostic
                      Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90802

                  

                	
                  
                    Interactive
                      Diagnostic Interview

                  

                	
                  
                    2

                  

                
	
                  
                    90804

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90806

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90808

                  

                	
                  
                    Individual
                      Psychotherapy-Office or other Outpatient (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90810

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (20-30
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90812

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (45-50
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90814

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Office or other Outpatient (75-80
                      min)

                  

                	
                  
                    2

                  

                
	
                  
                    90816

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90818

                  

                	
                  
                    Individual
                      psychotherapy, insight oriented 45-50 minutes

                  

                	
                  
                    2

                  

                
	
                  
                    90821

                  

                	
                  
                    Individual
                      Psychotherapy-Facility Based (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90823

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (20-30 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90826

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (45-50 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90828

                  

                	
                  
                    Interactive
                      Individual Psychotherapy-Facility Based (75-80 min)

                  

                	
                  
                    2

                  

                
	
                  
                    90846

                  

                	
                  
                    Family
                      Psychotherapy (without the patient present)

                  

                	
                  
                    2

                  

                
	
                  
                    90847

                  

                	
                  
                    Family
                      Psychotherapy (conjoint)

                  

                	
                  
                    2

                  

                
	
                  
                    90849

                  

                	
                  
                    Multi-group
                      family psychotherapy

                  

                	 	
                  
                    2

                  

                
	
                  
                    90853

                  

                	
                  
                    Group
                      Psychotherapy

                  

                	 	
                  
                    2

                  

                
	
                  
                    90857

                  

                	
                  
                    Interactive
                      Group psychotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90875

                  

                	
                  
                    Individual
                      psychophysiological therapy incorporating biofeedback training
                      (20-30

                  

                	
                  
                    min)

                  

                	
                  
                    2

                  

                
	
                  
                    90876

                  

                	
                  
                    Individual
                      psychophysiological therapy incorporating biofeedback training
                      (45-50

                  

                	
                  
                    min)

                  

                	
                  
                    2

                  

                
	
                  
                    90880

                  

                	
                  
                    Hypnotherapy

                  

                	
                  
                    2

                  

                
	
                  
                    90887

                  

                	
                  
                    Interpretation
                      or explanation of results of psychiatric or other medical examinations
                      and
                      procedures or other accumulated data to family or other responsible
                      persons.

                  

                	
                  
                    2

                  

                
	
                  
                    96110

                  

                	
                  
                    Developmental
                      testing with report

                  

                	
                  
                    2

                  

                


        

        
          5/1/2007

        

        
          


          10
            of 11
            HUSKY A B Appendix O - BMP Master Covered Services Table
            05/01/07]

        



        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        


        


        
          


          
            	
                     

                  	
                    CTBHP
                      Covered Services Table Revised July 31,
                      2006

                  


          

        

        
          


          0507

        

        


        
          	 	
                  
                    HUSKY
                      A and B Appendix O - CT BMP Master Covered Services Table -
                      September
                      2006

                  

                	 
	
                  
                    Coverage

                  

                	
                  
                    1=
                      HUSKY MCO - All diagnoses

                  

                	 
	
                  
                    Responsibility

                  

                	
                  
                    2=
                      BMP - All diagnoses

                  

                	 
	
                  
                    Legend:

                  

                	
                  
                    3=
                      BMP for Primary Diagnoses 291-316, HUSKY MCO all other
                      diagnoses

                  

                	 
	 	
                  
                    4=
                      Not covered

                  

                	 
	
                  
                    96111

                  

                	
                  
                    Developmental
                      testing, extended

                  

                	
                  
                    2

                  

                
	
                  
                    T1016

                  

                	
                  
                    Case
                      Management - Coordination of health care services - each 15
                      min.

                  

                	
                  
                    2

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Home
                      Health Care Agencies

                  

                	
                  
                    Coverage

                  

                
	
                  
                    RCC/HCPC

                  

                	 	 
	
                  
                    421

                  

                	
                  
                    Physical
                      Therapy

                  

                	
                  
                    1

                  

                
	
                  
                    424

                  

                	
                  
                    Physical
                      Therapy Evaluation

                  

                	
                  
                    1

                  

                
	
                  
                    431

                  

                	
                  
                    Occupational
                      Therapy

                  

                	
                  
                    1

                  

                
	
                  
                    434

                  

                	
                  
                    Occupational
                      Therapy Evaluation

                  

                	
                  
                    1

                  

                
	
                  
                    441

                  

                	
                  
                    Speech
                      Therapy

                  

                	
                  
                    1

                  

                
	
                  
                    444

                  

                	
                  
                    Speech
                      Therapy Evaluation

                  

                	
                  
                    1

                  

                
	
                  
                    570/T1004

                  

                	
                  
                    Services
                      of a qualified nursing aide, up to 15 minutes

                  

                	
                  
                    3

                  

                
	
                  
                    580/S9123

                  

                	
                  
                    Nursing
                      care, in the home by an RN, per hour

                  

                	
                  
                    3

                  

                
	
                  
                    580/S9124

                  

                	
                  
                    Nursing
                      Care, in the home by an LPN, per hour

                  

                	
                  
                    3

                  

                
	
                  
                    580/T1001

                  

                	
                  
                    Nursing
                      Assessment/Evaluation

                  

                	
                  
                    3

                  

                
	
                  
                    580/T1002

                  

                	
                  
                    RN
                      Services, up to 15 minutes

                  

                	
                  
                    3

                  

                
	
                  
                    580/T1003

                  

                	
                  
                    LPN/LVN
                      services, up to 15 minutes

                  

                	
                  
                    3

                  

                
	
                  
                    580/T1502

                  

                	
                  
                    Administration
                      of oral, intramuscular and/or subcutaneous medication by health
                      care
                      agency/professional, per visit

                  

                	
                  
                    3

                  

                
	 	
                  
                    *BHP
                      covers home health services for children with autism including
                      when autism
                      is co-morbid with mental retardation.

                  

                	 
	
                  
                    Code

                  

                	
                  
                    Independent
                      Occupational Therapist

                  

                	
                  
                    Coverage

                  

                
	
                  
                    All
                      codes

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Independent
                      Physical Therapist

                  

                	
                  
                    Coverage

                  

                
	
                  
                    All
                      codes

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Medical
                      Transportation

                  

                	
                  
                    Coverage

                  

                
	
                  
                    All
                      codes

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Emergency
                      Medical Transportation

                  

                	
                  
                    Coverage

                  

                
	
                  
                    All
                      codes

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Independent
                      Laboratory Services

                  

                	
                  
                    Coverage

                  

                
	
                  
                    80100

                  

                	
                  
                    Drug
                      screen, qualitative, chromatographic method, each
                      procedure

                  

                	
                  
                    1

                  

                
	
                  
                    81000

                  

                	
                  
                    Urinalysis,
                      by dip stick or tablet reagent, non-automated, with
                      microscopy

                  

                	
                  
                    1

                  

                
	
                  
                    83840

                  

                	
                  
                    Methadone
                      chemistry (quantitative analysis)

                  

                	
                  
                    1

                  

                
	
                  
                    All
                      other codes

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Pharmacy

                  

                	
                  
                    Coverage

                  

                
	
                  
                    All
                      codes

                  

                	 	
                  
                    1

                  

                
	 	 	 
	
                  
                    Code

                  

                	
                  
                    Other
                      Community Services

                  

                	
                  
                    Coverage

                  

                
	
                  
                    H2017

                  

                	
                  
                    Psychosocial
                      Rehabilitation services, per 15 minutes

                  

                	 
	
                  
                    H2019

                  

                	
                  
                    Therapeutic
                      Behavioral Services, per 15 minutes (IICAPS, MST, MDFT, FFT,
                      FST, HBV)
                      (Clients under 21 only)

                  

                	
                  
                    2

                  

                
	
                  
                    T1017

                  

                	
                  
                    Targeted
                      case management, each 15 minutes (part of home-based services
                      only -
                      IICAPS, MST, MDFT, FFT, FST, HBV) (Clients under 21
                      only)

                  

                	
                  
                    2***

                  

                
	
                  
                    H2032

                  

                	
                  
                    Activity
                      Therapy, per 15 minutes (Therapeutic Mentoring/Behavioral Management
                      Service) (Clients under 21 only)

                  

                	
                  
                    2***

                  

                
	 	
                  
                    "'Coverage
                      restricted to providers certified by DCF to provide this
                      service

                  

                	 
	 	
                  
                    ""Coverage
                      restricted to providers licensed by DCF to provide this
                      service

                  

                	 


        

        
          5/1/2007

        

        
          


          11
            of 11
            HUSKY A B Appendix 0 - BHP Master Covered Services Table
            05/01/07]