Contract



 Exhibit 10.1 
  
 FEBRUARY 2006 – DECEMBER 2007 
  
 Contract for Medicaid and BadgerCare HMO Services 
  
 Between 
  
 HMO 
  
 and 
  
 Wisconsin Department of 
 Health and Family Services 
  
 

 
  
  







 TABLE OF CONTENTS 
  

											
	 	  	 	  	 	  	 	  	 	  	Page No.


	 ARTICLE I - DEFINITIONS
	  	1
		
	 ARTICLE II - DELEGATIONS OF AUTHORITY
	  	9
		
	 ARTICLE III - FUNCTIONS AND DUTIES OF THE HMO
	  	9
				
	 	  	A.	  	Statutory Requirement	  	9
				
	 	  	B.	  	Compliance with Applicable Law	  	9
				
	 	  	C.	  	Organizational Responsibilities and Duties	  	10
	 	  	 	  	1.	  	Ineligible Organizations	  	10
	 	  	 	  	2.	  	Contract Representative	  	12
	 	  	 	  	3.	  	Attestation	  	12
	 	  	 	  	4.	  	Affirmative Action (AA) and Civil Rights Compliance (CRC) Plan for Profit and Non-Profit Entities	  	13
	 	  	 	  	5.	  	Non-Discrimination in Employment	  	15
	 	  	 	  	6.	  	Provision of Services to all HMO Members	  	16
	 	  	 	  	7.	  	Access to Premises	  	16
	 	  	 	  	8.	  	Liability for the Provision of Care	  	17
	 	  	 	  	9.	  	Subcontracts	  	17
	 	  	 	  	10.	  	Coordination with:	  	17
	 	  	 	  	 	  	a.	  	Community-Based Health Organizations	  	17
	 	  	 	  	 	  	b.	  	Local Health Departments	  	18
	 	  	 	  	 	  	c.	  	Bureau of Milwaukee Child Welfare	  	18
	 	  	 	  	 	  	d.	  	Prenatal Care Coordination (PNCC) Agencies	  	19
	 	  	 	  	 	  	e.	  	School-Based Services (SBS) Providers	  	19
	 	  	 	  	 	  	f.	  	Targeted Case Management (TCM) Agencies	  	19
	 	  	 	  	11.	  	Clinical Laboratory Improvement Amendments (CLIA)	  	19
				
	 	  	D.	  	Payment Requirements/Procedures	  	20
	 	  	 	  	1.	  	Claims Retrieval	  	20
	 	  	 	  	2.	  	Thirty Day Payment Requirement	  	20
	 	  	 	  	3.	  	Payment to a Non-HMO Provider for Services Provided to a Disabled Participant Less Than Three or for Services Ordered by the Courts	  	21
	 	  	 	  	4.	  	Payment of HMO Referrals to Out-of-Area or Non-Affiliated Providers	  	21
	 	  	 	  	5.	  	Health Professional Shortage Area (HPSA) Payment Provision	  	21
	 	  	 	  	6.	  	Payment of Physician Services to Pregnant Women and Children Under Age 19	  	22
	 	  	 	  	7.	  	Federally Qualified Health Centers (FQHC) and Rural Health Centers (RHC)	  	22
	 	  	 	  	 	  	 	  	 

  

 -i- 









											
	 	  	 	  	 	  	 	  	 	  	Page No.


	 	  	 	  	8.	  	Immunization Program	  	22
	 	  	 	  	9.	  	Transplants	  	23
	 	  	 	  	10.	  	Hospitalization at the Time of Enrollment or Disenrollment	  	23
	 	  	 	  	11.	  	Enrollees living in a public institution	  	24
				
	 	  	E.	  	Covered Medicaid Services	  	24
	 	  	 	  	1.	  	Provision of Contract Services	  	24
	 	  	 	  	2.	  	Medical Necessity	  	25
	 	  	 	  	3.	  	Required Services Under Wis. Stats., and Wis. Adm. Code	  	26
	 	  	 	  	4.	  	Pre-Existing Medical Conditions	  	26
	 	  	 	  	5.	  	Ambulance Services	  	26
	 	  	 	  	6.	  	Chiropractic Services	  	26
	 	  	 	  	7.	  	Common Carrier Transportation	  	27
	 	  	 	  	8.	  	Dental Services	  	28
	 	  	 	  	9.	  	Emergency and Post-Stabilization Services	  	31
	 	  	 	  	 	  	a.	  	24-Hour Coverage	  	31
	 	  	 	  	 	  	b.	  	Provision/Payment Requirements	  	32
	 	  	 	  	 	  	c.	  	Memoranda of Understanding (MOU) or Contract with Hospitals/Urgent Care Centers for the Provision of Emergency Services	  	32
	 	  	 	  	10.	  	Family Planning Services and Confidentiality of Family Planning Information	  	33
	 	  	 	  	11.	  	Fertility Drugs	  	33
	 	  	 	  	12.	  	Prenatal Care Coordination (PNCC) Agencies	  	33
	 	  	 	  	13.	  	School-Based Services (SBS)	  	34
	 	  	 	  	14.	  	Targeted Case Management (TCM) Services	  	34
				
	 	  	F.	  	Mental Health and Substance Abuse Coverage Requirements/Coordination of Services with Community Agencies	  	34
	 	  	 	  	1.	  	Conditions on Coverage of Mental Health/Substance Abuse Treatment	  	35
	 	  	 	  	2.	  	Mental Health/Substance Abuse Assessment Requirements	  	35
	 	  	 	  	3.	  	Assurance of Expertise for Child Abuse, Child Neglect and Domestic Violence	  	36
	 	  	 	  	4.	  	Court-Related Children’s Services	  	37
	 	  	 	  	5.	  	Court-Related Substance Abuse Services	  	37
	 	  	 	  	6.	  	Crisis Intervention Benefit	  	37
	 	  	 	  	7.	  	Emergency Detention and Court-Related Mental Health Services	  	38
	 	  	 	  	8.	  	Institutionalized Individuals	  	39
	 	  	 	  	9.	  	Transportation Following Emergency Detention	  	40
	 	  	 	  	10.	  	Mental Health and/or Substance Abuse Exemptions	  	40
	 	  	 	  	11.	  	Memoranda of Understanding (MOU)/Contract Requirement and Relations with other Human Service Agencies	  	40
				
	 	  	G.	  	Provider Appeals	  	41

  

 -ii- 









											
	 	  	 	  	 	  	 	  	 	  	Page No.


	 	  	H.	  	Provider Network and Access Requirements	  	42
	 	  	 	  	1.	  	Use of Medicaid Certified Providers	  	42
	 	  	 	  	2.	  	Protocols/Standards to Ensure Access	  	43
	 	  	 	  	3.	  	Written Standards for Accessibility of Care	  	43
	 	  	 	  	4.	  	Access to Selected Medicaid Providers and/or Covered Services	  	43
	 	  	 	  	 	  	a.	  	Dental Providers	  	43
	 	  	 	  	 	  	b.	  	Mental Health or Substance Abuse Providers	  	43
	 	  	 	  	 	  	c.	  	High Risk Prenatal Care Services	  	44
	 	  	 	  	 	  	d.	  	HMO Referrals to Out-of-Network Providers for Services	  	44
	 	  	 	  	 	  	e.	  	Primary Care Providers	  	44
	 	  	 	  	 	  	f.	  	Second Medical Opinions	  	45
	 	  	 	  	 	  	g.	  	Women’s Health Specialists	  	45
	 	  	 	  	5.	  	Network Adequacy Requirements	  	45
				
	 	  	I.	  	Responsibilities to Enrollees	  	46
	 	  	 	  	1.	  	Advocate Requirements	  	46
	 	  	 	  	2.	  	Advance Directives	  	49
	 	  	 	  	3.	  	Choice of Health Care Professional	  	50
	 	  	 	  	4.	  	Coordination and Continuation of Care	  	50
	 	  	 	  	5.	  	Conversion Privileges	  	51
	 	  	 	  	6.	  	Cultural Competency	  	51
	 	  	 	  	7.	  	Enrollee Handbook, Education and Outreach for Newly Enrolled Recipients	  	51
	 	  	 	  	8.	  	Health Education and Disease Prevention	  	53
	 	  	 	  	9.	  	Interpreter Services	  	55
				
	 	  	J.	  	Prohibitions to Billing Enrollees	  	56
				
	 	  	K.	  	HealthCheck	  	56
				
	 	  	L.	  	Marketing Plans and Informing Materials	  	59
	 	  	 	  	1.	  	Approval of Marketing and Informing Materials	  	59
	 	  	 	  	2.	  	Prohibited Practices	  	60
	 	  	 	  	3.	  	HMOs Agreement to Abide by Marketing/Informing Criteria	  	61
				
	 	  	M.	  	Reproduction/Distribution of Materials	  	61
				
	 	  	N.	  	HMO ID Cards	  	61
				
	 	  	O.	  	Open Enrollment	  	61
				
	 	  	P.	  	Selective Reporting Requirements	  	62
	 	  	 	  	1.	  	Communicable Disease Reporting	  	62
	 	  	 	  	2.	  	Fraud and Abuse Investigations	  	62
	 	  	 	  	3.	  	Physician Incentive Plans	  	62
				
	 	  	Q.	  	Abortions, Hysterectomies and Sterilization Requirements	  	63

  

 -iii- 









							
	 	 	 	  	 	  	Page No.


	 ARTICLE IV - QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT (QAPI)
	  	63
				
	 	 	 A.
	  	QAPI Program	  	63
				
	 	 	 B.
	  	Monitoring and Evaluation	  	66
				
	 	 	 C.
	  	Health Promotion and Disease Prevention Services	  	67
				
	 	 	 D.
	  	Provider Selection (Credentialing) and Periodic Evaluation (Recredentialing)	  	68
				
	 	 	 E.
	  	Enrollee Feedback on Quality Improvement	  	69
				
	 	 	 F.
	  	Medical Records	  	70
				
	 	 	 G.
	  	Utilization Management (UM)	  	72
				
	 	 	 H.
	  	External Quality Review Contractor	  	73
				
	 	 	 I.
	  	Dental Services Quality Improvement (Applies only to HMOs Covering Dental Services)	  	74
				
	 	 	 J.
	  	Accreditation	  	75
				
	 	 	 K.
	  	Performance Improvement Priority Areas and Projects	  	76
		
	 ARTICLE V - FUNCTIONS AND DUTIES OF THE DEPARTMENT
	  	83
				
	 	 	 A.
	  	Eligibility Determination	  	83
				
	 	 	 B.
	  	Enrollment	  	84
				
	 	 	 C.
	  	Disenrollment	  	84
				
	 	 	 D.
	  	Enrollment Errors	  	84
				
	 	 	 E.
	  	HMO Enrollment Reports	  	84
				
	 	 	 F.
	  	Utilization Review and Control	  	85
				
	 	 	 G.
	  	HMO Review	  	85
				
	 	 	 H.
	  	Department Audit Schedule	  	85
				
	 	 	 I.
	  	HMO Review of Study or Audit Results	  	85
				
	 	 	 J.
	  	Vaccines	  	86
				
	 	 	 K.
	  	Coordination of Benefits	  	86
				
	 	 	 L.
	  	Wisconsin Medicaid Provider Reports	  	86
				
	 	 	 M.
	  	Enrollee Health Status and Primary Language Report	  	86
				
	 	 	 N.
	  	Fraud and Abuse Training	  	86
				
	 	 	 O.
	  	Provision of Data to HMOs	  	86
				
	 	 	 P.
	  	Special Procedures for Retroactive Payment Adjustments for Pregnant BadgerCare Enrollees	  	87

  

 -iv- 









									
	 	  	 	  	 	  	 	  	Page No.


	 ARTICLE VI - PAYMENT TO THE HMO
	  	88
				
	 	  	A.	  	Capitation Rates	  	88
				
	 	  	B.	  	Actuarial Basis	  	88
				
	 	  	C.	  	Annual Negotiation of Capitation Rates	  	88
				
	 	  	D.	  	Reinsurance	  	88
				
	 	  	E.	  	Payment Schedule	  	89
				
	 	  	F.	  	Capitation Payments For Newborns	  	89
				
	 	  	G.	  	Coordination of Benefits (COB)	  	90
				
	 	  	H.	  	Recoupments	  	92
				
	 	  	I.	  	Neonatal Intensive Care Unit (NICU) Risk-Sharing Payment(s)	  	93
	 	  	 	  	1.	  	Coverage Criteria	  	93
	 	  	 	  	2.	  	Reimbursement Criteria	  	94
	 	  	 	  	3.	  	Reporting Requirements	  	95
				
	 	  	J.	  	Payment(s) for AIDS/HIV and Ventilator Dependent Enrollees	  	96
	 	  	 	  	1.	  	Reimbursement Criteria	  	96
	 	  	 	  	2.	  	Adjustments to Final Payment	  	97
	 	  	 	  	3.	  	Reporting Requirements for AIDS, HIV-Positive and Ventilator Dependent Enrollees	  	98
	 	  	 	  	4.	  	Documentation Requirements for AIDS, HIV-Positive and Ventilator Dependent Enrollees	  	98
	 	  	 	  	5.	  	Dispute Resolution	  	99
				
	 	  	K.	  	Incentive for Expansion	  	99
				
	 	  	L.	  	Dental Care Utilization Incentive	  	99
		
	 ARTICLE VII - COMPUTER/DATA REPORTING SYSTEM, DATA, RECORDS AND REPORTS
	  	101
				
	 	  	A.	  	Access to and/or Disclosure of Financial Records	  	101
				
	 	  	B.	  	Access to and Audit of Contract Records	  	101
				
	 	  	C.	  	Computer Data Reporting System	  	101
				
	 	  	D.	  	Coordination of Benefits (COB), Encounter Record, Formal Grievances and Birth Cost Reporting Requirements	  	103
				
	 	  	E.	  	Encounter Data Reporting Requirements	  	103
	 	  	 	  	1.	  	Reporting Requirement	  	104
	 	  	 	  	2.	  	Testing Encounter Data	  	104
	 	  	 	  	3.	  	Primary HMO Contact Person	  	104
	 	  	 	  	4.	  	HMO Encounter Technical Workgroup Requirement	  	104
	 	  	 	  	5.	  	Encounter Data Completeness and Accuracy	  	105
	 	  	 	  	6.	  	Analysis of Encounter Data	  	105
				
	 	  	F.	  	Records Retention	  	105

  

 -v- 









									
	 	  	 	  	 	  	 	  	Page No.


	 	  	G.	  	Reporting of Corporate and Other Changes	  	105
				
	 	  	H.	  	Provider List Requirement	  	106
				
	 	  	I.	  	Contract Specified Reports and Due Dates	  	107
		
	 ARTICLE VIII - ENROLLMENT AND DISENROLLMENTS
	  	113
				
	 	  	A.	  	Enrollment	  	113
				
	 	  	B.	  	Enrollment/Disenrollment Practices	  	114
				
	 	  	C.	  	Disenrollment/Exemption Requests	  	114
	 	  	 	  	1.	  	AIDS or HIV-Positive Exemption	  	115
	 	  	 	  	2.	  	Developmental Disability or Admission to a Birth to Three Program Exemption	  	115
	 	  	 	  	3.	  	Certified Nurse Midwives or Nurse Practitioners Exemption	  	115
	 	  	 	  	4.	  	Commercial HMO Insurance Exemption	  	116
	 	  	 	  	5.	  	Federally Qualified Health Centers Exemption	  	116
	 	  	 	  	6.	  	Just Cause Disenrollment	  	117
	 	  	 	  	7.	  	Inmates of a Public Institution Disenrollment	  	117
	 	  	 	  	8.	  	Medicare Beneficiaries	  	117
	 	  	 	  	9.	  	Mental Health and/or Substance Abuse Exemption	  	117
	 	  	 	  	10.	  	Native American Disenrollment	  	118
	 	  	 	  	11.	  	Ninth Month Pregnancy Exemption	  	118
	 	  	 	  	12.	  	SSI Family Exemption and/or Disenrollment	  	119
	 	  	 	  	13.	  	Third Trimester Pregnancy Exemption	  	119
	 	  	 	  	14.	  	Transplant Exemption	  	119
		
	 ARTICLE IX - GRIEVANCE PROCEDURES
	  	120
				
	 	  	A.	  	Procedures	  	120
				
	 	  	B.	  	Grievance and Appeal Process	  	122
				
	 	  	C.	  	Notifications to Enrollees	  	123
				
	 	  	D.	  	Continuation of Benefits Requirements	  	124
				
	 	  	E.	  	Reporting of Grievances to the Department	  	125
		
	 ARTICLE X - SUBCONTRACTS
	  	125
				
	 	  	A.	  	Subcontract Standard Language	  	126
				
	 	  	B.	  	Subcontract Submission Requirements	  	128
				
	 	  	C.	  	Review and Approval of Subcontracts	  	128
				
	 	  	D.	  	Transition Plan	  	129
				
	 	  	E.	  	Notification Requirements Regarding Subcontract Additions or Terminations	  	129
				
	 	  	F.	  	Management Subcontracts	  	130

  

 -vi- 









							
	 	  	 	  	 	  	Page No.


	 ARTICLE XI - REMEDIES FOR VIOLATION, BREACH, OR NON-PERFORMANCE OF CONTRACT
	  	131
				
	 	  	A.	  	Suspension of New Enrollment	  	131
				
	 	  	B.	  	Department-Initiated Enrollment Reductions	  	131
				
	 	  	C.	  	Other Enrollment Reductions	  	132
				
	 	  	D.	  	Withholding of Capitation Payments and Orders to Provide Services	  	132
				
	 	  	E.	  	Inappropriate Payment Denials	  	135
				
	 	  	F.	  	Sanctions	  	135
				
	 	  	G.	  	Sanctions and Remedial Actions	  	135
		
	 ARTICLE XII - TERMINATION AND MODIFICATION OF CONTRACT
	  	136
				
	 	  	A.	  	Termination by Mutual Consent	  	136
				
	 	  	B.	  	Unilateral Termination	  	136
				
	 	  	C.	  	Obligations of Contracting Parties Upon Termination	  	137
				
	 	  	D.	  	Modification	  	138
		
	 ARTICLE XIII - INTERPRETATION OF CONTRACT LANGUAGE
	  	138
		
	 ARTICLE XIV - CONFIDENTIALITY OF RECORDS AND HIPAA REQUIREMENTS
	  	139
		
	 ARTICLE XV - DOCUMENTS CONSTITUTING CONTRACT
	  	142
				
	 	  	A.	  	Current Documents	  	142
				
	 	  	B.	  	Future Documents	  	142
		
	 ARTICLE XVI DISCLOSURE STATEMENT(S) OF OWNERSHIP OR CONTROLLING INTEREST IN AN HMO AND BUSINESS
TRANSACTIONS
	  	143
				
	 	  	A.	  	Ownership or Controlling Interest Disclosure Statement(s)	  	143
				
	 	  	B.	  	Business Transaction Disclosures	  	145
		
	 ARTICLE XVII - MISCELLANEOUS
	  	146
				
	 	  	A.	  	Indemnification	  	146
				
	 	  	B.	  	Independent Capacity of Contractor	  	147
				
	 	  	C.	  	Omissions	  	147
				
	 	  	D.	  	Choice of Law	  	147
				
	 	  	E.	  	Waiver	  	147
				
	 	  	F.	  	Severability	  	147

  

 -vii- 









							
	 	 	 	  	 	  	Page No.


	 	 	 G.
	  	Survival	  	147
				
	 	 	 H.
	  	Force Majeure	  	148
				
	 	 	 I.
	  	Headings	  	148
				
	 	 	 J.
	  	Assignability	  	148
				
	 	 	 K.
	  	Right to Publish	  	148
		
	 ARTICLE XVIII - HMO SPECIFIC CONTRACT TERMS
	  	149
				
	 	 	 A.
	  	Initial Contract Period	  	149
				
	 	 	 B.
	  	Renewals	  	149
				
	 	 	 C.
	  	Specific Terms of the Contract	  	149
		
	 ADDENDUM I - SUBCONTRACTS AND MEMORANDA OF UNDERSTANDING
	  	151
				
	 	 	 I.
	  	MOU Submission Requirements	  	151
				
	 	 	 II.
	  	Emergency Services MOU or Contract	  	151
				
	 	 	 III.
	  	County and Other Human Service Agencies MOU or Contract Requirements for Services Ordered by the Courts	  	152
				
	 	 	 IV.
	  	Required MOUs or Contracts	  	153
		
	 ADDENDUM II - STANDARD ENROLLEE HANDBOOK LANGUAGE
	  	160
		
	 ADDENDUM III - ACTUARIAL BASIS
	  	172
		
	 ADDENDUM IV - GUIDELINES FOR THE COORDINATION OF SERVICES BETWEEN HMOs AND THE BUREAU OF MILWAUKEE CHILD
WELFARE
	  	173
		
	 ADDENDUM V - GUIDELINES FOR THE COORDINATION OF SERVICES BETWEEN MEDICAID HMOS AND COUNTY BIRTH TO THREE
AGENCIES
	  	176
		
	 ADDENDUM VI - LOCAL HEALTH DEPARTMENTS AND COMMUNITY-BASED HEALTH ORGANIZATIONS A RESOURCE FOR HMOs
	  	181
		
	 ADDENDUM VII - GUIDELINES FOR THE COORDINATION OF SERVICES BETWEEN HMOS, TARGETED CASE MANAGEMENT (TCM) AGENCIES, AND CHILD
WELFARE AGENCIES
	  	184
		
	 ADDENDUM VIII - REPORT FORMS AND WORKSHEETS
	  	186
				
	 	 	 A.
	  	AIDS and Ventilator Dependent Quarterly Report Form and Detail Report Format	  	186

  

 -viii- 









							
	 	  	 	  	 	  	Page No.


	 	  	B.	  	Coordination of Benefits Quarterly Report Form and Instructions for Completing the Form	  	188
				
	 	  	C.	  	Medicaid and BadgerCare HMO Newborn Report	  	190
				
	 	  	D.	  	HealthCheck Worksheet	  	192
				
	 	  	E.	  	Neonatal Intensive Care Unit (NICU) Risk-Sharing Report Format and Detail Data Requirements	  	193
				
	 	  	F.	  	Court Ordered Birth Cost Requests	  	197
				
	 	  	G.	  	Formal and Informal Grievance Reporting Forms	  	200
				
	 	  	H.	  	Attestation Form	  	202
		
	 ADDENDUM IX - GENERAL INFORMATION ABOUT THE WIC PROGRAM AND SAMPLE HMO-TO-WIC REFERRAL FORMS
	  	203

  

 -ix- 








 CONTRACT FOR SERVICES 
  
 Between 
  
 The Wisconsin Department of Health and Family Services 
  
 and 
  
 HMO 
  
 The Wisconsin
Department of Health and Family Services (the Department) and the HMO, an insurer with a certificate of authority to do business in Wisconsin, and an organization that makes available to enrolled participants, in consideration of periodic fixed
payments, comprehensive health care services provided by providers selected by the organization and who are employees or partners of the organization or who have entered into a referral or contractual arrangement with the organization, for the
purpose of providing and paying for Medicaid and BadgerCare contract services to recipients enrolled in the HMO under the State of Wisconsin Medicaid Plan approved by the Secretary of the United States Department of Health and Human Services
pursuant to the provisions of the Social Security Act and for the further specific purpose of promoting coordination and continuity of preventive health services and other medical care including prenatal care, emergency care, and HealthCheck
services, do herewith agree: 
  
 ARTICLE I 
  

	I.	DEFINITIONS 

  
 Abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to
Medicaid/BadgerCare, in reimbursement for services that are not medically necessary, or services that fail to meet professionally recognized standards for health. Abuse also includes client or member practices that result in unnecessary costs to
Medicaid. 
  
 Action means the denial or limited
authorization of a requested service, including the type or level of service; the reduction, suspension or termination of a previously authorized service; the denial, in whole or in part, of payment for a service. 
  
 Appeal means a request for review of an action. 
  
 Assessment means an encounter where an appropriately qualified
health care professional evaluates an enrollee’s special health care needs using evaluation, examination or diagnostic tools, review of past medical history, records such as laboratory reports, patient interview, to adequately address the
enrollee’s health care and/or cultural needs in a multidisciplinary treatment plan, plan of care or approach to 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -1- 








 delivery of care. The evaluation must include an encounter of care, not merely a telephone contact.
Comprehensive physical examination is not required, unless it is necessary to fully assess the enrollee’s health care needs. For the purposes of an assessment, qualified health care professional may include non-physician providers such as a
psychologist for an enrollee with an identified mental health care need, or advanced practice nurse, physician assistant, registered nurse or social worker, where medical diagnosis is not required. 
  
 BadgerCare means part of the Wisconsin Medicaid Program operated by
the Wisconsin Department of Health and Family Services under Title XIX and Title XXI of the Federal Social Security Act, s. 49.665, Wis. Stats., and related state and federal rules and regulations. This term is used throughout this contract.

  
 Balanced Workforce means an equitable representation
of persons with disabilities, minorities and women available for jobs at each job category from the relevant labor market from which the recipient recruits job applicants. 
  
 Business Associate means a person (or company) that provides a service to a covered program that requires their use
of individually identifiable health information. 
  
 CESA
(Cooperative Educational Service Agencies) means cooperatives that include multiple school districts that work together for purchasing and other coordinated functions. There are 12 CESAs in Wisconsin. 
  
 CFR means Code of Federal Regulations. 
  
 Children With Special Health Care Needs means children with or at
increased risk for chronic physical, developmental, behavioral, or emotional conditions who also require health and related services of a type or amount beyond that required by children generally and who are enrolled in a Children with Special
Health Care Needs program operated by a Local Health Department or a local Title V funded Maternal and Child Health Program. 
  
 Clean Claim means a truthful, complete and accurate claim that does not have to be returned for additional information. 
  
 Community Based Health Organizations means non-profit agencies
providing community based health services. These organizations provide important health care services such as HealthCheck screenings, nutritional support, and family planning, targeting such services to high-risk populations. 
  
 Complaint is a general term used to describe an enrollee’s oral
expression of dissatisfaction with the HMO. It can include access problems such as difficulty getting an appointment or receiving appropriate care; quality of care issues such as long waiting times in the reception area of a provider’s office,
rude providers or provider staff; or denial or reduction of a service. A complaint may become a grievance or appeal if it is subsequently submitted in writing. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -2- 








 Continuing Care Provider means as stated in 42 CFR 441.60(a), a provider who has an agreement with
the Medicaid agency to provide: 
  

	 	A.	Any reports that the Department may reasonably require, and 

  

	 	B.	At least the following services to eligible HealthCheck recipients formally enrolled with the provider as enumerated in 42 CFR 441.60(a)(1)-(5): 

  

	 	1.	Screening, diagnosis, treatment, and referrals for follow-up services, 

  

	 	2.	Maintenance of the recipient’s consolidated health history, including information received from other providers, 

  

	 	3.	Physician’s services as needed by the recipient for acute, episodic or chronic illnesses or conditions, 

  

	 	4.	Provision or referral for dental services, and 

  

	 	5.	Transportation and scheduling assistance. 

  
 Contract means the agreement executed between the HMO and the Department to accomplish the duties and functions, in accordance with the rules and
arrangements specified in this document. The contract includes the base agreement and documents specified in Article XV, Sections A and B. 
  
 Contract Services means services that the HMO is required to provide under this contract. 
  
 Contractor means the HMO(s) awarded a contract resulting from the HMO
certification process to provide capitated managed care in accordance with the contract. 
  
 Covered Entity means a health plan, a health care clearinghouse, or a health care provider or HMO that transmits any health information in electronic form in connection with a transaction covered by 45 CFR
Parts 160 and 162. 
  
 Cultural Competency means a set of
congruent behaviors, attitudes, practices and policies that are formed within an agency, and among professionals that enable the system, agency, and professionals to work respectfully, effectively and responsibly in diverse situations. Essential
elements of cultural competence include understanding diversity issues at work, understanding the dynamic of difference, institutionalizing cultural knowledge, and adapting to and encouraging organizational diversity. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -3- 








 Department means the Wisconsin Department of Health and Family Services. 
  
 Emergency Medical Condition means: 
  

	 	A.	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: 

  

	 	1.	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, 

  

	 	2.	Serious impairment of bodily functions, or 

  

	 	3.	Serious dysfunction of any bodily organ or part; or 

  

	 	B.	With respect to a pregnant woman who is in active labor: 

  

	 	1.	Where there is inadequate time to effect a safe transfer to another hospital before delivery; or 

  

	 	2.	Where transfer may pose a threat to the health or safety of the woman or the unborn child. 

  

	 	C.	A psychiatric emergency involving a significant risk of serious harm to oneself or others. 

  

	 	D.	A substance abuse emergency exists if there is significant risk of serious harm to an enrollee or others, or there is likelihood of return to substance abuse without immediate
treatment. 

  

	 	E.	Emergency dental care is defined as an immediate service needed to relieve the patient from pain, an acute infection, swelling, trismus, fever, or trauma. In all emergency
situations, the HMO must document in the enrollee’s dental records the nature of the emergency. 

  
 Encounter includes the following: 
  

	 	A.	A service or item provided to a patient through the health care system. Examples include but are not limited to: 

  

	 	1.	Office visits 

  

	 	2.	Surgical procedures 

  

	 	3.	Radiology, including professional and/or technical components 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -4- 









	 	4.	Prescribed drugs 

  

	 	5.	Durable medical equipment 

  

	 	6.	Emergency transportation to a hospital 

  

	 	7.	Institutional stays (inpatient hospital, rehabilitation stays) 

  

	 	8.	HealthCheck screens 

  

	 	B.	A service or item not directly provided by the HMO, but for which the HMO is financially responsible. An example would include an emergency service provided by an out-of-network
provider or facility. 

  

	 	C.	A service or item not directly provided by the HMO, and one for which no claim is submitted but for which the HMO may supplement its encounter data set. Such services might include
HealthCheck screens for which no claims have been received and if no claim is received, the HMO’s medical chart. Examples of services or items the HMO may include are: 

  

	 	1.	HealthCheck services 

  

	 	2.	Lead Screening and Testing 

  

	 	3.	Immunizations 

  
 Services or items as used above include those services and items not covered by the Wisconsin Medicaid Program, but which the HMO chooses to provide as
part of its Medicaid managed care product. Examples include educational services, certain over-the-counter drugs, and delivered meals. 
  
 Encounter Record means an electronically formatted list of encounter data elements per encounter as specified in the current Wisconsin Medicaid HMO
Encounter Data User Manual. An encounter record may be prepared from paper claims such as the HCFA 1500, UB-92, or electronic transactions such as ASC XX12N 837. 
  
 Enrollee and Participant means a Medicaid or BadgerCare recipient who has been certified by the State as
eligible to enroll under this Contract, and whose name appears on the HMO Enrollment Reports that the Department transmits to the HMO every month according to an established notification schedule. Children who are reported to the certifying agency
within 100 days of birth shall be enrolled in the HMO their mother is enrolled in from their date of birth if the mother was an enrollee on the date of birth. Children who are reported to the certifying agency after the 100th day but before their first birthday may be eligible for Medicaid or BadgerCare on a fee-for-service (FFS) basis. 

 
 Enrollment Area means the geographic area within which recipients
must reside in order to enroll, on a mandatory basis, in the HMO under this Contract. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -5- 








 Experimental Surgery and Procedures means experimental services that meet the definition of HFS
107.035(1) and (2) Wis. Adm. Code. as determined by the Department. 
  
 Formally Enrolled with a Continuing Care Provider (as cited in 42 CFR 441.60(d)) means that a recipient (or recipient’s guardian) agrees to use one continuing care provider as the regular source of a
described set of services for a stated period of time. 
  
 Fraud means an intentional deception or misrepresentation made by a person or entity with the knowledge that the deception could result in some unauthorized benefit to him/herself, itself or some other person or entity. It includes
any act that constitutes fraud under applicable federal or state law. 
  
 Grievance means an expression of dissatisfaction or a complaint about any matter other than an action. The term is also used to refer to the overall system of complaints, grievances and appeals handled by the HMO. Possible grievance
subjects include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the enrollee’s rights. 
  
 HHS refers to the federal Department of Health and Human Services.

  
 HHS Transaction Standard Regulation means the 45 CFR,
Parts 160 and 162. 
  
 HIPAA means the Health Insurance
Portability and Accountability Act of 1996. 
  
 HMO means
the health maintenance organization or its parent corporation with a certificate of authority to do business in Wisconsin, that is obligated under this Contract. 
  
 HMO Encounter Technical Workgroup means a workgroup composed of HMO technical staff, contract administrators, claims
processing, eligibility, and/or other HMO staff, as necessary; Department staff from the Division of Health Care Financing; and staff from the Department’s Medicaid fiscal agent. 
  
 Individually Identifiable Health Information (IIHI) means patient demographic information, claims data, insurance
information, diagnosis information, and any other information that relates to the past, present, or future health condition, provision of health care, payment for health care and that identifies the individual (or that could reasonably be expected
to identify the individual). 
  
 Information means any
“health information” provided and/or made available by the Department to a Trading Partner, and has the same meaning as the term “health information” as defined by 45 CFR Part 160.103. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -6- 








 Local Health Department (LHD) means an agency of local government established according to Chapter
251, Wis. Stats. Local health departments have statutory obligation to perform certain core functions, including assessment, assurance, and policy development to protect and promote the health of their communities. 
  
 Medicaid means the Wisconsin Medical Assistance Program operated by
the Wisconsin Department of Health and Family Services under Title XIX of the Federal Social Security Act, Ch. 49, Wis. Stats., and related State and Federal rules and regulations. This term is used consistently in this Contract. Other
expressions or words equivalent to Medicaid are “MA” and “Medical Assistance.” 
  
 Medical Status Code means the two digit (alphanumeric) code in the Department’s computer system that defines the type of Medicaid eligibility
a recipient has. The code identifies the basis of eligibility, whether cash assistance is being provided, and other aspects of Medicaid. The medical status code is listed on the HMO enrollment reports. Article V, A of this contract includes a list
of HMO eligible medical status codes. 
  
 Medically
Necessary means a medical service that meets the definition of HFS 101.03(96m) Wis. Adm. Code. 
  
 Newborn means an enrollee less than 100 days old. 
  
 PCP means primary care provider including, but not limited to FQHCs, RHCs, tribal health centers, and physicians, nurse practitioners, nurse
midwives, physician assistants and physician clinics with specialties in general practice, family practice, internal medicine, obstetrics, gynecology, and pediatrics. 
  
 Post Stabilization Services means medically necessary non-emergency services furnished to an enrollee after he or she
is stabilized following an emergency medical condition. 
  
 Provider means a person who has been certified by the Department to provide health care services to recipients and to be reimbursed by Medicaid for those services. 
  
 Public Institution means an institution that is the responsibility of a governmental unit or over which a
governmental unit exercises administrative control as defined by federal regulations, including but not limited to prisons and jails. 
  
 Recipient means any individual entitled to benefits under Title XIX and XXI of the Social Security Act, and under the Medicaid State Plan as
defined in Chapter 49, Wis. Stats. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -7- 








 Screening means the use of data-gathering techniques, tests or tools to identify or quantify the
health and/or cultural needs of an enrollee. Screening methods may include telephonic contact, mailings, interactive web tools, or encounters in person with screeners or health care providers. 
  
 Service Area means an area of the State where the HMO has agreed to
provide Medicaid services to Medicaid enrollees. The Department monitors enrollment levels of HMOs by the HMO’s service area(s). The HMO indicates whether they will provide dental or chiropractic services by service area. A service area may be
as small as a zip code, may be a county, a number of counties, or the entire State. 
  
 Secretary means the Secretary of HHS and any other officer or employee of the Department of HHS to whom the authority involved has been delegated. 
  
 Risk means the possibility of monetary loss or gain by the HMO resulting from service costs exceeding or being less
than payments made to it by the Department. 
  
 State
means the State of Wisconsin. 
  
 Subcontract means
any written agreement between the HMO and another party to fulfill the requirements of this Contract. However, such term does not include insurance purchased by the HMO to limit its loss with respect to an individual enrollee, provided the HMO
assumes some portion of the underwriting risk for providing health care services to that enrollee. 
  
 Trading Partner shall refer to a provider or HMO that transmits any health information in electronic form in connection with a transaction covered
by 45 CFR Parts 160 and 162, or a business associate authorized to submit health information on the Trading Partner’s behalf. 
  
 Transaction means the exchange of information between two parties to carry out financial or administrative activities related to health care as
defined by 45 CFR Part 160.103. 
  
 Wisconsin Tribal Health
Directors Association (WTHDA) means the coalition of all Wisconsin American Indian Tribal Health Departments. 
  
 Terms that are not defined above shall have their primary meaning identified in HFS 101-108, Wis. Adm. Code. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -8- 








 ARTICLE II 
  


	II.	DELEGATIONS OF AUTHORITY 

  
 The HMO shall oversee and remain accountable for any functions and responsibilities that it delegates to any subcontractor. For all major or minor
delegation of function or authority: 
  

	 	•	 	There shall be a written agreement that specifies the delegated activities and reporting responsibilities of the subcontractor and provides for revocation of the delegation or
imposition of other sanctions if the subcontractor’s performance is inadequate. 

  

	 	•	 	Before any delegation, the HMO shall evaluate the prospective subcontractor’s ability to perform the activities to be delegated. 

  

	 	•	 	The HMO shall monitor the subcontractor’s performance on an ongoing basis and subject the subcontractor to formal review at least once a year. 

  

	 	•	 	If the HMO identifies deficiencies or areas for improvement, the HMO and the subcontractor shall take corrective action. 

  

	 	•	 	If the HMO delegates selection of providers to another entity, the HMO retains the right to approve, suspend, or terminate any provider selected by that entity.


  
 ARTICLE III 
  

	III.	FUNCTIONS AND DUTIES OF THE HMO 

  

	 	A.	Statutory Requirement 

  
 In consideration of the functions and duties of the Department contained in this Contract the HMO shall retain at all times during the period of this
Contract a valid Certificate of Authority issued by the State of Wisconsin Office of the Commissioner of Insurance. 
  

	 	B.	Compliance with Applicable Law 

  
 In the provision of services under this contract, the Contractor and its subcontractors shall comply with all applicable federal and state statutes and
rules and regulations, that are in effect when the contract is signed, or that come into effect during the term of the contract. This includes, but is not limited to Title XIX of the Social Security Act and Title 42 of the CFR. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -9- 








 Changes to Medicaid covered services mandated by federal or state law subsequent to the signing of this
Contract will not affect the contract services for the term of this Contract, unless agreed to by mutual consent, or the change is necessary to continue to receive federal funds or due to action of a court of law. 
  
 The Department may incorporate into the Contract any change in covered
services mandated by federal or state law effective the date the law goes into effect, if it adjusts the capitation rate accordingly. The Department will give the HMO at least 30 days notice before the intended effective date of any such change that
reflects service increases, and the HMO may elect to accept or reject the service increases for the remainder of that contract year. The Department will give the HMO 60 days notice of any such change that reflects service decreases, with a right of
the HMO to dispute the amount of the decrease within that 60 days. The HMO has the right to accept or reject service decreases for the remainder of the Contract year. The date of implementation of the change in coverage will coincide with the
effective date of the increased or decreased funding. This section does not limit the Department’s ability to modify this Contract due to changes in the State Budget. 
  

	 	C.	Organizational Responsibilities and Duties 

  

	 	1.	Ineligible Organizations  

  
 Upon obtaining information or receiving information from the Department or from another verifiable source, the HMO must exclude from participation in the
HMO all organizations that could be included in any of the categories defined in a, 1), a) through e) of this section (references to the Act in this section refer to the Social Security Act). 
  

	 	a.	Entities that could be excluded under Section 1128(b)(8) of the Social Security Act are entities in which a person who is an officer, director, agent or managing employee of
the entity, or a person who has direct or indirect ownership or control interest of 5% or more in the entity has: 

  

	 	1)	Been convicted of the following crimes: 

  

	 	a)	Program related crimes (i.e., any criminal offense related to the delivery of an item or service under Medicare or Medicaid (Section 1128(a)(1) of the Act).


  

	 	b)	Patient abuse (i.e., criminal offense relating to abuse or neglect of patients in connection with the delivery of health care (Section 1128(a)(2) of the Act).


  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -10- 









	 	c)	Fraud (i.e., a state or federal crime involving fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct in connection with the delivery of
health care or involving an act or omission in a program operated by or financed in whole or part by federal, state or local government (Section 1128(b)(1) of the Act). 

  

	 	d)	Obstruction of an investigation (i.e., conviction under state or federal law of interference or obstruction of any investigation into any criminal offense described in subsections
a), b), or c) (Section 1128(b)(2) of the Act). 

  

	 	e)	Offenses relating to controlled substances (i.e., conviction of a state or federal crime relating to the manufacture, distribution, prescription or dispensing of a controlled
substance (Section 1128(b)(3) of the Act). 

  

	 	2)	Been excluded, debarred, suspended, otherwise excluded, or is an affiliate (as defined in such Act) of a person described in C, 1, a, above from participating in procurement
activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued pursuant to Executive Order No. 12549 or under guidelines implementing such order. 

  

	 	3)	Been assessed a civil monetary penalty under Section 1128A of the Act. Civil monetary penalties can be imposed on individual providers, as well as on provider organizations,
agencies, or other entities by the DHHS Office of Inspector General. Section 1128A authorizes their use in case of false or fraudulent submittal of claims for payment, and certain other violations of payment practice standards. (Section
1128(b)(8)(B)(ii) of the Act.) 

  

	 	b.	Entities that have a direct or indirect substantial contractual relationship with an individual or entity listed in subsection 1. A substantial contractual relationship is defined
as any contractual relationship which provides for one or more of the following services: 

  

	 	1)	The administration, management, or provision of medical services. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -11- 









	 	2)	The establishment of policies pertaining to the administration, management, or provision of medical services. 

  

	 	3)	The provision of operational support for the administration, management, or provision of medical services. 

  

	 	c.	Entities that employ, contract with, or contract through any individual or entity that is excluded from participation in Medicaid under Section 1128 or 1128A, for the provision
(directly or indirectly) of health care, utilization review, medical social work or administrative services. For the services listed, the HMO must refrain from contracting with any entity that employs, contracts with, or contracts through an entity
that has been excluded from participation in Medicaid by the Secretary of Health and Human Services under the authority of Section 1128 or 1128A of the Act. 

  
 The HMO attests by signing this Contract, that it excludes from participation in the HMO all organizations that could be
included in any of the above categories. 
  

	 	2.	Contract Representative  

  
 The HMO is required to designate a staff person to act as liaison to the Department on all issues that relate to the contract between the Department and
the HMO. The contract representative will be authorized to represent the HMO regarding inquiries pertaining to the Contract, will be available during normal business hours, and will have decision making authority in regard to urgent situations that
arise. The Contract representative will be responsible for follow-up on contract inquiries initiated by the Department. 
  

	 	3.	Attestation  

  
 The HMO’s Chief Executive Officer (CEO), the Chief Financial Officer (CFO) or designee must attest to the best of their knowledge to the
truthfulness, accuracy, and completeness of all data submitted to the Department at the time of submission. This includes encounter data, NICU, AIDS/Vent, or any other data regarding claims the HMO paid. HMOs may use the Department’s
attestation form in Addendum VIII, H. For encounter data, the form should be submitted to a Contract Specialist in the Bureau of Managed Health Care Programs quarterly. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -12- 









	 	4.	Affirmative Action (AA) and Civil Rights Compliance (CRC) Plan for Profit and Non-Profit Entities 

  
 The AA/CRC Plan contains three components: Affirmative Action, Equal Opportunity, and Language Access. 
  

	 	a.	HMOs that have more than 25 employees and receive more than $25,000 must submit an Affirmative Action Civil Rights Compliance Plan in accordance to the most recently revised
instructions and format requirements for the funding period of January 1, 2004 to December 31, 2006. A new plan will be due on January 15, 2007 for the funding period covering January 1, 2007, to December 31, 2009.


  
 For agreements of $25,000 or more and with 25
employees or more, HMOs shall conduct, keep on file, and update annually, a separate and additional accessibility self-evaluation of all programs and facilities, including employment practices for compliance with the Americans with Disabilities
(ADA) Title I regulations, unless an updated self-evaluation under Section 503 of the Rehabilitation Act of 1973 exists that meets the ADA requirements. For technical assistance on all the aspects of Civil Rights Compliance, HMOs are encouraged
to contact the Department’s AA/CRC Office at (608) 266-9372 (voice), (888) 701-1251 (TTY), or the Department of Health and Family Services, 1 W. Wilson Street, Room 555, P.O. Box 7850, Madison, Wisconsin 53707-7850. 
  
 HMOs should use the link listed below to access the instructions and format
for completing the AA/CRC Plan: 
  
 http://www.dwd.state.wi.us/civil_rights/cr0406/cr_plans.htm. (Select Instructions for Profit and Non-profit Organizations for the instructions to complete the plan and Civil Rights Compliance Plan for Profit and Non-profit
Organizations. Use MS Word version for downloading the format.) 
  

	 	b.	HMOs that have less than 25 employees or receive less than $25,000 must submit a Letter of Assurance and proof that it is exempt from submitting AA information in accordance to
s. 16.675, Wis. Stats., and ADM 50, Wis. Adm. Code. HMOs meeting this criteria can find the necessary forms and instructions to comply as noted in section 4, a) above. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -13- 









	 	c.	AA/CRC Reporting Requirements: 

  

	 	1)	All HMOs must submit language access information as part of the HMO Certification application. 

  

	 	2)	Established HMOs (HMOs that submitted a plan in 2004) must submit a new AA/CRC plan by January 15, 2007. 

  

	 	3)	New HMOs must file a 2006 AA/CRC Plan within 15 days after the award of the contract. 

  

	 	4)	All HMOs must submit a new plan by January 15, 2007. 

  

	 	5)	AA/CRC plans must be submitted to the Department of Health and Family Services, Office of Affirmative Action and Civil Rights Compliance, Box 7850, Madison, Wisconsin 53707-7850.


  

	 	d.	Assurances: 

  

	 	1)	No otherwise qualified person shall be excluded from participation in, be denied the benefits of, or otherwise be subject to discrimination in any manner on the basis of race,
color, national origin, sex, disability or age. This policy covers eligibility for and access to service delivery, and treatment in all programs and activities. All employees of the HMO are expected to support goals and programmatic activities
relating to nondiscrimination in service delivery. 

  

	 	2)	No otherwise qualified person shall be excluded from employment, be denied the benefits of employment or otherwise be subject to discrimination in employment in any manner or term
of employment on the basis of age, race/ ethnicity, color, sex, or sexual orientation, national origin or ancestry, disability (as defined in Section 504 of the Rehab Act, ADA of 1990 and Subchapter II Wisconsin Fair Employment Law 111.32),
arrest or conviction record, marital status, political affiliation, military service, the use of legal products during non-work hours, non-job related genetic and honesty testing. All employees are expected to support goals and programmatic
activities relating to non-discrimination in employment. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -14- 









	 	3)	The HMO must post the Equal Opportunity Policy, the name of the Equal Opportunity Coordinator and the discrimination complaint process in conspicuous places available to applicants
and clients of services, and applicants for employment and employees. The complaint process will be according to Department standards as outlined in the AA/CRC Plan and made available in languages and formats understood by enrollees, applicants and
employees. The Department will continue to provide appropriate translated program brochures and forms for distribution. 

  

	 	4)	The HMO agrees to comply with all of the requirements in the revised Department AA/CRC Plan for Profit and Non-Profit Entities and their subcontractors during this contract period.


  

	 	5)	The Department will monitor the Civil Rights Compliance of the HMO. The Department will conduct reviews to ensure that the HMO is ensuring compliance by its subcontractors or
grantees according to guidelines in the Affirmative Action, Equal Opportunity, and Language Access Compliance Plan. The HMO agrees to comply with Civil Rights monitoring reviews, including the examination of records and relevant files maintained by
the HMO, interview with staff, clients, and applicants for services, subcontractors, grantees, and referral agencies. The reviews will be conducted according to Department procedures. The Department will also conduct reviews to address immediate
concerns of complainants. 

  

	 	6)	The HMO agrees to cooperate with the Department in developing, implementing and monitoring corrective action plans that result from complaint investigations or monitoring efforts.


  

	 	5.	Non-Discrimination in Employment  

  
 The HMO must comply with all applicable federal and state laws relating to non-discrimination and equal employment opportunity including s. 16.765,
Wis. Stats., Federal Civil Rights Act of 1964, regulations issued pursuant to that Act and the provisions of Federal Executive Order 11246 dated September 26, 1985, and ensure physical and program accessibility of all services to persons with
physical and sensory disabilities pursuant to Section 504 of the Federal Rehabilitation Act of 1973, as amended (29 U.S.C. 794), all requirements imposed by the applicable Department 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -15- 








 regulations (45 CFR part 84) and all guidelines and interpretations issued pursuant thereto,
and the provisions of the Age Discrimination and Employment Act of 1967 and Age Discrimination Act of 1975. 
  
 Chapter 16.765, Wis. Stats., requires that in connection with the performance of work under this Contract, the Contractor agrees not to discriminate
against any employee or applicant for employment because of age, race, religion, color, handicap, sex, physical condition, developmental disability as defined in s. 51.01(5), sexual orientation or national origin. This provision shall include,
but not be limited to, the following: employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship.
Except with respect to sexual orientation, the Contractor further agrees to take affirmative action to ensure equal employment opportunities. The Contractor agrees to post in conspicuous places, available for employees and applicants for employment,
notices to be provided by the contracting officer setting forth the provisions of the non-discrimination clause. 
  
 With respect to provider participation, reimbursement, or indemnification, the HMO will not discriminate against any provider who is acting within the
scope of the provider’s license or certification under applicable state law, solely on the basis of such license or certification. This shall not be construed to prohibit an HMO from including providers to the extent necessary to meet the needs
of the Medicaid population or from establishing any measure designed to maintain quality and control cost consistent with these responsibilities. 
  

	 	6.	Provision of Services to all HMO Members  

  
 The HMO must provide contract services to Medicaid and BadgerCare enrollees under this contract in the same manner as those services are provided to
other members of the HMO. 
  
 The HMO must ensure that the
services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. 
  

	 	7.	Access to Premises  

  
 The HMO must allow duly authorized agents or representatives of the state or federal government access to the HMO’s or HMO subcontractor’s
premises during normal business hours to inspect, audit, monitor or otherwise evaluate the performance of the HMO’s or subcontractor’s contractual activities and shall produce all records requested as part of such review or audit within a
reasonable time, but not more than ten 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -16- 








 working days. Upon request for such right of access, the HMO or subcontractor must provide staff to
assist in the audit or inspection effort, and adequate space on the premises to reasonably accommodate the state or federal personnel conducting the audit or inspection effort. All inspections or audits must be conducted in a manner as will not
unduly interfere with the performance of HMO’s or subcontractor’s activities. The HMO will have 30 business days to respond to any findings of an audit before the Department finalizes it. All information obtained will be accorded
confidential treatment as provided under applicable laws, rules or regulations. 
  

	 	8.	Liability for the Provision of Care  

  
 Remain liable for provision of care for that period for which capitation payment has been made in cases where medical status code changes occur
subsequent to capitation payment. 
  

	 	9.	Subcontracts  

  
 The HMO must ensure that all subcontracts are in writing, comply with the provisions of Article X, include any general requirements of this Contract that
are appropriate to the service or activity identified in Article X, and ensure that all subcontracts do not terminate legal liability of the HMO under this Contract. The HMO may subcontract for any function covered by this Contract, subject to the
requirements of this Contract. 
  

	 	10.	Coordination with Community-Based Health Organizations, Local Health Departments, Bureau of Milwaukee Child Welfare, Prenatal Care Coordination Agencies, School-Based Services
Providers and Targeted Case Management Agencies: 

  

	 	a.	Community-Based Health Organizations 

  
 The Department encourages the HMO to contract with community-based health organizations for the provision of care to Medicaid and BadgerCare enrollees in
order to ensure continuity and culturally appropriate care and services. Community-based organizations can provide HealthCheck outreach and screening, immunizations, family-planning services, and other types of services. 
  
 The Department encourages HMOs to work closely with community-based health
organizations as noted in Addendum VI. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -17- 








 Community-based health organizations may also provide services, such as WIC services, that HMOs are
required by federal law to coordinate with and refer to, as appropriate. 
  

	 	b.	Local Health Departments 

  

	 	  	The Department encourages the HMO to contract with local health departments for the provision of care to Medicaid and BadgerCare enrollees in order to ensure continuity and
culturally appropriate care and services. Local health departments can provide HealthCheck outreach and screening, immunizations, blood lead screening services, and services to targeted populations within the community for the prevention,
investigation, and control of communicable diseases (e.g., tuberculosis, HIV/AIDS, sexually transmitted diseases, hepatitis and others). WIC projects provide nutrition services and supplemental foods, breastfeeding promotion and support; and
immunization screening. Many projects screen for blood lead poisoning during the WIC appointment. Refer to Article X, for basic contract requirements. 

  

	 	  	As noted in Addendum VI the Department encourages HMOs to work closely with local health departments. Local health departments have a wide variety of resources that could be
coordinated with HMOs to produce more efficient and cost-effective care for HMO enrollees. Examples of such resources are ongoing medical services programs, materials on health education, prevention, and disease states, expertise on outreaching
specific sub-populations, communication networks with varieties of medical providers, advocates, community-based health organizations, and social service agencies, and access to ongoing studies of health status and disease trends and patterns.


  

	 	c.	Bureau of Milwaukee Child Welfare 

  

	 	  	Milwaukee County HMOs must designate at least one individual to serve as a contact person for the Bureau of Milwaukee Child Welfare (BMCW). If the HMO chooses to designate more than
one contact person, the HMO should identify the service area for which each contact person is responsible. The HMO must provide all Medicaid covered mental health and substance abuse services to individuals identified as clients of BMCW. Disputes
regarding the medical necessity of services identified in the Family Treatment Plan will be adjudicated using the dispute process outlined in Addendum IV, except that HMOs must provide court-ordered services in accordance with Article III, F.
Addendum IV contains guidelines for how Milwaukee County HMOs and BMCW will 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -18- 









	 	  	work together to provide mental health and substance abuse services. Refer to Article III, F for more information regarding mental health and substance abuse covered services.


  

	 	d.	Prenatal Care Coordination (PNCC) Agencies 

  

	 	  	The HMO must sign a Memorandum of Understanding (MOU) with all agencies in the HMO service area that are Medicaid-certified PNCC agencies. The purpose of the MOU is to ensure
coordination of care between the HMO that provides medical services, and the PNCC agency that provides outreach, risk assessment, care planning, care coordination, and follow-up. Refer to Addendum I, IV, B for the MOU requirements and a sample PNCC
MOU. 

  

	 	  	In addition, the HMO must assign an HMO medical representative to interface with the care coordinator from the PNCC agency. Refer to Article III, E, 12 for more information
regarding payment/ non-payment requirements and the HMO representative’s care coordination responsibilities. 

  

	 	e.	School-Based Services (SBS) Providers 

  

	 	  	The HMO must use its best effort to sign a Memorandum of Understanding (MOU) with all SBS providers in the HMO service area to ensure continuity of care and to avoid duplication of
services. Refer to Article III, E, 13 for more information regarding the HMO’s responsibility to coordinate care with SBS providers and Addendum I, IV, C for the MOU requirements and a sample SBS MOU. 

  

	 	f.	Targeted Case Management (TCM) Agencies 

  

	 	  	The HMO must interface with the case manager from the TCM agency to identify what Medicaid covered services or social services are to be provided to an enrollee. Article III, E, 14
and Addendum VII contain more information on how HMOs and TCM agencies should work together to coordinate care. 

  

	 	11.	Clinical Laboratory Improvement Amendments (CLIA)  

  
 The HMO must use only certain laboratories. All laboratory testing sites providing services under this Contract must have a valid CLIA certificate along
with a CLIA identification number, and comply with CLIA regulations as specified by 42 CFR Part 493 “Laboratory Requirements.” Those laboratories with certificates must provide only the types of tests permitted under the terms of their
certification. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -19- 









	 	D.	Payment Requirements/Procedures 

  
 The HMO is responsible for the payment of all contract services provided to all Medicaid and BadgerCare recipients listed as ADDs or CONTINUEs on either
the Initial or Final Enrollment Reports (see Article V, B, D and E) generated for the month of coverage. The HMO is also responsible for: 
  

	 	•	 	The payment for services to all newborns meeting the criteria described in Article VI, F, “Capitation Payments for Newborns.” 

  

	 	•	 	The provision, or authorizing the provision of, services to all Medicaid enrollees with valid Forward cards indicating HMO enrollment, without regard to disputes about enrollment
status and without regard to any other identification requirements. Any discrepancies between the cards and the enrollment reports must be reported to the Department for resolution. The HMO must continue to provide and authorize provision of all
contract services until the discrepancy is resolved, including recipients who were PENDING on the Initial Report and held a valid Forward card indicating HMO enrollment, but did not appear as a CONTINUE on the Final Report. 


 

	 	1.	Claims Retrieval  

  
 The HMO must maintain a claim retrieval system that can upon request identify date of receipt, action taken on all provider claims (i.e., paid, denied,
other), and when action was taken. The HMO must have procedures in place that will show the date a claim was received whether the claim is a paper copy or an electronic submission. In addition, the HMO must maintain a claim retrieval system that can
identify, within the individual claim, the services provided and the diagnoses of the enrollees using nationally accepted coding systems: HCPCS including Level I CPT codes and Level II and Level III HCPCS codes with modifiers, ICD-9-CM diagnosis and
procedure codes, and other national code sets such as place of service, type of service, and EOB codes. Finally, the claim retrieval system must be capable of identifying the provider of services by the appropriate Wisconsin Medicaid provider ID
number assigned to all in-plan providers. Refer to Article III, H, 1, for use of providers certified by the Medicaid program. 
  

	 	2.	Thirty Day Payment Requirement  

  
 The HMO must pay at least 90% of adjudicated clean claims from subcontractors for covered medically necessary services within 30 days of receipt of a
clean claim, 99% within 90 days and 100% within 180 days of 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -20- 








 receipt, except to the extent subcontractors have agreed to later payment. HMO agrees not to delay
payment to a subcontractor pending subcontractor collection of third party liability unless the HMO has an agreement with the subcontractor to collect third party liability. 
  

	 	3.	Payment to a Non-HMO Provider for Services Provided to a Disabled Participant Less Than Three or for Services Ordered by the Courts  

  
 The HMO must pay for covered services provided by a non-HMO provider to a
disabled participant less than three years of age, or to any participant pursuant to a court order (for treatment), effective with the receipt of a written request for referral from the non-HMO provider, and extending until the HMO issues a written
denial of referral. This requirement does not apply if the HMO issues a written denial of referral within seven days of receiving the request for referral 
  

	 	4.	Payment of HMO Referrals to Non-Affiliated Providers  

  
 For HMO approved referrals to non-affiliated providers, the HMO must either establish payment arrangements in advance, or the HMO is liable for payment
only to the extent that Medicaid pays, including Medicare deductibles, or would pay, its FFS providers for services to the AFDC and BadgerCare population. This condition does not apply to cases where there are specific subcontract agreements, MOUs
or other binding agreements entered into before the referral. 
  

	 	5.	Health Professional Shortage Area (HPSA) Payment Provision  

  
 The following provision refers to payments made by the HMO. HMO covered primary care and emergency care services provided to a recipient living in a
Health Professional Shortage Area (HPSA) or by a provider practicing in a HPSA must be paid at an enhanced rate of 20% above the rate the HMO would otherwise pay for those services. Primary care providers (PCP) are defined in Article I. Specified
HMO-covered obstetric or gynecological services (see the Wisconsin Medicaid Physician Services Handbook) provided to a recipient living in a HPSA or by a provider practicing in a HPSA must be paid at an enhanced rate of 25% above the rate the HMO
would otherwise pay providers in HPSAs for those services. 
  
 However, this does not require the HMO to pay more than the enhanced Medicaid FFS rate or the actual amount billed for these services. The HMO shall ensure that the money for HPSA payments is paid to the physicians and is not used to
supplant funds that previously were used for payment to the physicians. The Department will supply a list of the services affected by this provision, the maximum FFS rates, and HPSAs. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -21- 








 The HMO must develop written policies and procedures to ensure compliance with this provision. These
policies must be available for review by the Department, upon request. 
  

	 	6.	Payment of Physician Services to Pregnant Women and Children Under Age 19  

  
 The HMO must adequately fund physician services provided to pregnant women and children under age 19, so that they are paid
at rates sufficient to ensure that provider participation and services are as available to the Medicaid and BadgerCare population as to the general population in the HMO service area. 
  

	 	7.	Federally Qualified Health Centers (FQHC) and Rural Health Centers (RHC) 

  
 If an HMO contracts with a Medicaid certified FQHC or RHC for the provision of services to its enrollees, the HMO must
negotiate payment rates for that FQHC or RHC on the same basis it negotiates with other clinics and primary providers. An HMO that contracts with an FQHC or RHC must report to the Department within 45 days of the end of each quarter (for example,
January 1 – March 31 reports are due May 15) the total amount paid to each FQHC or RHC per month and as reported on the 1099 forms prepared by the HMO for each FQHC or RHC. FQHC or RHC payments include direct payments to a
medical provider who is employed by the FQHC or RHC. The report must be an aggregate of all payments made to contracted FQHCs or RHCs. 
  

	 	8.	Immunization Program  

  
 As a condition of certification as a Medicaid and BadgerCare provider, the HMO must share enrollee immunization status with Local Health Departments and
other non-profit HealthCheck providers upon their request without the necessity of enrollee authorization. The Department also requires that Local Health Departments and other non-profit HealthCheck providers share the same information with HMOs
upon request. This provision ensures proper coordination of immunization services and prevents duplication of services. 
  
 The HMO must have a signed user agreement with the Wisconsin Immunization Registry (WIR) or must be able to demonstrate that its major providers have
signed WIR user agreements. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -22- 









	 	9.	Transplants  

  
 As a general principle, Wisconsin Medicaid does not pay for items that it determines to be experimental in nature. 
  

	 	a.	Medicaid covers cornea transplants and kidney transplants. These services are no longer considered experimental. Therefore, HMOs must also cover these services.


  

	 	b.	HMOs are not required to cover procedures that are approved only at particular institutions, including bone marrow transplants, liver, heart, heart-lung, lung, pancreas-kidney, and
pancreas transplants. There are no funds in the FFS experience data (and thus in the HMO capitation rates) for these services. 

  
 Enrollees who have had one or more of the transplant surgeries referenced in 9, b, above will be permanently exempted from HMO enrollment. Refer to
Article VIII, C, 14 for the exemption criteria. 
  

	 	10.	Hospitalization at the Time of Enrollment or Disenrollment  

  
 Enrollees, including newborn enrollees, who are hospitalized at the time of disenrollment from the HMO shall remain the financial responsibility of the
HMO. The financial liability of the HMO shall encompass all contract services. The HMO’s financial liability shall continue for the duration of the hospitalization, except where: 
  

	 	a.	Loss of Medicaid and BadgerCare eligibility occurs. 

  

	 	b.	Disenrollment occurs because there is a voluntary disenrollment from the HMO as a result of one of the conditions in Article III, F, in which case HMO liability shall terminate upon
disenrollment being effective. 

  

	 	c.	Disenrollment is due to a medical status change to a code indicating SSI, 503 case, or institutionalized eligibility. 503 cases are SSI cases that continue Medicaid eligibility when
Social Security cost of living increases cause an SSI recipient to lose SSI eligibility. 

  
 In these three exceptions, the HMO’s liability shall not exceed the period for which it is capitated. 
  
 The HMO will not assume financial responsibility for enrollees who are
hospitalized at the time of enrollment (effective date of coverage) until an appropriate hospital discharge. The Department is responsible for paying on a FFS basis all Medicaid covered services for such hospitalized enrollees during
hospitalization. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -23- 








 Discharge from one hospital and admission to another within 24 hours for continued treatment shall not
be considered discharge under this section. Discharge is defined here as it is in the UB-92 Manual. 
  

	 	11.	Enrollees Living in a Public Institution  

  
 The HMO is liable for the cost of providing all medically necessary services to enrollees who are living in a public institution as defined in Article I,
during the month in which they first enter the public institution. Enrollees who remain in a public institution after the last day of the month are no longer eligible for Medicaid or BadgerCare and HMOs are not liable for providing care after the
end of the first month. Refer to Article VIII, C, 7 for the disenrollment criteria. 
  
 Enrollees who are living in a public institution and go directly from the public institution to a medical facility, court ordered or voluntarily, are no longer living in a public institution and remain eligible for
Medicaid or BadgerCare. The HMO shall be liable for the provision of medically necessary treatment if treatment is at the HMO’s facilities, or if unable to itself provide for such treatment. 
  

	 	E.	Covered Medicaid Services 

  
 HMOs are not restricted to providing Wisconsin Medicaid covered services. Sometimes HMOs find that other treatment methods may be more appropriate than
Medicaid covered services, or result in better outcomes. 
  
 None
of the provisions of this Contract that are applicable to Wisconsin Medicaid covered services apply to other services that an HMO may choose to provide, except that abortions, hysterectomies and sterilizations must comply with 42 CFR 441 Subpart E
and 42 CFR 441 Subpart F. 
  
 Whether the service provided is an
alternative or replacement to a Wisconsin Medicaid covered service or is a Wisconsin Medicaid covered service, the HMO or HMO provider is not allowed to bill the enrollee for the service. 
  

	 	1.	Provision of Contract Services  

  
 Promptly provide or arrange for the provision of all services required under s. 49.46(2), Wis. Stats., and HFS 107 Wis. Adm. Code as further
clarified in all Wisconsin Medicaid and BadgerCare Provider Publications and HMO Contract Interpretation Bulletins, and as otherwise specified in this Contract except: 
  

	 	a.	Common Carrier Transportation, except as defined in Article III, E, 7. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -24- 









	 	b.	Dental, except as defined in Article III, E, 8. 

  

	 	c.	Prenatal Natal Care Coordination (PNCC), except HMOs must sign a Memorandum of Understanding (MOU) as defined in Article III, C, 10, d, and Addendum I, IV, B.


  

	 	d.	Targeted Case Management (TCM), except HMOs must work with the TCM case manager as defined in Article III, E, 14 and Addendum VII. 

  

	 	e.	School-Based Services (SBS), except HMOs must use its best efforts to sign a Memorandum of Understanding (MOU) as defined in Addendum I, IV, C. 

  

	 	f.	Milwaukee Childcare Coordination. 

  

	 	g.	Tuberculosis-related Services. 

  

	 	h.	Crisis Intervention Benefit. 

  

	 	i.	Community Support Program (CSP) services. 

  

	 	j.	Comprehensive Community Services (CCS). 

  

	 	2.	Medical Necessity  

  
 The actual provision of any service is subject to the professional judgment of the HMO providers as to the medical necessity of the service, except that
the HMO must provide assessment, evaluation, and treatment services ordered by a court. Decisions to provide or not to provide or authorize medical services shall be based solely on medical necessity and appropriateness as defined in HFS
101.03(96m). Disputes between HMOs and recipients about medical necessity can be appealed through an HMO grievance system, and ultimately to the Department for a binding determination; the Department’s determinations will be based on whether
Medicaid would have covered that service on a FFS basis (except for certain experimental procedures discussed in Article III, D, 9). Alternatively, disputes between HMOs and enrollees about medical necessity can be appealed directly to the
Department. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -25- 









	 	3.	Required Services Under Wis. Stats., and Wis. Adm. Code  

  
 Services required under s. 49.46(2), Wis. Stats., and HFS 107, Wis. Adm. Code, include (without limitation due to enumeration) private duty nursing
services, nurse-midwife services, and independent nurse practitioner services; physician services, including primary care services, are not only services performed by physicians, but services under the direct, on-premises supervision of a physician
performed by other providers such as physician assistants and nurses of various levels of certification. 
  

	 	4.	Pre-Existing Medical Conditions  

  
 The HMO must assume responsibility for all covered pre-existing medical conditions of each enrollee as of the effective date of coverage under the
Contract. The aforementioned responsibility does not apply in the case of persons hospitalized at the time of initial enrollment, as defined in Article III, D, 10. 
  

	 	5.	Ambulance Services  

  
 HMOs may require submission of a trip ticket with ambulance claims before paying the claim. Claims submitted without a trip ticket need only be paid at
the service charge rate. HMOs must: 
  

	 	a.	Pay a service fee for ambulance response to a call in order to determine whether an emergency exists, regardless of the HMO’s determination to pay for the call.


  

	 	b.	Pay for emergency ambulance services based on established Medicaid criteria for claims payment of these services. 

  

	 	c.	Either pay or deny payment of a clean claim from an ambulance service within 45 days of receipt of the clean claim. 

  

	 	d.	Respond to appeals from ambulance providers within the time frame described in Article III, G. Failure will constitute HMO agreement to pay the appealed claim in full.


  

	 	6.	Chiropractic Services  

  
 The HMO must cover chiropractic services, or in the alternative, enter into a subcontract for chiropractic services with the state as provided in Article
XIX. State law mandates coverage. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -26- 









	 	7.	Common Carrier Transportation  

  

	 	a.	Enrollees Outside of Milwaukee County 

  
 All HMOs must arrange for transportation for HealthCheck screenings. When authorized by the Department, the HMO may provide non-emergency transportation
by common carrier or private motor vehicle for these visits and be reimbursed by the county. 
  
 HMOs may negotiate arrangements with local county Departments of Health and Social Services for common carrier or private vehicle transportation for HMO services in general and not just for HealthCheck screenings.

  

	 	b.	Enrollees in Milwaukee County 

  
 All Milwaukee County HMOs must provide common carrier transportation to and from Medicaid covered services to their Medicaid and BadgerCare enrollees
that reside in Milwaukee County. 
  
 The HMO is responsible for
arranging common carrier transportation and providing monthly costs incurred to Milwaukee County Department of Human Services (MCDHS). The HMO agrees to submit the monthly costs to the MCDHS within the first 15 days of the following month to:

  
 Milwaukee County DHS 
 Financial Assistant, Division Administrator 
 1220 W. Vliet Street 
 Milwaukee, WI 53206 
  

MCDHS is responsible for reimbursing the HMO for mileage and an administration fee. The Department reserves the right to adjust these rates.

  
 The HMO shall maintain adequate records for each enrollee,
including all pertinent and sufficient information relating to common carrier transportation, and make this information readily available to the Department. The HMO agrees to report suspected abuse by enrollees or providers to the Department.

  

	 	c.	The Department is issuing an RFP for common carrier transportation. The contract for transportation services is expected to be implemented in July 2006, at which time the HMOs must
use the Department’s contracted transportation broker. The Department will work with the HMOs to ensure a smooth transition for the enrollees, both in Milwaukee County and statewide. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -27- 









	 	8.	Dental Services  

  

	 	a.	Dental Services Covered by all HMOs 

  

	 	1)	Emergency Dental Care 

  
 All HMOs must cover emergency dental care. The only exception is the dentist’s or oral surgeon’s direct charges. 
  

	 	2)	Dental Surgeries performed in a Hospital 

  
 All HMOs must pay all ancillary charges relating to dental surgeries when a hospital or freestanding ambulatory care setting is medically indicated.
Ancillary charges include, but are not limited to physician, anesthesia, pharmacy and facility charges. The only exception is the dentist’s or oral surgeon’s direct charges. If an HMO is unable to arrange for the dental surgery to be
performed within their own provider network then the HMO must authorize the service(s) to be performed out of plan. 
  

	 	3)	Prescription Drugs Prescribed by a Dental Provider 

  
 All HMOs are liable for the cost of all medically necessary prescription drugs when ordered by a certified Medicaid dental provider. 
  

	 	b.	Dental Services Covered by HMOs Contracted to Provide Dental Care 

  

	 	1)	All Medicaid covered dental services as required under HFS 107.07, provider handbooks, bulletins, and periodic updates. 

  

	 	2)	Diagnostic, preventive, and medically necessary follow-up care to treat a dental disease, illness, injury or disability of enrollees while they are enrolled in an HMO, except as
required in subsection 3) below. 

  

	 	3)	Completion of orthodontic or prosthodontic treatment begun while an enrollee was enrolled in an HMO if the enrollee became ineligible for Medicaid or disenrolled from the HMO, no
matter how long the treatment takes. An HMO will not be required to complete orthodontic or prosthodontic treatment on an enrollee who began treatment as a FFS recipient and who subsequently was enrolled in an HMO. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -28- 








 [Refer to the chart following this page of the Contract for the specific details of completion of
orthodontic or prosthodontic treatment in these situations.] 
  

	 	c.	Reporting Requirements for HMOs that Cover Dental Services 

  
 HMOs that cover dental services must submit quarterly progress reports to the Department documenting the outcomes or current status of activities
intended to increase utilization. These reports are due 15 days after the end of each calendar quarter. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -29- 








 RESPONSIBILITY FOR PAYMENT OF ORTHODONTIC AND PROSTHODONTIC 
 TREATMENT WHEN THERE IS AN ENROLLMENT STATUS CHANGE 
 DURING THE COURSE OF TREATMENT 
  

											
	 	 	 	 	 	  	 Who pays for completion of orthodontic and
 prosthodontic treatment* when there is an enrollment
 status change


	 	 	 	 	 	  	First HMO

	  	Second HMO

	  	FFS


	 Person converts from one status to another:
	  	 	  	 	  	 
					
	1.	 	FFS to an HMO covering dental.	  	 	  	N/A	  	X
					
	2a.	 	HMO covering dental to an HMO not covering dental, and person’s residence remains within 50 miles of the person’s residence when in the first HMO.	  	X	  	 	  	 
					
	2b.	 	HMO covering dental to an HMO not covering dental, and person’s residence changes to greater than 50 miles of the person’s residence when in the first HMO.	  	 	  	 	  	X
					
	3a.	 	HMO covering dental to the same or another HMO covering dental and the person’s residence remains within 50 miles of the residence when in the first HMO.	  	X	  	 	  	 
					
	3b.	 	HMO covering dental to the same or another HMO covering dental and the person’s residence changes to greater than 50 miles of the residence when in the first HMO.	  	 	  	 	  	X
					
	4.	 	 HMO with dental coverage to FFS because:
	  	 	  	 	  	 
						
	 	 	a.	 	Person moves out of the HMO service area but the person’s residence remains within 50 miles of the residence when in the HMO.	  	X	  	 	  	 
						
	 	 	b.	 	Person moves out of the HMO service area, but the person’s residence changes to greater than 50 miles of the residence when in the HMO.	  	 	  	N/A	  	X
						
	 	 	c.	 	Person exempted from HMO enrollment.	  	 	  	N/A	  	X
						
	 	 	d.	 	Person’s medical status changes to an ineligible HMO code and the person’s residence remains within 50 miles of the residence when in that HMO.	  	X	  	N/A	  	 
						
	 	 	e.	 	Person’s medical status changes to an ineligible HMO code and the person’s residence changes to greater than 50 miles of the residence when in that HMO.	  	 	  	N/A	  	X
					
	5a.	 	HMO with dental to ineligible for Medicaid/BC and the person’s residence remains within 50 miles of the residence when in that HMO.	  	X	  	N/A	  	 
					
	5b.	 	HMO with dental to ineligible for Medicaid/BC and the person’s residence changes to greater than 50 miles of the residence when in that HMO.	  	 	  	N/A	  	X
					
	6.	 	HMO without dental to ineligible for Medicaid/BC.	  	 	  	N/A	  	X



	*	Orthodontic treatment is only covered by Medicaid and BadgerCare for children under 21 as a result of a HealthCheck referral (HFS 107.07(3)). 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -30- 









	 	9.	Emergency and Post-Stabilization Services  

  

	 	a.	24-Hour Coverage 

  

	 	  	The HMO must provide all emergency contract services and post-stabilization services as defined in this Contract 24 hours each day, seven days a week, either by the HMO’s own
facilities or through arrangements approved by the Department with other providers. The HMO must: 

  

	 	1)	Have one toll-free telephone number that enrollees or individuals acting on behalf of an enrollee can call at any time to obtain assistance in determining if emergency services are
needed, to obtain authorization for urgent care and to obtain authorization for transportation. This telephone number must provide access to individuals with authority to authorize treatment as appropriate. Responses to these calls must be provided
within 30 minutes. If the HMO fails to respond timely, the HMO will be liable for the cost of subsequent care related to that illness or injury incident whether the treatment is rendered by in or out-of-plan providers and whether the condition is
emergency, urgent or routine. 

  

	 	  	Authorization here refers to the requirements defined in Addendum II, in the Standard Enrollee Handbook Language, regarding the conditions under which an enrollee must
receive permission from the HMO prior to receiving services from a non-HMO affiliated provider in order for the HMO to reimburse the provider. 

  

	 	2)	Be able to communicate with the caller in the language spoken by the caller or the HMO will be liable for the cost of subsequent care related to that illness or injury incident
whether the treatment is in or out-of-plan and whether the condition is emergency, urgent, or routine. These calls must be logged with the time, date and any pertinent information regarding the persons involved, resolution and follow-up
instructions. 

  

	 	3)	Notify the Department of any changes to this toll-free telephone number for emergency calls within seven working days of the change. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -31- 









	 	b.	Provision/Payment Requirements 

  

	 	  	HMOs must promptly provide or pay for needed contract services for emergency medical conditions and post-stabilization services as defined in Article I, regardless of whether the
provider that furnishes the service has a contract with the entity. Nothing in this requirement mandates HMOs to reimburse for non-authorized post-stabilization services. Payment and liability requirements include but are not limited to:


  

	 	1)	Payments for qualifying emergencies (including services at hospitals or urgent care centers within the HMO service area) are to be based on the medical signs and symptoms of the
condition upon initial presentation. The retrospective findings of a medical work-up may legitimately be the basis for determining how much additional care may be authorized, but not for payment for dealing with the initial emergency. Liability for
emergency services continues until the patient is stabilized and can be safely discharged or transferred. 

  

	 	2)	Paying for an appropriate medical screening examination to determine whether or not an emergency medical condition exists. 

  

	 	3)	When emergency services are provided by non-affiliated providers, be liable for payment only to the extent that Medicaid pays, including Medicare deductibles, or would pay, FFS
providers for services to the Medicaid and BadgerCare population. In no case will the HMO be required to pay more than billed charges. This condition does not apply to: (1) Cases where prior payment arrangements were established; and
(2) Specific subcontract agreements. 

  

	 	c.	Memoranda of Understanding (MOU) or Contract with Hospitals/ Urgent Care Centers for the Provision of Emergency Services 

  

	 	  	HMOs may have a contract or an MOU with hospitals or urgent care centers within the HMO’s service area to ensure prompt and appropriate payment for emergency services. The
provisions for this type of MOU are defined in Addendum I, II, A. Unless a contract or MOU specifies otherwise, HMOs are liable to the extent that FFS would have been liable for a situation that meets the definition of emergency. The Department
reserves the right to resolve disputes between HMOs, hospitals and urgent care centers 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -32- 









	 	  	regarding emergency situations based on the emergency definition in Article I of this contract. For situations where a contract or MOU is not possible, HMOs must identify for
hospitals and urgent care centers procedures that ensure prompt and appropriate payment for emergency services. 

  

	 	10.	Family Planning Services and Confidentiality of Family Planning Information  

  

	 	a.	The HMO must give enrollees the opportunity to have a different primary physician for the provision of family planning services. This physician does not replace the primary care
provider chosen by or assigned to the enrollee. 

  

	 	b.	The enrollee may choose to receive family planning services at any Medicaid certified family planning clinic. Family planning services provided at Medicaid certified family planning
clinics are paid FFS for HMO enrollees except for pharmacy items ordered by the family planning provider. The HMO is liable to provide the prescribed pharmacy items. 

  

	 	c.	All information and medical records relating to family planning shall be kept confidential including those of a minor. 

  

	 	11.	Fertility Drugs  

  
 The HMO must get prior authorization from the Chief Medical Officer in the Division of Health Care Financing before an HMO provider may treat an enrollee
with any of the following drug products: Chorionic Gonadotropin, Clomiphene, Gonadorelin, Menotropins, Urofollitropin and any other new fertility enhancing drugs. 
  

	 	12.	Prenatal Care Coordination (PNCC) Agencies  

  
 The HMO must assign an HMO medical representative to interface with the care coordinator from the PNCC agency. This HMO representative shall work with
the care coordinator to identify what Medicaid covered services, in conjunction with other identified social services, are to be provided to the enrollee. The HMO is not liable for medical services directed outside of their provider network by the
care coordinator unless prior authorized by the HMO. In addition, the HMO is not required to pay for services provided directly by the Prenatal Care Coordinating provider. Such services are paid on a FFS basis. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -33- 








 The HMO must sign an MOU with all agencies in the HMO service area that are Medicaid-certified PNCC
agencies. Article III, C, 10, d, and Addendum I, IV, B contain more information regarding this requirement. 
  

	 	13.	School-Based Services (SBS)  

  
 School-Based Services (SBS) are paid FFS by Medicaid when provided by a Medicaid certified SBS provider. However, in situations where an enrollee’s
course of treatment is interrupted due to school breaks, after school hours or during the summer months, the HMO is responsible for providing and paying for all Medicaid covered services. 
  
 To avoid duplication of services and to promote continuity of care the HMO
must use its best efforts to sign a Memorandum of Understanding (MOU) with all SBS providers in the HMO service area who are Medicaid certified. For Medicaid certification purposes, a SBS service provider is a school district under ch. 120, Wis.
Stats., or a cooperative educational service agency (CESA) under ch. 116, Stats. Refer to Addendum I, IV, C that contains the requirements for an MOU with SBS providers. 
  

	 	14.	Targeted Case Management (TCM) Services  

  
 The HMO must assign an HMO medical representative to interface with the case manager from the TCM agency. This HMO representative will work with the case
manager to identify what Medicaid covered services, in conjunction with other identified social services, are to be provided to the enrollee. The HMO is not required to pay for medical services directed outside of their provider network by the case
manager unless prior authorized by the HMO. The Department will distribute a statewide list of Medicaid-certified TCM agencies to the HMOs and periodically update the list. Addendum VII contains guidelines for how HMOs and TCM agencies should
coordinate care. 
  

	 	F.	Mental Health and Substance Abuse Coverage Requirements/Coordination of Services with Community Agencies 

  
 HMOs must provide Wisconsin Medicaid covered services, but HMOs are not
restricted to providing only those services. HMOs may provide additional or alternative treatments if the other treatment modalities are more appropriate and result in better outcomes than Medicaid covered services. Whether the service provided is a
Medicaid covered service or an alternative or replacement to a Wisconsin Medicaid covered service, the HMO or HMO provider is not allowed to bill the enrollee for the service. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -34- 









	 	1.	Conditions on Coverage of Mental Health/Substance Abuse Treatment  

  
 On the effective date of this contract, the HMO must, in compliance with s.632.89 Wis. Stats.: 
  

	 	a.	Be certified according to HFS 105.21, 105.22, 105.23, 105.24, 105.25 and/or 105.255, to provide mental health and/or substance abuse services; or 

  

	 	b.	Have contracted with facilities and/or providers certified according to HFS 105.21, 105.22, 105.23, 105.24, 105.25, and/or 105.255, to provide mental health and/or substance abuse
services. 

  
 The HMO may request variances of
certain certification requirements for mental health providers. The Department will approve the variances to the extent allowed under federal or state law. 
  
 Regardless of whether a. or b., above, is chosen, such treatment facilities and/or providers must provide arrangements for covered transitional treatment
in addition to other outpatient mental health and/or substance abuse services. Such transitional treatment arrangements may include but are not limited to Adult Day Treatment, Child/Adolescent Day Treatment and Substance Abuse Day Treatment.

  
 Department decisions to waive the requirement to cover these
services shall be based solely on whether there is a certified provider that is geographically or culturally accessible to enrollees, and whether the use of psychiatrists, or psychologists alone improves the quality and/or the cost-effectiveness of
care. 
  
 In compliance with said provisions, the HMO must
further guarantee all enrolled Medicaid and BadgerCare enrollees access to all medically necessary outpatient mental health/substance abuse and covered transitional treatment. No limit may be placed on the number of hours of outpatient treatment
that the HMO must provide or reimburse where it has been determined that treatment for mental illness and/or substance abuse or covered transitional treatment is medically necessary. The HMO shall not establish any monetary limit or limit on the
number of days of inpatient hospital treatment where it has been determined that this treatment is medically necessary. 
  

	 	2.	Mental Health/Substance Abuse Assessment Requirements  

  
 The HMO must assure that authorization for mental health/substance abuse treatment for its enrollees is governed by the findings of an assessment
performed promptly by the HMO upon request of a client or 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -35- 








 referral from a primary care provider or physician in the HMO’s network. Such assessments must be
conducted by qualified staff in a certified program, who are experienced in mental health/substance abuse treatment. All denials of service and the selection of particular modalities of service shall be governed by the findings of this assessment,
the effectiveness of the therapy for the condition, and the medical necessity of treatment. The lack of motivation of an enrollee to participate in treatment shall not be considered a factor in determining medical necessity and may not be used as a
rationale for withholding or limiting treatment of a client/enrollee. HMOs will use Wisconsin Uniform Placement Criteria (WI-UPC), or placement criteria developed by the American Society of Addiction Medicine (ASAM) as mandated for substance abuse
care providers in HFS 75. The requirement in no way obligates the HMOs to provide care options included in the placement criteria, that are not covered services of FFS Medicaid. 
  
 The HMO must involve and engage the enrollee in the process used to select a provider and treatment option. The purpose of
the participation is to get a good match between the enrollee’s condition, culture preference (see Article III, I, 6), medical needs and the provider who must seek to meet these needs. This section does not require HMOs to use providers who are
not qualified to treat the individual enrollee or who are not contracted providers. 
  

	 	3.	Assurance of Expertise for Child Abuse, Child Neglect and Domestic Violence  

  
 The HMO must consult with human service agencies on appropriate providers in their community. The HMO must arrange for the
provision of examination and treatment services by providers with expertise and experience in dealing with medical and psychiatric aspects of caring for victims and perpetrators of child abuse and neglect and domestic violence. Such expertise shall
include the identification of possible and potential victims of child abuse and neglect and domestic violence, statutory reporting requirements, and local community resources for the prevention and treatment of child abuse and neglect and domestic
violence. 
  
 The HMO must notify all persons employed by or
under contract to the HMO who are required by law to report suspected child abuse and neglect, and ensure they are knowledgeable about the law and about the identification requirements and procedures. Services provided must include and are not
limited to court-ordered physical, psychological and mental or developmental examinations and medical and psychiatric treatment appropriate for victims and perpetrators of child abuse and neglect. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -36- 








 The HMO must further assure that providers with appropriate expertise and experience in dealing with
perpetrators and victims of domestic abuse and incest are utilized in service provision. 
  

	 	4.	Court-Related Children’s Services  

  
 The HMO is liable for the cost of providing assessments under the Children’s Code, s. 48.295, Wis. Stats., and is responsible for reimbursing for
the provision of medically necessary treatment if unable to itself provide for such treatment ordered by a juvenile court. The medical necessity of court-ordered evaluation and treatment is assumed to be established and the HMO is allowed to provide
the care through its network, if at all possible. The HMO may not withhold or limit services unless or until the court has agreed. 
  

	 	5.	Court-Related Substance Abuse Services  

  
 The HMO is liable for the cost of providing medically necessary substance abuse treatment, as long as the treatment occurs in an HMO-approved facility or
by an HMO-approved provider ordered in the subject’s Driver Safety Plan, pursuant to Chapter 343, Wis. Stats., and HFS 62 of the Wis. Adm. Code. The medical necessity of services specified in this plan is assumed to be established, and the
HMO shall provide those services unless the assessment agency agrees to amend the enrollee’s Driver Safety Plan. This is not meant to require HMO coverage of substance abuse educational programs, or the initial assessment used to develop the
Driver Safety Plan. Necessary HMO referrals or treatment authorizations by providers must be furnished promptly. It is expected that no more than five days will elapse between receipt of a written request by an HMO and the issuance of a referral or
authorization for treatment. Such referral or authorization, once determined to be medically necessary, will be retroactive to the date of the request. After the fifth day, an assumption will exist that an authorization has been made until such time
as the HMO responds in writing. 
  

	 	6.	Crisis Intervention Benefit  

  
 The HMO must assign a medical representative to interface with the designees of crisis intervention agencies certified under HFS 34 Wis. Adm. Code that
provide services within the HMOs service area. The HMO must work with the certified Crisis Intervention Agency to coordinate the transition from crisis intervention care to ongoing Medicaid covered mental health and substance abuse care within the
HMO’s network. The HMO is not responsible for payment for services provided to their enrollees by certified Crisis Intervention Agencies. Those services are to be billed directly to Medicaid FFS. In addition, the HMO is not 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -37- 








 required to pay for services directed by the certified Crisis Intervention Agency outside the HMO
network, unless the HMO has authorized those services. 
  

	 	7.	Emergency Detention and Court-Related Mental Health Services  

  
 The HMO is liable for the cost of all emergency detention and court-related mental health/substance abuse treatment, including stipulated and involuntary
commitment provided by non-HMO providers to HMO enrollees where the time required to obtain such treatment at the HMO’s facilities, or the facilities of a provider with which the HMO has arrangements, would have risked permanent damage to the
enrollee’s health or safety, or the health or safety of others. The extent of the HMO’s liability for appropriate emergency treatment is the current Medicaid FFS rate for such treatment. 
  

	 	a.	Care provided in the first three business days (72 hours), plus any intervening weekend days and/or holidays, is deemed medically necessary and the HMO is responsible for payment.


  

	 	b.	The HMO is responsible for payment for additional care beyond the time period in paragraph a. above only if notified of the emergency treatment within 72 hours, excluding weekends
and holidays, and if given the opportunity to provide such care. The opportunity for the HMO to provide care to an enrollee admitted to a non-HMO facility is accomplished if the county or treating facility notifies and advises the HMO of the
admission within 72 hours, excluding weekends and/or holidays. The HMO may provide an alternative treatment plan for the county to submit at the probable cause hearing. The HMO must submit the name of an in-plan facility willing to treat the
enrollee if the court rejects the alternative treatment plan and the court orders the enrollee to receive an inpatient evaluation. 

  

	 	c.	If the county attempts to notify the person identified as the primary contact by the HMO to receive authorization for care, and does not succeed in reaching the HMO within 72 hours
of admission excluding weekends and holidays, the HMO is responsible for court-ordered care beyond the initial 72 hours. The county must document the attempts to notify with dates, times, names and numbers attempted to contact, and outcomes. The
care provided to the HMO enrollee by the non-HMO provider is deemed medically necessary, and coverage by the HMO is retroactive to the date of admission. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -38- 









	 	d.	The HMO is financially liable for the enrollee’s court ordered evaluation and/or treatment when an HMO enrollee is defending him/herself against a mental illness or substance
abuse commitment: 

  

	 	1)	If services are provided in an HMO facility; or 

  

	 	2)	If the HMO approves provision in a non-contracted facility; or 

  

	 	3)	If the HMO was given the opportunity but failed to provide the county with the name of an inpatient facility and, as a result, the enrollee is sent for court ordered evaluation to
an out-of-plan provider; or 

  

	 	4)	If the HMO gives the county the name of an in-plan facility and the facility refuses to accept the enrollee. 

  

	 	e.	The HMO is not liable for the enrollee’s court ordered evaluation and treatment if the HMO provided the name of an in-plan facility and the court ordered the evaluation at an
out-of-plan facility. 

  

	 	8.	Institutionalized Individuals  

  

	 	a.	Institutionalized Children 

  

	 	  	If inpatient or institutional services are provided in an HMO facility, or approved by the HMO for provision in a non-contracted facility, the HMO shall be financially liable for
all children enrolled under this Contract for the entire period for which capitation is paid. The HMO remains financially liable for the entire period a capitation is paid even if the child’s medical status code changes, or the child’s
relationship to the original AFDC case changes. 

  

	 	b.	Institutionalized Adults 

  

	 	  	The HMO is not liable for expenditures for any service to a person 21 to 64 years of age who is a resident of an institution for mental disease (IMD), except to the extent that
expenditures for a service to an individual on convalescent leave from an IMD are reimbursed by Medicaid FFS. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -39- 









	 	9.	Transportation Following Emergency Detention  

  
 The HMO shall be liable for the provision of medical transportation to an HMO-affiliated provider when the enrollee is under emergency detention or
commitment and the HMO requires the enrollee to be moved to a participating provider, provided the transfer can be made safely. If a transfer requires a secured environment by local law enforcement officials, (i.e., Sheriff Department, Police
Department, etc.), the HMO shall not be liable for the cost of the transfer. The HMO is not prohibited from entering into an MOU or agreement with local law enforcement agencies or with county agencies for such transfer. 
  

	 	10.	Mental Health and/or Substance Abuse Exemptions  

  
 The Medicaid or BadgerCare case head shall be given the option of disenrolling the enrollee who meets one or more of the mental health and/or substance
abuse criteria defined in Article VIII, C, 9 of this contract, or applying to have the affected person remain in the Medicaid FFS system. The same privilege applies to HMO enrollees who are thought to meet one or more of the criteria defined in
Article VIII, C, 9 at any point during the term of this contract. 
  

	 	11.	Memoranda of Understanding (MOU)/Contract Requirement and Relations with other Human Service Agencies  

  
 The HMO shall develop a working relationship with community agencies
involved in the provision of mental health and/or substance abuse services to enrollees. HMOs must work cooperatively with other community agencies, to treat mental health and/or substance abuse conditions as legitimate health care problems.

  
 The HMO must make a “good faith” attempt to
negotiate either an MOU or a contract with the county(ies) in its service area. A “good faith” attempt is defined as a minimum of one face-to-face meeting between the HMO and the county in an attempt to develop either an MOU or a contract.
If a face-to-face meeting is not possible, the HMO must maintain a written record of their attempt to negotiate either an MOU or a contract with the county(ies). The MOU(s), contract(s) or written documentation of a good faith attempt must be
available during the certification process and when requested by the Department. Failure of the HMO to have an MOU, contract or demonstrate a good faith effort, as specified by the Department, may result in the application by the Department of
remedies specified under Article XI of this Contract. MOU requirements are specified in Addendum I, III of this contract. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -40- 









	 	G.	Provider Appeals 

  
 Medicaid and BadgerCare providers must appeal first to the HMO and then to the Department if they disagree with the HMO’s payment or nonpayment of a
claim. 
  

	 	1.	The HMO must inform providers in writing of the HMO’s decision to pay or deny the original claim. 

  

	 	a.	A specific explanation of the payment amount or a specific reason for the nonpayment. 

  

	 	b.	A statement regarding the provider’s rights to appeal to the HMO. 

  

	 	c.	The name of the person and/or function at the HMO to whom provider appeals should be submitted. 

  

	 	d.	An explanation of the process the provider should follow when appealing the HMO’s decision. 

  

	 	1)	Include a separate letter or form clearly marked “appeal.” 

  

	 	2)	Include the provider’s name, date of service, date of billing, date of payment and/or nonpayment, recipient’s name and Medicaid or BadgerCare ID number.


  

	 	3)	Include the reason(s) the claim merits reconsideration. 

  

	 	4)	Address the letter or form to the person and/or function at the HMO that handles Provider Appeals. 

  

	 	5)	Send the appeal within 60 days of the initial denial or payment notice. 

  

	 	e.	A statement advising the provider of the provider’s right to appeal to the Department if the HMO fails to respond to the appeal within 45 days or if the provider is not
satisfied with the HMO’s response to the request for reconsideration. Appeals to the Department must be submitted in writing within 60 days of the HMO’s final decision or, in the case of no response, within 60 days from the 45 day timeline
allotted the HMO to respond. Appeals should be sent to: 

  
 Medicaid Fiscal Agent 
 Managed Care Unit 
 P.O. Box 6470 
 Madison, WI 53716-0470 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -41- 









	 	2.	The HMO must accept written appeals from providers submitted within 60 days of the HMO’s initial payment and/or nonpayment notice. The HMO must respond in writing within
45 days from the date of receipt of the request for reconsideration. If the HMO fails to respond within 45 days, or if the provider is not satisfied with the HMO’s response, the provider may seek a final determination from the Department.


  

	 	3.	After a provider has appealed to the HMO according to the terms described in Subsection 1 above and the provider disputes the determination, the provider may appeal to the
Department for the final determination. Appeals must be submitted to the Department within 60 days of the date of written notification of the HMO’s final decision resulting from a request for reconsideration or, if the HMO fails to respond,
within 60 days from the 45 day timeline allotted the HMO to respond. In exceptional cases, the Department may override the HMO’s time limit for the submission of claims and appeals. The Department will not exercise its authority in this regard
unreasonably. The Department will accept written comments from all parties to the dispute prior to making a final decision. The Department has 45 days from the date of receipt of all written comments to inform the provider and the HMO of the final
decision. If the Department’s decision is in favor of the provider, the HMO will pay provider(s) within 45 days of receipt of the Department’s final determination. The HMO must accept the Department’s determinations regarding appeals
of disputed claims. 

  

	 	H.	Provider Network and Access Requirements 

  
 The HMO must provide medical care to its Medicaid and BadgerCare enrollees that is as accessible to them, in terms of timeliness, amount, duration, and
scope, as those services are to non-enrolled Medicaid and BadgerCare recipients within the area served by the HMO. 
  

	 	1.	Use of Medicaid Certified Providers  

  
 Except in emergency situations, HMOs must use only providers who have been certified by the Medicaid program for services or items covered by Wisconsin
Medicaid. The Department reserves the right to withhold from the capitation payments the monies related to services provided by non-Medicaid-certified providers, at the Medicaid FFS rate for those services, unless the HMO can demonstrate that it
reasonably believed, based on the information provided by the Department, that the provider was certified by the Medicaid program at the time the HMO reimbursed the provider for service provision. The Wis. Adm. Code, Chapter HFS 105, contains
information regarding provider certification requirements. Every Medicaid HMO must require every physician providing services to enrollees to have a unique physician identifier, as specified in Section 1173(b) of the Social Security Act.

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -42- 









	 	2.	Protocols/Standards to Ensure Access  

  
 The HMO must have written protocols to ensure that enrollees have access to screening, diagnosis and referral, and appropriate treatment for those
conditions and services covered under the Wisconsin Medicaid program. 
  
 The HMO’s protocols must include methods for identification, outreach to and screening/assessment, as defined in Article I, of enrollees with special health care needs. 
  

	 	3.	Written Standards for Accessibility of Care  

  
 The HMO must have written standards for the accessibility of care and services. These standards must be communicated to providers and monitored by the
HMO. The standards must include the following: Waiting times for care at facilities; waiting times for appointments; statement that providers’ hours of operation do not discriminate against Medicaid and BadgerCare enrollees; and whether or not
provider(s) speak member’s language. The HMO must take corrective action if its standards are not met. 
  

	 	4.	Access to Selected Medicaid Providers and/or Covered Services  

  

	 	a.	Dental Providers 

  
 HMOs that cover dental services must have a dental provider within a 35-mile distance from any enrollee residing in the HMO service area or no further
than the distance for non-enrolled recipients residing in the service area. If there is no Medicaid certified provider within the specified distance, the travel distance shall be no more than for a non-enrolled recipient. The HMO must also consider
whether the dentist accepts new patients, and whether full or part-time coverage is available. 
  

	 	b.	Mental Health or Substance Abuse Providers 

  
 The HMO must have a mental health or substance abuse provider within a 35-mile distance from any enrollee residing in the HMO service area or no further
than the distance for non-enrolled recipients residing in the service area. If there is no Medicaid certified provider within the specified distance, the travel distance shall be no more than for a non-enrolled recipient. The HMO must also consider
whether the providers accept new patients, and whether full or part-time coverage is available. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -43- 









	 	c.	High Risk Prenatal Care Services 

  
 The HMO must provide medically necessary high risk prenatal care within two weeks of the enrollee’s request for an appointment, or within three
weeks if the request is for a specific HMO provider. 
  

	 	d.	HMO Referrals to Out-of-Network Providers for Services 

  
 HMO must provide adequate and timely coverage of services provided out of network, when the required medical service is not available within the HMO
network. The HMO must coordinate with out-of-network providers with respect to payment and ensure that cost to the enrollee is no greater than it would be if the services were furnished within the network. (42 CFR. §. 438.206(b)(v)(5)).

  

	 	e.	Primary Care Providers 

  
 Primary Care Providers are defined in Article I. HMOs may define other types of providers as primary care providers. If they do so, the HMOs must define
these other types of primary care providers and justify their inclusion as primary care providers during the pre-contract review phase of the HMO Certification process. 
  
 The HMO must have a Medicaid certified primary care provider within a 20-mile distance from any enrollee residing in the
HMO service area, unless there is no Medicaid certified provider within the specified distance. In that case, the travel distance shall be no more than for a non-enrolled recipient. A service area for an HMO will be specified down to the zip code.
Therefore, all portions of each zip code in the HMO service area must be within 20 miles from a Medicaid certified primary care provider. 
  
 This access standard does not prevent a recipient from choosing an HMO when the recipient resides in a zip code that does not meet the 20-mile distance
standard. However, the recipient will not be automatically assigned to that HMO. If the recipient has been assigned to the HMO or has chosen the HMO and becomes dissatisfied with the access to medical care, the recipient may disenroll from the HMO
because of distance. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -44- 









	 	f.	Second Medical Opinions 

  
 HMOs must upon enrollee request, provide enrollees the opportunity to have a second opinion from a qualified network provider subject to referral
procedures approved by the Department. If an appropriately qualified provider is not available within the network, the HMO must arrange for a second opinion outside the network at no charge to the enrollee. 
  

	 	g.	Women’s Health Specialists 

  
 In addition to a primary care provider a female enrollee may have a women’s health specialist. The HMO must provide female enrollees with direct
access to a women’s health specialist within the network for covered women’s routine and preventive health care services. 
  

	 	5.	Network Adequacy Requirements  

  
 The HMO must ensure that its delivery network is sufficient to provide adequate access to all services covered under this contract. In establishing the
network, the HMO must consider: 
  

	 	a.	The anticipated Medicaid and BadgerCare enrollment. 

  

	 	b.	The expected utilization of services, considering enrollee characteristics and health care needs. 

  

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

  

	 	d.	The number of network providers not accepting new patients. 

  

	 	e.	The geographic location of providers and enrollees, distance, travel time, normal means of transportation used by enrollees and whether provider locations are accessible to
enrollees with disabilities. 

  
 The HMO must
provide documentation and assurance of the above network adequacy criteria as required by the Department for pre-contract certification or upon request of the Department. In addition, the HMO must update the documentation and assurance to the
Department with respect to network adequacy whenever there has been a significant change, as defined by the Department, in the HMO’s operations that would affect adequate capacity and services, including changes in HMO benefits, geographic
service areas, provider network, payments, or enrollment of a new population in the HMO. (42 CFR, §. 438.207(c)(2)(i-ii)). 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -45- 









	 	I.	Responsibilities to Enrollees 

  

	 	1.	Advocate Requirements  

  
 Each HMO must employ a Medicaid/BadgerCare HMO Advocate during the entire contract term. The HMO Advocate must work with both enrollees and providers to
facilitate the provision of Medicaid benefits to enrollees, and the advocate is responsible for making recommendations to management on any changes needed to improve either the care provided or the way care is delivered. The advocate position must
be in an organizational location within the HMO that provides the authority needed to carry out these tasks. The detailed requirements of the HMO Advocate are listed below: 
  

	 	a.	Functions of the Medicaid/BadgerCare HMO Advocate(s) 

  

	 	1)	Investigate and resolve access and cultural sensitivity issues identified by HMO staff, state staff, providers, advocate organizations, and enrollees. 

  

	 	2)	Monitor formal and informal grievances with the grievance personnel for purposes of identification of trends or specific problem areas of access and care delivery. The monitoring
function includes ongoing participation in the HMO grievance committee. 

  

	 	3)	Recommend policy and procedural changes to HMO management including those needed to ensure and/or improve enrollee access to and quality of care. The recommended changes can be for
both internal administrative policies and subcontracted providers. 

  

	 	4)	Act as the primary contact for enrollee advocacy groups. Work with enrollee advocacy groups on an ongoing basis to identify and correct enrollee access barriers.


  

	 	5)	Act as the primary contact for local community based organizations (local governmental units, non-profit agencies, etc.). Work with the local community based organizations on an
ongoing basis to acquire knowledge and insight regarding the special health care needs of enrollees. 


	 	6)	Participate in the Department’s Advocacy Program for Managed Care. Such participation includes working with the Department’s managed care staff person assigned to the


  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -46- 








 HMO on issues of access to medical care and quality of medical care and working with the Enrollment
Specialist and Medicaid Ombudsmen on issues of access to medical care, quality of medical care, and enrollment/disenrollment. 
  

	 	7)	Analyze on an ongoing basis internal HMO system functions that affect enrollee access to medical care and quality of medical care. 

  

	 	8)	Organize and provide ongoing training and educational materials for HMO staff and providers to enhance their understanding of the values and practices of all cultures with which the
HMO interacts. 

  

	 	9)	Provide ongoing input to HMO management on how changes in the HMO provider network will affect enrollee access to medical care and enrollee quality and continuity of care.
Participate in the development and coordination of plans to minimize any potential problems that could be caused by provider network changes. 

  

	 	10)	Review and approve all HMO informing materials to be distributed to enrollees to assess clarity and accuracy. 

  

	 	11)	Assist enrollees and their authorized representatives for the purpose of obtaining their medical records. 

  

	 	12)	The lead advocate position is responsible for overall evaluation of the HMO’s internal advocacy plan and is required to monitor any contracts the HMO may enter into for
external advocacy with culturally diverse associations or agencies. The lead advocate is responsible for training the associations or agencies and ensuring their input into the HMO’s advocacy plan. 

  

	 	b.	Staff Requirements and Authority of the Medicaid/BadgerCare HMO Advocate 

  

	 	1)	At a minimum, one HMO Advocate must be located in the organizational structure so that the Advocate has the authority to perform the functions and duties listed in subsection
section 1, a, 1)-12) above. 

  
 The HMO
Certification Application requires HMOs to state the staffing levels to perform the functions and duties listed in subsection 1, a, 1)-12) above in terms of number of full 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -47- 








 and part time staff and total full time equivalents (FTEs) assigned to these tasks. The Department
assumes that an HMO acting as an Administrative Service Organization (ASO) for another HMO will have at least one advocate or FTE position for each ASO contract as well as maintain their own internal advocate(s). An HMO may employ less than a FTE
advocate position, but must justify to the satisfaction of the Department why less than one FTE position will suffice for the HMO’s enrollee population. The HMO must also regularly evaluate the advocate position, workplan(s), and job duties and
allocate an additional FTE advocate position or positions to meet the duties listed in subsection 1, a, 1)-12) above if there is significant increase in the HMO’s enrollee population or in the HMO service area. The Department reserves the right
to require an HMO to employ an FTE advocate position if the HMO does not demonstrate the adequacy of a part-time advocate position. 
  
 In order to meet the requirement for the advocate position statewide, the Department encourages HMOs to contract or have a formal memorandum of
understanding for advocacy and/or translation services with associations or organizations that have culturally diverse populations within the HMO service area. However, the overall or lead responsibility for the advocate position must be within each
HMO. HMOs must monitor the effectiveness of the associations and agencies under contract and may alter the contract(s) with written notification to the Department. 
  

	 	2)	The HMO advocate is responsible for facilitating and ensuring access to all medically necessary services for each enrollee as stipulated in this Contract. 


 

	 	3)	The HMO advocate staffing levels submitted in the HMO Certification Application must be maintained, and solely devoted to the functions and duties listed in subsection 1, a, 1)-12)
above throughout the contract term. Changes in the HMO advocate staffing levels must be approved by the Department 30 days prior to the effective date of the change. 

  

	 	4)	Prior to contract signing, the HMO advocate must develop a Medicaid and BadgerCare HMO advocacy workplan, with the timelines and activities specified, and must maintain and modify
it as necessary, throughout the contract term. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -48- 









	 	2.	Advance Directives  

  
 The HMO must maintain written policies and procedures related to advance directives. (Written information provided must reflect changes in state law as
soon as possible, but no later than 90 days after the effective date of the change.) An advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under Wisconsin law (whether statutory
or recognized by the courts of Wisconsin) and relating to the provision of such care when the individual is incapacitated. The HMO must: 
  

	 	a.	Provide written information at the time of HMO enrollment to all adults receiving medical care through the HMO regarding: 

  

	 	1)	The individual’s rights under Wisconsin law (whether statutory or recognized by the courts of Wisconsin) to make decisions concerning such medical care, including the right to
accept or refuse medical or surgical treatment and the right to formulate advance directives; and 

  

	 	2)	The HMO’s written policies respecting the implementation of such rights. 

  


	 	b.	Document in the individual’s medical record whether or not the individual has executed an advance directive. 

  

	 	c.	Not discriminate in the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive. This provision
shall not be construed as requiring the provision of care which conflicts with an advance directive. 

  

	 	d.	Ensure compliance with the requirements of Wisconsin law (whether statutory or recognized by the courts of Wisconsin) respecting advance directives. 

  

	 	e.	Provide education for staff and the community on issues concerning advance directives. 

  
 The above provisions shall not be construed to prohibit the application of any Wisconsin law which allows for an objection
on the basis of conscience for any health care provider or any agent of such provider which as a matter of conscience cannot implement an advance directive. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -49- 









	 	3.	Choice of Health Care Professional  

  
 The HMO must offer each enrollee covered under this Contract the opportunity to choose a primary health care professional affiliated with the HMO, to the
extent possible and appropriate. If the HMO assigns recipients to primary care providers, then the HMO must notify recipients of the assignment. HMOs must permit Medicaid and BadgerCare enrollees to change primary providers at least twice in any
calendar year, and to change primary providers more often than that for just cause, just cause being defined as lack of access to quality, culturally appropriate, health care. Such just cause will be handled as a formal grievance. If the HMO has
reason to lock in an enrollee to one primary provider and/or pharmacy in cases of difficult case management, the HMO must submit a written request in advance of such lock-in to the Department’s Contract Specialist. Culturally appropriate care
in this section means care by a provider who can relate to the enrollee and who can provide care with sensitivity, understanding, and respect for the enrollee’s culture. 
  

	 	4.	Coordination and Continuation of Care  

  
 Have systems in place to ensure well-managed patient care, including at a minimum: 
  

	 	a.	Management and integration of health care through primary provider/gatekeeper/other means. 

  

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

  

	 	c.	Systems to ensure provision of care in emergency situations, including an education process to ensure that enrollees know where and how to obtain medically necessary care in
emergency situations. 

  

	 	d.	Systems that clearly specify referral requirements to providers and subcontractors. The HMO must keep copies of referrals (approved and denied) in a central file or the
patient’s medical records. 

  

	 	e.	Systems to ensure the provision of a clinical determination of the medical necessity and appropriateness of the enrollee to continue with MH/SA providers who are not subcontracted
with the HMO. The determination must be made within 10 business days of the enrollee’s request. If the HMO determines that the enrollee does not need to continue with the non-contracted provider, it must ensure an orderly transition of care.


  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -50- 









	 	5.	Conversion Privileges  

  
 The HMO must offer any enrollee covered under this Contract, whose enrollment is subsequently terminated due to loss of Medicaid/BadgerCare eligibility,
the opportunity to convert to a private enrollment contract without underwriting. The time period for conversion following Medicaid/BadgerCare termination notice must comply with Wis. Stats. 632.897 regarding conversion rights. 
  

	 	6.	Cultural Competency  

  
 The HMO must address the special health needs of enrollees who are low income or members of specific population groups needing specific culturally
competent services. The HMO must incorporate in its policies, administration, and service practice such as (1) recognizing members’ beliefs, (2) addressing cultural differences in a competent manner, and (3) fostering in its
staff and providers behaviors that effectively address interpersonal communication styles that respect enrollees’ cultural backgrounds. The HMO must have specific policy statements on these topics and communicate them to subcontractors.

  
 The HMO must encourage and foster cultural competency among
providers. When appropriate the HMO must permit enrollees to choose providers from among the HMO’s network based on linguistic/cultural needs. The HMO must permit enrollees to change primary providers based on the provider’s ability to
provide services in a culturally competent manner. Enrollees may submit grievances to the HMO and/or the Department regarding their inability to obtain culturally appropriate care, and the Department may, pursuant to such a grievance, permit an
enrollee to disenroll from that HMO and enroll into another HMO, or into FFS in a county where HMOs do not enroll all eligibles. 
  

	 	7.	Enrollee Handbook, Education and Outreach for Newly Enrolled Recipients  

  

	 	a.	Within one week of initial enrollment notification to the HMO, annually thereafter and whenever the enrollee’s requests, the HMO must mail to each casehead an enrollee handbook
which is at the “sixth grade reading comprehension level” and which at a minimum will include information about: 

  

	 	1)	The telephone number that can be used for assistance in obtaining emergency care or for prior authorization for urgent care. 

  

	 	2)	Information on contract services offered by the HMO. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -51- 









	 	3)	Location of facilities. 

  

	 	4)	Hours of service. 

  

	 	5)	Informal and formal grievance procedures, including notification of the enrollee’s right to a fair hearing. 

  

	 	6)	Grievance appeal procedures. 

  

	 	7)	HealthCheck. 

  

	 	8)	Family planning policies. 

  

	 	9)	Policies on the use of emergency and urgent care facilities. 

  

	 	10)	Providers and whether the provider is accepting new “enrollees.” 

  

	 	11)	Changing HMOs. 

  

	 	b.	As needed the HMO must provide periodic updates to the handbook and explain changes to the information listed above. Such changes must be approved by the Department prior to
printing. 

  

	 	c.	When HMOs reprint their enrollee handbooks, they must include all of the changes to the standard language as specified in Addendum II, to this Contract. 

  

	 	d.	Enrollee handbooks (or other enrollee information approved by the Department that explains HMO services and how to use the HMO) must be made available in at least: Spanish, Russian
and Hmong if the HMO has enrollees who are conversant only in those languages. The handbook must tell enrollees how to obtain a copy of the handbook in those languages. The Department will translate the standard handbook language in Addendum II into
the three specified languages. HMOs may use the translated standard handbook language as appropriate to its service area. However, HMOs must have local resources review the final handbook language to ensure that the appropriate dialect(s) is/are
used in the standard translation. HMOs must also arrange for translation into any other dialects appropriate for its enrollees. 

  

	 	e.	HMOs may create enrollee handbook language that is simpler than the standard language of Addendum II, but this language must be approved by the Department. HMOs must also
independently arrange for the translation of any non-standard language. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -52- 









	 	f.	HMOs must submit their enrollee handbook for review and approval within 60 days of signing the contract for 2006-2007. 

  

	 	g.	Standard language on several subjects, including HealthCheck, family planning, grievance and appeal rights, conversion rights, and emergency and urgent care, must appear in all
handbooks and is included in Addendum II. Any exceptions to the standard must be approved in advance by the Department, and will be approved only for exceptional reasons. If the standard language changes during the course of the contract period, due
to changes in federal or state laws, rules or regulations, HMOs must insert the new language into the enrollee handbooks as of the effective date of any such change. 

  

	 	h.	In addition to the above requirements for the enrollee handbook, HMOs must perform other education and outreach activities for newly enrolled recipients. HMOs must submit to the
Department for prior written approval an education and outreach plan targeted towards newly enrolled recipients. The outreach plan will be examined by the Department during pre-contract review. Newly enrolled recipients are listed as
“ADD-New” on the enrollment reports (Article V, E). The plan must identify at least two educational/outreach activities the HMO will undertake to tell new enrollees how to access services within the HMO network. The plan must include the
frequency (i.e., weekly, monthly, etc.) of the activities, the person within the HMO responsible for the activities, and how the activities will be documented and evaluated for effectiveness. 

  

	 	8.	Health Education and Disease Prevention  

  
 The HMO must inform all enrollees of ways they can maintain their own health and properly use health care services. 
  
 The HMO must have a health education and disease prevention program that is
readily accessible to its enrollees. The program must be offered within the normal course of office visits, as well as by discrete programming. The program must include: 
  

	 	a.	An individual responsible for the coordination and delivery of services. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -53- 









	 	b.	Information on how to obtain these services (locations, hours, telephone numbers, etc.). 

  

	 	c.	Health-related educational materials in the form of printed, audiovisual, and/or personal communication. 

  
 Health-related educational materials produced by the HMO must be at a sixth grade reading comprehension level and reflect
sensitivity to the diverse cultures served. Also, if the HMO uses material produced by other entities, the HMO must review these materials for grade level comprehension and sensitivity to the diverse cultures served. Finally, the HMO must make all
reasonable efforts to locate and use culturally appropriate health-related material. 
  

	 	d.	Information on recommended check ups and screenings, and prevention and management of disease states that affect the general population. This includes specific information for
persons who have or who are at risk of developing such health problems as hypertension, diabetes, STD, asthma, breast and cervical cancer, osteoporosis and postpartum depression. 

  

	 	e.	Health education and disease prevention programs, including injury control, family planning, teen pregnancy, sexually transmitted disease prevention, prenatal care, nutrition,
childhood immunization, substance abuse prevention, child abuse prevention, parenting skills, stress control, postpartum depression, exercise, smoking cessation, weight gain and healthy birth, postpartum weight loss, and breast-feeding promotion and
support. (Note: any education and prevention programs for family planning and substance abuse would supplement the required family planning and substance abuse health care services covered by Medicaid and BadgerCare. 

  

	 	f.	Promotion of the health education and disease prevention program, including use of languages understood by the population served, and use of facilities accessible to the population
served. 

  

	 	g.	Information on and promotion of other available prevention services offered outside of the HMO, including child nutrition programs, parenting classes, programs offered by local
health departments and other programs. 

  

	 	h.	Systematic referrals of potentially eligible women, infants, and children to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and relevant medical


  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -54- 








 information to the WIC program. Addendum IX contains general information about recipient eligibility
requirements for the WIC program as well as sample WIC referral forms. More information about the WIC program as well a list of the local WIC agencies can be found on the WIC website (www.dhfs.state.wi.us/wic). 
  

	 	9.	Interpreter Services  

  
 As soon as it is determined that the enrollee is of limited English proficiency the HMO must provide interpreter and sign language services free of
charge for enrollees as necessary to ensure availability of effective communication regarding treatment, medical history or health education and/or any other component of this contract. The HMO must: 
  

	 	a.	Provide for 24-hour a day, seven days a week access to interpreter and sign language services in languages spoken by those individuals eligible to receive the services provided by
the HMO or its providers. 

  

	 	b.	Provide an interpreter in time to assist adequately with all necessary care, including urgent and emergency care, when a recipient or provider requests interpreter services in a
specific situation where care is needed. The HMO must clearly document all such actions and results. This documentation must be available to the Department upon request. 

  

	 	c	Use professional interpreters, as needed, where technical, medical, or treatment information or other matters, where impartiality is critical, are to be discussed or where use of a
family member or friend, as interpreter is otherwise inappropriate. Family members, especially children, should not be used as interpreters in assessments, therapy and other situations where impartiality is critical. 

  

	 	d.	Maintain a current list of “On Call” interpreters who can provide interpreter services. Provision of interpreter services must be in compliance with Title VI of the Civil
Rights Act. 

  

	 	e.	Designate a staff person to be responsible for the administration of interpreter/translation services. 

  

	 	f.	Receive Department approval of written policies and procedures for the provision of interpreter services. 

  
 As part of the certification application, the HMOs must submit the policies
and procedures for interpreters, a list of interpreters the HMO uses, and the 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -55- 








 language spoken by each interpreter. The HMO must also submit, as part of certification, its policy on
provision of auxiliary aids to hearing-impaired enrollees. The policy must include a description of the HMO’s process for assessing the preferred method of communication of each hearing-impaired enrollee. The HMO must offer each
hearing-impaired enrollee the type of auxiliary aid(s) s/he prefers in order to access program services and benefits. Once the hearing-impaired enrollee identifies the type of auxiliary aid(s) s/he prefers, a less effective form of communication may
not be used. For example, a person who can most effectively communicate in sign language may not be required to communicate using hand written notes. 
  

	 	J.	Prohibitions to Billing Enrollees 

  
 The HMO and its providers and subcontractors must not bill a Medicaid or BadgerCare enrollee for medically necessary services covered under this Contract
and provided during the enrollee’s period of HMO enrollment. The HMO and its providers and subcontractors must not bill a Medicaid or BadgerCare enrollee for copayments and/or premiums for medically necessary services covered under this
Contract and provided during the enrollee’s period of HMO enrollment. Any provider who knowingly and willfully bills a Medicaid or BadgerCare enrollee for a Medicaid covered service shall be guilty of a felony and upon conviction shall
be fined, imprisoned, or both, as defined in Section 1128B.(d)(1) [42 U.S.C. 1320a-7b] of the Social Security Act. This provision shall continue to be in effect even if the HMO becomes insolvent. 
  
 However, if an enrollee agrees in advance in writing to pay for a service
not covered by Medicaid or BadgerCare, then the HMO, HMO provider, or HMO subcontractor may bill the enrollee. The standard release form signed by the enrollee at the time of services does not relieve the HMO and its providers and subcontractors
from the prohibition against billing an enrollee in the absence of a knowing assumption of liability for a non-Medicaid or BadgerCare covered service. The form or other type of acknowledgment relevant to an enrollee’s liability must
specifically state the admissions, services, or procedures that are not covered by Medicaid and BadgerCare. 
  

	 	K.	HealthCheck 

  

	 	1.	HMO Responsibilities 

  

	 	a.	Provide HealthCheck services as a continuing care provider as defined in Article I, and according to policies and procedures in the Wisconsin Medicaid HealthCheck Provider
Handbook related to covered services. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -56- 









	 	b.	Provide HealthCheck screens upon request. For enrollees over one year of age, if an enrollee, parent or guardian of an enrollee requests a HealthCheck screen, the HMO must provide
such a screen within 60 days, if a screen is due according to the periodicity schedule. If the screen is not due within 60 days, then the HMO must schedule the appointment in accordance with the periodicity schedule. For enrollees up to one year of
age, if a parent or guardian of an enrollee requests a HealthCheck screen, the HMO must provide such a screen within 30 days, if a screen is due according to the periodicity schedule. If the screen is not due within 30 days, then the HMO must
schedule the appointment in accordance with the periodicity schedule. 

  

	 	c.	Provide HealthCheck screens at a rate equal to or greater than 80% of the expected number of screens. The rate of HealthCheck screens will be determined by the calculation in the
HealthCheck Worksheet in Addendum VIII, D. The HMO may complete the worksheet on its own, periodically, as a means to monitor its HealthCheck screening performance. 

  
 HealthCheck data provided by the HMO must agree with its medical record documentation. For the purpose of the HealthCheck
recoupment process, the Department will not include any additional HealthCheck encounter records that are received after January 16, 2008, and 2009 for the year under consideration. (Please note: This date marks the end of the twelve and one
half month period of time from the end of the year under consideration. For example, for dates of service in 2006 the cut-off date will be January 16, 2008). 
  

	 	2.	Department Responsibilities 

  
 The Department will provide quarterly reports to inform the HMO of their progress in meeting the HealthCheck requirements. Quarterly reports will be
provided 90 days following the end of the quarter. 
  
 If the
HMO provides fewer screens in the contract year than 80%, the Department will: 
  

	 	a.	Recoup the funds provided to the HMO for the provision of the remaining screens. The following formula will be used: 

  
 (0.80 x A - B) x (C - D), where 
  

	 	A  =	Expected number of screens (line 6 of HealthCheck Worksheet). 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -57- 









	 	B  =	Number of screens paid in the contract year as reported in the HMO’s Encounter Data Set as of January 16, 2006, and January 16, 2007. (The end of the twelve and one
half month period following the year under consideration.) 

  

	 	C  =	*FFS maximum allowable fee (line 11 of the HealthCheck Worksheet). The FFS maximum allowable fee is the average maximum fee for the year. For example, if the maximum allowable fee
for HealthCheck is $50 from January through June, and $52 from July through December in one calendar year, then the average maximum allowable fee for the year is $51. 

  

	 	D  =	HMO discount, if applicable. 

  

	 	b.	Determine the amount of the HMO’s HealthCheck recoupment, by Rate Region, excluding Dane, Eau Claire, Kenosha, Milwaukee and Waukesha counties, which will be determined
separately. Rate Regions are defined in Addendum III. 

  

	 	c.	Determine the actual number of screens completed, for the recoupment calculation (Line 8 of the Worksheet), by using the number of screens reported in the HMO’s Encounter
Database for calendar years 2006 and 2007 by Rate Region, except for Dane, Eau Claire, Kenosha, Milwaukee and Waukesha counties which will be determined separately. The Department will identify and retrieve the HealthCheck screening data from the
Encounter Database. 

  
 When assigning HealthCheck
screens to an age category, the Department will use the member’s age on the first day of the month in which the screening occurred. If a newborn enrollee is screened in the month of their birth, the newborn’s screen will be assigned to the
under one age category. 
  

	 	d.	Determine the number of eligible months and unduplicated enrollees (Lines 1 and 2 of the Worksheet) per HMO per year by using the Medicaid Management Information System Recipient
Eligibility File. When calculating member months for each age category, the Department will use the member’s age on the first day of the month except for newborns. Newborns enrolled in an HMO in the month of their birth will be counted as
eligible from their date of birth. 

  
 Inform the
HMO in writing of its preliminary analysis of the HealthCheck data and allow the HMO 30 business days to review and respond to the calculations. If the HMO responds within 30 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -58- 








 business days, the Department will review the HMO’s concerns and notify the HMO of its final
decision. If an HMO does not respond within 30 business days, the Department will send a “Notice of Intent to Recover” letter 40 days after the initial letter. 
  

	 	3.	HealthCheck Redesign Project 

  
 The Department is analyzing options for replacing the HMO HealthCheck utilization monitoring and recoupment process with a performance improvement
incentive system. The Department and HMOs will work closely on the HealthCheck redesign project. If the new system requires any changes to this contract, the Department will initiate an amendment to incorporate the changes. 
  

	 	L.	Marketing Plans and Informing Materials 

  
 As used in this section, “marketing materials, other marketing activities, and informing materials” include the production and dissemination of
any informing materials, marketing plans, marketing materials and other marketing activities that refer to Medicaid, Title XIX, BadgerCare, or Title XXI and are intended for Medicaid and BadgerCare recipients. This requirement includes marketing or
informing materials that are produced by providers under contract to the HMO or owned by the HMO in whole or in part. Educational materials prepared by the HMO or by their contracted providers and sent to the HMOs entire membership (i.e. Medicare,
Medicaid, commercial recipients) do not require the Department’s approval, unless there is specific mention of Medicaid or BadgerCare. Educational material prepared by outside entities (i.e. the American Cancer Society, the Diabetic Association
etc.) does not require the Department’s approval. 
  

	 	1.	Approval of Marketing and Informing Materials  

  
 HMOs must submit to the Department for prior written approval all informing materials, marketing plans, and all marketing materials and other marketing
activities that refer to Medicaid Title XIX, BadgerCare, or Title XXI or are intended for Medicaid and BadgerCare recipients. This requirement includes marketing or informing materials that are produced by providers under contract to the HMO or
owned by the HMO in whole or in part. 
  
 Marketing plans and
informing materials must be written at a “sixth grade comprehension level.” The Department will review them in a manner that does not unduly restrict or inhibit the HMO’s informing or marketing plans. When applying this provision to
specific marketing plans, informing materials and/or activities, the entire content and use of the informing/marketing materials or activities will be taken into consideration. The Department will review all materials as follows: 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -59- 









	 	a.	The Department will review and either approve, approve with modifications, or deny all marketing or informing materials within 10 business days of receipt of the informing
materials. If the HMO does not receive a response from the Department within 10 business days, the HMO must contact the Contracts Section Chief in the Bureau of MHCP. A response will be prepared within two business days of this contact.


  

	 	b.	Time-sensitive marketing or informing materials must be clearly marked time-sensitive by the HMO and will be approved, approved with modifications or denied by the Department within
three business days. The Department reserves the right to determine whether the material is, indeed, time-sensitive. If the HMO does not receive a response from the Department within three business days the HMO must contact the Contracts Section
Chief in the Bureau of MHCP. A response will be prepared within one business day of this contact. 

  

	 	c.	The Department will not approve any materials it deems confusing, fraudulent, or misleading, or that do not accurately reflect the scope, philosophy, or covered benefits of the
Medicaid and BadgerCare program. 

  

	 	d.	Problems and errors the Department subsequently identifies must be corrected by the HMO when they are identified. The HMO agrees to comply with Ins. 6.07 and 3.27, Wis. Adm.
Code, and practices consistent with the Balanced Budget Amendment of 1997 P.L. 105-33 Sec. 4707(a) [42 U.S.C. 1396v(d)(2)]. 

  

	 	2.	Prohibited Practices  

  

	 	a.	Practices that are discriminatory. 

  

	 	b.	Practices that seek to influence enrollment in conjunction with the sale of any other insurance product. 

  

	 	c.	Direct and indirect cold calls, either door-to-door or telephonic. 

  

	 	d.	Offer of material or financial gain to potential members as an inducement to enroll. 

  

	 	e.	Activities and material that could mislead, confuse or defraud consumers. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -60- 









	 	f.	Materials that contain false information. 

  

	 	g	Practices that are reasonably expected to have the effect of denying or discouraging enrollment. 

  

	 	3.	HMOs Agreement to Abide by Marketing/Informing Criteria  

  
 The HMO agrees to engage only in marketing activities and distribute only those informing and marketing materials that are pre-approved in writing. Any
activities must occur in its entire service area and only as indicated in the agreement. HMOs that fail to abide by these marketing requirements may be subject to any and all sanctions available under Article XI. In determining any sanctions, the
Department will take into consideration any past unfair marketing practices, the nature of the current problem and the specific implications on the health and wellbeing of the Medicaid enrollees. In the event that an HMO’s affiliated provider
fails to abide by these requirements, the Department will evaluate whether the HMO should have had knowledge of the marketing issue and the HMO’s ability to adequately monitor ongoing future marketing activities of the subcontractor(s).

  

	 	M.	Reproduction/Distribution of Materials 

  
 Reproduce and distribute at HMO expense, according to a reasonable Department timetable, information or documents sent to the HMO from the Department that
contains information the HMO-affiliated providers must have in order to fully implement this Contract. 
  

	 	N.	HMO ID Cards 

  
 The HMO may issue its own HMO ID cards. The HMO may not deny services to an enrollee solely for failure to present an HMO issued ID card. The Forward ID
card will always determine HMO enrollment, even where an HMO issues HMO ID cards. 
  

	 	O.	Open Enrollment 

  
 Conduct a continuous open enrollment period during which the HMO shall accept recipients eligible for coverage under this Contract in the order in which
they are enrolled. The HMO will not discriminate against individuals eligible to enroll on the basis of race, color, national origin or health status and will not use any policy or practice that has the effect of discriminating on the basis of race,
color, or national origin or health status. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -61- 









	 	P.	Selective Reporting Requirements 

  

	 	1.	Communicable Disease Reporting  

  
 As required by Wis. Stats. 252.05, 252.15(5)(a)6 and 252.17(7)(9b), physicians, physician assistants, podiatrists, nurses, nurse midwives, physical
therapists, and dietitians affiliated with a Medicaid HMO shall report the appearance, suspicion or diagnosis of a communicable disease or death resulting from a communicable disease to the Local Health Department for any enrollee treated or visited
by the provider. Reports of human immunodeficiency virus (HIV) infection shall be made directly to the State Epidemiologist. Such reports shall include the name, sex, age, residence, communicable disease, and any other facts required by the Local
Health Department and Wisconsin Division of Public Health. Such reporting shall be made within 24 hours of learning about the communicable disease or death or as specified in Wis. Adm. Code HFS 145.04, Appendix A. Charts and reporting forms on
communicable diseases are available from the Local Health Department. Each laboratory subcontracted or otherwise affiliated with the HMO shall report to the Local Health Department the identification or suspected identification of any communicable
disease listed in Wis. Adm. Rules 145, Appendix A. Reports of HIV infections shall be made directly to the State Epidemiologist. 
  

	 	2.	Fraud and Abuse Investigations  

  
 The HMO agrees to cooperate with the Department on fraud and abuse investigations. In addition, the HMO agrees to report allegations of fraud and abuse
(both provider and enrollee) to the Department within 15 days of the suspected fraud or abuse coming to the attention of the HMO. Failure on the part of HMOs to cooperate or report fraud and/or abuse may result in any applicable sanctions under
Article XI. 
  

	 	3.	Physician Incentive Plans  

  
 A physician incentive plan is any compensation arrangement between the HMO and a physician or physician group that may directly or indirectly have the
effect of reducing or limiting services provided with respect to individuals enrolled with the HMO. 
  
 The HMO shall fully comply with the physician incentive plan requirements specified in 42 CFR s. 417.479(d) through (g) and the requirements
relating to subcontracts set forth in 42 CFR s. 417.479(i), as those provisions may be amended from time to time. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -62- 









	 	Q.	Abortions, Hysterectomies and Sterilization Requirements 

  
 The HMO shall comply with the following state and federal compliance requirements for the services listed below: 
  

	 	1.	Abortions must comply with the requirements of Chapter 20.927, Wis. Stats., and with 42 CFR 441 Subpart E—Abortions. 

  

	 	2.	Hysterectomies and sterilizations must comply with 42 CFR 441 Subpart F—Sterilizations. 

  
 Sanctions in the amount of $10,000.00 may be imposed for
non-compliance with the above compliance requirements. 
  

	 	3.	HMOs must abide by s. 609.30, Wis. Stats. 

  
 ARTICLE IV 
  

	IV.	QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT (QAPI) 

  
 The HMO QAPI program must conform to the requirements of 42 CFR, Part 400, Medicaid Managed Care Requirements, Subpart D, QAPI. The program must also
comply with 42 CFR 434.34 which states that the HMO must have a QAPI system that: 
  

	 	•	 	Is consistent with the utilization control requirement of 42 CFR 456. 

  

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

  

	 	•	 	Provides for systematic data collection of performance and patient results. 

  

	 	•	 	Provides for interpretation of this data to the practitioners. 

  

	 	•	 	Provides for making needed changes. 

  

	 	A.	QAPI Program 

  
 The HMO must have a comprehensive QAPI program that protects, maintains, and improves the quality of care provided to Wisconsin Medicaid and BadgerCare
program recipients. 
  

	 	1.	The HMO must evaluate the overall effectiveness of its QAPI program annually to determine whether the program has demonstrated improvement, where needed, in the quality of care and
service provided to its Medicaid and BadgerCare population. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -63- 









	 	2.	The HMO must have documentation of all aspects of the QAPI program available for Department review upon request. The Department may perform off-site and on-site QAPI audits to
ensure that the HMO is in compliance with contract requirements. The review and audit may include: on-site visits; staff and enrollee interviews; medical record reviews; review of all QAPI procedures, reports, committee activities, including
credentialing and recredentialing activities, corrective actions and follow-up plans; peer review process; review of the results of the member satisfaction surveys, and review of staff and provider qualifications. 

  

	 	3.	The HMO must have a written QAPI work plan that is ratified by the board of directors and outlines the scope of activity and the goals, objectives, and time lines for the QAPI
program. New goals and objectives must be set at least annually based on findings from quality improvement activities and studies and results of the HMO on DHCF enrollee satisfaction surveys and MEDDIC-MS performance measures.


  

	 	4.	The HMO governing body is ultimately accountable to the Department for the quality of care provided to HMO enrollees. Oversight responsibilities of the governing body include, at a
minimum; approval of the overall QAPI program and an annual QAPI plan; designating an accountable entity or entities within the organization to provide oversight of QAPI; review of written reports from the designated entity on a periodic basis which
include a description of QAPI activities, progress on objectives, and improvements made; formal review on an annual basis of a written report on the QAPI program; and directing modifications to the QAPI program on an ongoing basis to accommodate
review findings and issues of concern within the HMO. 

  

	 	5.	The QAPI committee must be in an organizational location within the HMO such that it can be responsible for all aspects of the QAPI program. The committee membership must be
interdisciplinary and be made up of both providers and administrative staff of the HMO, including: 

  

	 	•	 	A variety of health professions (e.g., pharmacy, physical therapy, nursing, etc.). 

  

	 	•	 	Qualified professionals specializing in mental health or substance abuse and dental care on a consulting basis when an issue related to these areas arises. 


 

	 	•	 	A variety of medical disciplines (e.g., medicine, surgery, radiology, etc.). 

  

	 	•	 	OB/GYN and pediatric representation. 

  

	 	•	 	HMO management or governing body. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -64- 









	 	6.	Enrollees of the HMO must be able to contribute input to the QAPI Committee. The HMO must have a system to receive enrollee input on quality improvement, document the input
received, document the HMO’s response to the input, including a description of any changes or studies it implemented as the result of the input and document feedback to enrollees in response to input received. The HMO response must be timely.


  

	 	7.	The committee must meet on a regular basis, but not less frequently than quarterly. The activities of the QAPI Committee must be documented in the form of minutes and reports. The
QAPI Committee must be accountable to the governing body. Documentation of Committee minutes and activities must be available to the Department upon request. 

  

	 	8.	QAPI activities of HMO providers and subcontractors, if separate from HMO QAPI activities, must be integrated into the overall HMO/QAPI program. Requirements to participate in QAPI
activities, including submission of complete encounter data, are incorporated into all provider and subcontractor contracts and employment agreements. The HMO QAPI program shall provide feedback to the providers/subcontractors regarding the
integration of, operation of, and corrective actions necessary in provider/subcontractor QAPI efforts. Other management activities (Utilization Management, Risk Management, Customer Service, Complaints and Grievances, etc.) must be integrated with
the QAPI program. Physicians and other health care practitioners and institutional providers must actively cooperate and participate in the HMO’s quality activities. 

  
 The HMO remains accountable for all QAPI functions, even if certain functions are delegated to other entities. If the HMO
delegates any activities to contractors, the conditions listed in Article II “Delegations of Authority” must be met. 
  

	 	9.	There is evidence that HMO management representatives and providers participate in the development and implementation of the QAPI plan of the HMO. This provision shall not be
construed to require that HMO management representatives and providers participate in every committee or subcommittee of the QAPI program. 

  

	 	10.	The HMO must designate a senior executive to be responsible for the operation and success of the QAPI program. If this individual is not the HMO Medical Director, the Medical
Director must have substantial involvement in the QAPI program. The designated individual shall be accountable for the QAPI activities of the HMO’s own providers, as well as the HMO’s subcontracted providers. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -65- 









	 	11.	The qualifications, staffing level and available resources must be sufficient to meet the goals and objectives of the QAPI program and related QAPI activities. Such activities
include, but are not limited to, monitoring and evaluation of important aspects of care and services, facilitating appropriate use of preventive services, monitoring provider performance, provider credentialing, involving members in QAPI initiatives
and conducting performance improvement projects. 

  
 Written documentation listing the staffing resources that are directly under the organizational control of the person who is responsible for QAPI (including total FTEs, percent of time dedicated to QAPI, background and experience, and role)
must be available to the Department upon request. 
  

	 	B.	Monitoring and Evaluation 

  

	 	1.	The QAPI program must monitor and evaluate the quality of clinical care on an ongoing basis. Important aspects of care (i.e., acute, chronic conditions, high volume, high-risk
preventive care and services) are studied and prioritized for performance improvement and/or development of practice guidelines. Standardized quality indicators must be used to assess improvement, ensure achievement of minimum performance levels
(Ref: MEDDIC-MS Measures and Technical Specifications), monitor adherence to guidelines, and identify patterns of over utilization and under utilization. The measurement of quality indicators selected by the HMO for areas other than those included
in MEDDIC-MS must be supported by appropriate data collection and analysis methods to improve clinical care and services. 

  

	 	2.	Provider performance must be measured against practice guidelines and standards adopted by the QAPI Committee. Areas identified for improvement must be tracked and corrective
actions taken when warranted. The effectiveness of corrective actions must be monitored until problem resolution occurs. Reevaluation must occur to ensure that the improvement is sustained. 

  

	 	3.	The HMO must use appropriate clinicians to evaluate the data on clinical performance, and multi-disciplinary teams to analyze and address data on systems issues.


  

	 	4.	The HMO must also monitor and evaluate care and services in certain priority clinical and non-clinical areas specified in Article IV, K, 3. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -66- 









	 	5.	The HMO must make documentation available to the Department upon request regarding quality improvement and assessment studies on plan performance, which relate to the enrolled
population. See reporting requirements in Article IV, K, “Performance Improvement Priority Areas and Projects.” 

  

	 	6.	The HMO must develop or adopt practice guidelines that are disseminated to providers and to enrollees as appropriate or upon request. The guidelines are based on valid and reliable
medical evidence or consensus of health professionals; consider the needs of the enrollees; developed or adopted in consultation with the contracting health professionals, and reviewed and updated periodically (42 CFR, §. 438.236.).


  
 Decisions with respect to utilization
management, enrollee education, coverage of services, and other areas to which the practice guidelines apply are consistent with the guidelines. Variations from the guidelines must be based on the clinical situation. 
  

	 	C.	Health Promotion and Disease Prevention Services 

  

	 	1.	The HMO must identify at-risk populations for preventive services and develop strategies for reaching Medicaid and BadgerCare members included in this population. Public health
resources can be used to enhance the HMO’s health promotion and preventive care programs. 

  

	 	2.	The HMO must have mechanisms for facilitating appropriate use of preventive services and educating enrollees on health promotion. At a minimum, an effective health promotion and
prevention program includes HMO outreach to and education of its enrollees, tracking preventive services, practice guidelines for preventive services, yearly measurement of performance in the delivery of such services, and communication of this
information to providers and enrollees. 

  

	 	3.	The Department encourages the HMO to develop and implement disease management programs and systems to enhance quality of care for individuals identified as having chronic or special
health care needs known to be responsive to application of clinical practice guidelines and other techniques. 

  

	 	4.	The HMO agrees to implement systems to independently identify enrollees with special health care needs and to utilize data generated by the systems or data that may be provided by
the Department to facilitate outreach, assessment and care for individuals with special health care needs. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -67- 









	 	D.	Provider Selection (Credentialing) and Periodic Evaluation (Recredentialing) 

  

	 	1.	The HMO must have written policies and procedures for provider selection and qualifications. For each practitioner, including each member of a contracting group that provides
services to the HMO’s enrollees, initial credentialing must be based on a written application, primary source verification of licensure, disciplinary status, eligibility for payment under Medicaid and certified for Medicaid. The HMO’s
written policies and procedures must identify the circumstances in which site visits are appropriate in the credentialing process. 

  
 The HMO may not employ or contract with providers excluded in federal health care programs under either Section 1128 or Section 1128A of the
Social Security Act. 
  

	 	2.	The HMO must periodically monitor (no less than every three years) the provider’s documented qualifications to ensure that the provider still meets the HMO’s specific
professional requirements. 

  

	 	3.	The HMO must also have a mechanism for considering the provider’s performance. The recredentialing method must include updating all the information (except medical education)
utilized in the initial credentialing process. Performance evaluation must include information from the QAPI system, reviewing enrollee complaints, and the utilization management system. 

  

	 	4.	The selection process must not discriminate against providers such as those serving high-risk populations, or specialize in conditions that require costly treatment. The HMO must
have a process for receiving advice on the selection criteria for credentialing and recredentialing practitioners in the HMO’s network. 

  
 If the HMO declines to include groups of providers in its network, the HMO must give the affected providers written notice of the reason for its
decision. 
  

	 	5.	If the HMO delegates selection of providers to another entity, the organization retains the right to approve, suspend, or terminate any provider selected by that entity.


  

	 	6.	The HMO must have a formal process of peer review of care delivered by providers and active participation of the HMO’s contracted providers in the peer review process. This
process may include internal medical audits, medical evaluation studies, peer review committees, evaluation of outcomes of care, and systems for correcting deficiencies. The HMO must supply documentation of its peer review process upon request.


  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -68- 









	 	7.	The HMO must have written policies that allow it to suspend or terminate any provider for quality deficiencies. There must also be an appeals process available to the provider that
conforms to the requirements of the HealthCare Quality Improvement Act of 1986 (42 USC §. 11101 et. Seq.). 

  

	 	8.	The names of individual practitioners and institutional providers who have been terminated from the HMO provider network as a result of quality issues must be immediately forwarded
to the Department and reported to other entities as required by law (42 USC §. 11101 et. Seq.). 

  

	 	9.	Institutional Provider Selection: The HMO must determine and verify at specified intervals that: 

  

	 	a.	Each provider, other than an individual practitioner is licensed to operate in the state, if licensure is required, and in compliance with any other applicable state or federal
requirements; and 

  

	 	b.	The HMO verifies if the provider claims accreditation, or is determined by the HMO to meet standards established by the HMO itself. 

  

	 	10.	Exceptions to credentialing and recredentialing requirements. These standards do not apply to: 

  

	 	a.	Providers who practice only under the direct supervision of a physician or other provider, and 

  

	 	b.	Hospital-based providers such as emergency room physicians, anesthesiologists, and other providers who provide services only incident to hospital services. 


 
 These exceptions do not apply if the provider contracts
independently with the HMO. 
  

	 	E.	Enrollee Feedback on Quality Improvement 

  

	 	1.	The HMO must have a process to maintain a relationship with its enrollees that promotes two way communication and contributes to quality of care and service. The HMO must treat
members with respect and dignity. 

  

	 	2.	The Department will conduct a satisfaction survey of a representative sample of enrolled Medicaid and BadgerCare recipients. The Department will work with HMOs to develop the survey
instrument and plan. The HMO must have systems in place for acting on survey results and must report to the Department any quality management projects planned in response to survey results. The frequency of the survey will be annually or biennially,
at the Department’s discretion. The Department will inform HMOs in advance of the audit date and audit plan. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -69- 









	 	3.	The HMO is encouraged to find additional ways to involve Medicaid and BadgerCare enrollees in quality improvement initiatives and in soliciting enrollee feedback on the quality of
care and services the HMO provides. Other ways to bring enrollees into the HMO’s efforts to improve the health care delivery system include but are not limited to focus groups, consumer advisory councils, enrollee participation on the governing
board, the QAPI committees or other committees, or task forces related to evaluating services. All efforts to solicit feedback from enrollees must be approved by the Department. 

  

	 	F.	Medical Records 

  

	 	1.	The HMO must have policies and procedures for participating provider medical records content and documentation that have been communicated to providers and a process for evaluating
its providers’ medical records based on the HMO’s policies. These policies must address patient confidentiality, organization and completeness, tracking, and important aspects of documentation such as accuracy, legibility, and safeguards
against loss, destruction, or unauthorized use. The HMO must also have confidentiality policies and procedures that are applicable to administrative functions that are concerned with confidential patient information. Those policies must include
information with respect to disclosure of enrollee-identifiable medical record and/or enrollment information and specifically provide: 

  

	 	a.	That enrollees may review and obtain copies of medical records information that pertains to them. 

  

	 	b.	That policies above must be made available to enrollees upon request. 

  

	 	2.	Patient medical records must be maintained in an organized manner (by the HMO, and/or by the HMO’s subcontractors) that permits effective patient care, reflect all aspects of
patient care and be readily available for patient encounters, administrative purposes, and Department review. 

  

	 	3.	Because HMOs are considered contractors of the state and therefore (only for the limited purpose of obtaining medical records of its enrollees) entitled to obtain medical records
according to Wis. Adm. Code, HFS 104.01(3), the Department requires Medicaid-certified providers to release relevant records to the HMO to assist in compliance with this section. HMOs that have not specifically addressed photocopying expenses
in their provider contracts or other arrangements, are liable for charges for copying records only to the extent that the Department would reimburse on a FFS basis. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -70- 









	 	4.	The HMO must have written confidentiality policies and procedures in regard to individually-identifiable patient information. Policies and procedures must be communicated to HMO
staff, members, and providers. The transfer of medical records to out-of-plan providers or other agencies not affiliated with the HMO (except for the Department) are contingent upon the receipt by the HMO of written authorization to release such
records signed by the enrollee or, in the case of a minor, by the enrollee’s parent, guardian, or authorized representative. 

  

	 	5.	The HMO must have written quality standards and performance goals for participating provider medical record documentation and be able to demonstrate, upon request of the Department,
that the standards and goals have been communicated to providers. The HMO must actively monitor compliance with established standards and provide documentation of monitoring for compliance with the standards and goals upon request of the Department.


  

	 	6.	Medical records must be readily available for HMO-wide Quality Assessment/Performance Improvement (QAPI) and Utilization Management (UM) activities and provide adequate medical and
other clinical data required for QAPI/UM, and Department use. 

  

	 	7.	The HMO must have adequate policies in regard to transfer of medical records to ensure continuity of care when enrollees are treated by more than one provider. This may include
transfer to local health departments subject to the receipt of a signed authorization form as specified in subsection 4 above (with the exception of immunization status information described in Article III, D, 8, which does not require enrollee
authorization). 

  

	 	8.	Requests for completion of residual functional capacity evaluation forms and other impairment assessments, such as queries as to the presence of a listed impairment, must be
provided within 10 business days of the request (at the discretion of the individual provider and subject to the provider’s medical opinion of its appropriateness) and according to the other requirements listed above. The HMO and its providers
and subcontractor may charge the enrollee, authorized representative, or other third party a reasonable rate for the completion of such forms and other impairment assessments. Such rates may be reviewed by the Department for reasonableness and may
be modified based on this review. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -71- 









	 	9.	Minimum medical record documentation per chart entry or encounter must conform to the Wis. Adm. Code, Chapter HFS 106.02, (9)(b) Medical record content.


  

	 	G.	Utilization Management (UM) 

  

	 	1.	The HMO must have documented policies and procedures for all UM activities that involve determining medical necessity, and the approval or denial of medical services. Qualified
medical professionals must be involved in any decision-making that requires clinical judgment. The decision to deny, reduce or authorize a service that is less than requested must be made by a health professional with appropriate clinical expertise
in treating the affected enrollee’s condition(s). Criteria used to determine medical necessity and appropriateness must be communicated to providers. The criteria for determining medical necessity may not be more stringent than HFS 101.03
(96m) Wis. Adm. Code. 

  

	 	2.	If the HMO delegates any part of the UM program to a third party, the delegation must meet the requirements in Article II Delegations of Authority. 

  

	 	3.	If the HMO utilizes telephone triage, nurse lines or other demand management systems, the HMO must document review and approval of qualification criteria of staff and of clinical
protocols or guidelines used in the system. The system’s performance will be evaluated annually in terms of clinical appropriateness. 

  

	 	4.	The HMO’s policies must specify time frames for responding to requests for initial and continued service determinations, specify information required for authorization
decisions, provide for consultation with the requesting provider when appropriate, and provide for expedited responses to requests for authorization of urgently needed services. In addition, the HMO must have in effect mechanisms to ensure
consistent application of review criteria for authorization decisions (interrater reliability). 

  

	 	a.	Within the time frames specified, the HMO must give the enrollee and the requesting provider written notice of: 

  

	 	1)	The decision to deny, limit, reduce, delay or terminate a service along with the reasons for the decision. 

  

	 	2)	The enrollee’s right to file a grievance or request a state fair hearing. 

  


 HMO Contract for February 1, 2006 - December 31, 2007 
 -72- 









	 	b.	Authorization decisions must be made within the following time frames and in all cases as expeditiously as the enrollee’s condition requires: 

  

	 	1)	Within 14 calendar days of the receipt of the request, or 

  

	 	2)	Within three business days if the physician indicates or the HMO determines that following the ordinary time frame could jeopardize the enrollee’s health or ability to regain
maximum function. 

  

	 	  	One extension of up to 14 calendar days may be allowed if the enrollee requests it or if the HMO justifies the need for more information. 

  

	 	  	On the date that the timeframes expire, HMO gives notice that service authorization decisions are not reached. Untimely service authorizations constitute a denial and are thus
adverse actions. 

  

	 	5.	Criteria for decisions on coverage and medical necessity are clearly documented, are based on reasonable medical evidence, current standards of medical practice, or a consensus of
relevant health care professionals, and are regularly updated. 

  

	 	6.	The HMO oversees and is accountable for any functions and responsibilities that it delegates to any subcontractor. (See Article II Delegations of Authority).


  

	 	7.	Postpartum discharge policy for mothers and infants must be based on medical necessity determinations. This policy must include all follow-up tests and treatments consistent with
currently accepted medical practice and applicable federal law. The policy must allow at least a 48-hour hospital stay for normal spontaneous vaginal delivery, and 96 hours for a cesarean section delivery, unless a shorter stay is agreed to by both
the physician and the enrollee. HMOs may not deny coverage, penalize providers, or give incentives or payments to providers or enrollees. Post hospitalization follow-up care must be based on the medical needs and circumstances of the mother and
infant. The Department may request documentation demonstrating compliance with this requirement. 

  

	 	H.	External Quality Review Contractor 

  

	 	1.	The HMO must assist the Department and the external quality review organization under contract with the Department in identification of provider and enrollee information required to
carry out on-site or off-site medical chart reviews. This includes arranging orientation meetings for 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -73- 









	 	  	physician office staff concerning medical chart review, and encouraging attendance at these meetings by HMO and physician office staff as necessary. The provider of service may
elect to have charts reviewed on-site or off-site. 

  

	 	2.	When the professional review organization under contract with the Department identifies an adverse health situation in which follow-up is needed to determine whether appropriate
care was provided, the HMO must: 

  

	 	a.	Assign a staff person(s) to conduct follow-up with the provider(s) concerning each adverse health situation identified by the Department’s external quality review organization,
including informing the provider(s) of the finding and monitoring the provider’s resolution of the finding; 

  

	 	b.	Inform the HMO’s QAPI Committee of the final finding and involve the QAPI Committee in the development, implementation and monitoring of the corrective action plan; and


  

	 	c.	Submit a corrective action plan or an opinion in writing to the Department within 60 days that addresses the measures that the HMO and the provider intend to take to resolve the
finding. The HMO’s final resolution of all cases must be completed within six months of HMO notification. A case is not considered resolved by the Department until the Department approves the response provided by the HMO and provider.


  

	 	3.	The HMO will facilitate training provided by the Department to its providers. 

  


	 	I.	Dental Services Quality Improvement (Applies only to HMOs Covering Dental Services) 

  
 The HMO QAPI Committee and QAPI coordinator will review subcontracted dental programs quarterly to ensure that quality
dental care is provided and that the HMO and the contractor comply with the following: 
  

	 	1.	The HMO or HMO affiliated dental provider must advise the enrollee within 30 days of effective enrollment of the name of the dental provider and the address of the dental
provider’s site. The HMO or HMO affiliated dental provider must also inform the enrollee in writing how to contact his/her dentist (or dental office), what dental services are covered, when the coverage is effective, and how to appeal denied
services. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -74- 









	 	2.	An HMO or HMO affiliated dental provider who assigns all or some Medicaid and BadgerCare HMO enrollees to specific participating dentists must give enrollees at least 30 days after
assignment to choose another dentist. Thereafter, the HMO and/or affiliated provider must permit enrollees to change dentists at least twice in any calendar year and more often than that for just cause. 

  

	 	3.	HMO-affiliated dentists must provide a routine dental appointment to an assigned enrollee within 90 days after the request. Enrollee requests for emergency treatment must be
addressed within 24 hours after the request is received. 

  

	 	4.	Dental providers must maintain adequate records of services provided. Records must fully disclose the nature and extent of each procedure performed and should be maintained in a
manner consistent with standard dental practice. 

  

	 	5.	The HMO affirms by execution of this Contract that the HMO’s peer review systems are consistently applied to all dental subcontractors and providers. 


 

	 	6.	The HMO must document, evaluate, resolve, and follow up on all verbal and written complaints they receive from Medicaid/BadgerCare enrollees related to dental services.


  

	 	J.	Accreditation 

  

	 	1.	The Department encourages the HMO to actively pursue accreditation by the National Committee for Quality Assurance (NCQA), the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) or other recognized accrediting bodies approved by the Department. 42 CFR §. 438.360 provides that the Department may recognize “a private national accrediting organization that CMS has approved as applying standards
at least as stringent as Medicare under the procedures in §. 422.158.” 

  
 The Centers for Medicare and Medicaid Services (CMS) has recognized the following accrediting bodies: The National Committee for Quality Assurance
(NCQA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Accreditation Association for Ambulatory Health Care (AAAHC). The Department may recognize other accreditation bodies as they may qualify for such
recognition. 
  

	 	2.	The achievement of full accreditation by an accreditation body approved by the Department and satisfaction of the requirements of the HMO Accreditation Incentive Program as
specified by the Department will result in the HMO qualifying for the Accreditation Incentive. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -75- 








 Where accreditation standards conflict with the standard set forth in this Contract, the Contract
prevails unless the accreditation standard is more stringent. 
  

	 	K.	Performance Improvement Priority Areas and Projects 

  

	 	1.	The HMO must develop and ensure implementation of program initiatives to address the specific clinical needs that have a higher prevalence in the HMO’s enrolled population
served under this Contract. These priority areas must include clinical and non-clinical Performance Improvement projects. The Department strongly advocates the development of collaborative relationships among HMOs, local health departments,
community based behavioral health treatment agencies (both public and private), and other community health organizations to achieve improved services in priority areas and must report complete encounter data for all services provided. Linkages
between managed care organizations and public health agencies is an essential element for the achievement of the public health objectives, potentially reducing the quantity and intensity of services the HMO needs to provide. The Department and the
HMO are jointly committed to on going collaboration in the area of service and clinical care improvements by the development and sharing of “best practices” and use of encounter data-driven performance measures (MEDDIC-MS).


  
 The HMO must annually monitor and evaluate the
quality of care and services through performance improvement projects for at least two of the priority areas specified by the Department and listed in subsections 3. below, or an HMO may propose to address alternative performance improvement topics
by making a request in writing to the Department. In addition, to two performance improvement projects required under subsection 3 below the HMO may be required to conduct up to two additional performance improvement initiatives and submit reports
as required to achieve performance goals specified in the MEDDIC-MS technical specifications. The final or on-going status report for each project must be submitted by October 1 of each calendar year, or as may be specified in the MEDDIC-MS
technical specifications. The performance improvement topic must take into account the prevalence of a condition among, or need for a specific service by, the HMO enrollees served under this Contract; enrollee demographic characteristics and health
risks; and the interest of consumers or purchasers in the aspect of care or services to be addressed. 
  
 The report for each performance improvement project must address each of the following points in order for the Department to evaluate the reliability and
validity of the data and the conclusions described in the study: 
  

	 	a.	Topic 

  

	 	1)	Is the topic important to the enrolled population? 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -76- 









	 	b.	Can it be affected by the actions of the HMO? 

  

	 	1)	Was the process of the topic selection described? 

  

	 	c.	Method 

  

	 	1)	Was the method and procedure used to study the topic clear? 

  

	 	2)	Study question: 

  

	 	•	 	Was the study question clearly stated and consistent throughout the study? 

  

	 	•	 	Is the study question specific? 

  

	 	d.	Data Collection 

  

	 	1)	Was the data fully described in detail? 

  

	 	2)	Was the data appropriate to answer the study question? 

  

	 	3)	Was the data collection process fully described? 

  

	 	4)	Was the data collection appropriate to answer the study question? 

  

	 	5)	Were the data collectors appropriate to collect the data? 

  

	 	6)	Was interrater reliability adequate? 

  

	 	7)	Did the loss of data or subjects affect validity? 

  

	 	8)	Was the study time clear? 

  

	 	e.	Intervention (not applicable if the project is to establish a baseline only) 

  

	 	1)	Was the intervention fully described? 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -77- 









	 	2)	Was the intervention practical (can it be widely implemented?) 

  

	 	3)	Was the implementation of the intervention monitored and reported to ensure that it was done properly? 

  

	 	f.	Results and interpretation 

  

	 	1)	Was the data collected fully reported? 

  

	 	2)	Did the study include comparisons to give meaning to the results? 

  

	 	3)	Is the norm or standard expressed in a specific numerical manner? 

  

	 	4)	Is the goal, norm or standard appropriate to this population and study? 

  

	 	5)	Was the comparison group (if applicable) as close as possible to the population under study and were any differences acknowledged? 

  

	 	6)	If pre-and-post measures were used, was an explanation for the differences between the measures considered? 

  

	 	7)	Was assignment to groups random? 

  

	 	8)	Did the study appropriately use statistical testing? (x2 t-test, regression analysis, etc.)? 

  

	 	9)	Were the conclusions consistent with the results? 

  

	 	10)	Were data tables, figures and graphs consistent with the text? 

  

	 	11)	Did the study consider its limitations? 

  

	 	12)	Did the study conclude or imply causality when the supporting data is only correlational? 

  

	 	13)	Did the study include how to improve the study? 

  

	 	14)	Did the study present recommendations on the results? 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -78- 









	 	15)	Did the report clearly state whether performance improvement goals were met (if an intervention was carried out), and if the goals were not met, was there an analysis of why not and
a plan for future action? 

  

	 	g.	Miscellaneous 

  

	 	1)	Was enrollee confidentiality protected? 

  

	 	2)	Did consumers participate in the study (other than as the subjects)? 

  

	 	3)	Did the study include cost/benefit analysis or some other consideration of financial impact? 

  

	 	4)	Were next steps described in detail? (Dates and timelines) 

  

	 	5)	Were the results and conclusions distributed throughout the HMO? 

  

	 	6)	Did table, figures and graphs convey their information clearly without reference to the report text? 

  

	 	7)	Did the study report include an accurate summary? 

  

	 	8)	Was the study clearly written? 

  

	 	2.	Performance reporting will utilize standardized indicators appropriate to the performance improvement area or as specified in the MEDDIC-MS technical specifications. Minimum
performance levels must be specified for each performance improvement area, using normative standards derived from regional, national norms, or from norms established by an appropriate practice organization. Goals for improvement for the
“Priority Areas” listed in Section 3. below, may be set by the organization itself. 

  
 The organization must ensure that improvements are sustained through periodic audits of relevant data and maintenance of the interventions that resulted
in the improvement. The HMO agrees to open at least one new performance improvement project during the contract period. In all cases, not less than two performance improvement projects must be reported to the Department in any year and not less than
three different projects must be reported to the Department in 2006-2007. These projects are in addition to any that may be required as the result of sub-goal performance on any MEDDIC-MS Targeted Performance Improvement Measures. However, if the
HMO chooses to initiate or continue a project on a topic that coincides with a required MEDDIC-MS project, the Department will accept the report as fulfilling both requirements during the next contract year. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -79- 








 The organization must implement a performance improvement project in the area if a quality improvement
opportunity is identified. The HMO must report to the Department on each study, including those areas where the HMO will not pursue a performance improvement project. 
  
 The Department will accept for fulfillment of the above requirement Performance Improvement Project Reports arising out of
voluntary HMO participation in collaborative quality improvement projects including, but not limited to, the Improving Birth Outcomes Project (IBOP), First Breath smoking cessation project, Care Analysis Projects (CAP) or other collaborative efforts
designated by the Department. In order to be accepted the project report by the HMO must meet all the content criteria described in Performance Improvement Project Outline in subsection K, 1. 
  

	 	3.	Priority Areas 

  

	 	Clinical	Priority Areas: 

  

	 	•	 	Prenatal services; 

  

	 	•	 	Identification of adequate treatment for high-risk pregnancies, including those involving substance abuse; 

  

	 	•	 	Evaluating the need for specialty services; 

  

	 	•	 	Availability of comprehensive, ongoing nutrition education, counseling, and assessments; 

  

	 	•	 	Family Health Improvement Initiative: Smoking Cessation; 

  

	 	•	 	Enrollees with special health care needs; 

  

	 	•	 	Outpatient management of asthma; 

  

	 	•	 	The provision of family planning services; 

  

	 	•	 	Early postpartum discharge of mothers and infants; 

  

	 	•	 	STD screening and treatment; 

  

	 	•	 	High volume/high risk services selected by the HMO; 

  

	 	•	 	Prevention and care of acute and chronic conditions; 

  

	 	•	 	Coordination and continuity of care; 

  

	 	•	 	Obesity; and 

  

	 	•	 	Overuse and inappropriate use of antibiotics. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -80- 









	 	  	Non-Clinical Priority Areas: 

  

	 	•	 	Grievances, appeals and complaints; 

  

	 	•	 	Access to and availability of services; 

  

	 	•	 	Enrollee satisfaction with HMO customer service; and 

  

	 	•	 	Satisfaction with services for enrollees with special health care needs or cultural competency of the HMO and its providers. 

  

	 	  	In addition, the HMO may be required to conduct performance improvement projects specific to the HMO and to participate in one annual statewide project that may be specified by the
Department. 

  

	 	4.	Performance Measurement and Goal-setting for Improvement – MEDDIC-MS Medicaid Encounter Data-Driven Improvement Core Measure Set and MEDDIC-MS Goal-setting Procedures.


  

	 	  	The Department will evaluate HMO performance using the MEDDIC-MS automated performance measures. Evaluation of HMO performance on each measure will be conducted on timetables
determined by the Department. The technical specifications for each measure are established by the Department with HMO and other stakeholder input and are described in “MEDDIC-MS Measures and Technical Specifications,” as revised.


  

	 	  	The Department will inform the HMO of its performance on each measure, whether the HMO’s performance satisfied the goal requirements set by the Department and whether a
performance improvement initiative by the HMO is required. The HMO will have 60 business days to review and respond to the Department’s performance report. When a performance improvement initiative is required due to sub-goal performance on the
measure, the HMO may request recalculation of the performance level based on new or additional data the HMO may supply, or if the HMO can demonstrate material error in the calculation of the performance level. The Department will provide a tentative
schedule of measure calculation dates to the HMO within 90 days of the beginning of each calendar year in the contract period. 

  

	 	  	MEDDIC-MS consists of targeted performance improvement measure (TPIMS) and monitoring measures. The specifications for each TPIM includes denominator and numerator specifications,
performance goals and requirements for actions to be taken when sub-goal performance occurs. 

  

	 	  	Unless otherwise noted within a specific targeted performance improvement measure, the Department may specify minimum performance levels and require that the HMOs develop plans to
respond to levels below the minimum performance levels. Additions, deletions or modifications to the Targeted Performance Improvement Measures and 

  


 HMO Contract for February 1, 2006 - December 31, 2007 
 -81- 









	 	  	Monitoring Measures in the MEDDIC-MS Technical Specifications and goals must be mutually agreed upon by the parties. The Department will give 90 days notice to the HMO of its intent
to change any measures, technical specifications or goals. The HMO shall have the opportunity to comment on the measure specifications, goals and implementation plan within the 90 day notice period. The Department reserves the right to require the
HMO to report such performance measure data as may be deemed necessary to monitor and improve HMO-specific or program-wide quality performance. 

  

	 	5.	Pay for Performance – The Department will implement pay for performance incentives for HMOs for selected health status or outcomes improvements to be mutually agreed. The
incentive payment will be based on the criteria to be developed and agreed through a contract amendment. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -82- 








 ARTICLE V 
  

	V.	FUNCTIONS AND DUTIES OF THE DEPARTMENT 

  

	  	In consideration of the functions and duties of the HMO contained in this Contract, the Department must: 

  

	 	A.	Eligibility Determination 

  
 Identify Medicaid and BadgerCare recipients who are eligible for enrollment in HMOs as a result of eligibility under the following eligibility status:

  

							
	 Med Stat

	  	 Cap Rate*

	  	 Description

	  	 
	 31
	  	 A
	  	 AFDC-Regular
	  	 
	 32
	  	 A
	  	 AFDC-Unemployed
	  	 
	 38, 39
	  	 A
	  	 AFDC-Related, No Cash Payment
	  	 
	 CC, CM, GC, PC
	  	 A
	  	Healthy Start Children	  	 
	 E2
	  	 A
	  	AFDC-Related, No Cash Payment	  	 
	 GE
	  	 A
	  	Healthy Start Children Ages 15-18	  	 
	 N1, N2
	  	 A
	  	Medicaid Newborn	  	 
	 UA
	  	 A
	  	AFDC-Related, Unemployed	  	 
	 WH
	  	 A
	  	AFDC Employed over 100 Hours a Month	  	 
	 X1, X2, X3, X4
	  	 A
	  	AFDC-Related, No Cash Payment	  	 
	 B1
	  	 A
	  	BadgerCare – Income equal or greater than 100% of FPL, and less than or equal to 150% of FPL, Kids, No premium.	  	 
	 B4
	  	 A
	  	BadgerCare – Income equal or greater than 100% of FPL, and less than or equal to 150% of FPL, Adults, No premium.	  	 
	 B2
	  	 A
	  	BadgerCare – Income greater than 150% of FPL, and less than 185% of FPL, Kids, Premium.	  	 
	 B5
	  	 A
	  	Income greater than 150% of FPL, and less than 185% of FPL, Adults, Premium.	  	 
	 B3
	  	 A
	  	Income equal or greater than 185% of the FPL, and less than 200% of the FPL, Kids, Premium.	  	 
	 B6
	  	 A
	  	Income equal or greater than 185% of the FPL, and less than 200% of the FPL, Adults, Premium.	  	 
	 GP
	  	 A
	  	Income less than 100% of FPL, Adults Parents of OBRA kids (AFDC), No premium.	  	 
	 95
	  	 B
	  	Pregnant Women in Intact Families	  	 
	 A6, A7, A8,
	  	 B
	  	Pregnant Woman, IRCA Alien	  	 
	 E3, E4
	  	 B
	  	Extension for Pregnant Woman	  	 
	 PW, P1
	  	 B
	  	 Healthy Start Pregnant Women
	  	 



	*	A = AFDC/Healthy Start Children/BadgerCare capitation rate. 


	*	B = Pregnant Women Healthy Start capitation rate. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -83- 









	 	B.	Enrollment 

  
 Promptly notify the HMO of all Medicaid and BadgerCare recipients enrolled in the HMO under this Contract. Notification will be effected through the HMO
Enrollment Reports. All recipients listed as an ADD or CONTINUE on either the Initial or Final HMO Enrollment Report are members of the HMO during the enrollment month. The reports will be generated in the sequence specified under HMO enrollment
reports Article V, E. These reports shall be in both tape and hard copy formats or available through electronic file transfer capability and will include medical status codes. The Department will make all reasonable efforts to enroll pregnancy cases
as soon as possible. 
  

	 	C.	Disenrollment 

  
 Promptly notify the HMO of all Medicaid and BadgerCare recipients no longer eligible to receive services through the HMO under this Contract. Notification
will be effected through the HMO Enrollment Reports which the Department will transmit to the HMO for each month of coverage throughout the term of the Contract. The reports will be generated in the sequence under HMO enrollment reports Article V,
E. Any recipient who was enrolled in the HMO in the previous enrollment month, but does not appear as an ADD or CONTINUE on either the Initial or Final HMO Enrollment Report for the current enrollment month, is disenrolled from the HMO effective the
last day of the previous enrollment month. 
  

	 	D.	Enrollment Errors 

  
 The Department must investigate enrollment errors brought to its attention by the HMO. The Department must correct systems errors and human errors and
ensure that the HMO is not financially responsible for recipients that the Department determines have been enrolled in error. Capitation payments made in error will be recouped. 
  

	 	E.	HMO Enrollment Reports 

  
 For each month of coverage throughout the term of the Contract, the Department will transmit “HMO Enrollment Reports” to the HMO. These reports
will provide the HMO with ongoing information about its Medicaid and BadgerCare enrollees and disenrollees and will be used as the basis for the monthly capitation claims described in Article VI, payments to the HMO. The HMO Enrollment Reports
will be generated in the following sequence: 
  

	 	1.	The Initial HMO Enrollment Report will list all of the HMO’s enrollees and disenrollees for the enrollment month that are known on the date of report generation. The Initial
HMO Enrollment Report will be available to the HMO on or about the twenty-first of each month. A capitation claim shall be generated for each enrollee listed as an ADD or CONTINUE on 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -84- 








 this report. Enrollees who appear as PENDING on the Initial Report and are reinstated into the HMO prior
to the end of the month will appear as a CONTINUE on the Final Report and a capitation claim will be generated at that time. 
  

	 	2.	The final HMO Enrollment Report will list all of the HMO’s enrollees for the enrollment month, who were not included in the Initial HMO Enrollment Report. The Final HMO
Enrollment Report will be available to the HMO by the first day of the capitation month. A capitation claim will be generated for every enrollee listed as an ADD or CONTINUE on this report. Enrollees in PENDING status will not be included on the
final report. 

  

	 	3.	The Department will provide HMOs with effective dates for medical status code changes, county changes and other address changes in each enrollment report to the extent that the
county reports these to the Department. 

  

	 	F.	Utilization Review and Control 

  
 Waive, to the extent allowed by law, any present Department requirements for prior authorization, second opinions, copayment, or other Medicaid
restrictions for the provision of contract services provided by the HMO to enrollees, except as may be provided in Article III, F. 
  

	 	G.	HMO Review 

  
 Submit to HMOs for prior approval materials that describe specific HMOs and that will be distributed by the Department or County to recipients.

  

	 	H.	Department Audit Schedule 

  
 HMOs will be notified approximately 30 days prior to regularly scheduled, routine audits being conducted via a letter from the Division of Health Care
Financing. The Department will develop an annual schedule of known audits for the next contract period. 
  

	 	I.	HMO Review of Study or Audit Results 

  
 Submit to HMOs for a 30 business day review/comment period, any Medicaid and BadgerCare HMO audits, the annual HMO Comparison Report, HMO Consumer
Satisfaction Reports, or any other Medicaid and BadgerCare HMO studies the Department releases to the public. The review/comment period will commence on the fifth business day after the audit report was mailed. The HMO may request an extension and
the Department will exercise reasonable discretion in making the determination to waive the 30 business day review/comment requirement. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -85- 









	 	J.	Vaccines 

  
 Provide certain vaccines to HMO providers for administration to Medicaid and BadgerCare HMO enrollees according to the policies and procedures in the
Wisconsin Medicaid and BadgerCare Physicians Services Handbook. The Department will reimburse the HMO for the cost of vaccines that are newly approved during the contract year and not yet part of the Vaccine for Children program. The cost of the
vaccine shall be the same as the cost to the Department of buying the new vaccine through the Vaccine for Children program. The HMO retains liability for the cost of administering the vaccines. 
  

	 	K.	Coordination of Benefits 

  
 Maintain a report of recovered money reported by the HMO and its subcontractor. 
  

	 	L.	Wisconsin Medicaid Provider Reports 

  
 Provide a monthly electronic listing of all Wisconsin Medicaid certified providers to include, at a minimum, the name, address, Wisconsin Medicaid
provider ID number, and dates of certification in Wisconsin Medicaid. 
  

	 	M.	Enrollee Health Status and Primary Language Report 

  
 The Department will provide the HMO with an enrollee health status and primary language report of all enrollees who have agreed to participate with the
gathering of this data. The reports will be provided to the HMO on a monthly basis. The purpose of this report is to assist HMOs with continuity of care issues and with the identification of non-English speaking enrollees and to facilitate
appointments for enrollees who have urgent health care needs. 
  

	 	N.	Fraud and Abuse Training 

  
 The Department will provide fraud and abuse detection training to the HMOs annually. 
  

	 	O.	Provision of Data to HMOs 

  
 Provide to each HMO the following data related to the HMO’s members: 
  

	 	1.	Lead testing performed and sent to the State Lab of Hygiene for analysis. 

  

	 	2.	Immunization information from the Wisconsin Immunization Registry to the extent available. The Department will make every effort to get the Wisconsin Immunization Registry
information to HMOs. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -86- 









	 	P.	Special Procedures for Retroactive Payment Adjustments for Pregnant BadgerCare Enrollees 

  
 The Department will continue to work on development and implementation of an automated procedure by which payment
adjustments will be made for BadgerCare enrollees who should have been designated as a Healthy Start Pregnant Woman. As long as the woman was enrolled in the HMO at the time of delivery, the adjustment will be made for up to seven months of
enrollment before the delivery and two months following the delivery. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -87- 








 ARTICLE VI 
  


	VI.	PAYMENT TO THE HMO 

  

	 	A.	Capitation Rates 

  
 In consideration of full compliance by the HMO with contract requirements, the Department agrees to pay the HMO monthly payments based on the capitation
rates specified in Addendum III. The HMO accepts the monthly capitation payment as payment in full except for cost payments from third party payers and payments under the contract for NICU, AIDS and vent services. The HMO assumes full risk for the
cost of services covered by the capitation payment. The capitation rate does not include any amount for recoupment of losses incurred by the HMO under previous contracts nor does it include services that are not covered under the State Plan.

  
 The Department’s enhanced funding policies include NICU
risk sharing, ventilator dependent and AIDS/HIV enrollees. HMOs cannot submit a request for enhanced funding under more than one of the three funding policies for the same enrollee for the same date(s) of service. 
  

	 	B.	Actuarial Basis 

  
 The capitation rate is calculated on an actuarial basis recognizing the payment limits set forth in 42 CFR 438.6. 
  

	 	C.	Annual Negotiation of Capitation Rates 

  
 The monthly capitation rates set forth in this article are recalculated on an annual basis. The HMO will have 30 calendar days from the date of the
written notification to accept the new capitation rates in writing or to initiate termination or non-renewal of the Contract. The capitation rates are not subject to renegotiation once they have been accepted, unless such renegotiation is required
by changes in federal or state laws, rules or regulations. 
  

	 	D.	Reinsurance 

  
 The HMO may obtain a risk-sharing arrangement from an insurer other than the Department for coverage of enrollees under this Contract, provided that the
HMO remains substantially at risk for providing services under this Contract. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -88- 









	 	E.	Payment Schedule 

  
 Payment to the HMO is based on the HMO Enrollment Reports that the Department transmits to the HMO according to the schedule in Article V, E. Payment for
each person listed as an ADD or CONTINUE on the HMO Enrollment Reports shall be made by the Department within 60 days of the date the report is generated. Also, all retroactive capitation payments for newborns will be paid within 60 days of the
child’s first appearance on an enrollment report. (See Article VI, F.) Any claim that is not paid within these time limits will be denied by the Department and the recipient will be disenrolled from the HMO for the capitation month specified on
the claim. Notification of all paid and denied claims will be given through the weekly Remittance Status Report, which is available on both tape and hard copy. 
  

	 	F.	Capitation Payments For Newborns 

  
 The HMO will authorize provision of contract services to the newborn child of an enrolled mother for the first ten days of life. The child’s date of
birth should be counted as day one. In addition, if the child is reported within 100 days of the date of birth, the HMO will provide contract services to the child from its date of birth until the child is disenrolled from the HMO. The HMO will
receive a separate capitation payment for the month of birth and for all other months the HMO is responsible for providing contract services to the child. If the child is not reported within 100 days of the date of birth, the child will not be
retroactively enrolled into the HMO. In this case, the HMO is not responsible for payment of services provided prior to the child’s enrollment and will receive no capitation payments for that time period and may recoup payments from providers
for any services that were authorized in that 100 day time period. The providers who gave services in this 100 day time period may then bill the Department on a FFS basis. More detailed information for providers on billing the Department on a FFS
basis in these situations can be found in the Claims Submission section of the Wisconsin Medicaid and BadgerCare All-Provider handbook. 
  
 HMOs or their providers must complete an HMO Newborn Report (refer to the example and instructions in Addendum VIII, C. for newborns. The HMO will report
all births to the Department’s fiscal agent as soon as possible after the date of birth, but at least monthly. Prompt HMO reporting of newborns will facilitate retroactive enrollment and capitation payments for newborns, since this newborn
reporting will ensure the newborn’s Medicaid or BadgerCare eligibility for the first 12 months of life contingent upon the newborn continuously residing with the mother. 
  
 Infants weighing less than 1200 grams will be exempt from enrollment if the data submitted by the HMO or the provider
supports the infant’s low birth weight. If an infant weighs less than 1200 grams, the HMO or provider should check the box on the Medicaid and BadgerCare Newborn Report (Addendum VIII, C) to identify the infant as a low birth-weight baby.

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -89- 









	 	G.	Coordination of Benefits (COB) 

  
 The HMO must actively pursue, collect and retain all monies from all available resources for services to enrollees covered under this Contract except
where the amount of reimbursement the HMO can reasonably expect to receive is less than the estimated cost of recovery (this exception does not apply to collections for AIDS and ventilator dependent patients), or except as provided in Article III,
F. COB recoveries will be done by post-payment billing (pay and chase) for certain prenatal care and preventive pediatric services. Post-payment billing will also be done in situations where the third party liability (TPL) is derived from a parent
whose obligation to pay is being enforced by the state Child Support Enforcement Agency and the provider has not received payment within 30 days after the date of service. 
  

	 	1.	Cost effectiveness of recovery is determined by, but not limited to time, effort, and capital outlay required to perform the activity. The HMO upon request of the Department, must
be able to specify the threshold amount or other guidelines used in determining whether to seek reimbursement from a liable third party, or describe the process by which the HMO determines seeking reimbursement would not be cost effective.


  

	 	2.	To ensure compliance, the HMO must maintain records of all COB collections and report them to the Department on a quarterly basis. The COB report must be submitted in the format
specified in Addendum VIII, B. HMOs must be able to demonstrate that appropriate collection efforts and appropriate recovery actions were pursued. The Department has the right to review all billing histories and other data related to COB activities
for enrollees. HMOs must seek from all enrollees’ information on other available resources. HMOs must also seek to coordinate benefits before claiming reimbursement from the Department for the AIDS and ventilator dependent enrollees:


  

	 	a.	Other available resources may include, but are not limited to, all other state or federal medical care programs that are primary to Medicaid, group or individual health insurance,
ERISAs, service benefit plans, the insurance of absent parents who may have insurance to pay medical care for spouses or minor enrollees, and subrogation/worker’s compensation collections. 

  

	 	b.	Subrogation collections are any recoverable amounts arising out of the settlement of personal injury, medical malpractice, product liability, or Worker’s Compensation. State
subrogation rights have been extended to HMOs under s. 49.89(9), Act 31, Laws of 1989. After attorneys’ fees and expenses have been paid, the HMO will collect the full amount paid on behalf of the enrollee. 


 

 HMO Contract for February 1, 2006 - December 31, 2007 
 -90- 









	 	3.	Section 1912(b) of the Social Security Act must be construed in a beneficiary-specific manner. The purpose of the distribution provision is to permit the beneficiary to retain
TPL benefits to which he or she is entitled except to the extent that Medicaid (or the HMO on behalf of Medicaid) is reimbursed for its costs. The HMO is free, within the constraints of state law and this Contract, to make whatever case it can to
recover the costs it incurred on behalf of its enrollee. It can use the Medicaid fee schedule, an estimate of what a capitated physician would charge on a FFS basis, the value of the care provided in the market place, or some other acceptable proxy
as the basis of recovery. However, any excess recovery, over and above the cost of care (however the HMO chooses to define that cost), must be returned to the beneficiary. HMOs may not collect from amounts allotted to the beneficiary in a judgment
or court-approved settlement. The HMO must follow the practices outlined in the Department’s Casualty Recovery Manual. 

  

	 	4.	COB collections are the responsibility of the HMO or its subcontractors. Subcontractors must report COB information to the HMO. HMOs and subcontractors must not pursue collection
from the enrollee, but directly from the third party payer. Access to medical services must not be restricted due to COB collection. 

  

	 	5.	The following requirement applies if the Contractor (or the Contractor’s parent firm and/or any subdivision or subsidiary of either the Contractor’s parent firm or of the
Contractor) is a health care insurer (including, but not limited to, a group health insurer and/or health maintenance organization) licensed by the Wisconsin Office of the Commissioner of Insurance and/or a third-party administrator for a group or
individual health insurer(s), health maintenance organization(s), and/or employer self-insurer health plan(s): 

  

	 	a.	Throughout the contract term, these insurers and third-party administrators must comply in full with the provision of subsection 49.475 of the Wisconsin Statutes. Such compliance
must include the routine provision of information to the Department in a manner and electronic format prescribed by the Department and based on a monthly schedule established by the Department. The type of information provided must be consistent
with the Department’s written specifications. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -91- 









	 	b.	Throughout the contract term, these insurers and third-party administrators must also accept and properly process post payment billings from the Department’s fiscal agent for
health care services and items received by Wisconsin Medicaid enrollees. 

  

	 	6.	If at any time during the contract term any of the insurers or third party administrators fail, in whole or in part, to adhere to the requirements of subsection 5, a or 5, b above,
the Department may take the remedial measures specified in Article XII, B, 2 and Article XII, C, 3, a. 

  

	 	H.	Recoupments 

  
 The Department will not normally recoup HMO per capita payments when the HMO actually provided services. However, if the Medicaid enrollee cannot use HMO
facilities, the Department will recoup HMO capitation payments. Such situations are described more fully below: 
  

	 	1.	The Department will recoup HMO capitation payments for the following situations where an enrollee’s HMO status has changed before the first day of a month for which a
capitation payment has been made: 

  

	 	a.	Enrollee moves out of the HMO’s service area. 

  

	 	b.	Enrollee enters a public institution. 

  

	 	c.	Enrollee dies. 

  

	 	2.	The Department will recoup HMO capitation payments for the following situations where the Department initiates a change in an enrollee’s HMO status on a retroactive basis,
reflecting the fact that the HMO was not able to provide services. In these situations, recoupments for multiple month’s capitation payments are more likely: 

  

	 	a.	Correction of a computer or human error, where the person was never really enrolled in the HMO. 

  

	 	b.	Disenrollments of enrollees for reasons of pregnancy and continuity of care, or for reasons specified in Article III, F. 

  

	 	3.	If membership is disputed between two HMOs, the Department will be the final arbitrator of HMO membership and reserve the right to recoup an inappropriate capitation payment.


  

	 	4.	If an HMO enrollee moves out of the HMO’s service area, the enrollee will be disenrolled from the HMO on the date the enrollee moved as verified by the eligibility worker. If
the eligibility worker is unable to 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -92- 








 verify the enrollee’s move, the HMO may mail a “certified return receipt requested”
letter to the enrollee to verify the move. The enrollee must sign for the letter. A copy of the letter and the signed return receipt must be sent to the Department or its designee within twenty days of the enrollee’s signature date. If this
criteria is met the effective date of the disenrollment is the first of the month in which the certified returned receipt requested letter was sent. Documentation that fails to meet the 20 day criteria will result in disenrollment the first day of
the month that the HMO supplied information to the Department or its designee. This policy does not apply to extended service area requests that have been approved by the HMO unless the enrollee moves out of the extended service area or the
HMO’s service area. Any capitation payment made for periods of time after disenrollment will be recouped. 
  

	 	5.	If a contract is terminated, recoupments will be handled through a payment by the HMO within 30 business days of contract termination. 

  

	 	6.	If an HMO is unable to meet the HealthCheck requirements specified in Article III, K. 

  

	 	I.	Neonatal Intensive Care Unit (NICU) Risk-Sharing Payment(s) 

  
 The HMO may seek reimbursement as specified in Article VI, A. The Department will reimburse each HMO for a portion of the NICU costs incurred by the HMO
per county for those enrollees who meet the criteria defined in Subsection 1 below and if the HMO’s average number of NICU days per thousand member years per county exceeds 75 days per thousand member years per county during the contract
period. 
  

	 	1.	Coverage Criteria 

  

	 	a.	NICU days cover any newborn transferred or directly admitted after birth to a Level II, Level III or Level IV SCN/NICD for treatment and/or observation under the care of a
neonatologist or pediatrician. NICU coverage continues until the infant is deemed medically stable to be discharged to a newborn nursery, medical floor or home. Level II, III, and IV facilities provide the following services:


  

	 	1)	Level II facilities provide a full range of services for low birth weight neonates who are not sick, but require frequent feeding, and neonates who require more hours of nursing
than do normal neonates. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -93- 









	 	2)	Level III facilities provide a full range of newborn intensive care services for neonatal patients who do not require intensive care but require 6-12 hours of nursing each day.


  

	 	3)	Level IV facilities provide a full range of services for severely ill neonates who require constant nursing and continuous cardiopulmonary and other support.


  

	 	b.	NICU days also cover any newborn infant transferred or directly admitted after birth to a Level II, Level III or Level IV SCN/NICD who requires transfer to another institution for a
severe, compromised physical status, diagnostic testing or surgical intervention that cannot be provided at the hospital of initial admission. NICU coverage continues until the infant is transferred back to the initial hospital and deemed medically
stable to be discharged to a newborn nursery, medical floor or home. 

  

	 	2.	Reimbursement Criteria 

  

	 	a.	The HMO’s NICU reimbursement amount is calculated by contract period and by county. For NICU risk sharing, a “contract period” is defined as one calendar year.


  

	 	b.	The Department will reimburse the HMO for 90% of the HMO’s NICU cost per day, not to exceed a reimbursement of $1,443 per day, for each day that the HMO’s average number
of NICU days per thousand member years exceeds 75 NICU days per thousand member years per county during the contract period. 

  

	 	c.	The HMO’s NICU cost per day includes the HMO’s NICU inpatient payment per day and the HMO’s associated physician payments. Associated physician payments refer to the
total HMO payments made by the HMO to the physician(s) for services provided to the infant during the NICU stay. Associated physician payments are divided by the number of days reported for the NICU stay to determine the HMO’s payment per day
of associated physician payments. 

  
 Amounts paid
must include payments for all physician and hospital services that were provided during the report period regardless of the HMO’s actual payment date. 
  

	 	d.	The Department makes the NICU reimbursement to the HMO after the end of the contract year, after the HMO has submitted all needed NICU data. The Department will reimburse the HMO
within 60 days of receipt of all necessary data from the HMO. The 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -94- 








 Department may make a final adjustment to the NICU reimbursement amount one year after the initial
payment. This adjustment will be based on adjustments to eligible months and, updated information from the HMO such as the number of NICU days, inpatient payments, associated physician payments and amounts recovered from third parties. 

 

	 	e.	The number of eligible months for the NICU calculation must include the HMOs entire Healthy Start Pregnant Women, AFDC and Healthy Start Children population. If an enrollee’s
medical status code is retroactively backdated to an SSI medical status code and the HMO receives a capitation payment for those months, those months must also be included in the NICU calculation (refer to the NICU Risk-Sharing Worksheet in Addendum
VIII, E “calculation number 1”). The Department will make the final determination regarding the number of eligible months for the NICU calculation by HMO, by county and by year, using the Medicaid Management Information System Recipient
Eligibility File. 

  

	 	f.	Costs for care provided to NICU enrollees who are retroactively disenrolled under Article VIII of this Contract are not payable. The HMO must back out the costs of the care provided
during the backdated period from their NICU reports. 

  

	 	3.	Reporting Requirements 

  
 HMOs that choose to submit their report(s) under the NICU enhanced funding policy must follow the reporting requirements listed below: 
  

	 	a.	HMOs may submit an interim and a final report for each contract period if the NICU criteria are met. The HMO does not have to file a report if the NICU criteria are not met:


  

	 	1)	Interim reports must be submitted to the Department on or before May 1 of the following year (i.e., an interim report for the period January 1, 2006, through
December 31, 2006, must be submitted on or before May 1, 2007. 

  

	 	2)	Final reports must be submitted on or before May 1, one year after the submission of an interim report (i.e., a final report for the period January 1, 2006, through
December 31, 2006, must be submitted on or before May 1, 2008). 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -95- 









	 	b.	HMOs must submit all data by county and in the format requested by the Department for calculating the NICU reimbursement on or before May 1 of the following calendar year. The
data and data format requirements are defined in Addendum VIII, E. 

  

	 	c.	HMO’s must submit their NICU report(s) to the Department’s Contract Specialist as specified in Article VII, I. 

  

	 	4.	Dispute Resolution 

  
 Disputes regarding the Department’s payment or nonpayment of NICU services as well an any adjustments made by the HMO (e.g., adjustments to provider
payments, NICU days or adjustments due to amounts recovered from third parties) must be submitted in the next report period as specified in Article VII, I. 
  

	 	J.	Payment(s) for AIDS/HIV and Ventilator Dependent Enrollees 

  
 The Department will pay 100% of the HMO’s costs of providing Medicaid covered services to HMO enrollees who meet the AIDS, HIV-positive or ventilator
dependent criteria in this section, by county. The HMO may seek reimbursement as specified in Article VI, A. 
  

	 	1.	Reimbursement criteria specific to each policy is defined below 

  

	 	a)	AIDS 

  
 For those enrollees with a confirmed diagnosis of AIDS, as indicated by an ICD-9-CM diagnosis code, the 100% reimbursement is effective on the first day of the month in which they were diagnosed as having AIDS.

  

	 	b)	HIV-positive 

  
 For those enrollees who are HIV-Positive and on anti-retroviral drug treatment approved by the Food and Drug Administration, qualify for reimbursement.
The 100% reimbursement is effective on the first day of the month that the first anti-retroviral medication was dispensed. If the name of the anti-retroviral medication and the date it was started is unclear, the Department will use the HMO’s
pharmacy detail record(s) to determine the effective date of enhanced funding. In cases where pharmacy detail records are used, the effective date will be the first day of the month that the first anti-retroviral medication was dispensed.

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -96- 









	 	c)	Ventilator dependent 

  
 For the purposes of this reimbursement, a ventilator-assisted patient must have died while on total respiratory support or the patient must require
equipment that provides total respiratory support. This equipment may be a volume ventilator, a negative pressure ventilator, a continuous positive airway pressure (CPAP) system, or a Bi (inspiratory and expiratory) PAP. The patient may need a
combination of these systems. Any equipment used only for the treatment of sleep apnea does not qualify as total respiratory support. Total respiratory support must be required for a total of six or more hours per 24 hours. The patient must have
total respiratory support for at least 30 days that need not be continuous. The absolute need for the respiratory support must be supported by appropriate medical documentation. 
  
 The period of enhanced funding starts on the first day of the month that the patient was placed on ventilator support. It
ends on the last day of the month that the patient is removed from the ventilator support, or at the end of the hospital stay, whichever is later. 
  
 Dates of enhanced funding are based on the following: 
  

	 	•	 	Day one is the day that the patient is placed on the ventilator. If the patient is on the ventilator for less than six hours on the first day, the use must continue into the next
day and be more than six total hours. 

  

	 	•	 	Each day that the patient is on the ventilator for part of any day, as long as it is part of the six total hours per 24 hours, counts as a day for enhanced funding.


  

	 	2.	Adjustments that will be made to the HMO’s final payment include but are not limited to 

  

	 	a.	Reimbursement(s) already paid to the HMO in the form of capitation payments for enrollees who qualify as being AIDS, HIV-positive or ventilator dependent will be deducted from the
HMOs 100% reimbursement. 

  

	 	b.	Costs for care provided to AIDS, HIV-positive or ventilator dependent enrollees who are retroactively disenrolled under Article VIII of this contract are not payable. The HMO must
back out the cost of the care provided during the backdated period from their reports. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -97- 









	 	3.	Reporting Requirements for AIDS, HIV-Positive and Ventilator Dependent Enrollees 

  

	 	a.	HMOs must submit detail reports on disk in a text delimited file and hard copy and must include the data fields specified in Addendum VIII, A of this Contract.


  

	 	b.	HMOs must submit their reports to the Department’s Contract Specialist on a quarterly basis as specified in Article VII, I, of this Contract. 

  

	 	c.	As required by the Wis. Adm. Code HFS 106.03, payment data or adjustment data must be received within 365 days after the date of the service. Since HMOs are required to submit their
AIDS, HIV and ventilator claim(s) to the Department on a quarterly basis, the HMOs will be given an additional three months plus 10 days to file their claim(s) or payment data adjustment data. In addition, if the last date of service for an
inpatient hospital facility stay occurs within the time line specified (365 days plus three months plus 10 days) the Department will reimburse the HMO for the facility charges that entire stay. If the HMO cannot meet these requirements, the HMO must
provide documentation that substantiates the delay. The Department will make the final determination to pay or deny the services. The Department will exercise reasonable discretion in making the determination to waive these filing requirements.


  

	 	4.	Documentation Requirements for AIDS, HIV-Positive and Ventilator 

 Dependent Enrollees 
  
 To qualify enrollees for
reimbursement the HMO must submit the documentation that is required for each policy at the same time as the quarterly reports identified in Article VII, I. HMOs may use the Department’s designated form or develop their own as long as it
contains the required information as specified for each policy. 
  

	 	a.	AIDS documentation 

  
 A signed statement from a physician that indicates a confirmed diagnosis of AIDS and the diagnosis date must accompany each new request. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -98- 









	 	b.	HIV-positive documentation 

  
 A signed statement from the physician that the enrollee is HIV-Positive and on antiretroviral medications, the name of the drug and the date it was
started must accompany each new request. If the name of the drug and the date it was started are not available, the date of enhanced funding will be determined as defined in Article VI, J, 1., b) above. 
  

	 	c.	Ventilator dependent documentation 

  

	 	1)	A signed statement from the physician attesting to the need of the patient. 

  

	 	2)	Copies of progress notes that show the need for continuation of total ventilator support, any change in the type of ventilator support and the removal of the ventilatory support.
Copies of lab reports must be submitted if the progress notes do not include blood gas levels. 

  

	 	5.	Dispute Resolution 

  
 Disputes regarding the Department’s payment or nonpayment of AIDS, HIV-positive or ventilator dependent Medicaid services as well as any adjustments
made by the HMO (e.g., adjustments to provider payments or adjustments due to amounts recovered from third parties) must be submitted in the next report period as specified in Article VII, I. 
  

	 	K.	Incentive for Expansion 

  
 A special incentive payment will be made for an HMO that increases its net enrollment in those areas significantly below enrollment capacity, or those
areas currently designated as voluntary or fee-for-service only. Incentive payments will be awarded based on enrollment increases in the selected areas compared to enrollment numbers shown on the January 2006 MMIS enrollment report. The incentive
payment award will be made at the sole discretion of the Department and will be based on criteria to be developed and communicated to the HMO through a contract amendment. 
  

	 	L.	Dental Care Utilization Incentive 

  
 NOTE: This incentive does not apply to HMOs that first contracted with the Department after January 1, 2004. 
  
 To improve access to dental care for Medicaid and BadgerCare enrollees, the
Department will provide incentive payments for HMOs that increase enrollees’ 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -99- 








 utilization of dental services to a specific target. The performance targets will be set for each
individual HMO that provides dental services as part of its benefit package and will be based on selected existing managed care performance measures. 
  

	 	a.	Performance Measures 

  
 Existing managed care dental performance measures will be used as the basis for awarding the incentive for calendar year (CY) 2006. The existing measures
that will be used to determine the incentive are: 
  

	 	1.	Preventive care measure children – preventive care, such as dental varnishes, cleanings and comprehensive exams for children ages 3-20. 

  

	 	2.	General dental care measure children – all dental services, both preventive and restorative care for children ages 3-20. 

  

	 	3.	General dental care measure adults – all dental services, both preventive and restorative care for adults 21 and over. 

  

	 	b.	Performance Target 

  
 Performance targets will be set for the selected measures. HMOs will be awarded incentives for achieving the target(s). 
  
 Specific details regarding incentive payment methodology will be developed
and communicated to the HMOs through a contract amendment. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -100- 








 ARTICLE VII 
  

	VII.	COMPUTER/DATA REPORTING SYSTEM, DATA, RECORDS AND REPORTS 

  

	 	A.	Access to and/or Disclosure of Financial Records 

  
 The HMO and any subcontractors must make available to the Department, the Department’s authorized agents, and appropriate representatives of the U.S.
Department of Health and Human Services any financial records of the HMO or subcontractors that relate to the HMO’s capacity to bear the risk of potential financial losses, or to the services performed and amounts paid or payable under this
Contract. The HMO must comply with applicable record keeping requirements specified in HFS 105.02(1)-(7) Wis. Adm. Code, as amended. 
  

	 	B.	Access to and Audit of Contract Records 

  
 Throughout the duration of this Contract, and for a period of five years after termination of this Contract, the HMO must provide duly authorized
representatives of the state or federal government access to all records and material relating to the HMO’s provision of and reimbursement for activities contemplated under the Contract. Such access shall include the right to inspect, audit and
reproduce all such records and material and to verify reports furnished in compliance with the provisions of this Contract. All information so obtained will be accorded confidential treatment as provided under applicable laws, rules or regulations.

  

	 	C.	Computer Data Reporting System 

  
 The HMO must maintain a computer/data reporting system that meets the following Department requirements. The HMO is responsible for complying with all the
Department’s reporting requirements and with ensuring the accuracy and completeness of the data as well as the timely submission of data. The data submitted must be supported by records available to the Department or its designee. The
Department reserves the right to conduct on-site inspections and/or audits prior to awarding the Contract. The HMO must have a contact person responsible for the computer/data reporting system and who can answer questions from the Department and
resolve problems identified by the Department regarding the requirements listed below: 
  

	 	1.	The HMO must have a claims processing system that is adequate to meet all claims processing and retrieval requirements specified in this Contract, specifically Article III, D, 1.


  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -101- 









	 	2.	The HMO must have a computer/data collection, processing, and reporting system sufficient to monitor HMO enrollment/disenrollment (in order to determine on any specific day which
recipients are enrolled or disenrolled from the HMO) and to monitor service utilization for the Utilization Management requirements of Quality Assessment/Performance Improvement (QAPI) that are specified in Article IV, G of this Contract.


  

	 	3.	The HMO must have a computer/data collection, processing, and reporting system sufficient to support the QAPI requirements described in Article IV. The system must be able to
support the variety of QAPI monitoring and evaluation activities, including the monitoring/evaluation of quality of clinical care and service (Article IV, B); periodic evaluation of HMO providers (Article IV, D, 2); member feedback on QAPI (Article
IV, E, 1 and 2); maintenance of and use of medical records in QAPI (Article IV, F, 6 and 9); and monitoring and evaluation of priority areas (Article IV, B). 

  

	 	4.	The HMO must have a computer and data processing system sufficient to accurately produce the data, reports, and encounter data set, in the formats and time lines prescribed by the
Department in this contract, that are included in Article VII, I of this Contract. Newly certified HMOs and HMOs who substantially change the IS system during the contract period are required to submit electronic test encounter data files as
required by the Department in the format specified in the HMO encounter data user manual and timelines specified in Article VII, I of this Contract and as may be further specified by the Department. The electronic test encounter data files are
subject to Department review and approval before production data is accepted by the Department. Production claims or other documented encounter data must be used for the test data files. 

  

	 	5.	The HMO must capture and maintain a claim record of each service or item provided to enrollees, using HCFA 1500, UB-92, NCPDP, HIPAA transaction code sets, or other claim, or claim
formats that are adequate to meet all reporting requirements of this Contact. The computerized database must be a complete and accurate representation of all services the HMO covers for the contract period. The HMO is responsible for monitoring the
integrity of the database, and facilitating its appropriate use for such required reports as encounter data and targeted performance improvement studies. 

  

	 	6.	The HMO must have a computer processing and reporting system that is capable of following or tracing an encounter within its system using a unique encounter record identification
number for each encounter. 

  

	 	7.	The HMO reporting system must have the ability to identify all denied claims/encounters using national HIPAA Claim Adjustment Reason. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -102- 









	 	8.	The HMO system must be capable of reporting original and reversed claim detail records and encounter records. 

  

	 	9.	The HMO system must be capable of correcting an error to the encounter record within 90 days of notification by the Department. 

  
 The HMO must notify the Department of all significant personnel changes and
system changes that may impact the integrity of the data, including new claims processing software and vendors. 
  

	 	D.	Coordination of Benefits (COB), Encounter Record, Formal Grievances and Birth Cost Reporting Requirements 

  
 The HMO agrees to furnish to the Department and to its authorized agents,
within the Department’s time frame and format, information that the Department requires to administer this Contract, including but not limited to the following: 
  

	 	1.	Coordination of Benefits (COB) 

  
 Summaries of amounts recovered from third parties for services rendered to enrollees under this Contract in the format specified in Addendum
VIII, B. 
  

	 	2.	Encounter Record for Each Enrollee Service 

 An
encounter record for each service provided to enrollees covered under this Contract. The encounter data set must include at least those data elements specified in section E of this Article. 
  
 The encounter data set must be submitted no less frequently then monthly
via electronic media. Refer to Article I, Definitions, for the definition of an encounter. 
  

	 	3.	Formal Grievances 

  
 Copies of all formal grievances and documentation of actions taken on each grievance, as specified in Addendum VIII, G. 
  

	 	4.	Birth Cost as specified in Addendum VIII, F 

  

	 	E.	Encounter Data Reporting Requirements 

  
 All HMOs that contract with the Department to provide Medicaid services must submit monthly encounter data files according to the specifications and
submission protocols published in the Wisconsin Medicaid HMO Encounter Data User Manual. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -103- 









	 	1.	Reporting Requirement 

  
 The rules governing the level of detail when reporting encounters should be those rules established by the following classification schemes: ICD-9-CM (or
ICD-10-CM) diagnosis codes and CPT procedure codes (HCPCS Level I codes), Level II HCPCS codes, Level III HCPCS codes, National Drug Codes (NDC), CDT-2 codes, Hospital revenue codes for inpatient and outpatient hospital services, and hospital
inpatient Diagnostic Related Group (DRG) codes, if DRG codes are used. 
  
 Multiple encounters can occur between a single provider and a single recipient on a day. For example, if a physician provides a limited office visit, administers an immunization, and takes a chest x-ray, and the
provider submits a claim or report specifically identifying all three services, then there are three encounters, and the HMO will report three encounters to the Wisconsin Medicaid Program. 
  

	 	2.	Testing Encounter Data 

  
 New HMOs must test the encounter data set until the Department is satisfied that the HMO is capable of submitting valid, accurate, and timely encounter
data according to the schedule and timetable in Article VII, I. 
  

	 	3.	Primary HMO Contact Person 

  
 Each HMO must specify to the Department the name of the primary contact person assigned responsibility for submitting and correcting HMO encounter and
utilization data, and a secondary contact person in the event the primary contact person is not available. 
  

	 	4.	HMO Encounter Technical Workgroup Requirement 

  
 All HMOs must assign staff to participate in HMO encounter technical workgroup meetings periodically scheduled by the Department. This workgroup’s
purpose is to enhance the HMO and Medicaid data submission protocols and improve the accuracy and completeness of the data. The HMO encounter technical workgroup is also responsible for planning the implementation of the 820 and 834 electronic
transaction formats mandated by the Health Insurance Portability and Accountability Act (HIPAA). 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -104- 









	 	5.	Encounter Data Completeness and Accuracy 

  
 The Department will conduct data validity and completeness audits during the contract period. At least one of these audits will include a review of the
HMO’s encounter data system and system logic. 
  

	 	6.	Analysis of Encounter Data 

  
 The Department retains the right to analyze encounter data and use it for any purpose it deems necessary. However, the Department will make every effort
to ensure that the analysis does not violate the integrity of the reported data submitted by the HMO. 
  

	 	F.	Records Retention 

  
 The HMO must retain, preserve and make available upon request all records relating to the performance of its obligations under the contract, including
paper and electronic claim forms, for a period of not less than five years from the date of termination of this contract. Records involving matters that are the subject of litigation shall be retained for a period of not less than five years
following the termination of litigation. Microfilm copies of the documents contemplated herein may be substituted for the originals with the prior written consent of the Department, if the Department approves the microfilming procedures as reliable
and supported by an effective retrieval system. 
  
 Upon
expiration of the five year retention period and upon request, the subject records must be transferred to the Department’s possession. No records shall be destroyed or otherwise disposed of without the prior written consent of the Department.

  

	 	G.	Reporting of Corporate and Other Changes 

  
 The HMO must report to the Department any change in corporate structure or any other change in information previously reported. The HMO must report the
change as soon as possible, but not later than 30 days after the effective date of the change. Changes in information covered under this section include all of the following: 
  

	 	1.	Any change to the information the HMO previously provided in response to the Department’s questions in the current HMO Certification Application or any previous RFB for
Medicaid and BadgerCare HMO Contracts. This includes any change in information provided by the HMO as a “new HMO,” within the meaning of the HMO Certification Application or RFB. 

  

	 	2.	Any change in information relevant to Article III, C, 1 of this Contract, relating to ineligible organizations. 

  

	 	3.	Any change in information relevant to Article XVI of this Contract, relating to ownership and business transactions of the HMO. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -105- 









	 	H.	Provider List Requirement 

  
 All HMOs that contract with the Department to provide Medicaid services must submit provider data once per contract period, based on the HMO files as of
December 31, 2006. 
  
 The data must be provided in a
Microsoft Access database by January 31, 2007. A CD containing the database with instructions for the required fields will be provided by the Department by November 1, 2006. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -106- 








 I. Contract Specified Reports and Due Dates 
  
 REPORTS AND DUE DATES 
  

													
	 Due Date*

	  	 Type of Report

	  	 Reporting Period

	  	 Due to

	  	 Report Format

	  	 Reporting Unit

	  	 Contract
Reference


	Within 15 days of contract signing	  	Civil Rights Compliance Plan: Affirmative Action Plan and Civil Rights Plan components	  	Contract period	  	DHFS	  	 	  	Affirmative Action/Civil Rights Compliance Office	  	 Art. III, C, 4,
 a and b

							
	Within 30 days of contract signing	  	Disclosure Statements	  	As of present time	  	BMHCP	  	 	  	 	  	Art. XVI
							
	 YEAR 2006
	  	 	  	 	  	 	  	 	  	 	  	 
	Jan 1	  	Encounter Data File (AFDC/HS & BC)	  	Dec. 2005	  	 Medicaid
 Fiscal Agent-MEDS
	  	Electronic Media	  	Encounter	  	Art. VII, D and E
							
	Jan 10	  	Electronic list of HMO providers	  	Oct. – Dec. 2005	  	Enrollment Broker	  	As Agreed Upon	  	HMO Service Area	  	Art. X, E, 3
							
	Jan 15	  	**Dental Progress Report	  	Oct. – Dec. 2005	  	BMHCP	  	Hardcopy	  	Dental Service Area	  	Art. III, E, 8, c
							
	Jan 31	  	Formal/Informal Grievance Experience Summary report (AFDC/HS & BC)	  	Oct. – Dec. 2005	  	BMHCP	  	Hardcopy	  	Entire HMO	  	Art. IX; Add. VIII, G
							
	Feb 1	  	Encounter Data File (AFDC/HS & BC)	  	Jan. 2006	  	 Medicaid
 Fiscal Agent – MEDS
	  	Electronic Media	  	Encounter	  	Art. VII, D and E
							
	Feb 1	  	AIDS/Ventilator Dependent (AFDC/HS & BC)	  	Oct. – Dec. 2005	  	BMHCP	  	Hardcopy & Disc	  	HMO Service Area	  	Art. VI, J; Add. VIII, A
							
	Feb 15	  	Federally Qualified Health Centers & Rural Health Centers (AFDC/HS & BC)	  	Oct. – Dec. 2005	  	BMHCP	  	Hardcopy – no form	  	By FQHC/RHC	  	Art, III, D, 7
							
	Feb 15	  	Coordination of Benefits Report (AFDC/HS & BC)	  	Oct. – Dec. 2005	  	BMHCP	  	Hardcopy	  	Entire HMO	  	Art. VI, G; Add VIII, B
							
	Mar 1	  	Encounter Data File AFDC/HS and BC)	  	Feb. 2006	  	 Medicaid
 Fiscal Agent-MEDS
	  	Electronic Media	  	Encounter	  	Art. VII, D and E
							
	Apr 1	  	Encounter Data File (AFDC/HS & BC)	  	March 2006	  	 Medicaid
 Fiscal Agent–MEDS
	  	Electronic Media	  	Encounter	  	Art. VII, D and E
							
	Apr 10	  	Electronic list of HMO providers	  	Jan. – Mar. 2006	  	Enrollment Broker	  	As Agreed Upon	  	HMO Service Area	  	Art. X, E, 3
							
	Apr 15	  	**Dental Progress Report	  	Jan. – Mar. 2006	  	BMHCP	  	Hardcopy	  	Dental Service Area	  	Art. III, E, 8, c

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -107- 









													
	 Due Date*

	  	 Type of Report

	  	 Reporting Period

	  	 Due to

	  	 Report Format

	  	 Reporting Unit

	  	 Contract
Reference


	Apr 30	  	Formal/Informal Grievance Experience Summary report (AFDC/HS & BC)	  	Jan. – Mar. 2006	  	BMHCP	  	 Hardcopy
	  	 Entire HMO
	  	 Art. IX; Add. VIII, G

							
	May 1	  	Neonatal ICU Patient Care Data	  	Jan. – Dec. 2005	  	BMHCP	  	 Hardcopy
	  	 HMO By County
	  	 Art. VI, I; Add VIII, E

							
	May 1	  	Encounter Data File (AFDC/HS & BC)	  	Apr. 2006	  	Medicaid Fiscal Agent-MEDS	  	 Electronic Media
	  	 Encounter
	  	 Art. VII, D and E

							
	May 1	  	AIDS/Ventilator Dependent (AFDC/HS & BC)	  	Jan. – Mar. 2006	  	BMHCP	  	 Hardcopy & Disc
	  	 HMO Service Area
	  	 Art. VI, J; Add. VIII, A

							
	May 15	  	Federally Qualified Health Centers & Rural Health Centers (AFDC/HS & BC)	  	Jan. – Mar. 2006	  	BMHCP	  	 Hardcopy - no form
	  	 By FQHC/RHC
	  	 Art. III, D, 7

							
	May 15	  	Coordination of Benefits Report (AFDC/HS & BC)	  	Jan. – Mar. 2006	  	BMHCP	  	 Hardcopy
	  	 Entire HMO
	  	 Art. VI, G; Add VIII, B

							
	Jun 1	  	Encounter File (AFDC/HS & BC)	  	May 2006	  	Medicaid Fiscal Agent-MEDS	  	 Electronic Media
	  	 Encounter
	  	 Art. VII, D and E

							
	Jul 1	  	Encounter File (AFDC/HS & BC)	  	Jun. 2006	  	Medicaid Fiscal Agent – MEDS	  	 Electronic Media
	  	 Encounter
	  	 Art. VII, D and E

							
	Jul 10	  	Electronic list of HMO providers	  	Apr.– Jun.. 2006	  	Enrollment Broker	  	 As Agreed Upon
	  	 HMO Service Area
	  	 Art. X, E, 3

							
	Jul 15	  	**Dental Progress Report	  	Mar. – Jun. 2006	  	BMHCP	  	 Hardcopy
	  	 Dental Service Area
	  	 Art. III, E, 8, c

							
	Jul 31	  	Formal/Informal Grievance Experience Summary report (AFDC/HS & BC)	  	Apr. – Jun. 2006	  	BMHCP	  	 Hardcopy
	  	 Entire HMO
	  	 Art. IX; Add. VIII, G

							
	Aug 1	  	AIDS/Ventilator Dependent (AFDC/HS & BC)	  	Apr. – Jun. 2006	  	BMHCP	  	 Hardcopy & Disc
	  	 HMO Service Area
	  	 Art. VI, J; Add. VIII, A

							
	Aug 1	  	Encounter File (AFDC/HS & BC)	  	Jul. 2006	  	Medicaid Fiscal Agent-MEDS	  	 Electronic Media
	  	 Encounter
	  	 Art. VII, D and E

							
	Aug 15	  	Federally Qualified Health Centers & Rural Health Centers	  	Apr. – Jun. 2006	  	BMHCP	  	 Hardcopy - no form
	  	 By FQHC/RHC
	  	 Art. III, D, 7

							
	Aug 15	  	Coordination of Benefits Report (AFDC/HS & BC)	  	Apr. – Jun. 2006	  	BMHCP	  	 Hardcopy
	  	 Entire HMO
	  	 Art. VI, G; Add VIII, B

							
	Sept 1	  	Encounter File (AFDC/HS & BC)	  	Aug. 2006	  	Medicaid Fiscal Agent-MEDS	  	 Electronic Media
	  	 Encounter
	  	 Art. VII, D and E

							
	Oct 1	  	Performance Improvement Projects (AFDC/HS & BC)	  	Jan. – Dec. 2005	  	BMHCP	  	 Hardcopy
	  	 Per Improvement Project
	  	 Art. IV, K


  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -108- 









													
	 Due Date*

	  	 Type of Report

	  	 Reporting Period

	  	 Due to

	  	 Report Format

	  	 Reporting Unit

	  	 Contract
Reference


	Oct 1	  	Encounter File (AFDC/HS & BC)	  	Sep. 2006	  	 Medicaid
 Fiscal Agent-MEDS
	  	Electronic Media	  	Encounter	  	Art. VII, D and E
							
	Oct 10	  	Electronic list of HMO providers	  	Jul. – Sep.. 2006	  	Enrollment Broker	  	As Agreed Upon	  	HMO Service Area	  	Art. X, E, 3
							
	Oct 15	  	**Dental Progress Report	  	Jul. – Sep. 2006	  	BMHCP	  	Hardcopy	  	Dental Service Area	  	Art. III, E, 8, c
							
	Oct 31	  	Formal/Informal Grievance Experience Summary report (AFDC/HS & BC)	  	Jul. – Sep. 2006	  	BMHCP	  	Hardcopy	  	Entire HMO	  	Art. IX; Add. VIII, G
							
	Nov 1	  	AIDS/Ventilator Dependent (AFDC/HS & BC)	  	Jul. – Sep. 2006	  	BMHCP	  	Hardcopy & Disc	  	HMO Service Area	  	Art. VI, J; Add. VIII, A
							
	Nov 1	  	Encounter File (AFDC/HS & BC)	  	Oct. 2006	  	 Medicaid
 Fiscal Agent-MEDS
	  	Electronic Media	  	Encounter	  	Art. VII, D and E
							
	Nov 15	  	Federally Qualified Health Centers & Rural Health Centers (AFDC/HS & BC)	  	Jul. – Sep. 2006	  	BMHCP	  	Hardcopy - no form	  	By FQHC/RHC	  	Art. III, D, 7
							
	Nov 15	  	Coordination of Benefits Report (AFDC/HS & BC)	  	Jul. – Sep. 2006	  	BMHCP	  	Hardcopy	  	Entire HMO	  	Art. VI, G; Add VIII, B
							
	Dec 1	  	Encounter File (AFDC/HS & BC)	  	Nov. 2006	  	 Medicaid
 Fiscal Agent–MEDS
	  	Electronic Media	  	Encounter	  	Art. VII, D and E
							
	 YEAR 2007
	  	 	  	 	  	 	  	 	  	 	  	 
							
	Jan 1	  	Encounter File (AFDC/HS & BC)	  	Dec. 2006	  	 Medicaid
 Fiscal Agent-MEDS
	  	Electronic Media	  	Encounter	  	Art. VII, D and E
							
	Jan 10	  	Electronic list of HMO providers	  	Oct. – Dec. 2006	  	Enrollment Broker	  	As Agreed Upon	  	HMO Service Area	  	Art. X, E, 3
							
	Jan 15	  	**Dental Progress Report	  	Oct. – Dec. 2006	  	BMHCP	  	Hardcopy	  	Dental Service Area	  	Art. III, E, 8, c
							
	Jan 31	  	Formal/Informal Grievance Experience Summary report (AFDC/HS & BC)	  	Oct. – Dec. 2006	  	BMHCP	  	Hardcopy	  	Entire HMO	  	Art. IX; Add. VIII, G
							
	Jan 31	  	Provider List on Tape	  	Dec. 31, 2006	  	BMHCP	  	Disc	  	HMO Service Area	  	Art. VII, H
							
	Feb 1	  	AIDS/Ventilator Dependent (AFDC/HS & BC)	  	Oct. – Dec. 2006	  	BMHCP	  	Hardcopy & Disc	  	HMO Service Area	  	Art. VI, J; Add. VIII, A
							
	Feb 1	  	Encounter File (AFDC/HS & BC)	  	Jan. 2007	  	 Medicaid
 Fiscal Agent-MEDS
	  	Electronic Media	  	Encounter	  	Art. VII, D and E

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -109- 









													
	 Due Date*

	  	 Type of Report

	  	 Reporting Period

	  	 Due to

	  	 Report Format

	  	 Reporting Unit

	  	 Contract
Reference


	Feb 15	  	Federally Qualified Health Centers & Rural Health Centers (AFDC/HS & BC)	  	Oct. – Dec. 2006	  	BMHCP	  	Hardcopy - no form	  	By FQHC/RHC	  	Art. III, D, 7
							
	Feb 15	  	Coordination of Benefits Report (AFDC/HS & BC)	  	Oct. – Dec. 2006	  	BMHCP	  	Hardcopy	  	Entire HMO	  	Art. VI, G; Add VIII, B
							
	Mar 1	  	Encounter File (AFDC/HS & BC)	  	Feb. 2007	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, D and E
							
	Apr 1	  	Encounter File (AFDC/HS & BC)	  	Mar. 2007	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, D and E
							
	Apr 10	  	Electronic list of HMO providers	  	Jan. – Mar. 2007	  	Enrollment Broker	  	As Agreed Upon	  	HMO Service Area	  	Art. X, E, 3
							
	Apr 15	  	**Dental Progress Report	  	Jan. – Mar. 2007	  	BMHCP	  	Hardcopy	  	Dental Service Area	  	Art. III, E, 8, c
							
	Apr 30	  	Formal/Informal Grievance Experience Summary report (AFDC/HS & BC)	  	Jan. – Mar. 2007	  	BMHCP	  	Hardcopy	  	Entire HMO	  	Art. IX; Add. VIII, G
							
	May 1	  	Neonatal ICU Patient Care Data	  	Jan. – Dec. 2006	  	BMHCP	  	Hardcopy	  	HMO By County	  	Art. VI, I; Add. VIII, E
							
	May 1	  	Encounter File (AFDC/HS & BC)	  	Apr. 2007	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, D and E
							
	May 1	  	AIDS/Ventilator Dependent (AFDC/HS & BC)	  	Jan. – Mar. 2007	  	BMHCP	  	Hardcopy & Disc	  	HMO Service Area	  	Art. VI, J; Add. VIII, A
							
	May 15	  	Federally Qualified Health Centers & Rural Health Centers (AFDC/HS & BC)	  	Jan. – Mar. 2007	  	BMHCP	  	Hardcopy - no form	  	By FQHC/RHC	  	Art. III, D, 7
							
	May 15	  	Coordination of Benefits Report (AFDC/HS & BC)	  	Jan. – Mar. 2007	  	BMHCP	  	Hardcopy	  	Entire HMO	  	Art. VI, G; Add VIII, B
							
	Jun 1	  	Encounter File (AFDC/HS & BC)	  	May 2007	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, D and E
							
	Jul 1	  	Encounter File (AFDC/HS & BC)	  	Jun. 2007	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, D and E
							
	Jul 10	  	Electronic list of HMO providers	  	Apr. – Jun. 2007	  	Enrollment Broker	  	As Agreed Upon	  	HMO Service Area	  	Art. X, E, 3
							
	Jul 15	  	**Dental Progress Report	  	Apr. – Jun. 2007	  	BMHCP	  	Hardcopy	  	Dental Service Area	  	Art. III, E, 8, c
							
	Jul 31	  	Formal/Informal Grievance Experience Summary report (AFDC/HS & BC)	  	Apr. – Jun. 2007	  	BMHCP	  	Hardcopy	  	Entire HMO	  	Art. IX; Add. VIII, G

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -110- 









													
	 Due Date*

	  	 Type of Report

	  	 Reporting Period

	  	 Due to

	  	 Report Format

	  	 Reporting Unit

	  	 Contract
Reference


	Aug 1	  	AIDS/Ventilator Dependent (AFDC/HS & BC)	  	Apr. – Jun. 2007	  	BMHCP	  	Hardcopy & Disc	  	HMO Service Area	  	Art. VI, J; Add. VIII, A
							
	Aug 1	  	Encounter File (AFDC/HS & BC)	  	Jul. 2007	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, D and E
							
	Aug 15	  	Federally Qualified Health Centers & Rural Health Centers (AFDC/HS & BC)	  	Apr. – Jun. 2007	  	BMHCP	  	Hardcopy - no form	  	By FQHC/RHC	  	Art. III, D, 7
							
	Aug 15	  	Coordination of Benefits Report (AFDC/HS & BC)	  	Apr. – Jun. 2007	  	BMHCP	  	Hardcopy	  	Entire HMO	  	Art. VI, G; Add VIII, B
							
	Sep 1	  	Encounter File (AFDC/HS & BC)	  	Aug. 2007	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, D and E
							
	Oct 1	  	Performance Improvement Projects (AFDC/HS & BC)	  	Jan. – Dec. 2006	  	BMHCP	  	Hardcopy	  	Per Improvement Project	  	Art. IV, K
							
	Oct 1	  	Encounter File (AFDC/HS & BC)	  	Sep. 2007	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, D and E
							
	Oct 10	  	Electronic list of HMO providers	  	Jul.-Sep. 2007	  	Enrollment Broker	  	As Agreed Upon	  	HMO Service Area	  	Art. X, E, 3
							
	Oct 15	  	**Dental Progress Report	  	Jul. – Sep. 2007	  	BMHCP	  	Hardcopy	  	Dental Service Area	  	Art III, E, 8 c
							
	Oct 31	  	Formal/Informal Grievance Experience Summary report (AFDC/HS & BC)	  	Jul. – Sep. 2007	  	BMHCP	  	Hardcopy	  	Entire HMO	  	Art. IX; Add. VIII, G
							
	Nov 1	  	AIDS/Ventilator Dependent (AFDC/HS & BC)	  	Jul. – Sep. 2007	  	BMHCP	  	Hardcopy & Disc	  	HMO Service Area	  	Art. VI, J; Add. VIII, A
							
	Nov 1	  	Encounter File (AFDC/HS & BC)	  	Oct. 2007	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Entire HMO	  	Art. VII, D and E
							
	Nov 15	  	Federally Qualified Health Centers & Rural Health Centers (AFDC/HS & BC)	  	Jul. – Sep. 2007	  	BMHCP	  	Hardcopy - no form	  	By FQHC/RHC	  	Art. III, D, 7
							
	Nov 15	  	Coordination of Benefits Report (AFDC/HS & BC)	  	Jul. – Sep. 2007	  	BMHCP	  	Hardcopy	  	Entire HMO	  	Art. VI, G; Add VIII, B
							
	Dec 1	  	Encounter File (AFDC/HS & BC)	  	Nov. 2007	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, D and E

  
 Any reports that are due on a weekend
or holiday are due the following business day. 
  


	**	Only HMOs that are certified to provide dental services are required to submit dental progress reports for the service area in which the HMO is certified to provide dental.


  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -111- 









							
	Report Mailing Addresses:	  	 Medicaid Fiscal Agent -MEDS
 10 E. Doty Street, Suite
200
 Madison, WI 53703
	  	 *BMHCP
 Department of Health and Family
Services
 Bureau of Managed Health Care Programs
 P.O. Box
309
 Madison, WI 53701-0309
	  	 Medicaid Fiscal Agent
 Managed Care Unit
 P.O. Box 6470
 Madison, WI 53716-0470

				
	 	  	 Department of Health and Family Services
 Affirmative Action/Civil Rights Compliance Office
 P.O. Box 7850
 Madison ,WI 53707-7850
	  	 	  	 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -112- 








 ARTICLE VIII 
  

	VIII.    ENROLLMENT	AND DISENROLLMENTS 

  

	 	A.	Enrollment 

  
 The HMO must accept as enrolled all persons who appear as enrollees on the HMO Enrollment Reports and newborns as defined in Article I. Enrollment in the
HMO is voluntary by the recipient except where limited by departmental implementation of a State Plan Amendment or a Section 1115(a) waiver. The current State Plan Amendment and 1115(a) waiver require mandatory enrollment into an HMO for
those service areas in which there are two or more HMOs with sufficient slots for the HMO eligible population and in rural areas, as defined in 42 CFR 438.52, where there is only one HMO with an adequate provider network as determined by the
Department. The Department reserves the right to assign a Medicaid or BadgerCare recipient to a specific HMO when the recipient fails to choose an HMO during a required enrollment period. 
  

	 	1.	Section 1115(A) Waiver and State Plan Amendment 

  
 If at any time during the contract period the Department obtains a State Plan Amendment, a waiver or revised waiver authority under the Social Security
Act (as amended), the conditions of enrollment described in this Contract, including but not limited to voluntary enrollment and the right to voluntary disenrollment, will be amended by the terms of said waiver and State Plan Amendment. 

 

	 	2.	Enrollee Lock-In Period 

  
 Under the Department’s State Plan Amendment and waiver authority of Section 1115(a) of the Social Security Act (as amended) enrollees in
mandatory HMO service areas will be locked into an HMO for 12 months. The first 90 days of the 12-month lock-in period are open enrollment period during which the enrollee may change HMOs without cause. The conditions of disenrollment specified in
Article VIII, C, apply during this lock-in period. 
  

	 	3.	Enrollment Levels 

  
 As specified in Article XIX and Article XVIII of this Contract, the HMO must designate its maximum enrollment level for its entire service area. The
Department may take up to 60 days from the date of written notification to implement maximum enrollment level changes. The HMO must accept as enrolled all persons who appear as enrollees on the HMO Enrollment Reports and newborns up to the HMO
specified enrollment 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -113- 








 level for its service area. The number of enrollees may exceed the maximum enrollment level by 5% on a
temporary basis. The Department does not guarantee any minimum enrollment level. The maximum enrollment level for a service area may be increased or decreased during the course of the contract period based on mutual acceptance of a different maximum
enrollment level. 
  

	 	4.	Additional Health-Related Services 

  
 The HMO must not obtain enrollment through the offer of any compensation, reward, or benefit to the enrollee except for additional health-related
services that have been approved by the Department. 
  

	 	B.	Enrollment/Disenrollment Practices 

  
 The HMO must permit the Department to monitor its enrollment and disenrollment practices under this Contract. The HMO will not discriminate in
enrollment/disenrollment activities between individuals on the basis of health status or requirement for health care services, including those who have AIDS or are HIV-Positive. This includes an enrollee with a diminished mental capacity, who is
uncooperative and displays disruptive behavior due to the enrollee’s special needs. 
  
 The Department must ensure that recipients with medical status codes that are not eligible for HMO enrollment are appropriately disenrolled according to Department policy. 
  
 This section does not prevent the HMO from assisting in the disenrollment
process for individuals who the Department determines should be assigned a different medical status code. 
  

	 	C.	Disenrollment/Exemption Requests 

  
 All enrollees shall have the right to disenroll from the HMO pursuant to 42 CFR 434.27(b)(1) unless otherwise limited by a State Plan Amendment
or a Section 1115(a) waiver of federal laws, or pursuant to Article III, F. A voluntary disenrollment shall be effective no later than the first day of the second month following the month in which the enrollee requests termination. The HMO
will promptly forward to the Department or its designee all requests from enrollees for disenrollment. Wisconsin currently has a State Plan Amendment and an 1115(a) waiver which allows the Department to “lock-in” enrollees to an HMO for a
period of 12 months in mandatory HMO service areas, except that disenrollment is allowed for good cause as described in subsections 1 through 14 below. The lock-in policy is described more completely in Section A, 2 above. Article III, F allows
voluntary exemptions and disenrollment from HMOs for a variety of reasons. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -114- 








 Disenrollment/exemption requests will be processed as soon as possible and will generally be effective
the first day of the month of the request unless otherwise specified. Disenrollments/exemptions will not normally be backdated further. The Department will not use its authority regarding backdating unreasonably. If the disenrollment or exemption is
approved, the HMO will not be liable for services, as of the effective date of the disenrollment or exemption. If the Department fails to make a disenrollment determination within 30 days of receipt of all necessary information the disenrollment is
considered approved. 
  

	 	1.	AIDS or HIV-Positive Exemption 

  
 Enrollees with a confirmed diagnosis of AIDS, as indicated by an ICD-9-CM diagnosis code, or who are HIV-Positive and on anti-retroviral drug treatment
approved by the Federal Food and Drug Administration, are eligible for an exemption. The HMO must not counsel or otherwise influence an enrollee or potential enrollee in such a way as to encourage exemption from enrollment or continued enrollment.

  
 Exemption requests must come from the casehead or the
enrollee and should be directed to the Department’s Enrollment Specialist. Exemptions are processed as soon as possible and are effective on the first day of the month that anti-retroviral treatment begins or the date that the enrollee was
diagnosed with AIDS. Exemptions are not backdated more than nine months from the date the request is received. 
  

	 	2.	Developmental Disability or Admission to a Birth to Three Program Exemption 

  
 A child from birth through two years of age (including two-year-olds), who is severely developmentally disabled or
suspected of a severe developmental delay, or who is admitted to a Birth to 3 program is eligible for an exemption. Exemption requests must be made by the casehead of the enrollee or by the County Birth to 3 programs, on behalf of an enrollee.
Exemption requests should be directed to the Department’s Enrollment Specialist. Exemptions are backdated no more than two months from the date the request is received. 
  

	 	3.	Certified Nurse Midwives or Nurse Practitioners Exemption 

  
 Enrollees may be eligible for an exemption from enrollment if all of the following criteria are met: 
  

	 	a.	The enrollee resides in a service area of a certified nurse midwife or nurse practitioner. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -115- 









	 	b.	The enrollee chooses to receive her care from a certified nurse midwife or nurse practitioner. 

  

	 	c.	The certified nurse midwife or nurse practitioner is not affiliated with any HMO in the service area either as an independently certified provider or as a non-billing provider.


  
 Exemption requests are made by the casehead or
the enrollee and should be directed to the Department’s Enrollment Specialist. 
  

	 	4.	Commercial HMO Insurance Exemption 

  
 Enrollees who have commercial HMO insurance may be eligible for an exemption or disenrollment from a Medicaid and BadgerCare HMO if the commercial HMO
does not participate in Medicaid. In addition, enrollees who have commercial insurance that limits them to a restricted provider network (e.g., PPOs, PHOs, etc.) may be eligible for an exemption from enrollment in a Medicaid and BadgerCare HMO or
disenrollment. 
  
 Exemption or disenrollment requests are made
by the enrollee and should be directed to the Department’s Enrollment Specialist. The HMO may request assistance from the Department’s contracted Enrollment Specialist in situations where the enrollee has commercial insurance that limits
the enrollee to providers outside the HMO’s network. 
  
 When the Department’s recipient eligibility file indicates commercial HMO coverage limiting an enrollee to providers outside the Medicaid HMO network, and the enrollee seeks services from the Medicaid HMO network providers, the
Medicaid HMO network providers may refuse to provide services to that enrollee and refer him/her to their commercial network, except in the case of an emergency. 
  

	 	5.	Federally Qualified Health Centers Exemption 

  
 Enrollees may be eligible for an exemption from enrollment if the following criteria are met: 
  

	 	a.	The enrollee resides in the service area of an FQHC. 

  

	 	b.	The enrollee chooses to receive their primary care from the FQHC. 

  

	 	c.	The FQHC is not affiliated with any HMO within the service area. 

  
 Exemption requests may be made by the casehead and should be directed to the Department’s Enrollment Specialist. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -116- 









	 	6.	Just Cause Disenrollment 

  
 The HMO may request and the Department will approve disenrollment for specific cases or persons where there is just cause. Just cause is defined as a
situation where enrollment would be harmful to the interests of the recipient or in which the HMO cannot provide the recipient with appropriate medically necessary contract services for reasons beyond its control. Disruptive behavior resulting from
diminished mental capacity from a special needs enrollee will not qualify as a just cause disenrollment. Disenrollment requests should be directed to the Department’s fiscal agent Nurse Consultant. 
  

	 	7.	Inmates of a Public Institution Disenrollment 

  
 HMOs are not liable for providing care to enrollees who are inmates in a public institution for more than a full calendar month as defined in HFS
101.03(85). The HMO must provide documentation that shows that the enrollee is incarcerated. The disenrollment will be effective the first of the month following the first full month of incarceration or the date of Medicaid ineligibility, whichever
comes first. Disenrollment requests may be made by the HMO and should be directed to the Department’s Enrollment Specialist. 
  

	 	8.	Medicare Beneficiaries 

  
 Enrollees who become eligible for Medicare will be disenrolled effective the first of the month of notification to the Medicaid and BadgerCare programs
from the Social Security Administration (SSA). Even if SSA awards Medicare eligibility retroactively, the effective date of HMO disenrollment will be the first of the month of notification. 
  

	 	9.	Mental Health and/or Substance Abuse Exemption 

  
 Requests for exemption from HMO enrollment must be initiated by the casehead or the enrollee who meets one or more of the following: 
  

	 	a.	A child meeting criteria for severe emotional disturbance (SED) who is enrolled or has been accepted in a SED program, such as intensive in-home psychotherapy or child/adolescent
day treatment, during the term of the SED treatment. 

  

	 	b.	A person participating in a methadone treatment program, or who has been determined to need methadone treatment unless the person declines to receive such treatment. Enrollees who
request exemption prior to participation in a methadone treatment program may be exempted for a maximum of two months, and the exemption may be extended if they continue to participate in the program. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -117- 









	 	c.	A person with a complex physical or psychiatric condition who has extensive non-medical programming needs best provided or coordinated by the 51.42, 51.437, and/or social/human
services system (such as Community Support Programs, Comprehensive Community Services etc). 

  
 When the HMO confirms that at least one of these conditions exists, the HMO must inform the Medicaid or BadgerCare casehead of their options to enroll
the affected enrollee in the HMO or to request that the person remain in the Medicaid FFS system. The HMO shall not encourage an enrollee to request an exemption from enrollment or to continue enrollment. The Department, the local boards, and the
county social service departments may notify enrollees or potential enrollees of their options independently where such notification is deemed appropriate. Exemption requests should be directed to the Department’s Enrollment Specialist.

  

	 	10.	Native American Disenrollment 

  
 Enrollees who are Native American and members of a federally recognized tribe are eligible for disenrollment. Disenrollment requests should be directed
to the Department’s Enrollment Specialist. 
  

	 	11.	Ninth Month Pregnancy Exemption 

  
 Enrollees who deliver or are expected to deliver the first month they are assigned to a HMO may be eligible for exemption. In order for exemption to
occur: 
  

	 	a.	The enrollee must have been automatically assigned or reassigned and must not have been in the HMO to which they were assigned or reassigned within the last seven months.; and


  

	 	b.	The enrollee must be seeking care from a provider (physician and/or hospital) not affiliated with the HMO to which they were assigned. 

  
 Exemption requests can be made by the HMO, a provider, or the enrollee.
Providers and HMOs should direct their exemption request to the Department’s fiscal agent Contract Monitor. Enrollees should direct their exemption request to the Department’s Enrollment Specialist. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -118- 









	 	12.	SSI Family Exemption and/or Disenrollment 

  
 Families may be eligible for an exemption from enrollment or be disenrolled if: 
  

	 	a.	There are one or more members in the family who are receiving SSI benefits, and 

  

	 	b.	The SSI member receives primary care from a provider who does not accept any Medicaid HMO, and 

  

	 	c.	Other family members receive their primary care from the same provider as the SSI member. 

  
 Exemption and disenrollment requests may be made by the SSI member, parent or guardian and should be directed to the
Department’s Enrollment Specialist. 
  

	 	13.	Third Trimester Pregnancy Exemption 

  
 Enrollees who are in their third trimester of pregnancy when they are expected to enter an HMO may be eligible for exemption. In order for exemption to
occur: 
  

	 	a.	The enrollee must have been automatically assigned or reassigned to their current HMO; and 

  

	 	b.	The enrollee must be seeking care from a provider (physician and/or hospital) who is either not affiliated with the HMO to which they were assigned or is affiliated but the HMO is
closed to new enrollment. 

  
 Exemption requests
can only be made by the enrollee and/or casehead. Exemption requests must be made before the end of the second month in the HMO or before the birth, whichever occurs first. Exemption requests should be directed to the Department’s Enrollment
Specialist. 
  

	 	14.	Transplant Exemption 

  
 Enrollees who have had a transplant that is considered experimental such as a liver, heart, lung, heart-lung, pancreas, pancreas-kidney or bone marrow
transplant are eligible for an exemption: 
  

	 	a.	The person to get the transplant will be permanently exempted from HMO enrollment the first of the month in which surgery is performed. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -119- 









	 	b.	In the case of autologous bone marrow transplants, the person will be permanently exempted from HMO enrollment the date the bone marrow was extracted. 

  

	 	c.	Enrollees who have had one or more of the transplant surgeries referenced above prior to enrollment in an HMO will be permanently exempted. The effective date will be either the
first of the month not more than six months prior to the date of the request, or the first of the month of the HMO enrollment, whichever is later. Exemption requests may be made by the HMO and should be directed to the Department’s fiscal agent
Nurse Consultant. 

  
 ARTICLE IX 

 

	IX.	COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES 

  
 The grievance process refers to the overall system that includes complaints, grievances and appeals as defined in Article I. Medicaid and BadgerCare
enrollees may grieve any aspect of service delivery provided or arranged by the HMO to the HMO and to the Department (described in Sections A and B below). The enrollee may appeal an action as defined in Article I to the HMO, the Department and/or
to the Division of Hearings and Appeals as described in section C below. 
  

	 	A.	Procedures 

  
 The HMO must: 
  

	 	1.	Have written policies and procedures that detail what the grievance and appeal system is and how it operates. 

  

	 	2.	Identify a contact person in the HMO to receive grievances and appeals and be responsible for routing/processing. 

  

	 	3.	Operate a complaint process that enrollees can use to get problems resolved without going through the formal, written grievance process. 

  

	 	4.	Operate a grievance process that enrollees can use to grieve in writing. 

  

	 	5.	Inform enrollees about the existence of the complaint and grievance processes and how to use them. 

  

	 	6.	Attempt to resolve complaints, grievances and appeals informally. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -120- 









	 	7.	Respond to grievances and appeals in writing within 10 business days of receipt, except in cases of emergency or urgent (expedited grievance) situations. This represents the first
response. HMOs must resolve the grievance or appeal within two business days of receipt of an expedited grievance, or sooner if possible. More complete procedures are described in Section B of this Article. 

  

	 	8.	Operate a grievance process within the HMO that enrollees can use to grieve or appeal any negative response to the Board of Directors of the HMO. The HMO Board of Directors may
delegate the authority to review grievances and appeals to an HMO grievance appeal committee, but the delegation must be in writing. If a grievance appeal committee is established, the Medicaid HMO Advocate must be a member of the committee.


  

	 	9.	Provide the enrollee and his or her representative opportunity, before and during the appeals process, to examine enrollee’s case file, including medical records, and any other
documents and records considered during the appeals process. 

  

	 	10.	Grant the enrollee the right to appear in person before the grievance appeal committee to present written and oral information. The enrollee may bring a representative to the
meeting. The HMO must inform the enrollee in writing of the time and place of the meeting at least seven calendar days before the meeting. 

  

	 	11.	Maintain a record keeping “log” of complaints and grievances that includes a short, dated summary of each problem, the response, and the resolution. The log must
distinguish Medicaid and BadgerCare from commercial enrollees, if the HMO does not have a separate log for Medicaid and BadgerCare. The HMO must submit quarterly reports to the Department of all complaints, grievances and appeals. The analysis of
the log will include the number of complaints, grievances and appeals divided into two categories, program administration and benefit denials. 

  

	 	12.	Maintain a record keeping system for grievances and appeals that includes a copy of the original grievance or appeal, the response, and the resolution. The system must distinguish
Medicaid and BadgerCare from commercial enrollees. 

  

	 	13.	At the time of the HMO’s initial grievance denial of an action decision the HMO must notify the enrollee that the grievance denial decision may be appealed to the Department
and/or to the Division of Hearings and Appeals. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -121- 









	 	14.	Ensure that individuals with the authority to require corrective action are involved in the grievance process. 

  

	 	15.	Distribute to its gatekeepers* and IPAs the informational flyer on enrollee grievance and appeal rights (the ombudsman brochure). When a new brochure is available, the HMO must
distribute copies to its gatekeepers and IPAs within three weeks of receipt of the new brochure. 

  

	 	16.	Ensure that its gatekeepers* and IPAs have written procedures for describing how enrollees are informed of denied services. The HMO will make copies of the gatekeepers’ and
IPAs’ grievance procedures available for review upon request by the Department. 

  

	 	17.	Inform enrollees about the availability of interpreter services and provide interpreter services for non-English speaking and hearing impaired enrollees throughout the HMO’s
grievance process. 



	*	The word “gatekeeper” in this context refers to any entity that performs a management services contract, a behavioral health science IPA, or a dental IPA, and not to
individual physicians acting as a gatekeeper to primary care services. 

  

	 	B.	Grievance and Appeal Process 

  
 The enrollee may choose to use the HMO’s grievance and appeal process or may appeal to the Department instead of using the HMO’s grievance and
appeal process. If the enrollee chooses to use the HMO’s process, the HMO must provide an initial response within 10 business days and a final response within 30 calendar days of receiving the grievance or appeal. If the HMO is unable to
resolve the grievance or appeal within 30 calendar days, the time period may be extended another 14 calendar days from receipt if the HMO notifies the enrollee in writing that the HMO has not resolved the grievance or appeal, when the resolution may
be expected, and why the additional time is needed. The total timeline for HMOs to finalize a formal grievance or appeal may not exceed 45 calendar days from the date of the receipt. 
  
 Any grievance or appeal decision by the HMO may be appealed by the enrollee to the Department. The Department shall review
such appeals and may affirm, modify, or reject any formal decision of the HMO at any time after the enrollee files the formal appeal. The Department will request the name and credentials of the person making the denial decision as part of the
grievance process. The Department will give a final response within 30 days from the date the Department has all information needed for a decision. Also, an enrollee can submit a grievance or appeal directly to the Department at any time during the
grievance process. Any decision made by the Department under this section is subject to enrollee appeal rights to the extent provided by state and federal laws and rules. The Department will receive input from the recipient and the HMO in
considering grievances and appeals. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -122- 








 For an expedited grievance or appeal, the HMO must resolve all issues within two business days of
receiving the written request for an expedited grievance. The HMO must make reasonable effort to provide oral notice, in addition to written notice for the resolution. 
  
 The HMO must ensure that punitive action is not taken against anyone who either requests an expedited resolution or supports
an enrollee’s appeal. 
  

	 	C.	Notifications to Enrollees 

  
 When an HMO, its *gatekeepers, or its IPAs discontinues, terminates, suspends, limits, or reduces a service (including services authorized by an HMO the
enrollee was previously enrolled in or services received by the enrollee on a Medicaid FFS basis), the HMO must notify the affected enrollee(s), and his/her provider when appropriate, in writing at least 10 days before the date of action. When an
HMO, its gatekeepers, or its IPAs deny coverage of a new service, the HMO must notify the enrollee of the denial in writing. Notices for both ongoing services and new benefits must include all of the following: 
  

	 	1.	The nature of the intended action. 

  

	 	2.	The reasons for the intended action. The reason must be clearly stated in sufficient detail to ensure that the enrollee understands the action being taken by the HMO.


  

	 	3.	The fact that the enrollee if appealing the action must do so within 45 days. 

  


	 	4.	The fact that the enrollee has the right to examine the documentation the HMO used to make its determination. 

  

	 	5.	The fact that interpreter services are available free of charge during the grievance and appeal process and how the enrollee can access those services. 

  

	 	6.	The fact that the enrollee may bring a representative with him/her to the hearing. 

  

	 	7.	The fact that the enrollee may present “new” information during the grievance and appeal process. 

  

	 	8.	The process for requesting an oral or written expedited grievance or appeal. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -123- 









	 	9.	An explanation of the enrollee’s right to appeal the HMO’s decision to the Department at any point in the process. 

  

	 	10.	The fact that the enrollee, if appealing the HMO action, may file a request for a hearing with the Division of Hearings and Appeals (DHA) at any point in the process and the address
of the DHA. 

  

	 	11.	The fact that the enrollee can receive help in filing a grievance or appeal by calling either the Enrollment Specialist or the Ombudsman. 

  

	 	12.	The telephone number of the HMO Advocate, the Enrollment Specialist and the Ombudsman. 

  
 Notifications to enrollees of termination, suspension, or reduction of an ongoing benefit (including services authorized by
an HMO the enrollee was previously enrolled in or services received by the enrollee on a Medicaid FFS basis), must in addition to items 1 through 12 above, also include the following: 
  

	 	13.	The circumstance under which a benefit will continue during the grievance and appeal process. 

  

	 	14.	The fact that if the enrollee continues to receive the disputed service, the enrollee may be liable for the cost of care if the decision is adverse to the enrollee.




	*	The word “gatekeeper” in this context refers to any entity that performs a management services contract, a behavioral health science IPA, or a dental IPA, and not to
individual physicians acting as a gatekeeper to primary care services. 

  
 This notice requirement does not apply when an HMO, its gatekeeper or its IPA triages an enrollee to a proper health care provider or when an individual health care provider determines that a service is medically
unnecessary. 
  
 The Department must review and approve all
notice language prior to its use by the HMO. Department review and approval will occur during the Medicaid certification process of the HMO and prior to any change of the notice language by the HMO. 
  

	 	D.	Continuation of Benefits Requirements 

  
 If the enrollee files a request for a hearing with the DHA on or before the later of the effective date or within 10 days of the HMO mailing the notice of
action to reduce, limit, terminate or suspend benefits, upon notification by the DHA the 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -124- 








 HMO will notify the enrollee they are eligible to continue receiving care but may be liable for care if
DHA upholds the HMO’s decision. If the enrollee requests that the services in question be continued pending the outcome of the fair hearing, the following conditions apply: 
  

	 	1.	If the DHA reverses the HMO’s decision the HMO is responsible to cover services provided to the enrollee during the administrative hearing process. 

  

	 	2.	If the DHA upholds the HMO’s decision, the HMO may pursue reimbursement from the enrollee for all services provided to the enrollee, to the extent that the services were
covered solely because of this requirement. 

  
 Benefits must be continued until one of the following occurs: 
  

	 	•	 	The enrollee withdraws the appeal. 

  

	 	•	 	A state fair hearing decision adverse to the enrollee is made. 

  

	 	•	 	The authorization expires or the authorization service is met. 

  

	 	E.	Reporting of Grievances to the Department 

  
 HMOs must forward both the complaint, and grievance reports to the Department within 30 days of the end of a quarter in the format specified in Addendum
VIII, G. Failure on the part of an HMO to submit the quarterly complaint and grievance reports in the required format within five days of the due date may result in any or all sanctions available under Article XI. 
  
 ARTICLE X 
  

	X.	SUBCONTRACTS 

  
 This Article does not apply to subcontracts between the Department and the HMO. The Department shall have sole authority to determine the conditions and
terms of such subcontracts. Subcontractor (hereinafter identified as subcontractor) agrees to abide by all applicable provisions of (HMO NAME)’s contract with the Department of Health and Family Services, hereinafter referred to as the Medicaid
and BadgerCare HMO Contract. Subcontractor compliance with the Medicaid and BadgerCare HMO Contract specifically includes but is not limited to the requirements specified in Section A below. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -125- 









	 	A.	Subcontract Standard Language 

  
 HMOs must ensure that all subcontracts are in writing and include the following standard language when applicable. 
  

	 	1.	Subcontractor uses only Medicaid-certified providers in accordance with Article III, H, 1 of the Medicaid and BadgerCare HMO Contract. 

  

	 	2.	No terms of this subcontract are valid which terminate legal liability of the HMO. 

  

	 	3.	Subcontractor agrees to participate in and contribute required data to HMO Quality Assessment/Performance Improvement programs as required in Article IV of the Medicaid and
BadgerCare HMO Contract. 

  

	 	4.	Subcontractor agrees to abide by the terms of the Medicaid and BadgerCare HMO Contract (Article III, E, 9) for the timely provision of emergency and urgent care. Where applicable,
subcontractor agrees to follow those procedures for handling urgent and emergency care cases stipulated in any required hospital/emergency room MOUs signed by the HMO in accordance with Article III, E, 9, c and Addendum I of the Medicaid and
BadgerCare HMO Contract. 

  

	 	5.	Subcontractor agrees to submit HMO encounter data in the format specified by the HMO, so that the HMO can meet the Department specifications required by Article VII of the Medicaid
and BadgerCare HMO Contract. HMOs will evaluate the credibility of data obtained from subcontracted vendors’ external databases to ensure that any patient-reported information has been adequately verified. 

  

	 	6.	Subcontractor agrees to comply with all non-discrimination requirements in Article III, C, 5 of the Medicaid and BadgerCare HMO Contract. 

  

	 	7.	Subcontractor agrees to comply with all record retention requirements and, where applicable, the special compliance requirements on abortions, sterilizations, hysterectomies, and
HealthCheck reporting requirements. 

  

	 	8.	Subcontractor agrees to provide representatives of the HMO, as well as duly authorized agents or representatives of the Department and the Federal Department of Health and Human
Services, access to its premises and its contracts and/or medical records in accordance with Article III and Article VII of the Medicaid and BadgerCare HMO Contract. Subcontractor agrees otherwise to preserve the full confidentiality of medical
records in accordance with Article XIV of the Medicaid and BadgerCare HMO Contract. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -126- 









	 	9.	Subcontractor agrees to the requirements for maintenance and transfer of medical records stipulated in Article IV, F of the Medicaid and BadgerCare HMO Contract.


  

	 	10.	Subcontractor agrees to ensure confidentiality of family planning services in accordance with Article III, E, 10 of the Medicaid and BadgerCare HMO Contract.


  

	 	11.	Subcontractor agrees not to create barriers to access to care by imposing requirements on recipients that are inconsistent with the provision of medically necessary and covered
Medicaid benefits (e.g., COB recovery procedures that delay or prevent care). 

  

	 	12.	Subcontractor agrees to clearly specify referral approval requirements to its providers and in any sub-subcontracts. 

  

	 	13.	Subcontractor agrees not to bill Medicaid and BadgerCare enrollees for medically necessary services covered under the Medicaid and BadgerCare HMO Contract and provided during the
enrollees’ period of HMO enrollment. Subcontractor also agrees not to bill enrollees for any missed appointments while the enrollees are eligible under the Medicaid and BadgerCare Program. This provision will remain in effect even if the HMO
becomes insolvent. However, if an enrollee agrees in writing to pay for a non-Medicaid covered service, then the HMO, HMO provider, or HMO subcontractor can bill. 

  
 The standard release form signed by the enrollee at the time of services does not relieve the HMO and its providers and
subcontractors from the prohibition against billing a Medicaid enrollee in the absence of a knowing assumption of liability for a non-Medicaid covered service. The form or other type of acknowledgment relevant to Medicaid or BadgerCare enrollee
liability must specifically state the admissions, services, or procedures that are not covered by Medicaid. 
  

	 	14.	Within 15 business days of the HMO’s request subcontractors must forward medical records pursuant to grievances to the HMO. If the subcontractor does not meet the 15 business
day requirement, the subcontractor must explain why and indicate when the medical records will be provided. 

  

	 	15	Subcontractor agrees to abide by the terms of Article III, G, regarding appeals to the HMO and to the Department regarding the HMO’s nonpayment for services providers render to
Medicaid or BadgerCare enrollees. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -127- 









	 	16.	Subcontractor agrees to abide by the HMO marketing/informing requirements. Subcontractor will forward to the HMO for prior approval all flyers, brochures, letters and pamphlets the
subcontractor intends to distribute to its Medicaid and BadgerCare enrollees concerning its HMO affiliation(s), or changes in affiliation, or relating directly to the Medicaid and BadgerCare population. Subcontractor will not distribute any
“marketing” or recipient informing materials without the consent of the HMO and the Department. 

  

	 	B.	Subcontract Submission Requirements 

  

	 	1.	Changes in Established Subcontracts 

  

	 	a)	The HMO must submit changes in previously approved subcontracts to the Department for review and approval before they take effect. This review requirement applies to changes that
affect the amount, duration, scope, location, or quality of services. 

  

	 	1)	Technical changes do not have to be approved. 

  

	 	2)	Changes in rates paid do not have to be approved, with the exception of changes in the amounts paid to HMO management services subcontractors. 

  

	 	b)	The Department will review the subcontract changes and respond to the HMO within 15 business days. If the Department does not respond to the request for review within 15 business
days of submission, the HMO must contact the Contracts Section Chief in the Bureau of MHCP. A response will be prepared within five business days of this contact. 

  

	 	2.	New Subcontracts 

  
 The HMO must submit new subcontracts to the Department for review and approval before they take effect. If the Department does not respond to the request
for review within 15 business days of submission, the HMO must contact the Contracts Section Chief in the Bureau of MHCP. A response will be prepared within five business days of this contact. 
  

	 	C.	Review and Approval of Subcontracts 

  
 The Department may approve, approve with modification, or deny subcontracts under this Contract at its sole discretion. The Department may, at its sole
discretion and without the need to demonstrate cause, impose such conditions or limitations on its approval of a subcontract as it deems appropriate. The Department may consider such factors as it deems appropriate to protect the interests of the
state and Medicaid and BadgerCare recipients, including but not limited to the proposed subcontractor’s past performance. The Department will: 
  

	 	1.	Give the HMO (1) 120 days to implement a change that requires the HMO to find a new subcontractor, and (2) 60 days to implement any other change required by the
Department. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -128- 









	 	2.	Acknowledge the approval or disapproval of a subcontract within 15 business days after its receipt from the HMO. 

  

	 	3.	Review and approve or disapprove each new subcontract before the contract takes effect. Any disapproval of subcontracts may result in the application by the Department of remedies
pursuant to Article XI of this Contract. 

  

	 	4.	Ensure that the HMO has included the standard subcontract language as specified in section A of this Article (except for specific provisions that are inapplicable in a specific HMO
management subcontract). 

  

	 	D.	Transition Plan 

  
 The HMO may be required to submit transition plans when a primary care provider(s), mental health provider(s), gatekeeper or dental clinic terminates
their contractual relationship with the HMO. The transition plan will address continuity of care issues, enrollee notification and any other information required by the Department to ensure adequate enrollee access. The Department will either
approve, deny, or modify the transition plan within 15 business days of receipt or prior to the effective date of the subcontract change. 
  

	 	E.	Notification Requirements Regarding Subcontract Additions or Terminations 

  
 HMOs must: 
  

	 	1.	Notify the Department of Additions or Terminations 

  
 The HMO must notify the Department within 10 days of subcontract additions or terminations involving: (i) a clinic or group of physicians,
(ii) an individual physician (iii) an individual mental health provider and/or clinic, (iv) an individual dental provider and/or clinic. 
  

	 	2.	Notify the Department of a Termination or Modification that Involves Reducing Access to Care 

  
 The HMO must notify the Department within seven days of any notice by the HMO to a subcontractor, or any notice to the HMO
from a 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -129- 








 subcontractor, of a subcontract termination, a pending subcontract termination, or a pending modification
in subcontract terms, that could reduce Medicaid and BadgerCare enrollee access to care. 
  
 If the Department determines that a pending subcontract termination or pending modification in subcontract terms will jeopardize enrollee access to care, then the Department may invoke the remedies pursuant to Article
XI and Article XII of this Contract. These remedies include contract termination (notice to the HMO and opportunity to correct are provided for), suspension of new enrollment, and giving enrollees an opportunity to enroll in a different HMO.

  

	 	3.	Notify the Enrollment Broker of an Addition or Termination 

  
 The HMO must notify the Department’s enrollment broker within 10 days of additions to, and deletions from, the provider network. The HMO must also
submit to the enrollment broker an electronic listing of all network Medicaid providers, facilities and pharmacies within the first 10 days of each calendar quarter in a mutually agreed upon format approved by the Department. This listing will
include, but is not limited to, provider name, provider number, address, telephone number, and specialty as well as indicators designating whether a provider can be selected as a PCP, and whether the PCP is accepting new patients. The listing shall
include only Medicaid certified providers who are contracted with the HMO to provide contract services to Medicaid and BadgerCare enrollees. 
  

	 	4.	Notify Enrollees of Provider Terminations 

  
 Not less than 30 days prior to the effective date of the termination. The HMO must also send written notification to enrollees whose PCP, mental health
provider, gatekeeper or dental clinic terminates a contract with the HMO. The Department must approve all notifications before they are sent to enrollees. 
  

	 	F.	Management Subcontracts 

  
 The Department Will Review HMO Management Subcontracts to Ensure that: 
  

	 	1.	Rates are reasonable. 

  

	 	2.	They clearly describe the services to be provided and the compensation to be paid. 

  

	 	3.	Any potential bonus, profit-sharing, or other compensation, not directly related to the cost of providing goods and services to the HMO, is identified and clearly defined in terms
of potential magnitude and expected 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -130- 








 magnitude during the Medicaid and BadgerCare HMO Contract period. Any such bonus or profit-sharing must
be reasonable compared to the services performed. The HMO must document reasonableness. A maximum dollar amount for such bonus or profit-sharing shall be specified for the contract period. 
  
 The requirements addressed in a. through c. do not have to relate to
non-Medicaid and BadgerCare enrollees if the HMO wishes to have separate arrangements for non-Medicaid enrollees. 
  
 ARTICLE XI 
  

	XI.	REMEDIES FOR VIOLATION, BREACH, OR NON-PERFORMANCE OF CONTRACT 

  

	 	A.	Suspension of New Enrollment 

  
 Whenever the Department determines that the HMO is out of compliance with this Contract, the Department may suspend the HMO’s right to receive new
enrollment under this Contract. When exercising this option, the Department, must notify the HMO in writing of its intent to suspend new enrollment at least 30 days prior to the beginning of the suspension period. The suspension will take effect if
the non-compliance remains uncorrected at the end of this period. The Department may suspend new enrollment sooner than the time period specified in this paragraph if the Department finds that enrollee health or welfare is jeopardized. 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 expiration of the Contract as provided under Article XIX. 
  
 The Department may also notify enrollees of HMO non-compliance and provide
an opportunity to enroll in another HMO. 
  

	 	B.	Department-Initiated Enrollment Reductions 

  
 The Department may reduce the maximum enrollment level and/or number of current enrollees whenever it determines that the HMO has failed to provide one or
more of the contract services required under Article III or that the HMO has failed to maintain or make available any records or reports required under this Contract that the Department needs to determine whether the HMO is providing contract
services as required under Article III. The HMO will have at least 30 days to correct the non-compliance prior to the Department taking any action set forth in this paragraph. The Department may reduce enrollment sooner than the time period
specified in this paragraph if the Department finds that enrollee health or welfare is jeopardized. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -131- 









	 	C.	Other Enrollment Reductions 

  
 The Department may also suspend new enrollment or disenroll enrollees in anticipation of the HMO not being able to comply with federal or state law at its
current enrollment level. Such suspension shall not be subject to the 30-day notification requirement. 
  

	 	D.	Withholding of Capitation Payments and Orders to Provide Services 

  
 Notwithstanding the provisions of Article VI, the Department may withhold portions of capitation payments as liquidated damages or otherwise recover
damages from the HMO on the following grounds: 
  

	 	1.	Whenever the Department determines that the HMO has failed to provide one or more of the medically necessary Medicaid covered contract services required under Article III, the
Department may either order the HMO to provide such service, or withhold a portion of the HMO’s capitation payments for the following month or subsequent months, such portion withheld to be equal to the amount of money the Department must pay
to provide such services. 

  
 If the Department
orders the HMO to provide services under this section and the HMO fails to provide the services within the timeline specified by the Department, the Department may withhold from the HMO’s capitation payments an amount up to 150% of the FFS
amount for such services. 
  
 When it withholds payments under
this section, the Department must submit to the HMO a list of the participants for whom payments are being withheld, the nature of the service(s) denied, and payments the Department must make to provide medically necessary services. 
  
 If the Department acts under this section and subsequently determines that
the services in question were not covered services: 
  

	 	a.	If the Department withheld payments, it will restore to the HMO the full capitation payment; or 

  

	 	b.	If the Department ordered the HMO to provide services under this section, it will pay the HMO the actual documented cost of providing the services. 

  

	 	2.	If the HMO fails to submit required data and/or information to the Department or the Department’s authorized agents, or fails to submit such data or information in the required
form or format, by the deadline specified by the Department, the Department may immediately impose 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -132- 








 liquidated damages in the amount of $1,500 per day for each day beyond the deadline that the HMO fails
to submit the data or fails to submit the data in the required form or format, such liquidated damages to be deducted from the HMO’s capitation payments. 
  

	 	3.	If the HMO fails to comply with state and federal compliance requirements for abortions, hysterectomies and sterilizations, the Department may impose liquidated damages in the
amount of $10,000. 

  

	 	4.	The term “erred encounter record” means an encounter record that has failed an edit when a correction is expected by the Department. If the HMO fails to correct an error
to the encounter record within the timeframe specified, the Department may assess liquidated damages of $5 per erred encounter record per month until the error has been corrected. The liquidated damage amount will be deducted from the HMO’s
capitation payment. When applied, these liquidated damages will be calculated and assessed on a monthly basis. 

  
 If upon audit or review, the Department finds that the HMO has removed an erred encounter record without the Department’s approval, the Department
may assess liquidated damages for each day from the date of original error notification until the date of correction. 
  
 The following criteria will be used prior to assessing liquidated damages: 
  

	 	•	 	The Department will calculate a percentage rate by dividing the number of erred records not corrected within 90 days (numerator), by the total number of records in error
(denominator) and multiply the result by 100. 

  

	 	•	 	Records failing non-critical edits, as defined in the Wisconsin Medicaid and BadgerCare HMO Encounter Data User Manual, will not be included in the numerator.


  

	 	•	 	If this rate is 2% or less, liquidated damages will not be assessed. 

  

	 	•	 	The Department will calculate this rate each month. 

  

	 	5.	Whenever the Department determines that the HMO has failed to perform an administrative function required under this Contract, the Department may withhold a portion of future
capitation payments. For the purposes of this section, “administrative function” is defined as any contract obligation other than the actual provision of contract services. The amount withheld by the Department under this section will be
an amount that the Department determines in the reasonable exercise of its discretion to approximate the cost to the Department to perform the function. The Department may increase these amounts by 50% for each subsequent non-compliance.


  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -133- 








 Whenever the Department determines that the HMO has failed to perform the administrative functions
defined in Article VI, G, 1 and 2, the Department may withhold a portion of future capitation payments sufficient to directly compensate the Department for the Medicaid and BadgerCare program’s costs of providing health care services and items
to individuals insured by said insurers and/or the insurers/employers represented by said third party administrators. 
  

	 	6.	In any case under this Contract where the Department has the authority to withhold capitation payments, the Department also has the authority to use all other legal processes for
the recovery of damages. 

  

	 	7.	Notwithstanding the provisions of this subsection, in any case where the Department deducts a portion of capitation payments under subsection 2 above, the following procedures will
be used: 

  

	 	a.	The Department will notify the HMO’s contract administrator no later than the second business day after the Department’s deadline that the HMO has failed to submit the
required data or the required data cannot be processed. 

  

	 	b.	Beginning on the second business day after the Department’s deadline, the HMO will be subject without further notification to liquidated damages per data file or report.


  

	 	c.	If the HMO submits encounter data late but submits it within five business days from the deadline, the Department will rescind liquidated damages if the data can be processed
according to the criteria published in the Wisconsin Medicaid and BadgerCare HMO Encounter Data User Manual. The Department will not edit the data until the process period in the subsequent month. 

  

	 	d.	If the HMO submits any other required data or report but in the required format within five business days from the deadline, the Department will rescind liquidated damages and
immediately process the data or report. 

  

	 	e.	If the HMO repeatedly fails to submit required data or reports, or submits data that cannot be processed, the Department will require the HMO to develop an action plan to comply
with the contract requirements that must meet Department approval. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -134- 









	 	f.	After the corrective action plan has been implemented, if the HMO continues to submit data beyond the deadline, or continues to submit data that cannot be processed, the Department
will invoke the remedies under section A (Suspension of New Enrollment), or under section B (Department-Initiated Enrollment Reductions) of this Article, or both, in addition to liquidated damages that may have been imposed for a current violation.


  

	 	g.	If an HMO notifies the Department that it will discontinue contracting with the Department at the end of a contract period, but reports or data are due for a contract period, the
Department retains the right to withhold up to two months of capitation payments otherwise due the HMO that will not be released to the HMO until all required reports or data are submitted and accepted after expiration of the Contract. Upon
determination by the Department that the reports and data are accepted, the Department will release the monies withheld. 

  

	 	E.	Inappropriate Payment Denials 

  
 HMOs that inappropriately fail to provide or deny payments for services may be subject to suspension of new enrollments, withholding, in full or in part,
of capitation payments, contract termination, or refusal to contract in a future time period, as determined by the Department. The Department will select among these sanctions based upon the nature of the services in question, whether the failure or
denial was an isolated instance or a repeated pattern or practice, and whether the health of an enrollee was injured, threatened or jeopardized by the failure or denial. These sanctions apply not only to cases where the Department has ordered
payment after appeal, but also to cases where no appeal was made (i.e., the Department knows about the documented abuse from other sources). 
  

	 	F.	Sanctions 

  
 Section 1903(m)(5)(B)(ii) of the Social Security Act vests the Secretary of the Department of Health and Human Services with the authority to deny
Medicaid payments to an HMO for enrollees who enroll after the date on which the HMO has been found to have committed one of the violations identified in the federal law. State payment for enrollees of the contracting organization is automatically
denied whenever, and for so long as, federal payment for such enrollees has been denied as a result of the commission of such violations. 
  

	 	G.	Sanctions and Remedial Actions 

  
 The Department may pursue all sanctions and remedial actions with HMOs that are taken with Medicaid FFS providers, including any civil penalties not to
exceed the amounts specified in the Balanced Budget Amendment of 1997 P.L. 105-33 Sec. 4707(a) [42 U.S.C. 1396v(d)(2)]. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -135- 








 ARTICLE XII 
  

	XII.	TERMINATION AND MODIFICATION OF CONTRACT 

  

	 	A.	Termination by Mutual Consent 

  
 This Contract may be terminated at any time by mutual written agreement of both the HMO and the Department. 
  

	 	B.	Unilateral Termination 

  
 This Contract between the parties may be terminated by either party as follows: 
  

	 	1.	Either party may terminate this Contract at any time, due to modifications mandated by changes in federal or state laws, rules or regulations that materially affect either
party’s rights or responsibilities under this Contract. At least 90 days prior to the proposed date of termination, the party initiating the termination must notify the other party of its intent to terminate this Contract. Termination by the
Department under these circumstances shall impose an obligation upon the Department to pay the Contractor’s reasonable and necessarily incurred termination expenses. 

  

	 	2.	Either party may terminate this Contract at any time if it determines that the other party has substantially failed to perform any of its functions or duties under this Contract.
The party exercising this option must notify the other party in writing of this intent to terminate this Contract and give the other party 30 days to correct the identified violation, breach or non-performance of Contract. If such violation, breach
or non-performance of Contract is not satisfactorily addressed within this time period, the exercising party may terminate this Contract. The termination date shall always be the last day of a month. The Contract may be terminated by the Department
sooner than the time period specified in this paragraph if the Department finds that enrollee health or welfare is jeopardized by continued enrollment in the HMO. A “substantial failure to perform” for purposes of this paragraph includes
any violation of any requirement of this Contract that is repeated or ongoing, that goes to the essentials or purpose of the Contract, or that injures, jeopardizes or threatens the health, safety, welfare, rights or other interests of enrollees.


  

	 	3.	Either party may terminate this Contract if federal or state funding of contractual services rendered by the Contractor become or will become permanently unavailable. In the event
it becomes evident state or federal funding of claims payments or contractual services rendered by the Contractor will be temporarily suspended or unavailable, the Department shall immediately notify the Contractor, in writing, identifying the basis


  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -136- 








 for the anticipated unavailability or suspension of funding. Upon such notice, the Department or the
Contractor may suspend performance of any or all of the Contractor’s obligations under this Contract if the suspension or unavailability of funding will preclude reimbursement for performance of those obligations. The Department or Contractor
shall attempt to give notice of suspension of performance of any or all of the Contractor’s obligations by 60 calendar days prior to said suspension, if this is possible; otherwise, such notice of suspension should be made as soon as possible.
In the event funding temporarily suspended or unavailable is reinstated, the Contractor may remove suspension hereunder by written notice to the Department, to be made within 30 calendar days from the date the funds are reinstated. In the event the
Contractor elects not to reinstate services, the Contractor shall give the Department written notice of its reasons for such decision, to be made within 30 calendar days from the date the funds are reinstated. The Contractor shall make such decision
in good faith and will provide to the Department documentation supporting its decision. In the event of termination under this Section, this Contract shall terminate without termination costs to either party. 
  

	 	C.	Obligations of Contracting Parties Upon Termination 

  
 When termination of the Contract occurs, the following obligations must be met by the parties: 
  

	 	1.	Where this Contract is terminated unilaterally by the Department due to non-performance by the HMO or by mutual consent with termination initiated by the HMO:


  

	 	a.	The Department will be responsible for notifying all enrollees of the date of termination and process by which the enrollees will continue to receive contract services.


  

	 	b.	The HMO will be responsible for all expenses related to said notification 

  

	 	c.	The Department will grant the HMO a hearing before termination by the Department occurs. The Department will notify the enrollees of the hearing and allow them to disenroll from the
HMO without cause. 

  

	 	2.	Where this Contract is terminated on any basis not given in 1 above including non-renewal of the contract for a given contract period: 

  

	 	a.	The Department will be responsible for notifying all enrollees of the date of termination and process by which the enrollees will continue to receive contract services.


  

	 	b.	The Department will be responsible for all expenses relating to said notification. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -137- 









	 	3.	Where this contract is terminated for any reason the following payment criteria will apply: 

  

	 	a.	Any payments advanced to the HMO for coverage of enrollees for periods after the date of termination will be returned to the Department within the period of time specified by the
Department. 

  

	 	b.	The HMO will supply all information necessary for the reimbursement of any outstanding Medicaid and BadgerCare claims within the period of time specified by the Department.


  

	 	c.	If a contract is terminated, recoupments will be handled through a payment by the HMO within 90 days of contract termination. 

  

	 	D.	Modification 

  
 This Contract may be modified at any time by written mutual consent of the HMO and the Department or when modifications are mandated by changes in federal
or state laws, rules or regulations. If changes in state or federal laws, rules or regulations require the Department to modify its contract with the HMO, the HMO will receive written notice. 
  
 If the Department exercises its right to renew this Contract, as allowed by
Article XIX, the Department will recalculate the capitation rate for succeeding calendar years. The HMO will have 30 days to accept the new capitation rate in writing or to initiate termination of the Contract. If the Department changes the
reporting requirements during the contract period, the HMO shall have 180 days to comply with such changes or to initiate termination of the Contract. 
  
 ARTICLE XIII 
  
 XIII. INTERPRETATION OF CONTRACT LANGUAGE 
  
 When disputes arise, the Department has the right to final interpretation of the contract language. The HMO will abide by the interpretation of the
Department. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -138- 








 ARTICLE XIV 
  

	XIV.    CONFIDENTIALITY	OF RECORDS AND HIPAA REQUIREMENTS 

  
 The parties agree that all information, records, and data collected in connection with this Contract will be protected from unauthorized disclosure as
provided in Chapter 49, Subchapter IV, Wis. Stats., HFS 108.01, Wis. Adm. Code, 42 CFR 431 Subpart F and 42 CFR 438 Subpart F. Except as otherwise required by law, rule or regulation, access to such information shall be
limited by the HMO and the Department to persons who, or agencies which, require the information in order to perform their duties related to this Contract, including the U.S. Department of Health and Human Services and such others as may be required
by the Department. 
  

	 	A.	The HMO agrees to forward to the Department all media contacts regarding Medicaid and BadgerCare enrollees or the Medicaid and BadgerCare program. 

  

	 	B.	Regarding the services provided under this Contract, the HMO will comply with all applicable health data and information privacy and security policies, standards and regulations as
may be adopted or promulgated under the Health Insurance Portability and Accountability Act (HIPAA) of 1996 in final form, and as amended or revised from time to time. This includes cooperating with the Department in amending this Contract, or
developing a new agreement, if the Department deems it necessary to meet the Department’s obligations under HIPAA. 

  

	 	C.	Trading Partner requirements under HIPAA. For the purposes of this section Trading Partner means the HMO. 

  

	 	1.	Trading Partner Obligations: 

  

	 	a.	Trading Partner must not change any definition, data condition or use of a data element or segment as proscribed in the HHS Transaction Standard Regulation (45 CFR Part 162.915(a)).


  

	 	b.	Trading Partner must not add any data elements or segments to the maximum data set as proscribed in the HHS Transaction Standard Regulation (45 CFR Part 162.915(b)).


  

	 	c.	Trading Partner must not use any code or data elements that are either marked “not used” in the HHS Transaction Standard’s implementation specifications or are not in
the HHS Transaction Standard’s implementation specifications (45 CFR Part 162.915(c)). 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -139- 









	 	d.	Trading Partner must not change the meaning or intent of any of the HHS Transaction Standard’s implementation specifications (45 CFR Part 162.915(d)). 


 

	 	e.	Trading Partner must submit a new Trading Partner profile form in writing if any of the information provided as part of the Trading Partner profile form is modified.


  

	 	2.	Trading Partner understands that there exists the possibility that the Department or others may request an exception from the uses of a standard in the HHS Transaction Standards. If
this occurs, Trading Partner must participate in such test modification (45 CFR Part 162.940 (a) (4)). 

  

	 	3.	Trading Partners or Trading Partner’s Business Associate have responsibilities to adequately test business rules appropriate to their types and specialties.


  

	 	4.	Trading Partner or their Business Associate agrees to cure Transactions errors or deficiencies identified by the Department. 

  

	 	5.	Trading Partner or Trading Partner’s Business Associate understands that from time-to-time HHS may modify and set compliance dates for the HHS Transaction Standards. Trading
Partner or Trading Partner’s Business associate must incorporate by reference any such modifications or changes (45 CFR Part 160.104). 

  

	 	6.	The Department and the Trading Partner agree to keep open code sets being processed or used for at least the current billing period or any appeal period, whichever is longer (45 CFR
Part 162.925 (c)(2)). 

  

	 	7.	Privacy 

  

	 	a.	The Trading Partner or the Trading Partner’s Business Associate will comply with all applicable state and federal privacy statutes and regulations concerning the treatment of
Protected Health Information (PHI). 

  

	 	b.	The Department and the Trading Partner or Trading Partner’s Business Associate will promptly notify the other Party of any unlawful or unauthorized use or disclosure of PHI
that may have an impact on the other Party that comes to the Party’s attention, and will cooperate with the other Party in the event that any litigation arises concerning the unlawful or unauthorized disclosure of use of PHI.


  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -140- 









	 	c.	The Department retains all rights to seek injunctive relief to prevent or stop the unauthorized use or disclosure of PHI by the Trading Partner, Trading Partner’s Business
Associate, or any agent, contractor or third Party that received PHI from the Trading Partner. 

  

	 	8.	Security 

  

	 	a.	The Department and the Trading Partner or Trading Partner’s Business Associate must maintain reasonable security procedures to prevent unauthorized access to data, data
transmissions, security access codes, envelope, backup files, and source documents. Each party will immediately notify the other Party of any unauthorized attempt to obtain access to or otherwise tamper with data, data transmissions security access
codes, envelope, backup files, source documents other Party’s operating system when the attempt may have an impact on the other Party. 

  

	 	b.	The Department and the Trading Partner or Trading Partner’s Business associate must develop, implement, and maintain appropriate security measures for its own Operating System.
The Department and the Trading Partner or Trading Partner’s Business Associate must document and keep current its security measures. Each Party’s security measure will include, at a minimum, the requirements and implementation features set
forth in ‘site specific HIPAA rule’ and all applicable HHS implementation guidelines. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -141- 








 ARTICLE XV 
  


	XV.	DOCUMENTS CONSTITUTING CONTRACT 

  

	 	A.	Current Documents 

  
 In addition to this base agreement, the contract between the Department and the HMO includes, existing Medicaid provider publications addressed to HMOs,
the terms of the most recent HMO certification application issued by this Department for Medicaid and BadgerCare HMO contracts, any questions and answers released pursuant to said HMO certification application by the Department, and an HMO’s
signed application. The terms of the HMO certification application are also part of this Contract even if the HMO had a Medicaid and BadgerCare HMO Contract in the prior contract period and consequently did not have to answer all the questions in
the HMO certification application. In the event of any conflict in provisions among these documents, the terms of this base agreement will prevail. The provisions in any question and answer document will prevail over the HMO certification
application. And the HMO Certification Application terms shall prevail over any conflict with an HMO’s actual signed application. In addition, the Contract shall incorporate the following Addenda: 
  

			
	I.	  	Memoranda of Understanding
		
	II.	  	Standard Enrollee Handbook Language
		
	III.	  	Actuarial Basis
		
	IV.	  	Guidelines for the Coordination of Services between HMOs and the Bureau of Milwaukee Child Welfare
		
	V.	  	Guidelines for the Coordination of Services between Medicaid HMOs and County Birth to 3 Agencies
		
	VI.	  	Local Health Departments and Community Based Health Organizations a Resource for HMOs
		
	VII.	  	Guidelines for the Coordination of Services Between HMOs, Targeted Case Management (TCM) Agencies, and Child Welfare Agencies
		
	VIII.	  	Report Forms and Worksheets
		
	IX.	  	General Information about the WIC Program and Sample HMO-to-WIC Referral Forms

  

	 	B.	Future Documents 

  
 The HMO is required by this Contract to comply with all future Medicaid and BadgerCare provider publications and Contract Interpretation Bulletins issued
pursuant to this Contract. The documents listed in this section constitute the entire Contract between the parties. No other oral or written expression, constitutes any part of this Contract. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -142- 








 ARTICLE XVI 
  

	XVI.	 DISCLOSURE STATEMENT(S) OF OWNERSHIP OR CONTROLLING INTEREST IN AN HMO AND BUSINESS TRANSACTIONS 

  

	 	A.	Ownership or Controlling Interest Disclosure Statement(s) 

  
 Within 30 days of contract signing, the HMO agrees to submit to the Department full and complete information as to the identity of each person or
corporation with an ownership or controlling interest in the HMO, or any subcontractor in which the HMO has a 5% or more ownership interest. A “person with an ownership or controlling interest” means a person or corporation that:

  

	 	1.	Owns, directly or indirectly, 5% or more of the HMO’s capital or stock or receives 5% or more of its profits; 

  

	 	a.	Has an interest in any mortgage, deed of trust, note, or other obligation secured in whole or in part by the HMO or by its property or assets, and that interest is equal to or
exceeds 5% of the total property and assets of the HMO; or 

  

	 	b.	Is an officer or director of the HMO (if it is organized as a corporation or is a partner in the HMO (if it is organized as a partnership). 

  

	 	2.	Calculation of 5% Ownership or Control is as follows: 

  
 The percentage of direct ownership or control is the percentage interest in the capital, stock or profits. 
  
 The percentage of indirect ownership or control is calculated by
multiplying the percentages of ownership in each organization. Thus, if a person owns 10% of the stock in a corporation that owns 80% of the stock of the HMO, the person owns 8% of the HMO. 
  
 The percentage of ownership or control through an interest in a mortgage,
deed or trust, note or other obligation is calculated by multiplying the percent of interest that a person owns in that obligation by the percent of the HMO’s assets used to secure the obligation. Thus, if a person owns 10% of a note secured by
60% of the HMO’s assets, the person owns 6% of the HMO. 
  

	 	3.	Information to be Disclosed 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -143- 









	 	  	The following information must be disclosed: 

  

	 	a.	The name and address of each person with an ownership or controlling interest of 5% or more in the HMO or in any subcontractor in which the HMO has direct or indirect ownership of
5% or more; 

  

	 	b.	A statement as to whether any of the persons with ownership or controlling interest is related as spouse, parent, child, or sibling to any other of the persons with ownership or
controlling interest; and 

  

	 	c.	The name of any other organization in which the person also has ownership or controlling interest. This is required to the extent that the HMO can obtain this information by
requesting it in writing. The HMO must keep copies of all of these requests and the responses to them, make them available upon request, and advise the Department when there is no response to a request. 

  

	 	4.	Potential Sources of Disclosure Information 

  
 This information may already have been reported on Form HCFA-1513, “Disclosure of Ownership and Controlling Interest Statement.” Form HCFA-1513
is likely to have been completed in two different cases. First, if an HMO is federally qualified and has a Medicare contract, it is required to file Form HCFA-1513 with CMS within 120 days of the HMO’s fiscal year end. Secondly, if the HMO is
owned by or has subcontracts with Medicaid providers that are reviewed by the state survey agency, these providers may have completed Form HCFA-1513 as part of the survey process. If Form HCFA-1513 has not been completed, the HMO may supply the
ownership and controlling information on a separate report or submit reports filed with the State’s insurance or health regulators as long as these reports provide the necessary information for the prior 12 month period. 
  
 As directed by the CMS Regional Office (RO), the Department must provide
documentation of this disclosure information as part of the prior approval process for contracts. This documentation must be submitted to the Department and the RO prior to each contract period. If an HMO has not supplied the information that must
be disclosed, a contract with the HMO is not considered approved for this period of time and no FFP is available for the period of time preceding the disclosure. 
  
 A managed care entity may not knowingly have as a director, officer, partner, or person with beneficial ownership of more
than 5% of the entity’s a person who is debarred, suspended, or otherwise excluded from participating in procurement or non-procurement activities under the 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -144- 









	 	  	Federal Acquisition Regulation or who has an employment, consulting, or other agreement for the provision of items and services that are significant and material to the
entity’s obligations under its contract with the state. 

  

	 	B.	Business Transaction Disclosures 

  
 Within 30 days of contract signing, all HMOs that are not federally qualified must disclose to the Department information on certain types of transactions
they have with a “party in interest” as defined in the Public Health Service Act. (See Sections 1903(m)(2)(A)(viii) and 1903(m)(4) of the Act.). 
  

	 	1.	Party In Interest as defined in Section 1318(b) of the Public Health Service Act, is: 

  

	 	a.	Any director, officer, partner, or employee responsible for management or administration of an HMO and HIO; any person who is directly or indirectly the beneficial owner of more
than 5% of the equity of the HMO; any person who is the beneficial owner of more than 5% of the HMO; or, in the case of an HMO organized as a nonprofit corporation, an incorporator or member of such corporation under applicable state corporation
law; 

  

	 	b.	Any organization in which a person described in subsection A, 1 above is director, officer or partner; has directly or indirectly a beneficial interest of more than 5% of the equity
of the HMO; or has a mortgage, deed of trust, note, or other interest valuing more than 5% of the assets of the HMO; 

  

	 	c.	Any person directly or indirectly controlling, controlled by, or under common control with an HMO; or 

  

	 	d.	Any spouse, child, or parent of an individual described in subsections 1, 2, or 3 above. 

  

	 	2.	Business Transactions That Must Be Disclosed Include: 

  

	 	a.	Any sale, exchange or lease of any property between the HMO and a party in interest. 

  

	 	b.	Any lending of money or other extension of credit between the HMO and a party in interest. 

  

	 	c.	Any furnishing for consideration of goods, services (including management services) or facilities between the HMO and the party in interest. This does not include salaries paid to
employees for services provided in the normal course of their employment. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -145- 









	 	3.	Information That Must Be Disclosed In The Transactions Between an HMO and a Party In Interest Includes: 

  

	 	a.	The name of the party in interest for each transaction. 

  

	 	b.	A description of each transaction and the quantity or units involved. 

  

	 	c.	The accrued dollar value of each transaction during the fiscal year. 

  

	 	d.	Justification of the reasonableness of each transaction. 

  
 If the Medicaid and BadgerCare HMO Contract is being renewed or extended, the HMO must disclose information on those business transactions that occurred
during the prior contract period. If the Contract is an initial contract with Medicaid, but the HMO has operated previously in the commercial or Medicare markets, information on business transactions for the entire year preceding the initial
contract period must be disclosed. The business transactions which must be reported are not limited to transactions related to serving Medicaid enrollment. All of these HMO business transactions must be reported. 
  
 ARTICLE XVII 
  

	XVII.   MISCELLANEOUS	

  

	 	A.	Indemnification 

  
 The HMO agrees to defend, indemnify and hold the Department harmless with respect to any and all claims, costs, damages and expenses, including reasonable
attorney’s fees, that are related to or arise out of: 
  

	 	1.	Any failure, inability, or refusal of the HMO or any of its subcontractors to provide contract services. 

  

	 	2.	The negligent provision of contract services by the HMO or any of its subcontractors. 

  

	 	3.	Any failure, inability or refusal of the HMO to pay any of its subcontractors for contract services. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -146- 









	 	B.	Independent Capacity of Contractor 

  
 The Department and the HMO agree that the HMO and any agents or employees of the HMO, in the performance of this Contract, will act in an independent
capacity, and not as officers or employees of Department. 
  

	 	C.	Omissions 

  
 In the event either party hereto discovers any material omission in the provisions of this Contract that is essential to the successful performance of
this Contract, said party may so inform the other party in writing. The parties hereto will thereafter promptly negotiate the issues in good faith in order to make all reasonable adjustments necessary to perform the objectives of this Contract.

  

	 	D.	Choice of Law 

  
 This Contract is governed by and construed in accordance with the laws of the State of Wisconsin. The HMO shall be required to bring all legal proceedings
against the Department in Wisconsin State courts. 
  

	 	E.	Waiver 

  
 No delay or failure by either party hereto to exercise any right or power accruing upon noncompliance or default by the other party with respect to any of
the terms of this Contract will impair that right or power or be construed as a waiver thereof. A waiver by either of the parties hereto of a breach of any of the covenants, conditions, or agreements to be performed by the other will not be
construed as a waiver of any succeeding breach thereof or of any other covenant, condition, or agreement contained herein. 
  

	 	F.	Severability 

  
 If any provision of this Contract is declared or found to be illegal, unenforceable, invalid or void, then both parties will be relieved of all
obligations arising under such provision. If such provision does not relate to payments or services to Medicaid and BadgerCare enrollees and if the remainder of this Contract is not affected then each provision not so affected will be enforced to
the fullest extent permitted by law. 
  

	 	G.	Survival 

  
 The terms and conditions contained in this contract that by their sense and context are intended to survive the completion of performance shall so survive
the completion, expiration or termination of the contract. This specifically includes, but is not limited to recoupments and confidentiality provisions. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -147- 









	 	H.	Force Majeure 

  
 Both parties shall be excused from performance hereunder for any period that they are prevented from meeting the terms of this Contract as a result of a
catastrophic occurrence or natural disaster including but not limited to an act of war, and excluding labor disputes. 
  

	 	I.	Headings 

  
 The article and section headings used herein are for reference and convenience only and do not affect its interpretation. 
  

	 	J.	Assignability 

  
 Except as allowed under subcontracting, the Contract is not assignable by the HMO either in whole or in part, without the prior written consent of the
Department. 
  

	 	K.	Right to Publish 

  
 The HMO must obtain prior written approval from the Department before publishing any material on subjects addressed by this Contract. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -148- 








 ARTICLE XVIII 
  

	XVIII.	   HMO SPECIFIC CONTRACT TERMS 

  

	 	A.	Initial Contract Period 

  
 The respective rights and obligations of the parties as set forth in this Contract shall commence on February 1, 2006, and, unless earlier terminated
under Article XII, shall remain in full force and effect through December 31, 2007. The specific terms for enrollment, rates, risk-sharing, dental coverage, and chiropractic coverage are as specified in Section C of this Article.

  

	 	B.	Renewals 

  
 By mutual written agreement of the parties, there may be one one-year renewal of the term of the Contract. An agreement to renew must be effected at least
30 calendar days prior to the expiration date of any contract term. The terms and conditions of the Contract shall remain in full force and effect throughout any renewal period, unless modified under the provision of Article XII, Section D.

  

	 	C.	Specific Terms of the Contract 

  
 The specific terms of the Medicaid/BadgerCare HMO Contract to which the HMO agrees are set forth in this Contract. The capitation rates to which the HMO
agrees are indicated by the Department in a completed Addendum III, Actuarial Basis of the Medicaid and BadgerCare HMO Contract. Except as stated below, the specific terms in the HMO’s completed application for certification are incorporated
into this Contract, including whether dental services and chiropractic services will be provided by the HMO. For each rate period in this Contract, the HMO agrees not to reduce its service area that was in effect at the time of acceptance of the
rates. The HMO’s service area and maximum enrollment are specified in its certification application. 
  
 In WITNESS WHEREOF, the State of Wisconsin has executed this agreement: 
  

			
	(Name of HMO)	 	State of Wisconsin
		
	Official Signature	 	Official Signature
		
	 /s/ Linda McKnew

	 	

	Title Chief Operating Officer	 	Title
	Date January 26, 2006	 	 

  
 Note: HMOs that elect to enter
into a subcontract with the state, for the provision of Chiropractic Services, must sign and date the Subcontract for Chiropractic Services. This subcontract will not become effective without a signature. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -149- 








 SUBCONTRACT FOR CHIROPRACTIC SERVICES 
  

	A.	THIS AGREEMENT is made and entered into by and between the HMO and the Department of Health and Family Services. 

  

	    	The parties agree as follows: 

  

	 	1.	The Department agrees to be at risk for and pay claims for chiropractic services covered under this Contract. 

  

	 	2.	The HMO agrees to a deduction from the capitation rate of an amount of money based on the cost of chiropractic services. This deduction is reflected in the Contract that is being
signed on the same date. 

  

	B.	This is the only subcontract for services that the Department is entering into with the HMO. 

  

	C.	The provisions of the Contract regarding subcontracts, in Article X, do not apply to this subcontract. 

  

	D.	The term of this subcontract is for the same period as the Contract between HMO and Department for medical services. 

  
 Signed: 
  

									
	 FOR
 HMO:
  
	 	 /s/ Linda McKnew

	 	 	  	 FOR
 STATE:
  
	  	  


	TITLE:	 	Chief Operating Officer	 	 	  	TITLE:	  	  


	DATE:	 	January 26, 2006	 	 	  	DATE:	  	  



  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -150- 








 ADDENDUM I 
  

MEMORANDA OF UNDERSTANDING 
  

	I.	MOU Submission Requirements 

  
 The HMO must submit to the Department copies of new MOUs, or changes in existing MOUs for review and approval before they take effect. This requirement
will be considered met if the Department has not responded within 15 business days after receipt of the MOU. 
  
 The HMO shall submit MOUs referred to in this Contract and this Addendum to the Department upon the Department’s request and during the certification
process if required by the Department. 
  

	II.	Emergency Services MOU or Contract 

  
 HMOs may have a contract or an MOU with hospitals or urgent care centers within the HMO’s service area(s) to ensure prompt and appropriate payment
for emergency services. 
  

	 	A.	The MOU Shall Provide For: 

  

	 	1.	The process for determining whether an emergency exists. 

  

	 	2.	The requirements and procedures for contacting the HMO before the provision of urgent or routine care. 

  

	 	3.	Agreements, if any, between the HMO and the provider regarding indemnification, hold harmless, or any other deviation from malpractice or other legal liability which would attach to
the HMO or provider in the absence of such an agreement. 

  

	 	4.	Payments for an appropriate medical screening examination to determine whether or not an emergency medical condition exists. 

  

	 	5.	Assurance of timely and appropriate provision of and payment for emergency services. 

  

	 	B.	HMO’s Liability for Emergency Situations 

  
 Unless a contract or MOU specifies otherwise, HMOs are liable to the extent that FFS would have been liable for the emergency situation. The Department
reserves the right to resolve disputes between HMOs, hospitals and urgent care centers regarding emergency situations based on FFS criteria. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -151- 









	III.	County and Other Human Service Agencies MOU or Contract Requirements for Services Ordered by the Courts 

  
 HMOs must make a “good faith” attempt to negotiate either an MOU
or a contract with the county(ies) in their service area. See Article III, F, 11. 
  

	 	A.	MOU Requirement with Boards Created Under §. 51.42, 51.437 or 46.23, Wis. Stats. 

  
 At a minimum the MOU must specify the conditions under which the HMO will either reimburse the Board(s) or another contract
provider, or directly cover medical services, including, but not limited to, examinations ordered by a court, specified by the Board’s designated assessment agency in an enrollee’s driver safety plan as provided under HFS 62. It is the
responsibility of both the HMO and the Board to ensure that courts order the use of the HMO’s providers. If the court orders a non-HMO source to provide the treatment or evaluation, the HMO is liable for the cost up to the full Medicaid rate if
the HMO could not have provided the service through its own provider arrangements. If the service was such that the HMO could reasonably have been expected to provide it through its own provider arrangements, the HMO is not liable. Reasonable
arrangements, in this situation, are certified providers with facilities and services to safely meet the medical and psychiatric needs of the recipient within a prompt and reasonable time frame. The MOU shall further specify reimbursement
arrangements between the HMO and the Board’s provider for assessments performed by the Board’s designated assessment agency under HFS 62, Intoxicated Driver Program rules. The MOU shall also specify other reporting and referral
relationships if required by the Board or the HMO. 
  

	 	B.	MOU Requirement with the Department of Social Services (DSS) Created Under s. 46.21 or 46.22, Wis. Stats., or the Human Service Department Created Under s. 46.23, Wis. Stats.


  
 At a minimum the MOU must specify that the HMO
will reimburse the DSS or its provider if the HMO cannot provide the treatment, or will directly cover medical services including examinations and treatment which are ordered by a court. It is the responsibility of both the HMO and the DSS to ensure
that courts order the use of the HMO’s providers. If the court orders a non-HMO source to provide the treatment or evaluation, the HMO is liable for the cost up to the full Medicaid rate if the HMO could not have provided the service through
its own provider arrangements. If the service was such that the HMO could reasonably have been expected to provide it through its own provider arrangements, the HMO is not liable. The MOU will also specify the reporting and referral relationships
for suspected cases of child abuse or neglect pursuant to s. 48.981, Wis. Stats. The MOU shall also specify a referral agreement for HMO enrollees who are physically disabled and who may be in need of Supportive Home Care or other programming
provided or purchased by the county agency. The MOU may 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -152- 








 specify that evaluations for substitute care will be provided by a provider acceptable to both parties;
the DSS may require in the MOU that the HMO specify expert providers acceptable to the DSS and the HMO in dealing with court-related children’s services, victims of child abuse and neglect, and domestic abuse. 
  
 HMOs and counties may develop alternative MOU language, if both parties
agree. However, all elements defined above must be addressed in the MOU. As an alternative to an MOU, HMOs may enter into contracts with the counties. Any contracts the HMO enters into with the counties must be in compliance with Part A of this
Addendum and would supersede any MOU requirements. 
  

	IV.	Required MOUs or Contracts 

  

	 	A.	Milwaukee County Common Carrier Transportation MOU 

  
 Refer to the sample Common Carrier Transportation MOU following this page. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -153- 








 MEMORANDUM OF UNDERSTANDING 
 BETWEEN 
 MILWAUKEE COUNTY MEDICAID AND BADGERCARE HMOS 
 AND 
 MILWAUKEE COUNTY DEPARTMENT OF
HUMAN SERVICES 
  
 All Milwaukee County Medicaid Health Maintenance
Organizations (HMOs) will provide common carrier transportation for their Medicaid and BadgerCare enrollees. Transportation services will be limited to: 
  

	•	 	Transportation of Medicaid and BadgerCare HMO members only. 

  

	•	 	Transportation of Medicaid and BadgerCare HMO members to and from Medicaid covered services only. 

  
 The HMO is responsible for arranging for the common carrier transportation and providing monthly costs to the Milwaukee County Department of
Human Services (DHS), of the common carrier transportation provided. Monthly costs will include the information specified in the attachment. The DHS is responsible for reimbursing the HMO for mileage and an administration fee. 
  
 The HMO and DHS agree to facilitate effective communication between agencies, work together
to resolve inter-agency coordination and communication problems, and inform staff from both the HMO and DHS about the policies and procedures for this cooperation, coordination and communication. 
  
 This agreement becomes effective when both the HMO and DHS
have signed. 
  

			
	 Milwaukee County Department of
 Human Services
	 	 Milwaukee County
 Health Maintenance Organization

		
	Signature	 	Signature
		
	Title	 	Title
		
	Date	 	Date

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -154- 








 Milwaukee County Medicaid/HMO Common Carrier Transportation 
 Monthly Invoice from HMO to County 
  
 (DATE) 
  
 Milwaukee County DHS 
 Financial Assistance Division Administrator 
 1220 West Vliet Street 
 Milwaukee, WI 53205 
  
 Dear Sir: 
  
 (HMO NAME)’s total transportation costs for the month of (MONTH, YEAR) was
($                    ). This amount includes transportation and administration fees. 
  
 Please remit the above dollar amount to: 
  
 (HMO NAME) 
 (AUTHORIZED INDIVIDUAL) 
 (ADDRESS)

  
 Thank you. 
  
 Sincerely, 
  
 (NAME/HMO) 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -155- 









	 	B.	Prenatal Care Coordination (PNCC) MOU 

  
 The HMO must sign an MOU with all agencies in the HMO service area that are Medicaid-certified prenatal care coordination agencies. The MOU will be
effective on the effective date of the agency’s PNCC Wisconsin Medicaid certification or when both the HMO and the PNCC agency have signed it, whichever is later. In addition, if the PNCC wants to negotiate additional provisions in the MOU, the
HMO must negotiate in good faith and document those negotiations. Such documentation must be available to the Department for review on request. 
  
 The main purpose of the MOU is to ensure coordination of care between the HMO, that provides medical services, and the Prenatal Care Coordinating Agency
that provides outreach risk assessment, care planning, care coordination, and follow-up. 
  
 Refer to the sample PNCC MOU following this page. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -156- 








 MODEL MEMORANDUM OF UNDERSTANDING 
 BETWEEN 
 HEALTH MAINTENANCE ORGANIZATION 
 AND 
 PRENATAL CARE COORDINATION
AGENCY 
  
 Prenatal care coordination services are paid FFS by the Wisconsin
Medicaid Program for all recipients, including those enrolled in HMOs. The prenatal care coordination agencies (PNCC) are responsible for services which include outreach, risk assessment, care planning, care coordination and follow-up support to
high-risk pregnant women. The HMOs are responsible for providing and managing medically necessary services. The successful provision of services to individual enrollees requires cooperation, coordination and communication between the HMO and the
PNCC. 
  
 The HMO and the PNCC agree to facilitate effective communication between
agencies, work to resolve inter-agency coordination and communication problems, and inform staff from both the HMO and the PNCC about the policies and procedures for this cooperation, coordination and communication. 
  
 Recognizing that these “clients-in-common” are at high risk for poor birth
outcomes, the HMO and the PNCC agree to cooperate in removing access barriers, coordinating care and providing culturally competent services. 
  
 This agreement becomes effective on the date the PNCC is certified by Wisconsin Medicaid or on the date when both the HMO and the PNCC have signed it, whichever is later.
It may be terminated in writing with two weeks notice by either signer. 
  

			
	 HMO
	 	PNCC
		
	Authorizing Signature	 	Authorizing Signature
		
	Title	 	Title
		
	Date	 	Date

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -157- 









	 	C.	School-Based Services (SBS) MOU 

  
 The HMO must sign an MOU with all School-Based Services (SBS) providers in the HMO service area who are Medicaid-certified. The MOU will be effective on
the date when both the HMO and the SBS provider have signed it or when the SBS provider is Medicaid-certified, whichever is later. Refer to Article III, C, 10, e and Article III, E, 13 that contain more information regarding SBS providers.

  
 Refer to the sample SBS MOU following this page.

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -158- 








 MODEL MEMORANDUM OF UNDERSTANDING 
 BETWEEN 
 HEALTH MAINTENANCE ORGANIZATION 
 AND 
 SCHOOL DISTRICT
OR CESA MEDICAID-CERTIFIED FOR THE SCHOOL BASED 
 SERVICES BENEFIT 
  
 School-based services are a benefit paid FFS by Wisconsin Medicaid for all school-enrolled
recipients, including those enrolled in HMOs. The School-Based Service (SBS) provider is responsible for services provided in the schools such as occupational/physical/speech therapies, private duty or home care individualized nursing services,
mental health services, testing services, school Individual Education Plan (IEP) services, and Individualized Family Service Program (IFSP) services. The HMOs are responsible for providing and managing medically necessary services outside of school
settings. However, the schools cannot provide services in some situations, such as after school hours, during school vacations, and during the summer. Therefore, avoidance of duplication of services and promotion of continuity of care for Medicaid
and BadgerCare HMO enrollees requires cooperation, coordination and communication between the HMO and the SBS provider. 
  
 The HMO and the SBS provider agree to facilitate effective communication between agencies, work to resolve inter-agency coordination and communication problems, and
inform staff from both the HMO and the SBS provider about the policies and procedures for this cooperation, coordination and communication. Recognizing that these “clients-in-common” could receive duplicate services and could suffer from
problems in continuity of care (e.g., when the school year ends in the middle of a series of treatments), the HMO and the SBS provider agree to cooperate in communicating information about the provision of services and in coordinating care.

  
 This agreement becomes effective on the date when the SBS provider is
certified by Wisconsin Medicaid or when both the HMO and the SBS provider have signed it, whichever is later. It may be terminated in writing with two weeks notice by either signer. The SBS provider is the School District or the CESA. 
  

			
	 HMO
	 	SBS Provider
		
	Authorizing Signature	 	Authorizing Signature
		
	Title	 	Title
		
	Date	 	Date

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -159- 








 ADDENDUM II 
  
 STANDARD ENROLLEE HANDBOOK LANGUAGE 
  
 INTERPRETER SERVICES 
  

			
	English –	  	For help to translate or understand this, please call [1-800-xxx-xxxx] (TTY).
		
	Spanish –	  	Si necesita ayuda para traducir o entender este texto, por favor llame al teléfono
	 	  	[1-800-xxx-xxxx] (TTY).
		
	Russian –	  	 


 [1-800-xxx-xxxx] (TTY).

		
	Hmong –	  	Yog xav tau kev pab txhais cov ntaub ntawv no kom koj totaub, hu rau
	 	  	[1-800-xxx-xxxx] (TTY).
		
	Laotian -	  	 grnjv-j;p.odkocx s]ng0Qk.9goNvsk.ooUF
 dti5ok3mitla[sk

	 	  	[1-800-xxx-xxxx] (TTY).

  
 Interpreter services are provided free
of charge to you. 
  
 IMPORTANT [HMO NAME] PHONE NUMBERS 
  

					
	Customer Service	  	[1-800-xxx-xxxx]	  	[Hours/Days Available]
			
	Emergency Number	  	[1-800-xxx-xxxx]	  	Call 24 hours a day, 7 days a week
			
	TDD/TTY	  	[1-800-xxx-xxxx]	  	 

  
 WELCOME 
  
 Welcome to [HMO NAME]. As a member of [HMO NAME], you will receive all your health care from
[HMO NAME] doctors, hospitals, and pharmacies. See [HMO NAME] Provider Directory for a list of these providers. You may also call our Customer Service Department at [1-800-xxx-xxxx]. Providers not accepting new patients are marked in the Provider
Directory. 
  
 YOUR FORWARD ID CARD 
  
 Always carry your Forward ID card with you, and show it every time you get care. You may
have problems getting care or prescriptions if you do not have your card with you. Also bring any other health insurance cards you may have. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -160- 








 PRIMARY CARE PHYSICIAN (PCP) 
  
 It is important to call your primary care physician (PCP) first when you need care. This doctor will manage all your health care. If you
think you need to see another doctor, or a specialist, ask your PCP. Your PCP will help you decide if you need to see another doctor, and give you a referral. Remember, you must get approval from your PCP before you see another doctor. 

 
 You can choose your primary care physician (PCP) from those available (NOTE: For women you
may also see a women’s health specialist (for example a OB/GYN doctor or a nurse midwife) without a referral, in addition to choosing your PCP). There are HMO doctors who are sensitive to the needs of many cultures. To choose a PCP, or to
change to a different PCP, call our Customer Service Department at [1-800-xxx-xxxx]. 
  
 EMERGENCY CARE 
  
 Emergency care is care needed right away. This
may be caused by an injury or a sudden illness. Some examples are: 
  

					
	Choking	 	Severe or unusual bleeding	 	 
	Trouble breathing	 	Suspected poisoning	 	 
	Serious broken bones	 	Suspected heart attack	 	 
	Unconsciousness	 	Suspected stroke	 	 
	Severe burns	 	Convulsions	 	 
	Severe pain	 	Prolonged or repeated seizures	 	 

  
 If you need emergency care, go to a
[HMO NAME] provider for help if you can. BUT, if the emergency is severe, go to the nearest provider (hospital, doctor or clinic). You may want to call 911 or your local police or fire department emergency services if the emergency is severe.

  
 If you must go to a [non-HMO NAME] hospital or provider, call [HMO NAME] at
[1-800-xxx-xxxx] as soon as you can and tell us what happened. This is important so we can help you get follow up care. 
  
 Remember, hospital emergency rooms are for true emergencies only. Call your doctor or our 24-hour emergency number at [1-800-xxx-xxxx] before you go to the emergency
room, unless your emergency is severe. 
  
 URGENT CARE 
  
 Urgent Care is care you need sooner than a routine doctor’s visit. Urgent care is not
emergency care. Do not go to a hospital emergency room for urgent care unless your doctor tells you to go there. Some examples of urgent care are: 
  

					
	Most broken bones	 	Minor cuts	 	 
	Sprains	 	Bruises	 	 
	Non-severe bleeding	 	Most drug reactions	 	 
	Minor burns	 	 	 	 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -161- 








 If you need urgent care, call [insert instructions here—call clinic, doctor, 24-hour number, nurse line, etc.] We
will tell you where you can get care. You must get urgent care from [HMO NAME] doctors unless you get our approval to see a [non-HMO NAME] doctor. 
  
 Remember, do not go to a hospital emergency room for urgent care unless you get approval from [HMO NAME] first. 
  
 HOW TO GET MEDICAL CARE WHEN YOU ARE AWAY FROM HOME 
  
 Follow these rules if you need medical care but are too far away from home to go to your
assigned primary care physician (PCP) or clinic. 
  
 For severe emergencies, go to
the nearest hospital, clinic, or doctor. 
  
 For urgent or routine care away from
home, you must get approval from us to go to a different doctor, clinic or hospital. This includes children who are spending time away from home with a parent or relative. Call us at [1-800-xxx-xxxx] for approval to go to a different doctor, clinic,
or hospital. 
  
 PREGNANT WOMEN AND DELIVERIES 
  
 You must go to a [HMO NAME] hospital to have your baby. Talk to your [HMO NAME] doctor to
make sure you understand which hospital you are to go to when it’s time to have your baby. 
  
 Also, talk to your doctor if you plan to travel in your last month of pregnancy. Because we want you to have a healthy birth and a good birthing experience, it may not be a good time for you and your unborn child to
be traveling. We want you to have a healthy birth and your [HMO Name] doctor knows your history and is the best doctor to help you have a healthy birth. Do not go out of area to have your baby unless you have [HMO NAME] approval. 
  
 You may also wish to pick a doctor for your child before you give birth. We will be able to
help you pick a doctor for your unborn child. 
  
 WHEN YOU MAY BE BILLED FOR
SERVICES 
  
 It is very important to follow the rules when you get medical
care so you are not billed for services. You must receive your care from [HMO NAME] providers, hospitals, and pharmacies unless you have our approval. The only exception is for severe emergencies. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -162- 








 If you travel outside of Wisconsin and need emergency services, health care providers can treat you and send claims to
[HMO NAME]. You will have to pay for any service you get outside Wisconsin if the health care provider refuses to submit claims or refuses to accept [HMO NAME’s] payment as payment in full. 
  
 [HMO NAME] does not cover any service, including emergency services, provided outside of the
United States, Canada and Mexico. 
  
 IF YOU ARE BILLED 
  
 If you receive a bill for services, call our Customer Service Department at
[1-800-xxx-xxxx]. You do not have to pay for covered services that are provided by a Wisconsin Medicaid certified provider and that [HMO NAME] is required to provide you. 
  
 OTHER INSURANCE 
  
 If you have other insurance in addition to [HMO NAME], you must tell your doctor or other provider. Your health care provider must bill your other insurance before
billing [HMO NAME]. If your [HMO NAME] doctor does not accept your other insurance, call the HMO Enrollment Specialist at 1-800-291-2002. The Enrollment Specialist can tell you how to match your HMO enrollment with your other insurance so you can
use both insurance plans. 
  
 SERVICES COVERED BY [HMO NAME] 
  
 [HMO NAME] provides all medically necessary covered services. Some services may require a
doctor’s order or a prior authorization. Covered services include: 
  

	•	 	Prescription drugs and certain over-the-counter drugs when ordered by a doctor. 

  

	•	 	Services by doctors and nurses, including nurse practitioners and nurse midwives. 

  

	•	 	Inpatient and outpatient hospital services. 

  

	•	 	Laboratory and X-ray services. 

  

	•	 	HealthCheck for members under 21 years of age, including referral for other medically necessary services. 

  

	•	 	Certain podiatrists’ (foot doctors) services. 

  

	•	 	Inpatient care at institutions for mental disease (care for persons 22-64 years of age is not included). 

  

	•	 	Optometrists’ (eye doctors) or opticians’ services, including eyeglasses. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -163- 









	•	 	Mental health treatment. 

  

	•	 	Substance abuse (drug and alcohol) services. 

  

	•	 	Family planning services and supplies. 

  

	•	 	Abortions when necessary to protect the health or life of the patient or when the pregnancy was the result of sexual assault or incest. 

  

	•	 	The following services when a doctor gives a written order: 

  

	 	•	 	Prostheses and other corrective support devices 

  

	 	•	 	Hearing aids and other hearing services 

  

	 	•	 	Home health care 

  

	 	•	 	Personal care 

  

	 	•	 	Independent nursing services 

  

	 	•	 	Medical supplies and equipment 

  

	 	•	 	Occupational therapy 

  

	 	•	 	Physical therapy 

  

	 	•	 	Speech therapy 

  

	 	•	 	Respiratory therapy 

  

	 	•	 	Nursing home services 

  

	 	•	 	Medical Nutrition Counseling 

  

	 	•	 	Hospice care 

  

	 	•	 	Appropriate transportation to obtain medical care by ambulance or specialized medical vehicles 

  

	•	 	Certain dental services (not all dental services are covered) [Eliminate if HMO does not provide dental]. 

  

	•	 	Certain chiropractic services [Eliminate if HMO does not provide chiropractic]. 

  
 MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES 
  

[HMO NAME] provides mental health and substance abuse (drug and alcohol) services to all enrollees. If you need these services, call [PCP, gatekeeper, Customer
Service, as appropriate]. 
  
 FAMILY PLANNING SERVICES 
  
 We provide confidential family planning services to all enrollees. This includes minors. If
you do not want to talk to your primary care doctor about family planning, call our Customer Service Department at [1–800-xxx-xxx]. We will help you choose a [HMO NAME] family planning doctor who is different from your primary care doctor.

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -164- 








 You can also go to any family planning clinic that will accept your Forward ID card even if the clinic is not part of
[HMO NAME]. But we encourage you to receive family planning services from a [HMO NAME] doctor. That way we can better coordinate all your health care. 
  
 DENTAL SERVICES 
  
 [Note to HMO: Use statement 1. if you provide dental services. Use statement 2. if you do not provide dental services. If you provide dental services in only part of your service area, use both statements and list the
appropriate counties with each statement.] 
  

	1.	[HMO NAME] provides all covered dental services. But you must go to a [HMO NAME] dentist. See the Provider Directory or call the Customer Service Department at [1-800-xxx-xxxx] for
the names of our dentists. 

  

	2.	You may get dental services from any dentist who will accept your Forward ID card. Your dental services are provided by the State, not [HMO NAME]. 

  
 Dental Emergency: 
  
 A dental emergency is an immediate dental service needed to treat dental pain, swelling, fever, infection, or injury to the teeth.

  
 WHAT TO DO IF YOU OR YOUR CHILD HAS A DENTAL EMERGENCY 
  

	1.	If you already have a dentist who is with [HMO NAME]: 

  

	 	•	 	Call the dentist’s office. 

  

	 	•	 	Identify yourself or your child as having a dental emergency. 

  

	 	•	 	Tell the dentist’s office what the exact dental problem is. This may be something like a toothache or swollen face. Make sure the office understands that you or your child is
having a “dental emergency.” 

  

	 	•	 	Call us if you need help with transportation to your dental appointment. 

  

	2.	If you do not currently have a dentist who is with [HMO NAME]: 

  

	 	•	 	Call {HMO specific dental gatekeeper or HMO}. Tell us that you/your child is having a dental emergency. We can help you get dental services. 

  

	 	•	 	Tell us if you need a ride to the dentist’s office. 

  

	 	•	 	Alternative language for HMO’s whose dental gatekeeper handles appointment for emergencies. Call [HMO NAME] if you need help with transportation to the dentist’s office.
We can help with transportation. 

  
 For help with a dental
emergency call [xxx-xxx-xxxx]. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -165- 








 CHIROPRACTIC SERVICES 
  
 [Note to HMO: Use statement 1 if you provide chiropractic services. Use statement 2 if you do not provide chiropractic services.] 
  

	1.	[HMO NAME] provides covered chiropractic services. But you must go to a [HMO NAME] chiropractor. See the Provider Directory or call the Customer Service Department at
[1-800-xxx-xxxx] for the names of our chiropractors. 

  

	2.	You may get chiropractic services from any chiropractor who will accept your Forward ID card. Your chiropractic services are provided by the State, not [HMO NAME].


  
 HEALTHCHECK 
  
 HealthCheck is a preventive health checkup program for members under the age of 21. The
HealthCheck program covers complete health checkups. These checkups are very important for children’s health. Your child may look and feel well, yet may have a health problem. Your doctor wants to see your children for regular checkups, not
just when they are sick. 
  
 The HealthCheck
health program has three purposes: 
  

	1.	To find and treat children’s health problems early, 

  

	2.	To let you know about the special child health services you can receive, and 

  

	3.	To make your children eligible for some health care not otherwise covered. 

  
 The HealthCheck program covers the care for any health problems found during the checkup including medical care, eye care and dental care. 
  
 The HealthCheck checkup includes: 
  

	•	 	a health history 

  

	•	 	physical exam 

  

	•	 	developmental assessment 

  

	•	 	hearing and vision test 

  

	•	 	blood and urine lab tests 

  

	•	 	complete immunizations (shots) 

  
 Children age three and older will be referred to a dentist. You will receive help in choosing and getting to a dentist. 
  
 [HMO NAME] will help arrange for transportation for HealthCheck visits. Call our Customer
Service Department a [1-800-xxx-xxxx]. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -166- 








 Ask your child’s primary care doctor (PCP) when your child should have his/her next HealthCheck exam or call our
Customer Service Department at [1-800-xxx-xxxx] for more information. 
  
 TRANSPORTATION 
  
 (Note to HMO: Use statement 1 if you arrange
transportation for your enrollees. Use statement 2 if you do not arrange transportation for your enrollees. Use statement 3 if you arrange transportation in only part of your service area.) 
  

	1.	Bus or taxi rides to receive care are arranged by [HMO NAME]. Call our Customer Service Department at [1-800-xxx-xxxx] if you need a ride. 

  

	2.	Bus or taxi rides to receive care are arranged by your county Department of Social or Human Services Call them for information. 

  

	3.	Bus or taxi rides to receive care are arranged by [HMO NAME] if you live in [INSERT COUNTIES]. Call our Customer Service Department at [1-800-xxx-xxxx] if you need a ride. If you
live in a county that is not listed, please call your county Department of Social or Human Services for information about arranging a ride. 

  
 AMBULANCE 
  
 [HMO NAME] covers ambulance service for Emergency Care. We may also cover this service at other times, but you must have approval for all non-emergency ambulance trips. Call our Customer Service Department at
[1-800-xxx-xxxx] for approval. 
  
 SPECIAL MEDICAL VEHICLE (SMV)

  
 [HMO NAME] covers transportation by special vehicle for those in
wheelchairs. We may also cover this service for others if your doctor asks for it. Call our Customer Service Department at [1-800-xxx-xxxx] if you need this service. 
  
 IF YOU MOVE 
  
 If you are planning to move, contact your county Department of Social or Human Services. If you move to a different county, you must also contact the Department of Social
or Human Services in your new county to update your eligibility. 
  
 If you move
out of [HMO NAME’S] service area, call the HMO Enrollment Specialist at 1-800 291-2002. [HMO NAME] will only provide emergency care if you move out of our service area. The Enrollment Specialist will help you choose an HMO that serves your
area. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -167- 








 HEALTH INSURANCE AFTER YOUR ELIGIBILITY ENDS 
  
 You have the right to purchase a private health insurance policy from [HMO NAME] when your eligibility ends. Call our Customer Service
Department at [1-800-xxx-xxxx]. If you decide to purchase a policy from us, you have 30 days after the date your eligibility ends to apply. 
  
 SECOND MEDICAL OPINION 
  
 A second medical opinion on recommended surgeries may be appropriate in some cases. Contact your doctor or our Customer Service Department for information. 
  
 HMO EXEMPTIONS 
  
 An HMO exemption means you are not required to join an HMO to receive your health care benefits. Most exemptions are granted for only a short period of time so you can
complete a course of treatment before you are enrolled in an HMO. If you think you need an exemption from HMO enrollment, call the HMO Enrollment Specialist at 1-800-291-2002 for more information. 
  
 LIVING WILL OR POWER OF ATTORNEY FOR HEALTH CARE 
  
 You have a right to make decisions about your medical care. You have a right to accept or
refuse medical or surgical treatment. You also have the right to plan and direct the types of health care you may receive in the future if you become unable to express your wishes. You can let your doctor know about your feelings by completing a
living will or power of attorney for health care form. Contact your doctor for more information. 
  
 RIGHT TO MEDICAL RECORDS 
  
 You have the
right to ask for copies of your medical record from your provider(s). We can help you get copies of these records. Please call [1-800-xxx-xxxx] for help. Please note: You may have to pay to copy your medical record. You also may correct wrong
information in your medical records if your doctor agrees to the correction. 
  
 [HMO NAME’S] MEMBER ADVOCATE 
  
 [HMO NAME] has a Member
Advocate to help you get the care you need. The Advocate can answer your questions about getting health care from [HMO NAME]. The Advocate can also help you solve any problems you may have getting health care from [HMO NAME]. You can reach the
Advocate at [1-800-xxx-xxxx]. 
  
 STATE OF WISCONSIN HMO OMBUDSMAN PROGRAM

  
 The State has Ombudsmen who can help you with any questions or problems
you have as an HMO member. The Ombudsman can tell you how to get the care you need from your HMO. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -168- 








 The Ombudsman can also help you solve problems or complaints you may have about the HMO Program or your HMO. Call
1-800-760-0001 and ask to speak to an Ombudsman. 
  
 COMPLAINTS, GRIEVANCES AND
APPEALS 
  
 We would like to know if you have a complaint about your care at
[HMO NAME]. Please call [HMO NAME’S] Member Advocate at [1-800-xxx-xxxx] if you have a complaint. Or you can write to us at: 
  
 [HMO name and mailing address] 
  
 If you want to talk to someone outside of [HMO NAME] about the problem, call the HMO Enrollment Specialist at 1-800-291-2002. The Enrollment Specialist may be able to
help you solve the problem, or can help you write a formal grievance to [HMO NAME] or to the Wisconsin Managed Care Program. The address to complain to the Wisconsin Managed Care Program is: 
  
 Wisconsin Managed Care 
 Ombudsman 
 P. O. Box 6470 
 Madison, WI 53716-0470 
 1-800-760-0001

  
 If your complaint or grievance needs action right away because a delay in
treatment would greatly increase the risk to your health, please call [HMO NAME] as soon as possible at [1-800-xxx-xxxx]. 
  
 We cannot treat you differently than other members because you file a complaint or grievance. Your health care benefits will not be affected. 
  
 You have the right to appeal to the State of Wisconsin Division of Hearings and Appeals (DHA)
for a Fair Hearing if you believe your benefits are wrongly denied, limited, reduced, delayed or stopped by [HMO NAME]. An appeal must be made no later than 45 days after the date of the action being appealed. If you appeal this action to DHA before
the effective date, the service may continue. You may need to pay for the cost of services if the hearing decision is not in your favor. 
  
 If you want a Fair Hearing, send a written request to: 
  
 Department of Administration 
 Division of Hearings and Appeals 
 P. O. Box 7875 
 Madison, WI 53707-7875 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -169- 








 The hearing will be held in the county where you live. You have the right to bring a friend or be represented at the
hearing. If you need a special arrangement for a disability, or for English language translation, please call (608) 266-3096 (voice) or (608) 264-9853 (hearing impaired). 
  
 We cannot treat you differently than other members because you request a Fair Hearing. Your health care benefits will not be affected.

  
 If you need help writing a request for a Fair
Hearing, please call: 
  

					
	Wisconsin Managed Care Ombudsman	 	1-800-760-0001	 	 
	                                       
         or	 	 	 	 
	HMO Enrollment Specialist	 	1-800-291-2002	 	 

  
 PHYSICIAN INCENTIVE PLAN

  
 You are entitled to ask if we have special financial arrangements with
our physicians that can affect the use of referrals and other services you might need. To get this information, call our Customer Service Department at [1-800-xxx-xxxx] and request information about our physician payment arrangements. 
  
 PROVIDER CREDENTIALS 
  
 You have the right to information about our providers that includes the provider’s education, board certification and recertification.
To get this information, call our Customer Service Department at [1-800-xxx-xxxx]. 
  
 MEMBER RIGHTS 
  
 You have the right to ask for an interpreter
and have one provided to you during any Medicaid/BadgerCare covered service. 
  
 You have the right to receive the information provided in this member handbook in another language or another format. 
  
 You have the right to receive health care services as provided for in federal and state law. All covered services must be available and accessible to you. When medically
appropriate, services must be available 24 hours a day, 7 days a week. 
  
 You have the right to receive information about treatment options including the right to request a second opinion. 
  
 You have the right to make decisions about your health care. 
  
 You have the right to be treated with dignity and respect. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -170- 








 You have the right to be free from any form of restraint or seclusion used as a means of force, control, ease or
reprisal. 
  
 YOUR CIVIL RIGHTS 
  
 [HMO NAME] provides covered services to all eligible members regardless of: 
  

	•	 	Age 

  

	•	 	Race 

  

	•	 	Religion 

  

	•	 	Color 

  

	•	 	Disability 

  

	•	 	Sex 

  

	•	 	Sexual Orientation 

  

	•	 	National Origin 

  

	•	 	Marital Status 

  

	•	 	Arrest or Conviction Record 

  

	•	 	Military Participation 

  
 All medically necessary covered services are available to all members. 
  
 All services are provided in the same manner to all members. 
  
 All persons or organizations connected with [HMO Name] who refer or recommend members for services shall do so in the same manner for all members. 
  
 Translating or interpreting services are available for those members who need them. This service is free. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -171- 








 Addendum III-A: 
 CY 2006 Final AFDC/HS Children Capitation Rates by Age/Gender & Rate Region 
 effective February
1st, 2006 
  

																																													
	All services Capitation Rate by Age/Gender and Rate Region
																
	 	 	 Rate Region >
 Age Code

	 	1

	 	2

	 	3

	 	4

	 	5

	 	6

	 	7

	 	8

	 	9

	 	40

	 	13

	 	18

	 	30

	 	67


	 Age
Range

	 	 	Duluth/
Sup

	 	Wausau/
Rldr

	 	Green
Bay

	 	Twin
Cities

	 	Mfld/St
Pt

	 	Appleton/Osh

	 	La
Crosse

	 	Madison

	 	SE Wis

	 	Milw Co

	 	Dane Co

	 	Eau
Claire Co

	 	Kenosha
Co

	 	Wauk
Co


	 < 1
	 	A	 	$	355.57	 	$	346.13	 	$	350.31	 	$	377.12	 	$	341.95	 	$	315.89	 	$	308.96	 	$	334.32	 	$	318.73	 	$	339.42	 	$	307.77	 	$	317.48	 	$	379.57	 	$	348.18
	 01-05
	 	B	 	$	76.91	 	$	74.64	 	$	75.32	 	$	80.73	 	$	75.02	 	$	68.64	 	$	67.05	 	$	72.35	 	$	68.53	 	$	72.56	 	$	 66.30	 	$	68.38	 	$	81.20	 	$	73.52
	 06-14
	 	C	 	$	65.72	 	$	63.60	 	$	64.01	 	$	68.36	 	$	64.89	 	$	58.86	 	$	57.45	 	$	61.83	 	$	58.22	 	$	61.31	 	$	 56.43	 	$	58.24	 	$	68.68	 	$	61.46
	 15-20F
	 	E	 	$	235.19	 	$	228.69	 	$	230.86	 	$	248.73	 	$	228.25	 	$	209.50	 	$	204.95	 	$	221.12	 	$	209.84	 	$	222.45	 	$	202.93	 	$	210.64	 	$	249.05	 	$	227.01
	 15-20M
	 	D	 	$	90.55	 	$	87.88	 	$	88.44	 	$	95.19	 	$	88.97	 	$	80.96	 	$	79.19	 	$	85.14	 	$	80.32	 	$	84.65	 	$	77.81	 	$	81.19	 	$	94.88	 	$	85.63
	 21-34F
	 	G	 	$	340.67	 	$	331.54	 	$	334.62	 	$	361.39	 	$	330.27	 	$	303.33	 	$	296.96	 	$	320.25	 	$	303.99	 	$	322.25	 	$	293.96	 	$	306.27	 	$	360.90	 	$	329.65
	 21-34M
	 	F	 	$	196.57	 	$	191.29	 	$	192.85	 	$	208.65	 	$	191.15	 	$	175.17	 	$	171.57	 	$	184.75	 	$	175.08	 	$	185.22	 	$	169.40	 	$	177.33	 	$	207.58	 	$	189.36
	 35+F
	 	I	 	$	415.78	 	$	404.79	 	$	408.40	 	$	441.89	 	$	403.13	 	$	370.20	 	$	362.59	 	$	390.80	 	$	370.85	 	$	392.92	 	$	358.67	 	$	374.88	 	$	440.20	 	$	402.44
	 35+M
	 	H	 	$	328.48	 	$	319.75	 	$	322.58	 	$	348.94	 	$	318.66	 	$	292.52	 	$	286.49	 	$	308.74	 	$	292.92	 	$	310.28	 	$	283.33	 	$	296.09	 	$	347.63	 	$	317.63
	
	Dental No Chiropractic Service Capitation Rate by Age/Gender and Rate Region
																
	 	 	 Rate Region >
 Age Code

	 	1

	 	2

	 	3

	 	4

	 	5

	 	6

	 	7

	 	8

	 	9

	 	40

	 	13

	 	18

	 	30

	 	67


	 Age
Range

	 	 	Duluth/
Sup

	 	Wausau/
Rldr

	 	Green
Bay

	 	Twin
Cities

	 	Mfld/St
Pt

	 	Appleton/Osh

	 	La
Crosse

	 	Madison

	 	SE Wis

	 	Milw Co

	 	Dane Co

	 	Eau
Claire Co

	 	Kenosha
Co

	 	Wauk
Co


	 < 1
	 	A	 	$	355.17	 	$	345.67	 	$	349.97	 	$	376.32	 	$	341.38	 	$	315.50	 	$	308.48	 	$	333.98	 	$	318.53	 	$	339.39	 	$	307.53	 	$	316.50	 	$	379.43	 	$	347.98
	 01-05
	 	B	 	$	76.50	 	$	74.17	 	$	74.97	 	$	79.91	 	$	74.43	 	$	68.24	 	$	66.56	 	$	72.00	 	$	68.32	 	$	72.52	 	$	66.05	 	$	67.38	 	$	81.06	 	$	73.31
	 06-14
	 	C	 	$	65.10	 	$	62.89	 	$	63.49	 	$	67.13	 	$	64.01	 	$	58.26	 	$	56.71	 	$	61.30	 	$	57.91	 	$	61.26	 	$	56.06	 	$	56.73	 	$	68.46	 	$	61.15
	 15-20F
	 	E	 	$	233.67	 	$	226.94	 	$	229.57	 	$	245.70	 	$	226.07	 	$	208.02	 	$	203.12	 	$	219.81	 	$	209.08	 	$	222.32	 	$	202.01	 	$	206.91	 	$	248.52	 	$	226.25
	 15-20M
	 	D	 	$	89.44	 	$	86.60	 	$	87.49	 	$	92.97	 	$	87.37	 	$	79.87	 	$	77.85	 	$	84.18	 	$	79.76	 	$	84.55	 	$	77.14	 	$	78.46	 	$	94.49	 	$	85.07
	 21-34F
	 	G	 	$	338.06	 	$	328.53	 	$	332.40	 	$	356.18	 	$	326.52	 	$	300.78	 	$	293.82	 	$	318.00	 	$	302.68	 	$	322.02	 	$	292.38	 	$	299.86	 	$	359.98	 	$	328.34
	 21-34M
	 	F	 	$	194.49	 	$	188.89	 	$	191.08	 	$	204.50	 	$	188.17	 	$	173.14	 	$	169.07	 	$	182.96	 	$	174.03	 	$	185.04	 	$	168.14	 	$	172.22	 	$	206.85	 	$	188.31
	 35+F
	 	I	 	$	412.01	 	$	400.45	 	$	405.20	 	$	434.36	 	$	397.72	 	$	366.52	 	$	358.06	 	$	387.55	 	$	368.95	 	$	392.59	 	$	356.39	 	$	365.63	 	$	438.87	 	$	400.55
	 35+M
	 	H	 	$	325.47	 	$	316.28	 	$	320.02	 	$	342.93	 	$	314.34	 	$	289.58	 	$	282.87	 	$	306.15	 	$	291.40	 	$	310.02	 	$	281.50	 	$	288.69	 	$	346.57	 	$	316.12
	
	Chiropractic No Dental Service Capitation Rate by Age/Gender and Rate Region
																
	 	 	 Rate Region >
 Age Code

	 	1

	 	2

	 	3

	 	4

	 	5

	 	6

	 	7

	 	8

	 	9

	 	40

	 	13

	 	18

	 	30

	 	67


	 Age
Range

	 	 	Duluth/
Sup

	 	Wausau/
Rldr

	 	Green
Bay

	 	Twin
Cities

	 	Mfld/St
Pt

	 	Appleton/Osh

	 	La
Crosse

	 	Madison

	 	SE Wis

	 	Milw Co

	 	Dane Co

	 	Eau
Claire Co

	 	Kenosha
Co

	 	Wauk
Co


	 < 1
	 	A	 	$	355.54	 	$	346.10	 	$	350.28	 	$	377.09	 	$	341.91	 	$	315.86	 	$	308.93	 	$	334.29	 	$	318.70	 	$	339.39	 	$	307.74	 	$	317.45	 	$	379.54	 	$	348.16
	 01-05
	 	B	 	$	72.06	 	$	70.21	 	$	70.95	 	$	76.74	 	$	69.46	 	$	64.05	 	$	62.72	 	$	67.73	 	$	64.47	 	$	68.51	 	$	62.29	 	$	64.85	 	$	 76.69	 	$	70.41
	 06-14
	 	C	 	$	57.93	 	$	56.48	 	$	56.99	 	$	61.95	 	$	55.96	 	$	51.50	 	$	50.51	 	$	54.42	 	$	51.70	 	$	54.81	 	$	49.99	 	$	52.58	 	$	61.44	 	$	 56.46
	 15-20F
	 	E	 	$	227.21	 	$	221.40	 	$	223.67	 	$	242.16	 	$	219.10	 	$	201.96	 	$	197.84	 	$	213.53	 	$	203.16	 	$	215.79	 	$	196.33	 	$	204.84	 	$	241.64	 	$	221.89
	 15-20M
	 	D	 	$	82.99	 	$	80.97	 	$	81.63	 	$	88.97	 	$	80.30	 	$	73.82	 	$	72.45	 	$	77.95	 	$	73.99	 	$	78.34	 	$	71.56	 	$	75.69	 	$	87.86	 	$	80.78
	 21-34F
	 	G	 	$	332.12	 	$	323.72	 	$	326.91	 	$	354.35	 	$	320.46	 	$	295.25	 	$	289.33	 	$	312.11	 	$	296.83	 	$	315.11	 	$	286.89	 	$	300.05	 	$	352.95	 	$	324.16
	 21-34M
	 	F	 	$	189.92	 	$	185.21	 	$	186.85	 	$	203.17	 	$	183.52	 	$	168.88	 	$	165.64	 	$	178.42	 	$	169.51	 	$	179.67	 	$	163.90	 	$	172.49	 	$	201.40	 	$	185.09
	 35+F
	 	I	 	$	406.50	 	$	396.30	 	$	400.03	 	$	434.25	 	$	392.49	 	$	361.42	 	$	354.31	 	$	381.96	 	$	363.08	 	$	385.17	 	$	350.99	 	$	368.13	 	$	431.57	 	$	396.48
	 35+M
	 	H	 	$	320.30	 	$	312.27	 	$	315.20	 	$	342.20	 	$	309.28	 	$	284.78	 	$	279.19	 	$	300.95	 	$	286.07	 	$	303.45	 	$	276.56	 	$	290.14	 	$	340.02	 	$	312.38
	
	No Chiropractic & No Dental Service Capitation Rate by Age/Gender and Rate Region
																
	 	 	 Rate Region >
 Age Code

	 	1

	 	2

	 	3

	 	4

	 	5

	 	6

	 	7

	 	8

	 	9

	 	40

	 	13

	 	18

	 	30

	 	67


	 Age
Range

	 	 	Duluth/
Sup

	 	Wausau/
Rldr

	 	Green
Bay

	 	Twin
Cities

	 	Mfld/St
Pt

	 	Appleton/Osh

	 	La
Crosse

	 	Madison

	 	SE Wis

	 	Milw Co

	 	Dane Co

	 	Eau
Claire Co

	 	Kenosha
Co

	 	Wauk
Co


	 < 1
	 	A	 	$	355.14	 	$	345.64	 	$	349.94	 	$	376.29	 	$	341.34	 	$	315.47	 	$	308.45	 	$	333.95	 	$	318.50	 	$	339.36	 	$	307.50	 	$	316.47	 	$	379.40	 	$	347.96
	 01-05
	 	B	 	$	71.65	 	$	69.74	 	$	70.60	 	$	75.92	 	$	68.87	 	$	63.65	 	$	62.23	 	$	67.38	 	$	64.26	 	$	68.47	 	$	62.04	 	$	63.85	 	$	76.55	 	$	70.20
	 06-14
	 	C	 	$	57.31	 	$	55.77	 	$	56.47	 	$	60.72	 	$	55.08	 	$	50.90	 	$	49.77	 	$	53.89	 	$	51.39	 	$	54.76	 	$	49.62	 	$	51.07	 	$	 61.22	 	$	56.15
	 15-20F
	 	E	 	$	225.69	 	$	219.65	 	$	222.38	 	$	239.13	 	$	216.92	 	$	200.48	 	$	196.01	 	$	212.22	 	$	202.40	 	$	215.66	 	$	195.41	 	$	201.11	 	$	241.11	 	$	221.13
	 15-20M
	 	D	 	$	81.88	 	$	79.69	 	$	 80.68	 	$	86.75	 	$	78.70	 	$	72.73	 	$	71.11	 	$	76.99	 	$	73.43	 	$	78.24	 	$	70.89	 	$	72.96	 	$	87.47	 	$	80.22
	 21-34F
	 	G	 	$	329.51	 	$	320.71	 	$	324.69	 	$	349.14	 	$	316.71	 	$	292.70	 	$	286.19	 	$	309.86	 	$	295.52	 	$	314.88	 	$	285.31	 	$	293.64	 	$	352.03	 	$	322.85
	 21-34M
	 	F	 	$	187.84	 	$	182.81	 	$	185.08	 	$	199.02	 	$	180.54	 	$	166.85	 	$	163.14	 	$	176.63	 	$	168.46	 	$	179.49	 	$	162.64	 	$	167.38	 	$	200.67	 	$	184.04
	 35+F
	 	I	 	$	402.73	 	$	391.96	 	$	396.83	 	$	426.72	 	$	387.08	 	$	357.74	 	$	349.78	 	$	378.71	 	$	361.18	 	$	384.84	 	$	348.71	 	$	358.88	 	$	430.24	 	$	394.59
	 35+M
	 	H	 	$	317.29	 	$	308.80	 	$	312.64	 	$	336.19	 	$	304.96	 	$	281.84	 	$	275.57	 	$	298.36	 	$	284.55	 	$	303.19	 	$	274.73	 	$	282.74	 	$	338.96	 	$	310.87








 Addendum III - A 
 CY 2006 BadgerCare Capitation Rates - by Age and Gender 
 Effective February 1st, 2006

  

																																													
	 2006 BadgerCare Rates - Applies to medical status codes B1,B2,B3,B4,B5,B6,GP
 All Services

																
	 Age Range

	  	Gender

	  	Duluth/
Superior
1

	  	Wausau/
Rhinelander
2

	  	Green Bay
3

	  	Twin Cities
4

	  	Marshfield/
Stevens Point
5

	  	 Appleton/
Oshkosh
 6

	  	La Crosse
7

	  	 Madison
 8

	  	Southeast
Wisconsin
9

	  	Milwaukee
10

	  	 Dane
 11

	  	Eau Claire
12

	  	Kenosha
13

	  	Waukesha
14


	 Age 0
	  	All	  	$	355.57	  	$	346.13	  	$	350.31	  	$	377.12	  	$	341.95	  	$	315.89	  	$	308.96	  	$	334.32	  	$	318.73	  	$	339.42	  	$	307.77	  	$	317.48	  	$	379.57	  	$	348.18
	 Age 1-14
	  	All	  	$	66.85	  	$	63.84	  	$	64.96	  	$	66.59	  	$	62.26	  	$	62.78	  	$	51.52	  	$	68.56	  	$	64.22	  	$	62.38	  	$	58.76	  	$	57.70	  	$	71.58	  	$	65.49
	 Age 15-20
	  	F	  	$	139.00	  	$	135.15	  	$	136.34	  	$	140.78	  	$	128.52	  	$	129.52	  	$	107.13	  	$	143.12	  	$	134.61	  	$	128.35	  	$	124.69	  	$	122.04	  	$	147.57	  	$	138.27
	 Age 15-20
	  	M	  	$	100.82	  	$	97.43	  	$	98.58	  	$	101.52	  	$	93.43	  	$	94.18	  	$	77.69	  	$	103.67	  	$	97.38	  	$	93.45	  	$	89.85	  	$	88.00	  	$	107.36	  	$	99.80
	 Age 21-34
	  	F	  	$	212.16	  	$	207.82	  	$	209.08	  	$	216.16	  	$	194.80	  	$	196.77	  	$	163.16	  	$	218.74	  	$	206.50	  	$	195.35	  	$	192.41	  	$	187.49	  	$	224.50	  	$	212.95
	 Age 21-34
	  	M	  	$	123.26	  	$	120.65	  	$	121.28	  	$	125.68	  	$	114.02	  	$	114.66	  	$	95.16	  	$	127.15	  	$	119.61	  	$	113.26	  	$	111.22	  	$	108.93	  	$	130.42	  	$	123.07
	 Age 35-44
	  	F	  	$	275.02	  	$	270.03	  	$	271.40	  	$	280.78	  	$	252.17	  	$	254.77	  	$	211.46	  	$	283.68	  	$	268.02	  	$	252.94	  	$	250.16	  	$	243.56	  	$	290.70	  	$	276.69
	 Age 35-44
	  	M	  	$	192.68	  	$	189.12	  	$	190.05	  	$	196.72	  	$	177.01	  	$	178.64	  	$	148.29	  	$	198.77	  	$	187.62	  	$	177.14	  	$	175.01	  	$	170.61	  	$	203.68	  	$	193.56
	 Age 45+
	  	F	  	$	356.39	  	$	349.91	  	$	351.78	  	$	363.75	  	$	326.30	  	$	329.97	  	$	273.81	  	$	367.56	  	$	347.50	  	$	327.97	  	$	324.44	  	$	315.57	  	$	376.74	  	$	358.90
	 Age 45+
	  	M	  	$	313.46	  	$	307.29	  	$	309.31	  	$	319.27	  	$	286.31	  	$	290.10	  	$	240.42	  	$	323.09	  	$	305.78	  	$	289.05	  	$	285.40	  	$	277.08	  	$	331.67	  	$	315.91
	
	 BadgerCare Rates - Applies to medical status codes B1,B2,B3,B4,B5,B6,GP
 Dental Services - No Chiropractic

																
	 Age Range

	  	Gender

	  	Duluth/
Superior
1

	  	Wausau/
Rhinelander
2

	  	Green Bay
3

	  	Twin Cities
4

	  	Marshfield/
Stevens Point
5

	  	 Appleton/
Oshkosh
 6

	  	La Crosse
7

	  	 Madison
 8

	  	Southeast
Wisconsin
9

	  	Milwaukee
10

	  	 Dane
 11

	  	Eau Claire
12

	  	Kenosha
13

	  	Waukesha
14


	 Age 0
	  	All	  	$	355.17	  	$	345.67	  	$	349.97	  	$	376.32	  	$	341.38	  	$	315.50	  	$	308.48	  	$	333.98	  	$	318.53	  	$	339.39	  	$	307.53	  	$	316.50	  	$	379.43	  	$	347.98
	 Age 1-14
	  	All	  	$	66.17	  	$	62.74	  	$	64.20	  	$	65.31	  	$	61.02	  	$	62.02	  	$	50.64	  	$	67.68	  	$	63.67	  	$	62.27	  	$	58.16	  	$	56.66	  	$	71.13	  	$	65.00
	 Age 15-20
	  	F	  	$	137.16	  	$	132.19	  	$	134.31	  	$	137.34	  	$	125.18	  	$	127.49	  	$	104.76	  	$	140.75	  	$	133.14	  	$	128.05	  	$	123.09	  	$	119.25	  	$	146.35	  	$	136.96
	 Age 15-20
	  	M	  	$	99.62	  	$	95.49	  	$	97.25	  	$	99.27	  	$	91.24	  	$	92.85	  	$	76.14	  	$	102.12	  	$	96.42	  	$	93.25	  	$	88.80	  	$	86.18	  	$	106.56	  	$	98.94
	 Age 21-34
	  	F	  	$	209.70	  	$	203.86	  	$	206.36	  	$	211.56	  	$	190.33	  	$	194.05	  	$	159.99	  	$	215.56	  	$	204.53	  	$	194.95	  	$	190.27	  	$	183.76	  	$	222.87	  	$	211.20
	 Age 21-34
	  	M	  	$	121.23	  	$	117.38	  	$	119.03	  	$	121.88	  	$	110.32	  	$	112.41	  	$	92.54	  	$	124.52	  	$	117.99	  	$	112.93	  	$	109.45	  	$	105.85	  	$	129.08	  	$	121.62
	 Age 35-44
	  	F	  	$	271.82	  	$	264.88	  	$	267.86	  	$	274.80	  	$	246.35	  	$	251.23	  	$	207.33	  	$	279.55	  	$	265.46	  	$	252.42	  	$	247.37	  	$	238.71	  	$	288.58	  	$	274.41
	 Age 35-44
	  	M	  	$	190.21	  	$	185.15	  	$	187.32	  	$	192.11	  	$	172.52	  	$	175.91	  	$	145.11	  	$	195.59	  	$	185.65	  	$	176.74	  	$	172.86	  	$	166.87	  	$	202.05	  	$	191.81
	 Age 45+
	  	F	  	$	352.61	  	$	343.83	  	$	347.60	  	$	356.69	  	$	319.43	  	$	325.79	  	$	268.94	  	$	362.68	  	$	344.48	  	$	327.35	  	$	321.15	  	$	309.85	  	$	374.24	  	$	356.21
	 Age 45+
	  	M	  	$	310.91	  	$	303.18	  	$	306.49	  	$	314.50	  	$	281.66	  	$	287.27	  	$	237.13	  	$	319.79	  	$	303.74	  	$	288.63	  	$	283.18	  	$	273.21	  	$	329.98	  	$	314.09
	
	 BadgerCare Rates - Applies to medical status codes B1,B2,B3,B4,B5,B6,GP
 Chiropractic Services - No Dental

																
	 Age Range

	  	Gender

	  	Duluth/
Superior
1

	  	Wausau/
Rhinelander
2

	  	Green Bay
3

	  	Twin Cities
4

	  	Marshfield/
Stevens Point
5

	  	 Appleton/
Oshkosh
 6

	  	La Crosse
7

	  	 Madison
 8

	  	Southeast
Wisconsin
9

	  	Milwaukee
10

	  	 Dane
 11

	  	Eau Claire
12

	  	Kenosha
13

	  	Waukesha
14


	 Age 0
	  	All	  	$	355.54	  	$	346.10	  	$	350.28	  	$	377.09	  	$	341.91	  	$	315.86	  	$	308.93	  	$	334.29	  	$	318.70	  	$	339.39	  	$	307.74	  	$	317.45	  	$	379.54	  	$	348.16
	 Age 1-14
	  	All	  	$	57.52	  	$	56.92	  	$	57.02	  	$	59.13	  	$	52.50	  	$	53.09	  	$	44.20	  	$	59.43	  	$	56.30	  	$	52.70	  	$	52.83	  	$	51.31	  	$	60.59	  	$	58.31
	 Age 15-20
	  	F	  	$	128.63	  	$	127.46	  	$	127.52	  	$	132.49	  	$	117.68	  	$	118.75	  	$	98.99	  	$	132.97	  	$	125.81	  	$	117.60	  	$	118.10	  	$	114.93	  	$	135.36	  	$	130.29
	 Age 15-20
	  	M	  	$	91.13	  	$	90.25	  	$	90.34	  	$	93.78	  	$	83.30	  	$	84.12	  	$	70.09	  	$	94.19	  	$	89.16	  	$	83.40	  	$	83.69	  	$	81.36	  	$	95.95	  	$	92.35
	 Age 21-34
	  	F	  	$	203.63	  	$	201.50	  	$	201.83	  	$	209.35	  	$	185.89	  	$	187.92	  	$	156.47	  	$	210.39	  	$	199.26	  	$	186.51	  	$	186.99	  	$	181.65	  	$	214.46	  	$	206.39
	 Age 21-34
	  	M	  	$	116.37	  	$	115.55	  	$	115.42	  	$	120.18	  	$	106.82	  	$	107.51	  	$	89.76	  	$	120.41	  	$	113.76	  	$	106.12	  	$	106.84	  	$	104.21	  	$	122.31	  	$	117.77
	 Age 35-44
	  	F	  	$	266.55	  	$	263.76	  	$	264.20	  	$	274.02	  	$	243.32	  	$	245.98	  	$	204.82	  	$	275.39	  	$	260.83	  	$	244.16	  	$	244.78	  	$	237.76	  	$	280.73	  	$	270.18
	 Age 35-44
	  	M	  	$	185.86	  	$	184.06	  	$	184.25	  	$	191.27	  	$	169.88	  	$	171.56	  	$	142.94	  	$	192.09	  	$	181.83	  	$	170.07	  	$	170.67	  	$	165.94	  	$	195.65	  	$	188.31
	 Age 45+
	  	F	  	$	346.33	  	$	342.46	  	$	343.23	  	$	355.71	  	$	315.79	  	$	319.53	  	$	265.92	  	$	357.72	  	$	338.96	  	$	317.54	  	$	318.05	  	$	308.68	  	$	364.90	  	$	351.16
	 Age 45+
	  	M	  	$	304.60	  	$	300.72	  	$	301.78	  	$	312.19	  	$	277.05	  	$	280.90	  	$	233.47	  	$	314.42	  	$	298.26	  	$	279.86	  	$	279.77	  	$	271.01	  	$	321.24	  	$	309.09
	
	 BadgerCare Rates - Applies to medical status codes B1,B2,B3,B4,B5,B6,GP
 No Dental or Chiropractic

																
	 Age Range

	  	Gender

	  	Duluth/
Superior
1

	  	Wausau/
Rhinelander
2

	  	Green Bay
3

	  	Twin Cities
4

	  	Marshfield/
Stevens Point
5

	  	 Appleton/
Oshkosh
 6

	  	La Crosse
7

	  	 Madison
 8

	  	Southeast
Wisconsin
9

	  	Milwaukee
10

	  	 Dane
 11

	  	Eau Claire
12

	  	Kenosha
13

	  	Waukesha
14


	 Age 0
	  	All	  	$	355.14	  	$	345.64	  	$	349.94	  	$	376.29	  	$	341.34	  	$	315.47	  	$	308.45	  	$	333.95	  	$	318.50	  	$	339.36	  	$	307.50	  	$	316.47	  	$	379.40	  	$	347.96
	 Age 1-14
	  	All	  	$	56.84	  	$	55.82	  	$	56.26	  	$	57.85	  	$	51.26	  	$	52.33	  	$	43.32	  	$	58.55	  	$	55.75	  	$	52.59	  	$	52.23	  	$	50.27	  	$	60.14	  	$	57.82
	 Age 15-20
	  	F	  	$	126.79	  	$	124.50	  	$	125.49	  	$	129.05	  	$	114.34	  	$	116.72	  	$	96.62	  	$	130.60	  	$	124.34	  	$	117.30	  	$	116.50	  	$	112.14	  	$	134.14	  	$	128.98
	 Age 15-20
	  	M	  	$	89.93	  	$	88.31	  	$	89.01	  	$	91.53	  	$	81.11	  	$	82.79	  	$	68.54	  	$	92.64	  	$	88.20	  	$	83.20	  	$	82.64	  	$	79.54	  	$	95.15	  	$	91.49
	 Age 21-34
	  	F	  	$	201.17	  	$	197.54	  	$	199.11	  	$	204.75	  	$	181.42	  	$	185.20	  	$	153.30	  	$	207.21	  	$	197.29	  	$	186.11	  	$	184.85	  	$	177.92	  	$	212.83	  	$	204.64
	 Age 21-34
	  	M	  	$	114.34	  	$	112.28	  	$	113.17	  	$	116.38	  	$	103.12	  	$	105.26	  	$	87.14	  	$	117.78	  	$	112.14	  	$	105.79	  	$	105.07	  	$	101.13	  	$	120.97	  	$	116.32
	 Age 35-44
	  	F	  	$	263.35	  	$	258.61	  	$	260.66	  	$	268.04	  	$	237.50	  	$	242.44	  	$	200.69	  	$	271.26	  	$	258.27	  	$	243.64	  	$	241.99	  	$	232.91	  	$	278.61	  	$	267.90
	 Age 35-44
	  	M	  	$	183.39	  	$	180.09	  	$	181.52	  	$	186.66	  	$	165.39	  	$	168.83	  	$	139.76	  	$	188.91	  	$	179.86	  	$	169.67	  	$	168.52	  	$	162.20	  	$	194.02	  	$	186.56
	 Age 45+
	  	F	  	$	342.55	  	$	336.38	  	$	339.05	  	$	348.65	  	$	308.92	  	$	315.35	  	$	261.05	  	$	352.84	  	$	335.94	  	$	316.92	  	$	314.76	  	$	302.96	  	$	362.40	  	$	348.47
	 Age 45+
	  	M	  	$	302.05	  	$	296.61	  	$	298.96	  	$	307.42	  	$	272.40	  	$	278.07	  	$	230.18	  	$	311.12	  	$	296.22	  	$	279.44	  	$	277.55	  	$	267.14	  	$	319.55	  	$	307.27








 ADDENDUM III - A: 
  
 CY 2006 Healthy Start Pregnant Women Capitation Rates by Rate Region and Service 
 effective February 1st, 2006 
  
 2006 HSPW RATES 
  

																																											
	 	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	10

	  	11

	  	12

	  	13

	  	14


	 	  	 Duluth/
Superior

	  	 Wausau/
Rhinelander

	  	 Green Bay

	  	 Twin Cities

	  	 Marshfield/
Stevens Point

	  	 Appleton/
Oshkosh

	  	 La Crosse

	  	 Madison

	  	 Southeast
Wisconsin

	  	 Milwaukee

	  	 Dane

	  	 Eau Claire

	  	 Kenosha

	  	 Waukesha


	 All Services
	  	$	639.61	  	$	599.26	  	$	599.54	  	$	690.68	  	$	626.57	  	$	590.99	  	$	597.21	  	$	660.79	  	$	612.54	  	$	750.10	  	$	669.84	  	$	721.56	  	$	678.93	  	$	627.14
	 Dental, No Chiro
	  	$	637.68	  	$	596.37	  	$	598.16	  	$	687.68	  	$	623.00	  	$	588.83	  	$	594.90	  	$	658.61	  	$	611.16	  	$	749.81	  	$	668.55	  	$	717.77	  	$	678.26	  	$	626.26
	 Chiro, No Dental
	  	$	636.78	  	$	597.20	  	$	597.31	  	$	687.66	  	$	623.30	  	$	587.36	  	$	594.95	  	$	657.64	  	$	609.96	  	$	745.55	  	$	666.72	  	$	719.61	  	$	673.64	  	$	624.89
	 No Dental or Chiro
	  	$	634.85	  	$	594.31	  	$	595.93	  	$	684.66	  	$	619.73	  	$	585.20	  	$	592.64	  	$	655.46	  	$	608.58	  	$	745.26	  	$	665.43	  	$	715.82	  	$	672.97	  	$	624.01
	
	 2006 Rates by service and Rate Region

	 All Services
	  	$	639.61	  	$	599.26	  	$	599.54	  	$	690.68	  	$	626.57	  	$	590.99	  	$	597.21	  	$	660.79	  	$	612.54	  	$	750.10	  	$	669.84	  	$	721.56	  	$	678.93	  	$	627.14
	 Medical
	  	$	634.85	  	$	594.31	  	$	595.93	  	$	684.66	  	$	619.73	  	$	585.20	  	$	592.64	  	$	655.46	  	$	608.58	  	$	745.26	  	$	665.43	  	$	715.82	  	$	672.97	  	$	624.01
	 Dental
	  	$	2.83	  	$	2.06	  	$	2.23	  	$	3.02	  	$	3.27	  	$	3.63	  	$	2.26	  	$	3.15	  	$	2.58	  	$	4.55	  	$	3.12	  	$	1.95	  	$	5.29	  	$	2.25
	 Chiro
	  	$	1.93	  	$	2.89	  	$	1.38	  	$	3.00	  	$	3.57	  	$	2.16	  	$	2.31	  	$	2.18	  	$	1.38	  	$	0.29	  	$	1.29	  	$	3.79	  	$	0.67	  	$	0.88








 Addendum III - B: 
 CY 2006 AFDC/HS Children Capitation Rates By Service Category 
  
 2006 Capitation - Medical Only 
  

																																													
	 Age Range

	  	Age Code

	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	40

	  	13

	  	18

	  	30

	  	67


	  	  	Duluth/Sup

	  	Wausau/Rldr

	  	Green Bay

	  	Twin Cities

	  	Mfld/St Pt

	  	Appleton/Osh

	  	La Crosse

	  	Madison

	  	SE Wis

	  	Milw Co

	  	Dane Co

	  	Eau Claire Co

	  	Kenosha Co

	  	Wauk Co


	 < 1
	  	A	  	$	355.14	  	$	345.64	  	$	349.94	  	$	376.29	  	$	341.34	  	$	315.47	  	$	308.45	  	$	333.95	  	$	318.50	  	$	339.36	  	$	307.50	  	$	316.47	  	$	379.40	  	$	347.96
	 01-05
	  	B	  	$	71.65	  	$	69.74	  	$	70.60	  	$	75.92	  	$	68.87	  	$	63.65	  	$	62.23	  	$	67.38	  	$	64.26	  	$	68.47	  	$	62.04	  	$	63.85	  	$	76.55	  	$	70.20
	 06-14
	  	C	  	$	57.31	  	$	55.77	  	$	56.47	  	$	60.72	  	$	55.08	  	$	50.90	  	$	49.77	  	$	53.89	  	$	51.39	  	$	54.76	  	$	49.62	  	$	51.07	  	$	61.22	  	$	56.15
	 15-20F
	  	E	  	$	225.69	  	$	219.65	  	$	222.38	  	$	239.13	  	$	216.92	  	$	200.48	  	$	196.01	  	$	212.22	  	$	202.40	  	$	215.66	  	$	195.41	  	$	201.11	  	$	241.11	  	$	221.13
	 15-20M
	  	D	  	$	81.88	  	$	79.69	  	$	80.68	  	$	86.75	  	$	78.70	  	$	72.73	  	$	71.11	  	$	76.99	  	$	73.43	  	$	78.24	  	$	70.89	  	$	72.96	  	$	87.47	  	$	80.22
	 21-34F
	  	G	  	$	329.51	  	$	320.71	  	$	324.69	  	$	349.14	  	$	316.71	  	$	292.70	  	$	286.19	  	$	309.86	  	$	295.52	  	$	314.88	  	$	285.31	  	$	293.64	  	$	352.03	  	$	322.85
	 21-34M
	  	F	  	$	187.84	  	$	182.81	  	$	185.08	  	$	199.02	  	$	180.54	  	$	166.85	  	$	163.14	  	$	176.63	  	$	168.46	  	$	179.49	  	$	162.64	  	$	167.38	  	$	200.67	  	$	184.04
	 35+F
	  	I	  	$	402.73	  	$	391.96	  	$	396.83	  	$	426.72	  	$	387.08	  	$	357.74	  	$	349.78	  	$	378.71	  	$	361.18	  	$	384.84	  	$	348.71	  	$	358.88	  	$	430.24	  	$	394.59
	 35+M
	  	H	  	$	317.29	  	$	308.80	  	$	312.64	  	$	336.19	  	$	304.96	  	$	281.84	  	$	275.57	  	$	298.36	  	$	284.55	  	$	303.19	  	$	274.73	  	$	282.74	  	$	338.96	  	$	310.87
	
	 2006 Capitation - Dental Only
  

	 Age Range

	  	Age Code

	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	40

	  	13

	  	18

	  	30

	  	67


	  	  	Duluth/Sup

	  	Wausau/Rldr

	  	Green Bay

	  	Twin Cities

	  	Mfld/St Pt

	  	Appleton/Osh

	  	La Crosse

	  	Madison

	  	SE Wis

	  	Milw Co

	  	Dane Co

	  	Eau Claire Co

	  	Kenosha Co

	  	Wauk Co


	 < 1
	  	A	  	$	0.03	  	$	0.03	  	$	0.03	  	$	0.03	  	$	0.04	  	$	0.03	  	$	0.03	  	$	0.03	  	$	0.03	  	$	0.03	  	$	0.03	  	$	0.03	  	$	0.03	  	$	0.02
	 01-05
	  	B	  	$	4.85	  	$	4.43	  	$	4.37	  	$	3.99	  	$	5.56	  	$	4.59	  	$	4.33	  	$	4.62	  	$	4.06	  	$	4.05	  	$	4.01	  	$	3.53	  	$	4.51	  	$	3.11
	 06-14
	  	C	  	$	7.79	  	$	7.12	  	$	7.02	  	$	6.41	  	$	8.93	  	$	7.36	  	$	6.94	  	$	7.41	  	$	6.52	  	$	6.50	  	$	6.44	  	$	5.66	  	$	7.24	  	$	5.00
	 15-20F
	  	E	  	$	7.98	  	$	7.29	  	$	7.19	  	$	6.57	  	$	9.15	  	$	7.54	  	$	7.11	  	$	7.59	  	$	6.68	  	$	6.66	  	$	6.60	  	$	5.80	  	$	7.41	  	$	5.12
	 15-20M
	  	D	  	$	7.56	  	$	6.91	  	$	6.81	  	$	6.22	  	$	8.67	  	$	7.14	  	$	6.74	  	$	7.19	  	$	6.33	  	$	6.31	  	$	6.25	  	$	5.50	  	$	7.02	  	$	4.85
	 21-34F
	  	G	  	$	8.55	  	$	7.82	  	$	7.71	  	$	7.04	  	$	9.81	  	$	8.08	  	$	7.63	  	$	8.14	  	$	7.16	  	$	7.14	  	$	7.07	  	$	6.22	  	$	7.95	  	$	5.49
	 21-34M
	  	F	  	$	6.65	  	$	6.08	  	$	6.00	  	$	5.48	  	$	7.63	  	$	6.29	  	$	5.93	  	$	6.33	  	$	5.57	  	$	5.55	  	$	5.50	  	$	4.84	  	$	6.18	  	$	4.27
	 35+F
	  	I	  	$	9.28	  	$	8.49	  	$	8.37	  	$	7.64	  	$	10.64	  	$	8.78	  	$	8.28	  	$	8.84	  	$	7.77	  	$	7.75	  	$	7.68	  	$	6.75	  	$	8.63	  	$	5.96
	 35+M
	  	H	  	$	 8.18	  	$	7.48	  	$	7.38	  	$	6.74	  	$	9.38	  	$	7.74	  	$	7.30	  	$	7.79	  	$	6.85	  	$	6.83	  	$	6.77	  	$	5.95	  	$	7.61	  	$	5.25
	
	 2006 Capitation - Chiropractic Only
  

	 	  	 	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	40

	  	13

	  	18

	  	30

	  	67


	 Age Range

	  	Age Code

	  	Duluth/Sup

	  	Wausau/Rldr

	  	Green Bay

	  	Twin Cities

	  	Mfld/St Pt

	  	Appleton/Osh

	  	La Crosse

	  	Madison

	  	SE Wis

	  	Milw Co

	  	Dane Co

	  	Eau Claire Co

	  	Kenosha Co

	  	Wauk Co


	 < 1
	  	A	  	$	0.40	  	$	0.46	  	$	0.34	  	$	0.80	  	$	0.57	  	$	0.39	  	$	0.48	  	$	0.34	  	$	0.20	  	$	0.03	  	$	0.24	  	$	0.98	  	$	0.14	  	$	0.20
	 01-05
	  	B	  	$	0.41	  	$	0.47	  	$	0.35	  	$	0.82	  	$	0.59	  	$	0.40	  	$	0.49	  	$	0.35	  	$	0.21	  	$	0.04	  	$	0.25	  	$	1.00	  	$	0.14	  	$	0.21
	 06-14
	  	C	  	$	0.62	  	$	0.71	  	$	0.52	  	$	1.23	  	$	0.88	  	$	0.60	  	$	0.74	  	$	0.53	  	$	0.31	  	$	0.05	  	$	0.37	  	$	1.51	  	$	0.22	  	$	0.31
	 15-20F
	  	E	  	$	1.52	  	$	1.75	  	$	1.29	  	$	3.03	  	$	2.18	  	$	1.48	  	$	1.83	  	$	1.31	  	$	0.76	  	$	0.13	  	$	0.92	  	$	3.73	  	$	0.53	  	$	0.76
	 15-20M
	  	D	  	$	1.11	  	$	1.28	  	$	0.95	  	$	2.22	  	$	1.60	  	$	1.09	  	$	1.34	  	$	0.96	  	$	0.56	  	$	0.10	  	$	0.67	  	$	2.73	  	$	0.39	  	$	0.56
	 21-34F
	  	G	  	$	2.61	  	$	3.01	  	$	2.22	  	$	5.21	  	$	3.75	  	$	2.55	  	$	3.14	  	$	2.25	  	$	1.31	  	$	0.23	  	$	1.58	  	$	6.41	  	$	0.92	  	$	1.31
	 21-34M
	  	F	  	$	2.08	  	$	2.40	  	$	1.77	  	$	4.15	  	$	2.98	  	$	2.03	  	$	2.50	  	$	1.79	  	$	1.05	  	$	0.18	  	$	1.26	  	$	5.11	  	$	0.73	  	$	1.05
	 35+F
	  	I	  	$	3.77	  	$	4.34	  	$	3.20	  	$	7.53	  	$	5.41	  	$	3.68	  	$	4.53	  	$	3.25	  	$	1.90	  	$	0.33	  	$	2.28	  	$	9.25	  	$	1.33	  	$	1.89
	 35+M
	  	H	  	$	3.01	  	$	3.47	  	$	2.56	  	$	6.01	  	$	4.32	  	$	2.94	  	$	3.62	  	$	2.59	  	$	1.52	  	$	0.26	  	$	1.83	  	$	7.40	  	$	1.06	  	$	1.51








 Addendum III - B: 
 CY 2006 BadgerCare Capitation Rates By Service Category 
  
 BadgerCare Rates 
 Medical Capitation Rates by Service Category - Medical Costs 
  

																																													
	 
																
	 Age Range

	  	Gender

	  	 Duluth/
Superior
 1

	  	 Wausau/
Rhinelander
 2

	  	Green Bay
3

	  	Twin Cities
4

	  	Marshfield/
Stevens Point
5

	  	 Appleton/
Oshkosh
 6

	  	La Crosse
7

	  	 Madison
 8

	  	 Southeast
Wisconsin
 9

	  	 Milwaukee
 10

	  	 Dane
 11

	  	Eau Claire
12

	  	 Kenosha
 13

	  	 Waukesha
 14


	 Age 0
	  	All	  	$	355.14	  	$	345.64	  	$	349.94	  	$	376.29	  	$	341.34	  	$	315.47	  	$	308.45	  	$	333.95	  	$	318.50	  	$	339.36	  	$	307.50	  	$	316.47	  	$	379.40	  	$	347.96
	 Age 1-14
	  	All	  	$	56.84	  	$	55.82	  	$	56.26	  	$	57.85	  	$	51.26	  	$	52.33	  	$	43.32	  	$	58.55	  	$	55.75	  	$	52.59	  	$	52.23	  	$	50.27	  	$	60.14	  	$	57.82
	 Age 15-20
	  	F	  	$	126.79	  	$	124.50	  	$	125.49	  	$	129.05	  	$	114.34	  	$	116.72	  	$	96.62	  	$	130.60	  	$	124.34	  	$	117.30	  	$	116.50	  	$	112.14	  	$	134.14	  	$	128.98
	 Age 15-20
	  	M	  	$	89.93	  	$	88.31	  	$	89.01	  	$	91.53	  	$	81.11	  	$	82.79	  	$	68.54	  	$	92.64	  	$	88.20	  	$	83.20	  	$	82.64	  	$	79.54	  	$	95.15	  	$	91.49
	 Age 21-34
	  	F	  	$	201.17	  	$	197.54	  	$	199.11	  	$	204.75	  	$	181.42	  	$	185.20	  	$	153.30	  	$	207.21	  	$	197.29	  	$	186.11	  	$	184.85	  	$	177.92	  	$	212.83	  	$	204.64
	 Age 21-34
	  	M	  	$	114.34	  	$	112.28	  	$	113.17	  	$	116.38	  	$	103.12	  	$	105.26	  	$	87.14	  	$	117.78	  	$	112.14	  	$	105.79	  	$	105.07	  	$	101.13	  	$	120.97	  	$	116.32
	 Age 35-44
	  	F	  	$	263.35	  	$	258.61	  	$	260.66	  	$	268.04	  	$	237.50	  	$	242.44	  	$	200.69	  	$	271.26	  	$	258.27	  	$	243.64	  	$	241.99	  	$	232.91	  	$	278.61	  	$	267.90
	 Age 35-44
	  	M	  	$	183.39	  	$	180.09	  	$	181.52	  	$	186.66	  	$	165.39	  	$	168.83	  	$	139.76	  	$	188.91	  	$	179.86	  	$	169.67	  	$	168.52	  	$	162.20	  	$	194.02	  	$	186.56
	 Age 45+
	  	F	  	$	342.55	  	$	336.38	  	$	339.05	  	$	348.65	  	$	308.92	  	$	315.35	  	$	261.05	  	$	352.84	  	$	335.94	  	$	316.92	  	$	314.76	  	$	302.96	  	$	362.40	  	$	348.47
	 Age 45+
	  	M	  	$	302.05	  	$	296.61	  	$	298.96	  	$	307.42	  	$	272.40	  	$	278.07	  	$	230.18	  	$	311.12	  	$	296.22	  	$	279.44	  	$	277.55	  	$	267.14	  	$	319.55	  	$	307.27
	
	 BadgerCare Rates
 Medical Capitation Rates by Service Category - Dental Costs
  

	 Age Range

	  	Gender

	  	Duluth/
Superior
1

	  	Wausau/
Rhinelander
2

	  	Green Bay
3

	  	Twin Cities
4

	  	Marshfield/
Stevens Point
5

	  	Appleton/
Oshkosh
6

	  	La Crosse
7

	  	Madison
8

	  	Southeast
Wisconsin
9

	  	Milwaukee
10

	  	 Dane
 11

	  	Eau Claire
12

	  	Kenosha
13

	  	Waukesha
14


	 Age 0
	  	All	  	$	0.03	  	$	0.03	  	$	0.03	  	$	0.03	  	$	0.04	  	$	0.03	  	$	0.03	  	$	0.03	  	$	0.03	  	$	0.03	  	$	0.03	  	$	0.03	  	$	0.03	  	$	0.02
	 Age 1-14
	  	All	  	$	9.33	  	$	6.92	  	$	7.94	  	$	7.46	  	$	9.76	  	$	9.69	  	$	7.32	  	$	9.13	  	$	7.92	  	$	9.68	  	$	5.93	  	$	6.39	  	$	10.99	  	$	7.18
	 Age 15-20
	  	F	  	$	10.37	  	$	7.69	  	$	8.82	  	$	8.29	  	$	10.84	  	$	10.77	  	$	8.14	  	$	10.15	  	$	8.80	  	$	10.75	  	$	6.59	  	$	7.11	  	$	12.21	  	$	7.98
	 Age 15-20
	  	M	  	$	9.69	  	$	7.18	  	$	8.24	  	$	7.74	  	$	10.13	  	$	10.06	  	$	7.60	  	$	9.48	  	$	8.22	  	$	10.05	  	$	6.16	  	$	6.64	  	$	11.41	  	$	7.45
	 Age 21-34
	  	F	  	$	8.53	  	$	6.32	  	$	7.25	  	$	6.81	  	$	8.91	  	$	8.85	  	$	6.69	  	$	8.35	  	$	7.24	  	$	8.84	  	$	5.42	  	$	5.84	  	$	10.04	  	$	6.56
	 Age 21-34
	  	M	  	$	6.89	  	$	5.10	  	$	5.86	  	$	5.50	  	$	7.20	  	$	7.15	  	$	5.40	  	$	6.74	  	$	5.85	  	$	7.14	  	$	4.38	  	$	4.72	  	$	8.11	  	$	5.30
	 Age 35-44
	  	F	  	$	8.47	  	$	6.27	  	$	7.20	  	$	6.76	  	$	8.85	  	$	8.79	  	$	6.64	  	$	8.29	  	$	7.19	  	$	8.78	  	$	5.38	  	$	5.80	  	$	9.97	  	$	6.51
	 Age 35-44
	  	M	  	$	6.82	  	$	5.06	  	$	5.80	  	$	5.45	  	$	7.13	  	$	7.08	  	$	5.35	  	$	6.68	  	$	5.79	  	$	7.07	  	$	4.34	  	$	4.67	  	$	8.03	  	$	5.25
	 Age 45+
	  	F	  	$	10.06	  	$	7.45	  	$	8.55	  	$	8.04	  	$	10.51	  	$	10.44	  	$	7.89	  	$	9.84	  	$	8.54	  	$	10.43	  	$	6.39	  	$	6.89	  	$	11.84	  	$	7.74
	 Age 45+
	  	M	  	$	8.86	  	$	6.57	  	$	7.53	  	$	7.08	  	$	9.26	  	$	9.20	  	$	6.95	  	$	8.67	  	$	7.52	  	$	9.19	  	$	5.63	  	$	6.07	  	$	10.43	  	$	6.82
	
	 BadgerCare Rates
 Medical Capitation Rates by Service Category - Chiropractic Costs

																
	 Age Range

	  	Gender

	  	Duluth/
Superior
1

	  	Wausau/
Rhinelander
2

	  	Green Bay
3

	  	Twin Cities
4

	  	Marshfield/
Stevens Point
5

	  	Appleton/
Oshkosh
6

	  	La Crosse
7

	  	Madison
8

	  	Southeast
Wisconsin
9

	  	Milwaukee
10

	  	 Dane
 11

	  	Eau Claire
12

	  	Kenosha
13

	  	Waukesha
14


	 Age 0
	  	All	  	$	0.40	  	$	0.46	  	$	0.34	  	$	0.80	  	$	0.57	  	$	0.39	  	$	0.48	  	$	0.34	  	$	0.20	  	$	0.03	  	$	0.24	  	$	0.98	  	$	0.14	  	$	0.20
	 Age 1-14
	  	All	  	$	0.68	  	$	1.10	  	$	0.76	  	$	1.28	  	$	1.24	  	$	0.76	  	$	0.88	  	$	0.88	  	$	0.55	  	$	0.11	  	$	0.60	  	$	1.04	  	$	0.45	  	$	0.49
	 Age 15-20
	  	F	  	$	1.84	  	$	2.96	  	$	2.03	  	$	3.44	  	$	3.34	  	$	2.03	  	$	2.37	  	$	2.37	  	$	1.47	  	$	0.30	  	$	1.60	  	$	2.79	  	$	1.22	  	$	1.31
	 Age 15-20
	  	M	  	$	1.20	  	$	1.94	  	$	1.33	  	$	2.25	  	$	2.19	  	$	1.33	  	$	1.55	  	$	1.55	  	$	0.96	  	$	0.20	  	$	1.05	  	$	1.82	  	$	0.80	  	$	0.86
	 Age 21-34
	  	F	  	$	2.46	  	$	3.96	  	$	2.72	  	$	4.60	  	$	4.47	  	$	2.72	  	$	3.17	  	$	3.18	  	$	1.97	  	$	0.40	  	$	2.14	  	$	3.73	  	$	1.63	  	$	1.75
	 Age 21-34
	  	M	  	$	2.03	  	$	3.27	  	$	2.25	  	$	3.80	  	$	3.70	  	$	2.25	  	$	2.62	  	$	2.63	  	$	1.62	  	$	0.33	  	$	1.77	  	$	3.08	  	$	1.34	  	$	1.45
	 Age 35-44
	  	F	  	$	3.20	  	$	5.15	  	$	3.54	  	$	5.98	  	$	5.82	  	$	3.54	  	$	4.13	  	$	4.13	  	$	2.56	  	$	0.52	  	$	2.79	  	$	4.85	  	$	2.12	  	$	2.28
	 Age 35-44
	  	M	  	$	2.47	  	$	3.97	  	$	2.73	  	$	4.61	  	$	4.49	  	$	2.73	  	$	3.18	  	$	3.18	  	$	1.97	  	$	0.40	  	$	2.15	  	$	3.74	  	$	1.63	  	$	1.75
	 Age 45+
	  	F	  	$	3.78	  	$	6.08	  	$	4.18	  	$	7.06	  	$	6.87	  	$	4.18	  	$	4.87	  	$	4.88	  	$	3.02	  	$	0.62	  	$	3.29	  	$	5.72	  	$	2.50	  	$	2.69
	 Age 45+
	  	M	  	$	2.55	  	$	4.11	  	$	2.82	  	$	4.77	  	$	4.65	  	$	2.83	  	$	3.29	  	$	3.30	  	$	2.04	  	$	0.42	  	$	2.22	  	$	3.87	  	$	1.69	  	$	1.82








 ADDENDUM III-C - CY 2006 Age & Gender Factors 
  
 Wisconsin Department of Health and Family Services 
 2006 MCE and HMO Capitation Rate Development for AFDC-Related, Healthy Start, and BadgerCare 
  
 ADFC-Related and Healthy Start Children Age / Gender Factors 
  

																																																
	Medical Services (Non-Dental, Non-Chiropractor)	 
			
	 	  	 	  	Region

	 
	 Age Range

	  	Gender

	  	1

	 	 	2

	 	 	3

	 	 	4

	 	 	5

	 	 	6

	 	 	7

	 	 	8

	 	 	9

	 	 	10

	 	 	11

	 	 	12

	 	 	13

	 	 	14

	 	 	Total

	 
	 Age 0
	  	All	  	2.078	 	 	2.175	 	 	2.079	 	 	2.422	 	 	2.210	 	 	2.248	 	 	2.206	 	 	1.499	 	 	1.898	 	 	2.686	 	 	2.019	 	 	2.164	 	 	2.043	 	 	1.653	 	 	2.290	 
	 Ages 1 - 5
	  	All	  	0.441	 	 	0.578	 	 	0.479	 	 	0.467	 	 	0.458	 	 	0.465	 	 	0.475	 	 	0.451	 	 	0.432	 	 	0.458	 	 	0.509	 	 	0.472	 	 	0.453	 	 	0.456	 	 	0.462	 
	 Ages 6 - 14
	  	All	  	0.446	 	 	0.428	 	 	0.395	 	 	0.453	 	 	0.421	 	 	0.390	 	 	0.432	 	 	0.432	 	 	0.396	 	 	0.327	 	 	0.414	 	 	0.377	 	 	0.334	 	 	0.457	 	 	0.370	 
	 Ages 15 - 20
	  	Female	  	1.300	 	 	1.181	 	 	1.316	 	 	1.370	 	 	1.321	 	 	1.225	 	 	1.341	 	 	1.582	 	 	1.451	 	 	1.529	 	 	1.461	 	 	1.364	 	 	1.370	 	 	1.273	 	 	1.455	 
	 Ages 15 - 20
	  	Male	  	0.555	 	 	0.508	 	 	0.500	 	 	0.556	 	 	0.562	 	 	0.548	 	 	0.562	 	 	0.466	 	 	0.521	 	 	0.530	 	 	0.479	 	 	0.411	 	 	0.398	 	 	0.975	 	 	0.528	 
	 Ages 21 - 34
	  	Female	  	2.361	 	 	2.210	 	 	2.038	 	 	2.029	 	 	2.360	 	 	2.120	 	 	2.005	 	 	2.319	 	 	2.194	 	 	2.059	 	 	2.265	 	 	2.045	 	 	2.142	 	 	2.121	 	 	2.125	 
	 Ages 21 - 34
	  	Male	  	1.124	 	 	0.985	 	 	2.271	 	 	0.975	 	 	1.194	 	 	1.187	 	 	1.224	 	 	1.349	 	 	1.172	 	 	1.061	 	 	1.023	 	 	0.968	 	 	1.739	 	 	1.210	 	 	1.211	 
	 Ages 35 & Over
	  	Female	  	2.350	 	 	3.103	 	 	2.604	 	 	2.151	 	 	2.561	 	 	2.601	 	 	2.626	 	 	2.653	 	 	2.542	 	 	2.593	 	 	2.580	 	 	2.594	 	 	2.652	 	 	2.692	 	 	2.597	 
	 Ages 35 & Over
	  	Male	  	1.684	 	 	2.115	 	 	1.817	 	 	1.862	 	 	1.771	 	 	2.020	 	 	2.205	 	 	1.779	 	 	2.826	 	 	2.069	 	 	1.819	 	 	2.600	 	 	2.684	 	 	1.660	 	 	2.046	 
	 	  	 	  	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	

	 Composite
	  	 	  	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 
	
	Dental Services	 
			
	 	  	 	  	Region

	 
	 Age Range

	  	Gender

	  	1

	 	 	2

	 	 	3

	 	 	4

	 	 	5

	 	 	6

	 	 	7

	 	 	8

	 	 	9

	 	 	10

	 	 	11

	 	 	12

	 	 	13

	 	 	14

	 	 	Total

	 
	 Age 0
	  	All	  	0.000	 	 	0.001	 	 	0.008	 	 	0.012	 	 	0.002	 	 	0.001	 	 	0.001	 	 	0.002	 	 	0.016	 	 	0.006	 	 	0.009	 	 	0.004	 	 	0.001	 	 	0.003	 	 	0.005	 
	 Ages 1 - 5
	  	All	  	0.689	 	 	1.085	 	 	0.699	 	 	0.711	 	 	0.833	 	 	0.673	 	 	0.797	 	 	0.629	 	 	0.758	 	 	0.728	 	 	1.035	 	 	0.700	 	 	0.684	 	 	0.556	 	 	0.750	 
	 Ages 6 - 14
	  	All	  	1.117	 	 	1.166	 	 	1.479	 	 	1.325	 	 	1.192	 	 	1.297	 	 	1.303	 	 	1.348	 	 	1.238	 	 	1.082	 	 	1.330	 	 	1.409	 	 	1.255	 	 	1.277	 	 	1.204	 
	 Ages 15 - 20
	  	Female	  	1.766	 	 	1.242	 	 	1.275	 	 	1.498	 	 	1.439	 	 	1.389	 	 	1.366	 	 	1.358	 	 	1.242	 	 	1.073	 	 	1.053	 	 	1.495	 	 	1.047	 	 	1.423	 	 	1.233	 
	 Ages 15 - 20
	  	Male	  	1.619	 	 	0.960	 	 	1.597	 	 	1.579	 	 	1.368	 	 	1.633	 	 	1.591	 	 	1.595	 	 	1.168	 	 	0.830	 	 	0.934	 	 	1.431	 	 	0.941	 	 	1.408	 	 	1.168	 
	 Ages 21 - 34
	  	Female	  	1.302	 	 	0.991	 	 	1.134	 	 	1.163	 	 	1.242	 	 	1.383	 	 	1.105	 	 	1.305	 	 	1.460	 	 	1.475	 	 	0.837	 	 	1.216	 	 	1.439	 	 	1.623	 	 	1.322	 
	 Ages 21 - 34
	  	Male	  	0.903	 	 	0.623	 	 	0.802	 	 	0.961	 	 	1.012	 	 	1.093	 	 	0.991	 	 	0.929	 	 	1.180	 	 	1.241	 	 	0.681	 	 	0.745	 	 	1.180	 	 	1.431	 	 	1.028	 
	 Ages 35 & Over
	  	Female	  	1.245	 	 	0.844	 	 	1.140	 	 	1.175	 	 	1.159	 	 	1.217	 	 	1.091	 	 	1.310	 	 	1.367	 	 	1.816	 	 	0.855	 	 	1.243	 	 	1.473	 	 	1.617	 	 	1.435	 
	 Ages 35 & Over
	  	Male	  	1.265	 	 	1.005	 	 	0.831	 	 	1.257	 	 	0.903	 	 	1.305	 	 	0.845	 	 	1.005	 	 	1.031	 	 	1.789	 	 	0.831	 	 	1.356	 	 	1.346	 	 	1.735	 	 	1.265	 
	 	  	 	  	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	

	 Composite
	  	 	  	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 
	
	Chiropractor Services	 
			
	 	  	 	  	Region

	 
	 Age Range

	  	Gender

	  	1

	 	 	2

	 	 	3

	 	 	4

	 	 	5

	 	 	6

	 	 	7

	 	 	8

	 	 	9

	 	 	10

	 	 	11

	 	 	12

	 	 	13

	 	 	14

	 	 	Total

	 
	 Age 0
	  	All	  	0.309	 	 	0.473	 	 	0.282	 	 	0.367	 	 	0.383	 	 	0.354	 	 	0.490	 	 	0.357	 	 	0.258	 	 	0.340	 	 	0.224	 	 	0.570	 	 	0.133	 	 	0.221	 	 	0.364	 
	 Ages 1 - 5
	  	All	  	0.268	 	 	0.443	 	 	0.388	 	 	0.388	 	 	0.369	 	 	0.245	 	 	0.458	 	 	0.401	 	 	0.313	 	 	0.241	 	 	0.247	 	 	0.420	 	 	0.257	 	 	0.329	 	 	0.373	 
	 Ages 6 - 14
	  	All	  	0.645	 	 	0.643	 	 	0.592	 	 	0.650	 	 	0.570	 	 	0.435	 	 	0.504	 	 	0.609	 	 	0.649	 	 	0.407	 	 	0.462	 	 	0.662	 	 	0.517	 	 	0.871	 	 	0.562	 
	 Ages 15 - 20
	  	Female	  	1.798	 	 	1.574	 	 	1.281	 	 	1.500	 	 	1.706	 	 	1.574	 	 	1.553	 	 	1.563	 	 	1.189	 	 	1.272	 	 	0.715	 	 	1.635	 	 	0.870	 	 	0.610	 	 	1.387	 
	 Ages 15 - 20
	  	Male	  	1.028	 	 	0.743	 	 	1.146	 	 	1.062	 	 	0.960	 	 	0.610	 	 	1.284	 	 	1.250	 	 	1.374	 	 	0.652	 	 	1.025	 	 	1.064	 	 	1.703	 	 	1.322	 	 	1.017	 
	 Ages 21 - 34
	  	Female	  	2.359	 	 	2.565	 	 	2.507	 	 	2.405	 	 	2.422	 	 	2.913	 	 	2.365	 	 	2.235	 	 	2.590	 	 	2.823	 	 	3.571	 	 	2.061	 	 	3.060	 	 	2.619	 	 	2.384	 
	 Ages 21 - 34
	  	Male	  	1.275	 	 	1.687	 	 	1.726	 	 	1.501	 	 	0.967	 	 	1.802	 	 	2.005	 	 	1.741	 	 	1.776	 	 	2.176	 	 	3.225	 	 	1.638	 	 	1.671	 	 	1.126	 	 	1.899	 
	 Ages 35 & Over
	  	Female	  	3.604	 	 	3.423	 	 	3.750	 	 	3.494	 	 	4.090	 	 	4.417	 	 	3.142	 	 	3.128	 	 	3.506	 	 	3.674	 	 	3.157	 	 	3.730	 	 	3.074	 	 	3.002	 	 	3.442	 
	 Ages 35 & Over
	  	Male	  	1.561	 	 	2.388	 	 	3.090	 	 	2.097	 	 	2.364	 	 	2.538	 	 	2.385	 	 	2.053	 	 	2.247	 	 	4.798	 	 	1.972	 	 	1.392	 	 	2.135	 	 	2.368	 	 	2.751	 
	 	  	 	  	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	

	 Composite
	  	 	  	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 
	
	Projected 2006 HMO Eligible Month Weights	 
			
	 	  	 	  	Region

	 
	 Age Range

	  	Gender

	  	1

	 	 	2

	 	 	3

	 	 	4

	 	 	5

	 	 	6

	 	 	7

	 	 	8

	 	 	9

	 	 	10

	 	 	11

	 	 	12

	 	 	13

	 	 	14

	 	 	Total

	 
	 Age 0
	  	All	  	7.4	%	 	7.5	%	 	8.3	%	 	8.1	%	 	7.4	%	 	8.3	%	 	8.2	%	 	7.7	%	 	8.4	%	 	6.6	%	 	7.7	%	 	9.0	%	 	7.0	%	 	9.1	%	 	7.4	%
	 Ages 1 - 5
	  	All	  	27.7	%	 	28.7	%	 	30.8	%	 	28.7	%	 	28.9	%	 	30.2	%	 	29.6	%	 	29.0	%	 	30.0	%	 	26.7	%	 	29.8	%	 	30.9	%	 	28.4	%	 	31.3	%	 	28.4	%
	 Ages 6 - 14
	  	All	  	28.2	%	 	30.8	%	 	28.1	%	 	29.0	%	 	29.2	%	 	27.9	%	 	28.4	%	 	28.8	%	 	27.6	%	 	31.7	%	 	29.5	%	 	25.6	%	 	29.7	%	 	27.4	%	 	29.8	%
	 Ages 15 - 20
	  	Female	  	6.3	%	 	6.3	%	 	6.4	%	 	6.3	%	 	6.6	%	 	6.1	%	 	6.5	%	 	6.4	%	 	6.1	%	 	7.9	%	 	6.4	%	 	6.0	%	 	6.1	%	 	5.2	%	 	6.9	%
	 Ages 15 - 20
	  	Male	  	5.7	%	 	5.2	%	 	4.1	%	 	4.8	%	 	5.0	%	 	4.2	%	 	4.6	%	 	4.1	%	 	4.0	%	 	5.3	%	 	4.4	%	 	4.5	%	 	4.9	%	 	3.7	%	 	4.8	%
	 Ages 21 - 34
	  	Female	  	11.7	%	 	10.7	%	 	11.9	%	 	11.1	%	 	11.3	%	 	12.6	%	 	11.7	%	 	13.2	%	 	12.8	%	 	13.1	%	 	12.5	%	 	13.2	%	 	13.1	%	 	12.8	%	 	12.6	%
	 Ages 21 - 34
	  	Male	  	3.4	%	 	2.7	%	 	2.6	%	 	3.2	%	 	2.7	%	 	2.6	%	 	2.9	%	 	2.7	%	 	2.6	%	 	1.5	%	 	2.2	%	 	3.4	%	 	2.5	%	 	2.3	%	 	2.2	%
	 Ages 35 & Over
	  	Female	  	6.4	%	 	5.5	%	 	5.6	%	 	5.9	%	 	6.1	%	 	5.7	%	 	5.6	%	 	6.0	%	 	6.1	%	 	5.9	%	 	5.7	%	 	5.4	%	 	6.1	%	 	6.6	%	 	5.9	%
	 Ages 35 & Over
	  	Male	  	3.2	%	 	2.6	%	 	2.2	%	 	2.9	%	 	2.9	%	 	2.3	%	 	2.6	%	 	2.2	%	 	2.3	%	 	1.3	%	 	1.9	%	 	2.1	%	 	2.3	%	 	1.8	%	 	2.0	%
	 	  	 	  	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	

	 Composite
	  	 	  	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%








 ADDENDUM III-C - CY 2006 Age & Gender Factors 
  
 Wisconsin Department of Health and Family Services 
 2006 MCE and HMO Capitation Rate Development for AFDC-Related, Healthy Start, and BadgerCare 
  
 BadgerCare Age / Gender Factors 
  

																																																
	Medical Services (Non-Dental, Non-Chiropractor)	 
			
	 	  	 	  	Region

	 
	 Age Range

	  	Gender

	  	1

	 	 	2

	 	 	3

	 	 	4

	 	 	5

	 	 	6

	 	 	7

	 	 	8

	 	 	9

	 	 	10

	 	 	11

	 	 	12

	 	 	13

	 	 	14

	 	 	Total

	 
	 Age 0 - 14
	  	All	  	0.327	 	 	0.383	 	 	0.358	 	 	0.355	 	 	0.362	 	 	0.356	 	 	0.359	 	 	0.315	 	 	0.349	 	 	0.325	 	 	0.445	 	 	0.344	 	 	0.324	 	 	0.347	 	 	0.344	 
	 Ages 15 - 20
	  	Female	  	0.878	 	 	0.665	 	 	0.680	 	 	0.841	 	 	0.728	 	 	0.853	 	 	0.901	 	 	0.710	 	 	0.686	 	 	0.758	 	 	1.123	 	 	0.732	 	 	0.697	 	 	0.678	 	 	0.768	 
	 Ages 15 - 20
	  	Male	  	1.016	 	 	0.694	 	 	0.407	 	 	0.436	 	 	0.454	 	 	0.670	 	 	0.549	 	 	0.762	 	 	0.485	 	 	0.442	 	 	0.433	 	 	0.603	 	 	0.546	 	 	0.570	 	 	0.544	 
	 Ages 21 - 34
	  	Female	  	1.327	 	 	1.231	 	 	1.161	 	 	1.304	 	 	1.262	 	 	1.134	 	 	1.239	 	 	1.329	 	 	1.204	 	 	1.177	 	 	1.256	 	 	1.155	 	 	1.144	 	 	1.250	 	 	1.218	 
	 Ages 21 - 34
	  	Male	  	0.785	 	 	0.690	 	 	0.851	 	 	0.583	 	 	0.652	 	 	0.708	 	 	0.706	 	 	0.616	 	 	0.661	 	 	0.748	 	 	0.713	 	 	0.632	 	 	0.714	 	 	0.763	 	 	0.692	 
	 Ages 35 - 44
	  	Female	  	1.606	 	 	1.422	 	 	1.507	 	 	1.583	 	 	1.631	 	 	1.512	 	 	1.684	 	 	1.463	 	 	1.430	 	 	1.689	 	 	1.749	 	 	1.766	 	 	1.647	 	 	1.447	 	 	1.594	 
	 Ages 35 - 44
	  	Male	  	0.940	 	 	1.036	 	 	1.134	 	 	0.948	 	 	1.175	 	 	1.205	 	 	0.920	 	 	1.174	 	 	1.338	 	 	1.191	 	 	1.043	 	 	0.916	 	 	0.914	 	 	1.486	 	 	1.110	 
	 Ages 45 & Over
	  	Female	  	1.552	 	 	2.364	 	 	2.335	 	 	2.382	 	 	1.864	 	 	1.761	 	 	1.753	 	 	1.815	 	 	2.316	 	 	2.160	 	 	1.457	 	 	3.518	 	 	2.437	 	 	1.654	 	 	2.074	 
	 Ages 45 & Over
	  	Male	  	1.348	 	 	1.809	 	 	1.457	 	 	1.734	 	 	1.545	 	 	2.213	 	 	1.747	 	 	1.868	 	 	1.902	 	 	2.191	 	 	1.106	 	 	1.676	 	 	2.250	 	 	1.317	 	 	1.828	 
	 	  	 	  	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	

	 Composite
	  	 	  	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 
	
	Dental Services	 
			
	 	  	 	  	Region

	 
	 Age Range

	  	Gender

	  	1

	 	 	2

	 	 	3

	 	 	4

	 	 	5

	 	 	6

	 	 	7

	 	 	8

	 	 	9

	 	 	10

	 	 	11

	 	 	12

	 	 	13

	 	 	14

	 	 	Total

	 
	 Age 0 - 14
	  	All	  	0.961	 	 	1.339	 	 	1.276	 	 	1.128	 	 	1.108	 	 	1.081	 	 	1.213	 	 	1.125	 	 	1.071	 	 	0.914	 	 	1.480	 	 	1.176	 	 	1.026	 	 	0.873	 	 	1.075	 
	 Ages 15 - 20
	  	Female	  	1.601	 	 	1.373	 	 	1.370	 	 	1.350	 	 	1.273	 	 	1.364	 	 	1.663	 	 	1.431	 	 	1.218	 	 	0.886	 	 	1.270	 	 	0.988	 	 	0.780	 	 	1.026	 	 	1.195	 
	 Ages 15 - 20
	  	Male	  	1.399	 	 	1.381	 	 	1.402	 	 	1.500	 	 	1.071	 	 	1.217	 	 	1.413	 	 	1.301	 	 	1.091	 	 	0.745	 	 	1.681	 	 	0.859	 	 	0.950	 	 	1.178	 	 	1.117	 
	 Ages 21 - 34
	  	Female	  	1.026	 	 	0.880	 	 	0.840	 	 	0.841	 	 	0.948	 	 	0.989	 	 	0.852	 	 	0.978	 	 	0.973	 	 	1.054	 	 	0.754	 	 	0.916	 	 	1.049	 	 	1.083	 	 	0.983	 
	 Ages 21 - 34
	  	Male	  	0.782	 	 	0.656	 	 	0.704	 	 	0.755	 	 	0.844	 	 	0.896	 	 	0.829	 	 	0.730	 	 	0.847	 	 	0.877	 	 	0.573	 	 	0.737	 	 	1.107	 	 	0.902	 	 	0.794	 
	 Ages 35 - 44
	  	Female	  	0.918	 	 	0.777	 	 	0.853	 	 	0.914	 	 	0.884	 	 	0.931	 	 	0.924	 	 	0.891	 	 	1.037	 	 	1.123	 	 	0.714	 	 	0.957	 	 	0.953	 	 	0.995	 	 	0.976	 
	 Ages 35 - 44
	  	Male	  	0.827	 	 	0.626	 	 	0.747	 	 	0.768	 	 	0.922	 	 	0.745	 	 	0.658	 	 	0.797	 	 	0.774	 	 	0.876	 	 	0.730	 	 	1.090	 	 	0.850	 	 	0.923	 	 	0.786	 
	 Ages 45 & Over
	  	Female	  	1.197	 	 	1.044	 	 	1.126	 	 	1.345	 	 	1.214	 	 	1.000	 	 	0.934	 	 	0.981	 	 	1.074	 	 	1.406	 	 	0.969	 	 	1.017	 	 	1.228	 	 	1.227	 	 	1.159	 
	 Ages 45 & Over
	  	Male	  	0.928	 	 	1.026	 	 	1.126	 	 	1.194	 	 	0.945	 	 	0.958	 	 	0.846	 	 	1.035	 	 	0.907	 	 	1.231	 	 	0.669	 	 	1.343	 	 	0.868	 	 	1.057	 	 	1.021	 
	 	  	 	  	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	

	 Composite
	  	 	  	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 
	
	Chiropractor Services	 
			
	 	  	 	  	Region

	 
	 Age Range

	  	Gender

	  	1

	 	 	2

	 	 	3

	 	 	4

	 	 	5

	 	 	6

	 	 	7

	 	 	8

	 	 	9

	 	 	10

	 	 	11

	 	 	12

	 	 	13

	 	 	14

	 	 	Total

	 
	 Age 0 - 14
	  	All	  	0.253	 	 	0.311	 	 	0.376	 	 	0.325	 	 	0.372	 	 	0.382	 	 	0.407	 	 	0.327	 	 	0.381	 	 	0.197	 	 	0.233	 	 	0.365	 	 	0.552	 	 	0.427	 	 	0.334	 
	 Ages 15 - 20
	  	Female	  	1.025	 	 	0.924	 	 	0.973	 	 	1.201	 	 	0.854	 	 	0.671	 	 	1.067	 	 	0.864	 	 	0.719	 	 	0.528	 	 	1.505	 	 	1.123	 	 	0.495	 	 	0.561	 	 	0.898	 
	 Ages 15 - 20
	  	Male	  	0.495	 	 	0.573	 	 	0.409	 	 	0.767	 	 	0.516	 	 	0.488	 	 	0.718	 	 	0.710	 	 	0.571	 	 	0.247	 	 	0.560	 	 	1.039	 	 	0.677	 	 	0.548	 	 	0.589	 
	 Ages 21 - 34
	  	Female	  	1.243	 	 	1.434	 	 	1.256	 	 	1.206	 	 	1.381	 	 	1.291	 	 	1.144	 	 	1.275	 	 	1.141	 	 	1.097	 	 	1.134	 	 	1.354	 	 	1.381	 	 	1.312	 	 	1.203	 
	 Ages 21 - 34
	  	Male	  	0.912	 	 	0.881	 	 	0.739	 	 	0.885	 	 	0.815	 	 	0.816	 	 	0.867	 	 	1.040	 	 	0.888	 	 	1.514	 	 	1.096	 	 	0.793	 	 	0.816	 	 	0.849	 	 	0.994	 
	 Ages 35 - 44
	  	Female	  	1.603	 	 	1.481	 	 	1.613	 	 	1.705	 	 	1.436	 	 	1.676	 	 	1.695	 	 	1.477	 	 	1.776	 	 	1.407	 	 	1.348	 	 	1.623	 	 	1.369	 	 	1.500	 	 	1.565	 
	 Ages 35 - 44
	  	Male	  	1.114	 	 	1.146	 	 	0.933	 	 	1.071	 	 	1.025	 	 	0.927	 	 	1.019	 	 	1.126	 	 	1.191	 	 	1.462	 	 	1.501	 	 	0.947	 	 	1.179	 	 	1.260	 	 	1.206	 
	 Ages 45 & Over
	  	Female	  	2.038	 	 	1.733	 	 	1.924	 	 	1.603	 	 	1.923	 	 	1.835	 	 	1.598	 	 	1.867	 	 	1.753	 	 	3.405	 	 	1.993	 	 	1.330	 	 	1.591	 	 	1.436	 	 	1.846	 
	 Ages 45 & Over
	  	Male	  	1.268	 	 	1.057	 	 	1.195	 	 	1.082	 	 	1.257	 	 	1.092	 	 	1.187	 	 	0.860	 	 	1.138	 	 	2.162	 	 	1.714	 	 	1.390	 	 	0.719	 	 	0.976	 	 	1.249	 
	 	  	 	  	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	

	 Composite
	  	 	  	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 	 	1.000	 
	
	Projected 2006 HMO Eligible Month Weights	 
			
	 	  	 	  	Region

	 
	 Age Range

	  	Gender

	  	1

	 	 	2

	 	 	3

	 	 	4

	 	 	5

	 	 	6

	 	 	7

	 	 	8

	 	 	9

	 	 	10

	 	 	11

	 	 	12

	 	 	13

	 	 	14

	 	 	Total

	 
	 Age 0 - 14
	  	All	  	23.1	%	 	25.3	%	 	22.2	%	 	24.5	%	 	23.7	%	 	22.6	%	 	24.9	%	 	23.7	%	 	24.0	%	 	25.5	%	 	26.6	%	 	25.3	%	 	24.7	%	 	25.7	%	 	24.7	%
	 Ages 15 - 20
	  	Female	  	5.2	%	 	5.0	%	 	5.1	%	 	5.4	%	 	5.0	%	 	5.1	%	 	4.9	%	 	5.0	%	 	5.2	%	 	5.5	%	 	5.0	%	 	4.9	%	 	5.3	%	 	5.2	%	 	5.1	%
	 Ages 15 - 20
	  	Male	  	5.2	%	 	5.0	%	 	4.0	%	 	4.2	%	 	4.7	%	 	4.0	%	 	4.3	%	 	4.3	%	 	5.0	%	 	4.8	%	 	4.1	%	 	4.8	%	 	5.3	%	 	4.4	%	 	4.5	%
	 Ages 21 - 34
	  	Female	  	17.7	%	 	18.9	%	 	25.4	%	 	19.7	%	 	19.6	%	 	23.6	%	 	20.0	%	 	22.9	%	 	22.6	%	 	27.7	%	 	25.4	%	 	22.5	%	 	23.4	%	 	24.0	%	 	22.8	%
	 Ages 21 - 34
	  	Male	  	11.0	%	 	9.7	%	 	8.9	%	 	11.3	%	 	11.6	%	 	10.3	%	 	10.8	%	 	10.3	%	 	8.7	%	 	6.0	%	 	8.5	%	 	12.8	%	 	8.9	%	 	7.2	%	 	9.6	%
	 Ages 35 - 44
	  	Female	  	14.0	%	 	13.5	%	 	14.6	%	 	13.8	%	 	13.8	%	 	14.6	%	 	13.9	%	 	14.8	%	 	14.8	%	 	14.9	%	 	12.3	%	 	12.9	%	 	14.5	%	 	14.7	%	 	13.8	%
	 Ages 35 - 44
	  	Male	  	11.1	%	 	10.4	%	 	8.9	%	 	10.1	%	 	9.1	%	 	8.7	%	 	9.5	%	 	8.4	%	 	7.9	%	 	6.1	%	 	7.5	%	 	7.3	%	 	7.6	%	 	7.1	%	 	8.5	%
	 Ages 45 & Over
	  	Female	  	6.4	%	 	6.0	%	 	5.7	%	 	5.5	%	 	6.2	%	 	6.0	%	 	6.2	%	 	5.6	%	 	6.5	%	 	5.6	%	 	6.0	%	 	5.1	%	 	5.8	%	 	6.2	%	 	6.0	%
	 Ages 45 & Over
	  	Male	  	6.3	%	 	6.2	%	 	5.3	%	 	5.5	%	 	6.3	%	 	5.0	%	 	5.6	%	 	5.0	%	 	5.3	%	 	3.8	%	 	4.4	%	 	4.5	%	 	4.4	%	 	5.3	%	 	5.1	%
	 	  	 	  	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	
	 	
	

	 Composite
	  	 	  	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%	 	100.0	%








 ADDENDUM III 
  
 ACTUARIAL BASIS 
  
 HMO Rate Regions and Established Counties 
  

															
	 Region 1: Duluth/Superior

	  	 Region 2: Wausau/Rhinelander


	 02
	  	Ashland	  	85	  	Red Cliff RNIP	  	21	  	Forest	  	86	  	Stockbridge RNIP
	 04
	  	Bayfield	  	 	  	(Bayfield Co.)	  	34	  	Langlade	  	 	  	(Shawano Co.)
	 07
	  	Burnett	  	89	  	Bad River RNIP	  	35	  	Lincoln	  	87	  	Potowatomi RNIP
	 16
	  	Douglas	  	 	  	(Ashland Co.)	  	37	  	Marathon	  	 	  	(Forest Co.)43 Oneida
	 26
	  	Iron	  	94	  	Lac Courte RNIP	  	50	  	Price	  	88	  	Lac du Flambeau RNIP
	 57
	  	Sawyer	  	 	  	(Sawyer Co.)	  	58	  	Shawano	  	 	  	(Vilas Co.)
	 65
	  	Washburn	  	95	  	St. Croix RNIP	  	60	  	Taylor	  	 	  	91 Sokaogaon RNIP
	 	  	 	  	 	  	(Burnett Co.)	  	63	  	Vilas	  	 	  	(Forest Co.)
		
	 Region 3: Green Bay

	  	 Region 4: Twin Cities


	 05
	  	Brown	  	38	  	Marinette	  	03	  	Barron	  	47	  	Pierce
	 15
	  	Door	  	42	  	Oconto	  	09	  	Chippewa	  	48	  	Polk
	 19
	  	Florence	  	72	  	Menominee	  	17	  	Dunn	  	54	  	Rusk
	 31
	  	Kewaunee	  	84	  	Menominee RNIP	  	46	  	Pepin	  	55	  	St. Croix
	 36
	  	Manitowoc	  	 	  	(Menominee Co.)	  	 	  	 	  	 	  	 
		
	 Region 5: Marshfield/Stevens Point

	  	 Region 6: Appleton/Oshkosh


	 01
	  	Adams	  	39	  	Marquette	  	08	  	Calumet	  	92	  	Oneida RNIP
	 10
	  	Clark	  	49	  	Portage	  	20	  	Fond Du Lac	  	 	  	(Outagamie Co.)
	 24
	  	Green Lake	  	69	  	Waushara	  	44	  	Outagamie	  	 	  	 
	 27
	  	Jackson	  	71	  	Wood	  	68	  	Waupaca	  	 	  	 
	 29
	  	Juneau	  	 	  	 	  	70	  	Winnebago	  	 	  	 
		
	 Region 7: LaCrosse

	  	 Region 8: Madison/South Central


	 06
	  	Buffalo	  	61	  	Trempealeau	  	11	  	Columbia	  	28	  	Jefferson
	 12
	  	Crawford	  	62	  	Vernon	  	14	  	Dodge	  	33	  	Lafayette
	 32
	  	LaCrosse	  	 	  	 	  	22	  	Grant	  	53	  	Rock
	 41
	  	Monroe	  	 	  	 	  	23	  	Green	  	56	  	Sauk
	 52
	  	Richland	  	 	  	 	  	25	  	Iowa	  	 	  	 

  

							
		
	 Region 9: Southeast Wisconsin

	  	Established Counties


	 45
	  	Ozaukee	  	13	  	Dane
	 51
	  	Racine	  	18	  	Eau Claire
	 59
	  	Sheboygan	  	30	  	Kenosha
	 64
	  	Walworth	  	40	  	Milwaukee
	 66
	  	Washington	  	67	  	Waukesha

  
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -172- 








 ADDENDUM IV 
  
 GUIDELINES FOR THE COORDINATION OF SERVICES BETWEEN HMOS AND 
 THE BUREAU OF MILWAUKEE CHILD WELFARE 
  

	I.	HMO Rights and Responsibilities: 

  

	 	A.	The HMO must designate at least one individual to serve as a contact person for the Bureau of Milwaukee Child Welfare (BMCW). If the HMO chooses to designate more than one contact
person, the HMO should identify the service area for which each contact person is responsible. 

  

	 	B.	The HMO must provide all Medicaid covered mental health and substance abuse services to individuals identified as clients of BMCW. Disputes in the medical necessity of services
identified in the Family Treatment Plan will be adjudicated using the dispute process outlined in this MOU, except that HMOs will provide court ordered services in accordance with Article III, F. 

  

	 	C.	The HMO liaison, or other appropriate staff as designated by the HMO, will participate in case conference with BMCW upon the request of BMCW. The planning session may be done
through telephone contact or other means of communication when attending a formal case conference is not feasible. 

  

	 	D.	The HMO liaison and BMCW will discuss who will be responsible for ensuring that the recipient receives the services authorized and provided through the HMO. The HMO must have a
mechanism in place for notifying BMCW of missed appointments or family crisis situations that could potentially lead to an out-of-home placement by BMCW. The notification will be within three business days of occurrence or sooner if possible.


  

	 	E.	The HMO agrees to participate in dispute resolution using the following process: 

  

	 	1.	The BMCW and the HMO designated personnel will meet or teleconference to discuss the case and attempt to resolve issues of dispute. 

  

	 	2.	If the BMCW designees and the HMO designees (known as the team) are unable to resolve the issues, BMCW and the HMO will schedule a meeting or a teleconference of representatives
with expertise in the area of dispute to look at outstanding issues within two days of the teleconference or sooner if indicated. 

  

	 	3.	If the team is unable to resolve the issues to both parties’ satisfaction, either party may appeal to the Department. It will be the disputing party’s responsibility to
supply the necessary documentation for the Department to adjudicate the dispute. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -173- 









	 	F.	The HMO will work with BMCW in developing lists of providers and fostering a provider network that has expertise in: 

  

	 	1.	Working with adults and children effectively. 

  

	 	2.	Working with dual diagnosed clients effectively. 

  

	 	3.	Understanding adult functioning problems in the context of parenting, child safety and child well-being. 

  

	 	4.	Recognizing the interrelationship of the problems BMCW families experience and, therefore, the value of close collaboration among the various service providers working with the
family. 

  

	 	G.	The HMO will share with BMCW agency(ies) the procedure and process for prior authorization and out-of-plan referrals. 

  

	II.	Bureau of Milwaukee Child Welfare’s Rights and Responsibilities: 

  

	 	A.	It is the BMCW’s responsibility to initiate contact with the HMO regarding child welfare families and/or individuals in need of service. BMCW will provide (through court order
and/or signed release of information) completed assessment information that supports the request for HMO services. 

  

	 	B.	BMCW will complete and involve the HMO in the development of a comprehensive case plan that identifies the outcomes to be achieved, the services to be provided and the measures to
be used for evaluation. 

  

	 	C.	BMCW will utilize the HMO’s provider network for routine services whenever possible and will attempt to utilize the HMO provider network for emergency services. BMCW will
obtain criteria from the HMO concerning BMCW’s ability to utilize non-participating providers and the mechanism for authorizing non-participating providers. 

  

	 	D.	BMCW will evaluate the progress of the case plan at 90-day intervals, including the effectiveness of services, and will forward those results to the HMO within 10 days of
completion. 

  

	 	E.	BMCW will be responsible for informing the HMO of the status of the case, including court-ordered revisions within two business days of the revisions. 

  

	 	F.	BMCW agrees to participate in dispute resolution using the following process: 

  


	 	1.	BMCW and the HMO designated personnel will meet or teleconference to discuss the case and attempt to resolve issues of dispute. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -174- 









	 	2.	If the BMCW designees and the HMO designees (known as the team) are unable to resolve the issues, the BMCW and the HMO will schedule a meeting of representatives to look at
outstanding issues within two days of the meeting or teleconference or sooner if indicated. 

  

	 	3.	If the team is unable to resolve the issues to both parties’ satisfaction, either party may appeal to the Department. It will be the disputing party’s responsibility to
supply the necessary documentation for the Department to adjudicate the dispute. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -175- 








 ADDENDUM V 
  

GUIDELINES FOR THE COORDINATION OF SERVICES BETWEEN MEDICAID 
 HMOS AND COUNTY BIRTH TO THREE AGENCIES 
  
 The Birth to 3 program is an entitlement program established by the Federal Individuals with Disabilities Education Act (IDEA) and is funded by federal, state, and local funds. The goal of the program is to provide Early Intervention (EI)
services to children from birth up to the age of three who have developmental disabilities or delays. The intended outcome of the program is to ensure maximum amelioration of the impact of developmental disabilities or delays on infants and toddlers
by early and ongoing provision of rehabilitation services. 
  
 Early Intervention
services under Part C of the IDEA are administered in Wisconsin under Administrative Code HSF 90 by county health and human service department Birth to 3 programs. Birth to 3 agencies arrange for the provision of rehabilitative services (including
needed physical therapy, occupational therapy, speech-language pathology, special instruction, audiology, certain nursing, psychological and other services), service coordination, and related parent education. Regulations require that Birth to 3
services be delivered in a “natural” environment, frequently the child’s home. Federal rules designate that IDEA, Part C funds are a payer of last resort after all other private and public funds, including Medicaid funds. 

 
 There are HMO enrollees that either are or will be in the Birth to 3 program. To summarize
the Birth to 3 program process for ease of HMO understanding, the Birth to 3 program has four stages. These “stages” are a conceptual tool. 
  

	1.	Stage 1 is the identification of a child as potentially eligible and in need of evaluation of whether the child is developmentally delayed. This can be done simply by a parent who
believes the child is not developing normally, or more formally though a medical evaluation by the HMO provider. The child is then referred to the HMO for evaluation of eligibility and assessment of medically necessary services for the Individual
Family Service Plan (IFSP). If the HMO originated the referral to the Birth to 3 agency, then any evaluations already completed by the HMO can be used as part of the eligibility decision process. 

  

	2.	Stage 2 is the evaluation for eligibility by the Birth to 3 program according to state and federal rules and the assessment of needed medical and developmental services for the
IFSP. 

  

	3.	Stage 3 is the coordinated development of an IFSP that describes the integrated set of services that the child and family should receive. The HMO, the family, the Birth to 3 agency,
and other relevant agencies are involved in the development of the IFSP. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -176- 









	4.	Stage 4 is the provision of services based on the IFSP. 

  
 The HMO is involved with the Birth to 3 program throughout all of the above stages. The HMO can identify and refer a child to the program based on the physician’s
determination that the child is not developing normally. The HMO will receive referrals from the program. The HMO will be involved in performing evaluation/assessment for eligibility determination and needed IFSP services. The HMO will be involved
in family members, program staff, and other agencies. Finally, the HMO will be providing the services in the IFSP that meet medical necessity per Medicaid guidelines. 
  
 Federal and state regulations require an evaluation for eligibility, an assessment of needs and the development of an IFSP within 45 days of
an EI referral to the Birth to 3 agency. A child eligible for receives services according to the IFSP document. Regulations require that Medicaid pay for covered IFSP services that meet Medicaid’s definition of medical necessity. Services
meeting Medicaid’s coverage requirement are to be paid by Medicaid funds before county, state or federal IDEA funds are used to pay for the services. Wisconsin Medicaid requires HMOs to seek payment from a recipient’s health insurance
first. However, in the Birth to 3 program, parents do not have to allow their Medicaid HMO to bill their health insurance for Birth to 3 services. In this situation, where the enrollee has other insurance but the parents do not allow billing of
their health insurance for services, the HMO must work with the Birth to 3 agency on how to bill the agency for services rendered. The agencies have established an “average insurance liability amount” per month for IFSP therapy services
for these situations and will reimburse the HMO this amount. HMOs would be responsible for the cost of services after the county pays the average insurance liability. The agency will inform the HMOs of those recipients participating in the program
for whom the parents/guardians do not allow billing of their health insurance. The agency will inform the HMOs of the alternative billing procedures for these recipients. 
  
 The following guidelines have been developed to establish the complementary roles of the HMO and the Birth to 3 agency for clients they have
in common and to identify the mutual activities of each party that will promote effective communication and coordination between the two parties. This language will also be incorporated as an Appendix in the county Birth to 3 provider materials
ensuring that both HMOs and county Birth to 3 providers have the same information available to them. All actions are governed by HSF 90, and HMOs are required to make a reasonable attempt to assure that HSF 90 standards are met (e.g., two day
referral). 
  
 HMO Rights and Responsibilities 
  

	A.	The HMO must designate at least one individual to serve as a contact person for county B-3 agencies. If the HMO chooses to designate more than one contact person, the HMO should
identify the counties for which each contact person is responsible. The contact person will work toward achieving a close, cooperative relationship between the HMO and the agency. The contact person will work with the agency to establish a mechanism
to identify and refer eligible recipients for services and for the distribution of appropriate paperwork. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -177- 









	B.	When the HMO identifies a recipient who may meet the eligibility guidelines for the Wis. Adm. Code, Chapter 90 HFS for Birth to 3 services it will make a referral to the county
agency within two days. A child under the age of three can be identified and referred to the agency based on the judgment of the HMO provider that the child is not developing normally. 

  

	C.	If the parent of a child requests the HMO to conduct an evaluation/assessment, the HMO will determine the need for such evaluation/assessment in accordance with the Medicaid and
Chapter 90 HFS definition of medical necessity. If the evaluation/assessment warrants eligibility for Birth to 3 services, a referral should be made to the agency as soon as possible. The HMO evaluation/assessment may be used by the agency for
eligibility determination. If additional information is needed, the HMO and program will coordinate a evaluation of eligibility and an assessment of IFSP services needed. The evaluation and assessment results should be completed within 35 days from
the date of the parent request. Results should be sent to the agency with the parent/guardian consent at the time of referral to give the agency sufficient time to complete the IFSP within the 45 day time limit mandated by HSF Chapter 90.


  

	D.	If the county Birth to 3 agency requests a eligibility determination evaluation and assessment of IFSP service needs, the agency will provide a copy of the recipient screening tool
to assist the HMO in determining the need for a full evaluation/assessment. If the HMO agrees with the agency request, the HMO will conduct a complete evaluation/assessment of the recipient’s rehabilitative needs. Federal regulations under
Chapter 90 HFS require the HMO to forward a copy of the findings to the county agency within 35 days from the date of the parent/guardian request. This allows the agency sufficient time to complete the IFSP within the 45 day deadline required by
federal regulations under Chapter 90 HFS. If the HMO determines that no evaluation/assessment is needed, the HMO will document the rationale for this decision. 

  

	E.	If the HMO requires copies of the recipient’s early intervention records held by the county Birth to 3 agency, the HMO may request the records directly from the agency with the
parents’/guardians’ consent: 

  

	 	1.	The HMO case management liaison and the county Birth to 3 case manager must establish feasible administrative procedures for obtaining parents’/guardians’ consent for
release of such records. 

  

	 	2.	If the parents’/guardians’ consent is not obtained, then any further actions on the part of the HMO requiring such records may cease. 

  

	F.	The HMO must determine the need for medical treatment related to Birth to 3 services covered under the HMO Contract based on the results of the evaluation/assessment and the HMO
determination of medical necessity. The HMO will not have final say on the entire IFSP, but only on whether the EI services indicated in the IFSP are the HMO’s responsibility. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -178- 









	G.	The HMO shall work cooperatively with the Birth to 3 agency so that the provision of medically necessary services identified in the IFSP plan do not suffer interruption due to
delays caused by HMO prior authorization and/or utilization management procedures. 

  

	H.	The HMO Birth to 3 liaison, or other appropriate staff as designated by the HMO, must participate in case planning for the development of the IFSP with the county agency, unless no
services are provided through the HMO: 

  

	 	1.	The case planning may be done through telephone contact or written communication rather than attending a formal case planning meeting. 

  

	 	2.	The HMO is encouraged to recommend the type, frequency, and amount of services that might be on the IFSP. 

  

	 	3.	The HMO must informally discuss differences in opinion regarding the HMO’s determination of medically necessary treatment needs if requested by the recipient or case manager.


  

	 	4.	The HMO case management liaison and the county Birth to 3 manager must discuss the follow-up to be undertaken so that IFSP services authorized by the HMO according to the criteria
of medical necessity are made available and accessible to the recipient, and work with agencies to assist in scheduling recipient appointments. 

  

	 	5.	The HMO’s role in the case planning may be limited to a confirmation of the services the HMO will authorize if the recipient and county Birth to 3 case manager find these
acceptable. 

  

	I.	The parent/guardian of a Birth to 3 recipient may chose to receive Birth to 3 services from the recipient’s HMO or may elect to disenroll the child from the HMO as allowed by
Medicaid. However, HMOs may not restrict in any way the right of the recipient to remain enrolled in the HMO and to receive medically necessary services through the HMO. 

  

	J.	HMOs must arrange for providers with expertise appropriate to treat the infant and toddler population to meet the medically necessary needs of recipients enrolled in the HMO.


  
 County Birth to 3 Agency Rights and Responsibilities

  

	A.	The county Birth to 3 agency is responsible for the initial contact with the HMO to coordinate services to recipient(s) they have in common, and will provide the HMO with the name
and phone number of the county Birth to 3 agency. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -179- 









	B.	If the HMO refers a recipient to the county Birth to 3 agency, the county agency must conduct an eligibility evaluation/assessment based on their usual procedures and policies in
collaboration with the HMO. 

  

	C.	If the county Birth to 3 agency requires copies of the recipient’s medical records, the agency may request the records directly from the HMO with the consent of the
parent/guardian. 

  

	D.	The Birth to 3 case manager (service coordinator) may also identify whether the recipient has service or treatment needs over and above what is included in the child’s IFSP. As
a part of this process, the county agency and the recipient may seek additional assessment for treatment of medical conditions not included in the IFSP which the HMO may be expected to assess and treat under the terms of its contract. In these
cases, the HMO will determine if there are specific signs and symptoms indicating the medical necessity for the assessment and treatment. The agency must refer and coordinate evaluation/ assessment with the HMO within two days of identifying a
potentially eligible child. 

  

	E.	The county Birth to 3 agency may not determine the need for specific medical care covered under the HMO contract, nor may the county agency make referrals directly to specific
providers of medical care covered through the HMO. 

  

	F.	The county Birth to 3 agency must complete an IFSP in accordance with the requirements of HSF 90. 

  

	G.	If the county Birth to 3 agency specifically requests the HMO liaison to attend a planning meeting in person, the county agency may coordinate with the HMO for the costs associated
with attending the planning meeting. These are not separately allowable costs for reimbursement through Wisconsin Medicaid. 

  

	H.	The county Birth to 3 agency is responsible for making timely referrals to School Based Services (SBS) providers for recipients participating in Birth to 3 programs, who turn the
age of three and lose eligibility for services and are likely to be eligible for the SBS program. 

  
 Nothing in these guidelines precludes the HMO and the county Birth to 3 agency from entering into a formal contract or memorandum of understanding to address issues not
outlined here. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -180- 








 ADDENDUM VI 
  
 LOCAL HEALTH DEPARTMENTS AND COMMUNITY-BASED HEALTH 
 ORGANIZATIONS A RESOURCE FOR HMOS 
  
 Local Health Departments (LHDs) throughout the state have an essential role in promoting the health of citizens of Wisconsin. They have general and specific statutory authority to prevent disease, promote health and
protect the health of the citizens. They work in collaboration with community-based organizations, medical care facilities, and local community agencies to develop and coordinate systems of care so that the public’s health can be protected.
Specific statutory authority includes the three public health core functions of assessment, policy development and assurance: 
  
 Assessment means the regular, systematic collection, assembly, analysis and dissemination of information on the health of the community. This includes incidence
and prevalence data, and morbidity, mortality and environmental data in areas that include: communicable disease, chronic disease and environmental health. 
  
 Policy Development means the exercise of responsibility to serve the public’s interest by fostering shared ownership with the community in the development of
comprehensive public health plans, programs, services and guidelines. 
  
 Assurance means to take reasonable and necessary action to assure citizens that services necessary to achieve public health goals are available. This is done by encouraging the actions of others in the private, public and/or
voluntary sectors, and by requiring action through enforcement or by directly providing services. 
  
 Description of Public Health Services LHDs’ capacities may vary; however, LHDs are required to provide or ensure five basic public health services. These include: 
  

	1.	Communicable disease surveillance 

  

	2.	Prevention and control 

  

	3.	Health promotion 

  

	4.	Disease prevention 

  

	5.	Human health hazard control 

  

	6.	Generalized public health nursing programs 

  
 Although LHDs serve the population as a whole, they have established traditions of working with population groups at increased risk of illness, disability and premature
death. The following specific services have been delineated with the hope of linking Medicaid Managed Care Plans with LHDs. Linking primary care and public health is an essential strategy to strengthen the health of local communities and thus
benefit the population of the state as a whole. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -181- 









	•	 	LHDs have access to population data that may be very useful to managed care organizations in determining their services and quality studies. 

  

	•	 	LHDs closely collaborate their programs with key community agencies that serve the Medicaid population. These include: Special Supplemental Nutrition Program for Women, Infants, and
Children (WIC), Prenatal Care Coordination, School Health Services, Birth to 3 programs, Family Planning, and Developmental Disabilities. 

  

	•	 	LHDs promote and provide health education programs on topics that include domestic abuse/violence prevention, smoking cessation, breast feeding, cardiovascular risk reduction,
prenatal/postpartum education, nutrition, and self-care skills. 

  

	•	 	LHDs provide health-related home/community inspections in areas that include lead poisoning, asbestos, indoor air quality, home safety, and drinking water safety.


  

	•	 	LHDs monitor communicable disease incidence/prevalence, provide information to the public on prevention, and conduct epidemiological investigations of outbreaks/unusual conditions.


  
 Access to Special Populations 
  
 Wisconsin’s LHDs perform many public health services, including the provision of direct
services to Medicaid recipients. Some LHDs provide Medicaid reimbursable services for which HMOs may contract, such as: 
  

	•	 	HealthCheck screening, outreach and follow-up. 

  

	•	 	Immunizations. 

  

	•	 	Blood lead screening. 

  

	•	 	Extended case management of medical conditions such as asthma, diabetes, hypertension and children with special health care needs. 

  

	•	 	Home health and personal care services. 

  

	•	 	LHDs provide important resources such as: 

  

	•	 	Clinics serving high-risk populations. 

  

	•	 	Culturally competent staff experienced in dealing with diverse, high risk populations. 

  

	•	 	Direct access to outreach and follow up with at-risk population groups in home and community settings. 

  

	•	 	Environmental inspection and case management for children with elevated blood lead levels. 

  

	•	 	Ability to contact hard-to-reach people to assist HMOs in achieving required rates, such as the HealthCheck screening rate. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -182- 









	•	 	Experience in family-centered care. 

  

	•	 	Linkages with other community based providers and advocacy groups. 

  

	•	 	Highly skilled staff who emphasize prevention and public health. 

  
 Community Based Health Organizations 
  
 Throughout the state, the health care network includes many nonprofit community based health organizations including private HealthCheck providers, family planning
clinics, and WIC clinics. These organizations may provide some of the same Medicaid reimbursable services as LHDs and are essential to advancing the health of community. They may also have the same access to special populations as LHDs. 

 
 Collaboration with Public and Community Based Health Organizations 
  
 HMOs should consider how to utilize the LHDs and community
based health organizations through: 
  

	•	 	Identifying and utilizing the resources they provide. 

  

	•	 	Contracting with LHDs and other community health agencies for Medicaid reimbursable services where appropriate. 

  
 The complementary roles of managed care and public health are significant and evolving.
Communities will be healthier and health care costs reduced if health care providers work together. To find out the names of key contacts at LHDs and community based health organizations in your area, contact your LHD. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -183- 








 ADDENDUM VII 
  
 GUIDELINES FOR THE COORDINATION OF SERVICES BETWEEN HMOS, 
 TARGETED CASE MANAGEMENT (TCM) AGENCIES, AND CHILD WELFARE 
 AGENCIES

  
 (The same language will be incorporated as an Appendix in the case
management provider handbook, ensuring that both HMOs and case management providers have the same language available to them.) 
  
 HMO Rights and Responsibilities 
  

	1.	The HMO must designate at least one individual to serve as a contact person for case management providers. If the HMO chooses to designate more than one contact person, the HMO
should identify the target populations for which each contact person is responsible. 

  

	2.	The HMO may make referrals to case management agencies when they identify an enrollee from an eligible target population who could benefit from case management services.


  

	3.	If the enrollee or case manager requests the HMO to conduct an assessment, the HMO will determine whether there are signs and symptoms indicating the need for an assessment. If the
HMO finds that assessment is needed, the HMO will determine the most appropriate level for an assessment to be conducted (e.g., primary care physician, specialist, etc.). If the HMO determines that no assessment is needed, the HMO will document the
rationale for this decision. 

  

	4.	The HMO must determine the need for medical treatment of those services covered under the HMO Contract based on the results of the assessment and the medical necessity of the
treatment recommended. 

  

	5.	The HMO case management liaison, or other appropriate staff as designated by the HMO, must participate in case planning with the case management agency, unless no services provided
through the HMO are required. 

  

	 	•	 	The case planning may be done through telephone contact or means of communication other than attending a formal case planning meeting. 

  

	 	•	 	The HMO must informally discuss differences in opinion regarding the HMO’s determination of treatment needs if requested by the recipient or case manager.


  

	 	•	 	The HMO case management liaison and the case manager must discuss who will be responsible for ensuring that the enrollee receives the services authorized by and provided through the
HMO. 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -184- 









	 	•	 	The HMO’s role in the case planning may be limited to a confirmation of the services the HMO will authorize if the enrollee and case manager find these acceptable.


  
 Case Management Agency Rights and Responsibilities

  

	1.	The case management agency is responsible for initiating contact with the HMO to coordinate services to recipient(s) they have in common and providing the HMO with the name and
telephone number of the case manager(s). 

  

	2.	If the HMO refers an enrollee to the case management agency, the case management agency must conduct an initial screening based on their usual procedures and policies. The case
management agency must determine whether or not they will provide case management services and notify the HMO of this decision. 

  

	3.	The case management agency must complete a comprehensive assessment of the enrollee’s needs in accordance with the requirements in the Case Management provider handbook. This
includes a review of the enrollee’s physical and dental health needs. 

  

	4.	If the case management agency requires copies of the enrollee’s medical records, the case management agency must obtain the records directly from the service provider, not from
the HMO. 

  

	5.	The case manager must identify whether the enrollee has additional service or treatment needs. As a part of this process, the case manager and the enrollee may seek additional
assessment of conditions which the HMO may be expected to treat under the terms of the HMO Contract, if the HMO determines there are specific signs and symptoms indicating the need for an assessment. 

  

	6.	The case management agency may not determine the need for specific medical care covered under the HMO Contract, nor may the case management agency make referrals directly to
specific providers of medical care covered through the HMO. 

  

	7.	The case manager must complete a comprehensive case plan in accordance with the requirements of the Case Management provider handbook. The plan must include the medical services the
enrollee requires as determined by the HMO. 

  

	8.	If the case management agency specifically requests the HMO liaison to attend a planning meeting in person, the case management agency must reimburse the HMO for the costs
associated with attending the planning meeting. These are allowable costs for case management reimbursement through Wisconsin Medicaid. 

  
 Nothing in these guidelines precludes the HMO and the case management agency from entering into a formal contract or memorandum of understanding to address issues not
outlined here. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -185- 








 ADDENDUM VIII 
  
 REPORT FORMS AND WORKSHEETS 
  

	A.	AIDS and Ventilator Dependent Quarterly Report Form and Detail Report Format 

  
 AIDS COST SUMMARY 
  
 HMO Name:
                                        

 Report Period:
                                        

 Number of Cases Reported:
                                       
  
  

					
	 Category of Service

	 	 Amount Billed

	 	 Amount Paid


	 Inpatient
	 	 	 	 
	 Outpatient
	 	 	 	 
	 Physician
	 	 	 	 
	 Pharmacy
	 	 	 	 
	 All Other
	 	 	 	 
	 Total
	 	 	 	 

  
 VENTILATOR COST
SUMMARY 
  
 HMO Name:
                                        

 Report Period:
                                       
  
 Number of Cases Reported:
                                       
  
  

					
	 Category of Service

	 	 Amount Billed

	 	 Amount Paid


	 Inpatient
	 	 	 	 
	 Outpatient
	 	 	 	 
	 Physician
	 	 	 	 
	 Pharmacy
	 	 	 	 
	 All Other
	 	 	 	 
	 Total
	 	 	 	 

  

			
	 MAIL TO:
	 	Bureau of Managed HealthCare Programs
	 	 	ATTN: A/V Contracts Specialist Rm 265
	 	 	P.O. Box 309
	 	 	Madison, WI 53701-0309

  
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -186- 








 AIDS and Ventilator Dependent Detail Report: The detail report must be provided on disk in a text delimited file
and paper and must be in the following layout: 
  

													
	 	  	 Field Name

	  	Type

	  	Width

	  	Dec

	  	Position

	  	 Explanation


	 1
	  	HMO_ID	  	Num	  	8	  	0	  	1-8	  	Right justified (HMO Service Area Provider Number)
	 2
	  	MA_ID	  	Num	  	10	  	0	  	9-18	  	Recipient Medicaid ID
	 3
	  	LNAME	  	Char	  	13	  	 	  	19-31	  	Recipient Last Name - Left justified
	 4
	  	FNAME	  	Char	  	10	  	 	  	32-41	  	Recipient First Name - Left justified
	 5
	  	ELIG_CODE	  	Char	  	1	  	 	  	42	  	A = AIDS; N = NICU vent dependent; V = Vent dependent, non-NICU
	 6
	  	DOB	  	Date	  	8	  	 	  	43-50	  	mmddyyyy
	 7
	  	SEX	  	Char	  	1	  	 	  	51	  	F or M
	 8
	  	PROV_ID	  	Num	  	8	  	0	  	52-59	  	Medicaid Provider Number
	 9
	  	PROV LNAME	  	Char	  	13	  	 	  	60-72	  	Medicaid Provider Last Name – Left Justified
	 10
	  	PROV FNAME	  	Char	  	10	  	 	  	73-82	  	Medicaid Provider First Name – Left Justified
	 11
	  	FROM_DATE	  	Date	  	8	  	 	  	83-90	  	mmddyyyy
	 12
	  	TO_DATE	  	Date	  	8	  	 	  	91-98	  	mmddyyyy
	 13
	  	DIAG_1	  	Char	  	5	  	 	  	99-103	  	Left justified, ICD-9, implied decimal
	 14
	  	DIAG_2	  	Char	  	5	  	 	  	104-108	  	Left justified, ICD-9, implied decimal
	 15
	  	QTY	  	Num	  	4	  	0	  	109-112	  	Right justified (do not zero fill)
	 16
	  	PROC_CODE	  	Char	  	5	  	 	  	113-117	  	Left justified, CPT-4, UB92
	 17
	  	PROC_DESC	  	Char	  	10	  	 	  	118-127	  	 
	 18
	  	DRUG_CODE	  	Num	  	11	  	0	  	128-138	  	National Drug Code
	 19
	  	DRUG DESC	  	Char	  	10	  	 	  	139-148	  	Drug Name – Left Justified
	 20
	  	AMT_BILL	  	Num	  	9	  	2	  	149-157	  	Include decimal (do not zero fill)
	 21
	  	AMT-PAID	  	Num	  	9	  	2	  	158-166	  	Include decimal (do not zero fill)
	 22
	  	ADMIT_DATE	  	Date	  	8	  	 	  	167-174	  	Hospital admission date: mmddyyyy
	 23
	  	DIS_DATE	  	Date	  	8	  	 	  	175-182	  	Hospital discharge date: mmddyyyy
	 24
	  	COUNTY CODE	  	Num	  	3	  	 	  	183-185	  	County Code - Where the enrollee resides for each date of service billed

  

			
	Note:	 	In addition to the total dollar amount(s) billed and paid for all enrollees the HMO must report the total dollar amount(s) billed and paid for each individual
enrollee.

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -187- 









	B.	Coordination of Benefits Quarterly Report Form and Instructions for Completing the Form 

  
 In order to comply with CMS reporting requirements, HMOs must submit a Coordination of Benefits (COB) report regarding their
Medicaid and BadgerCare enrollees. For the purposes of this report, an HMO enrollee is any Medicaid recipient listed as an ADD or CONTINUE on the monthly HMO enrollment report(s) that are generated by the Department’s Medicaid fiscal agent.

  
 Birth costs or delivery costs (e.g., routine delivery and
associated hospital charges) are not to be included in the report. 
  
 The report is to be for the HMOs entire service area, aggregating separate service areas if the HMO has more than one service area. The report must be completed on a calendar quarterly basis and submitted to the Department’s fiscal
agent within 45 days of the end of the quarter being reported, as specified in Article VII, I. 
  

			
	MAIL TO:	  	FAX TO:
		
	Bureau of Managed Health Care Programs	  	Bureau of Managed Health Care Programs
	ATTN: COB Analyst Room 265	  	ATTN: COB Analyst
	P.O. Box 309	  	(608) 261-7792
	Madison, WI 53701-0309	  	 

  
 The COB report form
follows this page. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -188- 








 STATE OF WISCONSIN 
 MEDICAID/BADGERCARE 
 HMO REPORT ON COORDINATION OF BENEFITS 
  

			
	 Name of HMO
                                       
 
	 	Mailing Address
                                       
 
	 Office Telephone
                                       
 
	 	                                      
                              
	 Provider Number
                                       
 
	 	                                      
                              

  
 Please designate below the quarter period for which information is given in this report. 

	                    ,	20                     through
            , 20 

  

	A.	Cost Avoidance – Indicate the dollar amount you denied as a result of your knowledge of other insurance that is available for the enrollee. 

  
 Amount Cost Avoided:
                         
  

	B.	Recoveries (Post-Pay Billing/Pay and Chase) – Indicate below the dollar amounts recovered as a result of: 

  
 Subrogation/Workers’
Compensation:                             
 (e.g., collections from auto, homeowners, or malpractice insurance, restitution payments from the Division of Corrections, collections from Worker’s
Compensation). 
  
 Other
Recoveries:                             
 (e.g., Third Party Liability (TPL), legal action, estate recoveries or any other recoveries that are not specifically noted above.) 
  
 I HEREBY CERTIFY that to the best of my knowledge and belief, the information contained in
this report is a correct and complete statement prepared from the records of the HMO, except as noted on the report. 
  

	


	
	Signed:
                                        
                                        
                                        
                                        
                                
	                                        
 Original Signature of Director or Administrator

	
	Title:
                                        
                                        
                                        
                                        
                                
	
	Date Signed:
                                        
                                        
                                        
                                        
                    


	

  
  
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -189- 









	C.	Medicaid and BadgerCare HMO Newborn Report 

  
 This report should be completed for infants born to mothers who are Medicaid or BadgerCare eligible and enrolled in the HMO at the time of birth of the infant.

  

			
	 1.      HMO Name:
	 	In this field enter the name of the HMO reporting.
		
	 HMO Provider Number:
	 	In this field enter the eight digit Medicaid provider number of the HMO reporting.
		
	 Telephone Number:
	 	In this field enter the HMO telephone number the fiscal agent can call with questions about submitted newborn reports.
		
	 2.      Newborn Name:
	 	In this field enter the name of the newborn infant. If the mother has not given a first and middle name to the baby at the time the report is completed, enter the last name of the newborn as the
mother’s last name; the first name/middle initial can be entered as “baby male” or “baby female.”
		
	 Date of Birth:
	 	In this field enter the date of birth of the newborn infant, in MM/DD/YY format.
		
	 Sex:
	 	In this field check the sex of the newborn infant, Male or.
		
	 Low Birth Weight
 <1200 grams:
	 	In this field check the box if the newborn infant weighs less than 1200 grams.
		
	 Twin:
	 	In this field check no if the newborn infant is not a twin, check yes if the newborn infant is a twin. If the newborn infant is a twin, complete one newborn report for each
twin.
		
	 Date of Death:
	 	In this field enter the date of death, if the newborn infant died, in MM/DD/YY format.
		
	 3.      Mother’s Name:
	 	In this field enter the first name, middle initial, and last name of the mother of the newborn infant.
		
	 Address:
	 	In this field enter the address of the mother of the newborn infant – street address, city, state, and zip code.
		
	 Mother’s Medicaid ID Number:
	 	In this field enter the 10 digit Medicaid or BadgerCare number of the mother of the newborn infant.

  
 The HMO staff person completing the
report should sign and date the form and send it to the address listed at the bottom of the report. 
  
 The HMO does not have to use the above format. However, whatever format the HMO uses, the HMO must submit all of the information described above to the Department’s fiscal agent. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -190- 








 MEDICAID AND BADGERCARE HMO NEWBORN REPORT 
  
 Please print, type, or complete in a legible manner 
  

					
	 1.
	  	HMO Name
                                        
                                        
                                        
                                        
                
		
	 	  	 HMO Provider Number
                                        
                                        
                                        
                                    

		
	 	  	 Telephone Number
                                        
                                        
                                        
                                        
    

		
	 2.
	  	 Newborn Name
                                        
                                        
                                        
                                        
          

	 	  	                                        
         (First)                         (M.I.)
	  	                                 (Last)

		
	 	  	 Date of Birth
                                       
                       ̈  Male                  ̈  Female

			
	 	  	  ̈  Low Birth Weight
<1200 grams
	  	 
			
	 	  	 Twins:               ̈  No               ̈  Yes (If yes, complete two forms)
	  	 
			
	 	  	 Date of Death if Applicable
                    
	  	 
		
	 3.
	  	 Mother’s Name
                                        
                                        
                                        
                                    

	 	  	                                        
     (First)                                  
       (M.I.)
	  	                     (Last)

		
	 	  	 Address
                                        
                                        
                                        
                                        
        

	 	  	                                        
                 (Street Address)

		
	 	  	                                       
                                        
                                        
                                        
                        

	 	  	                     (City)                  
                                      
(State)
	  	                         (Zip Code)

		
	 4.
	  	 Mother’s Medicaid or BadgerCare ID Number
                                        
                                        
                        

		
	 5.
	  	 I certify this information is accurate to the best of my knowledge.

			
	 	  	                                       
                                  
	  	                                       
                                     
 

	 	  	                         Signature
	  	                             Date


  

			
	Mail To:	 	FAX To:
		
	Medicaid Fiscal Agent	 	Medicaid Fiscal Agent
	ATTN: Managed Care Unit	 	ATTN: Managed Care Unit
	P.O. Box 6470	 	(608) 224-6318
	Madison, WI 53716-0470	 	 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -191- 









	D.	HealthCheck Worksheet 

  
 HEALTHCHECK WORKSHEET 
  

	HMO	NAME:                                     
                

  

															
	 	  	 	  	 	  	Age Groups

	  	 
	 	  	 	  	 Calculation

	  	< 1

	  	1-5

	  	6–14

	  	15–20

	  	Total


								
	 1
	  	Number of eligible months for enrollees under age 21	  	Entered (Total is sum of age groups.)	  	 	  	 	  	 	  	 	  	 
								
	 2
	  	Number of unduplicated enrollees under age 21	  	Entered	  	 	  	 	  	 	  	 	  	 
								
	 3
	  	Ratio of recommended screens per age group member	  	Given	  	5.00	  	1.4	  	0.56	  	0.50	  	 
								
	 4
	  	Average period of eligibility (in years)	  	Line 1 ÷ line 2 ÷ 12 (Total is calculated by formula.)	  	 	  	 	  	 	  	 	  	 
								
	 5
	  	Adjusted ratio of recommended screens per age group member	  	Line 3 x line 4	  	 	  	 	  	 	  	 	  	 
								
	 6
	  	Expected number of screens (100% of required screens for ages and months of eligibility)	  	Line 2 x line 5 (Total is sum of age groups.)	  	 	  	 	  	 	  	 	  	 
								
	 7
	  	Number of screens in goal (80%)	  	Line 6 x 0.80 (Total is calculated by formula.)	  	 	  	 	  	 	  	 	  	 
								
	 8
	  	Actual number of screens completed	  	Entered (Total is sum of age groups.)	  	 	  	 	  	 	  	 	  	 
								
	 9
	  	Difference between goal and actual	  	Line 8 – line 7 (Positive result means goal is met; negative result means goal is not met.)	  	 	  	 	  	 	  	 	  	 
								
	 10
	  	Percent of the HMO discount or premium if applicable except for Milwaukee, Dane, Eau Claire, Kenosha and Waukesha Counties.	  	 	  	 	  	 	  	 	  	 	  	 
								
	 11
	  	Amount per screen to be recouped	  	FFS maximum allowable fee *(Refer Article III, K, 2) x line 10	  	 	  	 	  	 	  	 	  	 
								
	 12
	  	Total recoupment	  	Line 11 x line 9	  	 	  	 	  	 	  	 	  	 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -192- 









	E.	Neonatal Intensive Care Unit (NICU) Risk-Sharing Report Format and Detail Data Requirements 

  
 HMO reporting of NICU costs must include all of the data elements specified in this section. Risk-sharing for NICU is based
on the criteria defined in Article VI, I of this Contract. As specified in Article VII, I of this Contract NICU reports must be submitted to the Department’s Contract Specialist on or before May 1 of the following year. The HMO does not
have to file a report if the NICU criteria is not met. 
  
 The
NICU report form, detailed data format and worksheet follow this page. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -193- 








 HMO NEONATAL INTENSIVE CARE UNIT (NICU) REPORT FORM 
  

	HMO	Name:
                                        
                                     

  
 HMO Medicaid (Payee) Number
                                     
  

	Report	Period: January 1, 200                 through December 31,
200     

  
 Questions regarding this report should be referred
to:                                       
      
                                        
                                        
                     (please print) 
  
 Phone Number:
                     
  

	A.	HMO DATA SUMMARY BY COUNTY 

  

	 	1.	Hospital Inpatient Costs Associated with Level II, III, and IV NICU Services as defined in Article VI, I, 1 of this Contract. 

  

							
	 Number
 of Days

	 	 Number of
 Admissions

	 	 Amount
 Billed

	 	 Amount
 Paid


	 	 	 	 	 	 	 

  

	2.	Physician Costs Associated with Level II, III, and IV NICU Services. 

  

			
	 Amount Billed:

	 	 Amount Paid


	 	 	 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -194- 









	B.	HMO DETAILED NICU DATA FORMAT 

  
 The costs summarized in Section A must be reported by month, by county, and by year (i.e., if an enrollee is in an NICU for two or more months, the NICU
days, physician and hospital costs must be separated by the month in which they occurred). Amounts paid must include payments for all physician and hospital services that were provided during the report period regardless of the HMO’s actual
payment date. 
  

																													
	 Enrollee
Name

	  	 Enrollee
MA ID
Number

	  	 Admit
 Date
(mm/dd/yy)

	  	 Discharge
 Date
(mm/dd/yy)

	  	Total
Number of
NICU
Admissions

	  	Month

	  	NICU Hospital
Data by month
First NICU Day
(mm/dd/yy)

	  	NICU Hospital
Data by month
Last NICU Day
(mm/dd/yy)

	  	 Total
 Number of
NICU Days
 (by month)

	  	 NICU
Amount
 Billed Hosp
(prorated by
month)

	  	NICU
Amount
Paid Hosp
(prorated by
month)

	  	NICU
Amount
Billed
Physician
(by month)

	  	NICU
Amount
Paid
Physician
(by month)


	 Name
	  	xxxxxxxxxx	  	07/01/02	  	07/22/02	  	1	  	Jul	  	07/01/02	  	07/22/02	  	20	  	$	00,000.00	  	$	00,000.00	  	$	0,00.00	  	$	00.00

  
 MAIL TO:

  
 Bureau of Managed HealthCare Programs 
 ATTN: NICU Contracts Specialist Room 265 
 P.O. Box 309 
 Madison, WI 53701-0309 
  

	C.	NICU WORKSHEET 

  
 HMOs may complete the worksheet following this page to determine if their NICU days meet the criteria defined in Article VI, I. HMOs do not have to file a
report if the NICU criteria is not met. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -195- 








 Neonatal Intensive Care Unit Risk-Sharing Worksheet 
  
 Calculation 
  

					
	 1.      HMO enrollee months:
	 	 	 	                                       
  

			
	 2.      Enrollee years:
	 	 (line 1/12)
	 	                                       
  

			
	 3.      Threshold (75 days per 1000 enrollee years):
	 	 (75 x line 2/1000)
	 	                                       
  

			
	 4.      NICU days reported by HMO:
	 	 	 	                                       
  

			
	 5.      NICU days over threshold to be reimbursed:
	 	 (line 4 – line 3)
	 	                                       
  

			
	 6.      Inpatient paid:
	 	 	 	                                       
  

			
	 7.      Physician paid:
	 	 	 	                                       
  

			
	 8.      Total cost:
	 	 (line 6 + line 7)
	 	                                       
  

			
	 9.      Average cost per day:
	 	 (line 8 /line 4)
	 	                                       
  

			
	 10.    90% of cost/day (Not to exceed $1,443):
	 	 (0.9 x line 9)
	 	                                       
  

			
	 11.    Reimbursement amount (Days x 90% cost):
	 	 (line 5 x line 10)
	 	                                       
  


  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -196- 









	F.	Court Ordered Birth Cost Requests 

  
 County Child Support Agencies (CSA) obtain court orders requiring fathers to repay birth costs that have been paid by Medicaid FFS as well as Medicaid
Health Maintenance Organizations (HMO). In some counties, judges will not assign birth costs to the father based upon average costs. Upon request of the Medicaid fiscal agent Contract Monitor, the HMO must provide actual charges less any payments
made by a third party payer for the use by the court in setting actual birth and related costs to be paid by the father. Birth cost information must be submitted to the Bureau of Managed Health Care Programs within 14 days from the date the request
was received by the HMO. 
  
 The birth cost report forms follows
this page. 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -197- 








 MEDICAID AND BADGERCARE HMO BIRTH COST REQUEST 
 PART I: Local Child Support Agency Portion 
  
 PART I: To be completed by the Local Child Support Agency. Please type or print, in a legible manner. 
  

			
	 1.
	  	HMO Name
                                        
                                        
                                        
                  
		
	 2.
	  	 Mother’s Name
                                        
                                        
                                        
            

	 	  	                                        
     (First)
                        (M.I.)               
              (Last)

	
	 Medicaid/BadgerCare ID Number
                                        
                                        
                      

	
	 Address
                                        
                                        
                                        
                        

	 	  	                                        
                                 (Street Address)

	 	  	                                       
                                        
                                        
                                        
  

	 	  	                                     (City)  
                                      
(State)                                     (Zip
Code)

		
	 3.
	  	 Newborn’s Name
                                        
                                        
                                        
        

	 	  	                                        
 (First)
                                        
        (M.I.)                                
(Last)

	
	 Medicaid/BadgerCare ID Number
                                        
                                        
                      

	
	 Date of Birth
                                        
                             Sex
                                        
                    


  
 Note: In cases of multiple births,
a form must be completed for each newborn. In addition, the form(s) should not be submitted to the BMHCP until 60 days after the birth. 
  

	4.	I certify this information is accurate to the best of my knowledge: 

  

			
	 Name of Local Child Support Agency
	  	 
	 Name (Please Print)
	  	 
	 Signature
	  	 
	 Title
	  	 
	 Date
	  	 
	 Telephone Number:
	  	FAX Number:
	 Email Address:
	  	 

  

			
	Mail To:	 	FAX To:
		
	Bureau of Managed HealthCare Programs	 	Bureau of Managed HealthCare Programs
	ATTN: Birth Costs, Room 265	 	ATTN: Birth Costs
	P.O. BOX 309	 	(608) 261-7792
	MADISON, WI 53701-0309	 	 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -198- 








 PART II: HMO Portion 
  
 Part II: To be completed by the HMO. Please type or print in a legible manner. 
  

	1.	The actual payment for birthing costs for the mother and her baby. 

  

			
	 Mother’s Name
                                        
                                     ID#
                                        
    
	  	 
		
	 Baby’s Name
                                    ID#  
                                      D.O.B
                    
	  	 
		
	 Hospital/Birthing Center Payment (Mother)
	  	$                    
		
	 Hospital/Birthing Center Payment (Newborn)
	  	$                    
		
	 Physician Payment (Mother)
	  	$                    
		
	 Physician Payment (Newborn)
	  	$                    
		
	 Amount Paid by Other Insurance
	  	$                    

  

	2.	Comments: (i.e., retroactively disenrolled from [HMO NAME] effective [DATE], services denied) 

  
 [State Denial Reason]:
                                        
                                        
                                        
                     
  

	3.	I certify this information is accurate to the best of my knowledge. 

  

			
	 Name of HMO
	  	 
	 Name (Please Print)
	  	 
	 Signature
	  	 
	 Title
	  	 
	 Date
	  	 
	 Telephone Number:
	  	FAX Number:
	 Email Address:
	  	 

  

	4.	Mail or FAX Part I and Part II within 14 days of receipt to: 

  

			
	Mail To:	 	FAX To:
		
	Bureau of Managed Health Care Programs	 	Bureau of Managed Health Care Programs
	ATTN: Birth Costs, Room 265	 	ATTN: Birth Costs
	P.O. Box 309	 	(608) 261-7792
	Madison, WI 53701-0309	 	 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -199- 









	G.	Complaint and Grievance Reporting Forms 

  

	 	1.	Grievance Experience Summary Report 

  
 Summarize each Medicaid and BadgerCare grievance reviewed in the past quarter. 
  

	 	a.	Grievances Related to Program Administration 

  

											
	 Member
 Identification
 Number

	 	 Date
 Grievance
 Filed

	 	 Nature of
 Grievance

	 	 Date
 Resolved

	 	 Summary of
 Grievance
 Resolution

	 	 Administrative
 Changes as a
 Result of
 Grievance Review



  

	 	b.	Grievances Related to Benefit Denial/Reduction 

  

											
	 Member
 Identification
 Number

	 	 Date
 Grievance
 Filed

	 	 Nature of
 Grievance

	 	 Date
 Resolved

	 	 Summary of
 Grievance
 Resolution

	 	 Administrative
 Changes as a
 Result of
 Grievance Review



  

	 	c.	Summary 

  

					
	 SUBTOTAL: Program Administration
	 	                                  	 	 
			
	 SUBTOTAL: Benefit Denial/Reduction
	 	                                  	 	 
			
	 TOTAL NUMBER OF GRIEVANCES:
	 	                                  	 	 

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -200- 









	 	2.	HMO Reporting Form for Complaints 

  

	
	                                      
                                        
                                        
                                        
                      
	                                        
         HMO Name

	  ̈        First Quarter

	
	  ̈        Second Quarter

	
	  ̈        Third Quarter

	
	  ̈        Fourth Quarter

	
	  ̈        Calendar Year 2004

	
	  ̈        Calendar Year 2005


  

			
	 TYPE OF COMPLAINT

	  	 TOTAL NUMBER OF COMPLAINTS


	 1.      ACCESS PROBLEMS
	  	 
		
	 2.      BILLING ISSUES
	  	 
		
	 3.      QUALITY OF CARE
	  	 
		
	 4.      DENIAL OF SERVICE
	  	 
		
	 5.      OTHER SPECIFY:
	  	 

  
 General
Definitions 
  

	 	1.	Access problems include any problem identified by the HMO that causes an enrollee to have difficulty getting an appointment, receiving care, or on culturally appropriate care,
including the provision of interpreter services in a timely manner. 

  

	 	2.	Billing issues include the denial of a service or a recipient receiving a bill for a Medicaid covered service that the HMO is responsible for providing or arranging for the
provision of that service. 

  

	 	3.	Quality of care includes long waiting time in the reception area of providers’ offices, rude providers or provider staff, or any other complaint related directly to patient
care. 

  

	 	4.	Denial of service includes any Medicaid covered service that the HMO denied. 

  

	 	5.	Others as identified by each HMO. 

  
 Return the completed forms to: 
  
 Bureau of Managed Health Care Programs 
 ATTN: Grievance Contracts Specialist, Rm 265 
 P.O. Box 309 
 Madison, WI 53701-0309 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -201- 









	H.	Attestation Form 

  
 ATTESTATION 
  

	 	I,	        
                                        
                , have reviewed the following data: 

                             (Name and Title) 
  

	 	 ̈	Encounter Data for (month)                     (year)
200    . 

  

	 	 ̈	AIDS/Vent Report for (quarter)                    for (year)
200    . 

  

	 	 ̈	Other
                                       
 (Specify Report) 

  
 I hereby attest and
affirm that the information being submitted is complete, factual and correct to the best of my knowledge. I furthermore attest and affirm that no material facts have been omitted from this form. I understand that payment and satisfaction of
this/these claim(s) will be from federal and state public funds and that I may be prosecuted under applicable federal and state laws for any false claims, statements, or documents, or concealment of a material fact. I furthermore understand that
state or federal authorities may inspect all claims, records or documents pertaining to the provision of these services. 
  

			
	                                      
                                        
                          	 	                                      
                                        
                          
	                                       
     (Signature)	 	                                       
             (Date)
		
	                                      
                                        
                          	 	                                      
                                        
                          
	                                       
     (Print Name)	 	                                       
         (Print Date)

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -202- 








 ADDENDUM IX 
  
 GENERAL INFORMATION ABOUT THE WIC PROGRAM AND SAMPLE HMO-TO- 
 WIC REFERRAL FORMS 
  
 General Information about the WIC Program and its Relationship to Medicaid HMOs 
  
 The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a program enacted as an amendment to the Child Nutrition Act of 1996, and is funded
by USDA. WIC provides supplemental nutritious foods, nutrition education, and referrals to pregnant and breastfeeding women, infants and children up to age five, who are determined to be at nutritional risk. Income eligibility is determined by
family size and gross income (185% of the poverty level). WIC uses “adjunctive” eligibility which means that any recipient of Medicaid (including Healthy Start and BadgerCare) is income eligible for WIC. 
  
 The State Division of Public Health contracts with 69 local agencies to provide WIC benefits.
In Wisconsin, most WIC agencies are local health departments, but other community-based organizations are contracted with WIC to provide WIC benefits, including community action programs. other private non-profit health agencies and one hospital.

  
 WIC serves approximately 106,000 women, infants and children each month.
Approximately fifty-three thirty-five (53) percent of all Wisconsin births are on WIC. Approximately half of all WIC participants were enrolled in a Medicaid HMO. Seventy-one (71) percent of all participants have incomes at or below the
poverty level; thirty-five (35) percent have less than a high school education. 
  
 Section 1902(a)(11)(C) of the Social Security Act requires coordination between Medicaid HMOs and WIC. This coordination includes the referral of potentially eligible women, infants, and children to the WIC program and the provision of
medical information by providers working within Medicaid managed care plans to the WIC program if requested by WIC agencies. Typical types of medical information requested by WIC agencies include information on nutrition related metabolic disease,
diabetes, low birth weight, failure to thrive, prematurity, infants of alcoholic, mentally retarded, or drug addicted mothers, AIDS, allergy or intolerance that affects nutritional status, and anemia. 
  
 The WIC referral forms follow this page. Multiple copies of the forms may be obtained from
local WIC agencies. More information about the WIC program and a list of local WIC agencies can be found on the WIC website (www.dhfs.state.wi.us/wic). 
  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -203- 









			
	DEPARTMENT OF HEALTH AND FAMILY SERVICES	 	STATE OF WISCONSIN
	Division of Public Health	 	Bureau of Family & Community Health
	DPH 4024B (Rev. 08/03)	 	WIC Program, Federal Reg. 246

  
 WIC MEDICAL REFERRAL
INFANTS AND CHILDREN (THROUGH 4 YEARS OF AGE) 
 Completion of this form is voluntary. Personally identifiable information is used to determine
WIC services 
 (e.g., certification / enrollment and food package issuance) and may be disclosed to others only as allowed by state and
federal laws. 
  

  
 INSTRUCTIONS: To facilitate WIC services (certification and food package issuance) for your WIC-eligible patient, fill in the blanks and check the boxes, as
appropriate, and return this form to the WIC Project indicated at the bottom of the page. 
  

  

					
	Patient’s First and Last Name
                                        
                                        
            	 	Birthdate
                                        
          
		
	Address
                                        
                                        
                                        
       	 	Telephone
                                        
        
	
	Parent / Caregiver’s First and Last Name
                                        
                                        
                                        
                          

  

  

					
	ALL INFANTS AND CHILDREN	  	 	 	INFANTS ONLY
			
	  Present weight
                                        
    	  	Hct             % and/or Hgb             
gm	 	    Birth weight
                                       
 
	  Length / stature
                                        
  	  	 	    Birth length
                                        
 
	     ̈  recumbent or     ̈  standing	  	Date taken
                                        
 	 	    Gestational age
                                    
	  Date taken
                                        
          	  	Blood lead
                                        
 	 	    E.D.D.
                                        
         
	  Vitamin / Mineral Rx
                                 	  	Date taken
                                        
 	 	 

  

  

					
	 INFANTS
 Medical conditions the
mother had prenatally
	 	 
			
	   ̈  anemia	 	 ̈  high blood lead	 	 ̈  food allergy or intolerance, specify
	   ̈  pregnancy-induced hypertension	 	 ̈  gestational diabetes	 	                                      
                        
	    ̈  nutrition-related infectious or chronic disease, genetic or central nervous system disorder,
        or other medical condition, specify
                                        
                                        
                                        
                            


  

											
	Current nutrition-related health problems
					
	   ̈  pyloric stenosis	 	 ̈  GI reflux	 	 ̈  LGA at birth	 	 ̈  currently LGA	 	 ̈  head circumference <5th percentile

  

							
	ALL INFANTS AND CHILDREN – Current nutrition-related health problems
			
	   ̈  SGA at birth	 	 ̈  food allergy or intolerance, specify
                                       
 	 	 ̈  failure to thrive
	   ̈  currently SGA	 	 ̈  recent surgery, trauma, or burns, specify
                               	 	 

  

							
	   ̈  infectious disease in last 6 months,
specify:	 	 
	         ̈  pneumonia	 	 ̈  HIV or AIDS	 	 ̈  tuberculosis
	         ̈  bronchiolitis (#
episodes in last 6 mos                             )	 	 ̈  meningitis	 	 ̈  parasitic infection
	   ̈  nutrition-related chronic disease, genetic or
central nervous system disorder, or other medical condition
                                       
 

  

  

									
	 FORMULA PRESCRIBED
 Special formula
for infants and children:

				
	   ̈  Similac NeoSure Advance	  	 ̈  Enfamil AR LIPIL or Enfamil AR	  	 ̈  Kindercal	  	 ̈  Pediatric EO28
	   ̈  Enfamil EnfaCare LIPIL	  	 ̈  Neocate	  	 ̈  PediaSure	  	 ̈  EleCare
	    ̈  Enfamil Nutramigen LIPIL or
         Enfamil Nutramigen
	  	  ̈  Similac PM
60/40
  ̈  Enfamil
Pregestimil
	  	 ̈  PediaSure w/Fiber	  	 ̈  Portagen
	   ̈  Alimentum Advance or Alimentum	  	  	 	  	 

  

					
	Standard formula for children:	 	 
			
	   ̈  Similac with Iron	 	 ̈  Isomil Soy with Iron	 	 ̈  Similac Lactose Free with Iron
	   ̈  Similac Advance with Iron	 	 ̈  Isomil Advance Soy with Iron	 	 ̈  Similac Lactose Free Advance with Iron
	
	Intended length of use
                                        
                                        
                                        
                                        
              

  

  
 Additional Diagnoses / Health Concerns / Diet Orders 
  
  

  

			
	SIGNATURE – Health Care Provider
                                        
                                       
 	  	Date Signed
                                        
  
	(Physician, physician assistant, or advanced practice nurse prescriber signature is required for prescription of special formulas and formulas for children.)
	
	Medical Office / Clinic
                                        
                                        
                                        
                                        
              
		
	Address
                                        
                                        
                                        
        	  	Telephone
                                        
    

  

   LOCAL WIC PROJECT: 
  
  
 WIC is an Equal Opportunity Provider and Employer 
  

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -204- 









			
	DEPARTMENT OF HEALTH AND FAMILY SERVICES	 	STATE OF WISCONSIN
	Division of Public Health	 	Bureau of Family & Community Health
	DPH 4024A (Rev. 11/02)	 	WIC Program, Federal Reg. 246

  
 WIC MEDICAL REFERRAL

 PREGNANT, BREASTFEEDING AND NONBREASTFEEDING POSTPARTUM WOMEN 
 Completion of this form is voluntary. Personally identifiable information is used to determine WIC services 
 (e.g., certification / enrollment and food package issuance) and may be disclosed to others only as allowed by state and federal laws. 
  

  
 INSTRUCTIONS: To facilitate WIC services
(certification and food package issuance) for your WIC-eligible patient, fill in the blanks and check the boxes, as appropriate, and return this form to the WIC Project indicated at the bottom of the page. 
  

  

			
	Patient’s First and Last Name
                                        
                                	  	Birthdate
                                        
                              
	Address
                                        
                                        
                           	  	Telephone
                                        
                            

  

  

							
	ALL WOMEN	 	 	 	PREGNANT	 	POSTPARTUM
				
	  Present weight                         	 	Hct
                                      %	 	E.D.D.
                                	 	Delivery date                       
	  Present height
                         	 	And/or	 	Weeks gest.                         	 	Prepreg. Weight                  
	  Date taken                     
          	 	Hgb
                                    gm	 	Prepreg. weight                   	 	Weight gained                     
	  Vitamin / Mineral Rx               	 	Date taken
                             	 	 	 	 

  

  

	
	 ALL WOMEN
 Current nutrition-related health
problems

	
	   ̈  food allergy or intolerance, specify
                                        
                                        
                                        
                            
	   ̈  recent major surgery, trauma, or burns, specify
                                        
                                        
                                        
         
	    ̈  infectious disease in last 6 months:
            ̈  pneumonia                 ̈  tuberculosis                 ̈  HIV or AIDS                 ̈  meningitis                 ̈  parasitic infection
    ̈  nutrition-related chronic disease, genetic or central nervous system disorder, or other medical condition,
           specify:
                                        
                                        
                                        
                                        
                             


  

					
	Obstetrical history in any previous pregnancy (if currently pregnant) or most recent pregnancy (if currently postpartum)
			
	   ̈  gestational diabetes	 	 ̈  large for gestational age infant	 	 
	   ̈  low birth weight or preterm infant	 	 ̈  fetal or neonatal death	 	 
	   ̈  infant with nutrition-related birth defect, specify
                                        
                                        
                                        
      

  

					
	PREGNANT WOMEN - Current nutrition-related health problems
			
	    ̈  gestational
diabetes
    ̈  pregnancy-induced
hypertension
	 	  ̈  hyperemesis
gravidarum
  ̈  fetal growth
restriction
	 	 

  

  

																			
	MEDICAL NUTRITIONAL PRESCRIBED
										
	  Ensure:	  	 ̈  Regular	  	 ̈  Fiber	  	 ̈  Glucerna	  	 ̈  Glucerna OS	  	 ̈  High Calcium	  	 ̈  High protein	  	 ̈  Light	  	 ̈  Plus	  	 ̈  Plus HN
										
	  Boost:	  	 ̈  Regular	  	 ̈  Fiber	  	 ̈  Plus	  	 ̈  High Protein	  	 ̈  Breeze	  	 	  	 	  	 	  	 
										
	  Sustacal:	  	 ̈  Regular	  	 ̈  Plus	  	 	  	 	  	 	  	 	  	 	  	 	  	 
	
	Intended length of use
                                        
                                        
                                        
                                        
                

  

  
 Additional Diagnoses / Health Concerns / Diet Orders 
  
  

  

			
	SIGNATURE – Health Care Provider
                                        
                                        
        Date Signed
                                        
  
	(Physician, physician assistant, or advanced practice nurse prescriber signature is required for prescription of a medical nutritional.)
	
	Medical Office / Clinic
                                        
                                        
                                        
                                        
                
	
	Address
                                        
                                        
                                        
                        Telephone
                                    

  

  
 LOCAL WIC PROJECT: 
  
  
 WIC is an Equal Opportunity Provider and Employer 
  
 Pages 190 through 241 have been deleted as the information contained in those
pages can be found on the Bureau of Family and Community Health Services that pertains to the WIC program. 
  

  

 HMO Contract for February 1, 2006 - December 31, 2007 
 -205-