exhibit101.htm


    Exhibit
10.1

     

    
      HHSC Contract
No. 529-06-0280-00014-K

      Version
1.11

      
 

      
        	 
      	 
      
	
                Part
      1: Parties to the Contract:

              


      

      


      
        	
                This
      Contract Amendment (the “Amendment”) is between the Texas Health and Human
      Services Commission (HHSC), an administrative agency within the executive
      department of the State of Texas, having its principal office at 4900
      North Lamar Boulevard, Austin, Texas 78751, and Superior HealthPlan, Inc. (HMO)
      a corporation organized under the laws of the State of Texas, having its
      principal place of business at: 2100 South IH-35, Suite 202, Austin,
      Texas 78704.  HHSC and HMO may be referred to in this
      Amendment individually as a “Party” and collectively as the
      “Parties.”   

                 

                The
      Parties hereby agree to amend their original contract, HHSC contract
      number 529-06-0280-00014 (the “Contract”) as set forth
      herein.  The Parties agree that the terms of the Contract will
      remain in effect and continue to govern except to the extent modified in
      this Amendment.   

                 

                This
      Amendment is executed by the Parties in accordance with the authority
      granted in Attachment A to the HHSC Managed Care Contract document, “HHSC
      Uniform Managed Care Contract Terms & Conditions,” Article 8,
      “Amendments and Modifications.”

              
	
                Part
      2: Effective Date of Amendment:

              	
                Part
      3: Contract Expiration Date

              	
                Part
      4: Operational Start Date:

              
	
                September 1,
      2008

              	
                August
      31, 2010

              	
                STAR
      and CHIP HMOs:  September 1, 2006 

                STAR+PLUS
      HMOs:  February 1, 2007 

                CHIP
      Perinatal HMOs:  January 1, 2007

              
	
                Part
      5: Project Managers:

              
	
                HHSC:
      

                Scott
      Schalchlin

                Director,
      Health Plan Operations

                11209
      Metric Boulevard, Building H 

                Austin,
      Texas 78758 

                Phone:
      512-491-1866

                Fax:
      512-491-1969

                 

                HMO:
      

                Stacey
      Hull 

                Vice
      President of Regulatory Affairs 

                2100
      South IH-35, Suite 202 

                Austin,
      Texas 78704 

                Phone:
      512-692-1465 

                Fax:
      512-692-1474 

                E-mail:
      shull@centene.com

              
	
                Part
      6: Deliver Legal Notices to:

              
	
                HHSC:
      

                General
      Counsel 

                4900
      North Lamar Boulevard, 4th Floor 

                Austin,
      Texas 78751 

                Fax:
      512-424-6586

                 

                HMO:

                Superior
      HealthPlan 

                2100
      South IH-35, Suite 202 

                Austin,
      Texas 78704 

                Fax:
      512-692-1435

              


      

      
        	
                Part
      7: HMO Programs and Service Areas:

              
	
                This Contract applies to the
      following HHSC HMO Programs and Service Areas (check all
      that apply). All
      references in the Contract Attachments to HMO Programs or Service
      Areas that are not checked are superfluous and do not apply to the
      HMO.

                 x Medicaid STAR HMO
      Program

                    Service
      Areas:

                    x
      Bexar                       
       x
       Lubbock  

                    o Dallas                         x
      Nueces

                    x El
      Paso                      o Tarrant

                    o
      Harris                         x
      Travis

                See
      Attachment B-6, “Map of Counties with HMO Program Service Areas,” for
      listing of counties included within the STAR Service
  Areas.

              
	
                  x Medicaid
      STAR+PLUS HMO Program

                    Service
      Areas:

                    xBexar               
      x
      Nueces

                    oHarris                 oTravis

                See
      Attachment B-6.1, “Map of Counties with STAR+PLUS HMO Program Service
      Areas,” for listing of counties included within the STAR+PLUS Service
      Areas.

              
	
                 xCHIP HMO
      Program

                    Core
      Service Areas:

                  x
      Bexar          x
      Nueces

                  o      
      Dallas        oTarrant   

                  x
      El
      Paso        x  Travis

                  o
      Harris           
      o
      Webb

                  x
      Lubbock       

                 

                    Optional
      Service Areas:

                  x
      Bexar                  x  Lubbock   

                  x   El
      Paso               xNueces

                  o
      Harris                  xTravis

                     

                 
      See Attachment B-6, “Map of Counties with HMO Program Service Areas,” for
      listing of counties included within the CHIP Core Service Areas and CHIP
      Optional Service Areas.

              


      

       

      
        	
                xCHIP Perinatal
      Program

                    Core
      Service Areas:

                    xBexar        
      x
      Nueces

                    o
      Dallas        oTarrant   

                    xEl
      Paso       x  Travis

                    oHarris          oWebb

                    xLubbock       

                 

                    Optional
      Service Areas:

                    xBexar                 x Lubbock   

                    xEl
      Paso               xNueces

                   oHarris                  xTravis

                     

                 
      See Attachment B-6.2, “Map of Counties with CHIP Perinatal HMO Program
      Service Areas,” for a list of counties included within the CHIP Perinatal
      Service Areas.

              
	
                Part
      8: Payment

              
	
                Part
      8 of the HHSC Managed Care Contract document, “Payment,” is modified to
      add the capitation rates for Rate Period
3.

              


      

       

      xMedicaid STAR HMO
PROGRAM

      Capitation: See Attachment A, “HHSC
Uniform Managed Care Contract Terms and Conditions,” Article 10, for a
description of the Capitation Rate-setting methodology and the Capitation
Payment requirements for the STAR Program. The following Rate Cells and
Capitation Rates will apply to Rate Period 3:

       

      
        	 
      	
                Service
      Area: BEXAR

              	 
      	 
      
	 
      	
                Rate
      Cell

              	 
      	
                 
      Rate
      Period 3 Capitation Rates

              
	
                1

              	
                
                  TANF
      Child>12 months

                

              	 
      	
                $
      115.68

              
	
                2

              	
                TANF
      child < 12 months

              	 
      	
                $
      371.16

              
	
                 3

              	
                TANF
      Adult

              	 	$
      325.72
	
                4

              	
                
                  Pregnant
      Woman

                

              	 
      	
                $
      466.92

              
	
                5

              	
                
                  Newborn
      < 12 months 

                

              	 
      	
                $
      775.12

              
	
                6

              	
                
                  Expansion
      Child>12 months

                

              	 
      	
                $123.76

              
	
                7

              	
                
                  Expansion
      child < 12 months 

                

              	 
      	
                $
      266.90

              
	
                8

              	
                
                  Federal
      Mandate child 

                

              	 
      	
                $
      85.65

              
	
                9

              	
                
                  Delivery
      Supplemental Payment

                

              	 
      	
                $
      3,266.59

              


      

       

       

      
        
          	 
      	
                  Service
      Area: EL PASO

                	 
      	 
      
	 
      	
                  Rate
      Cell

                	 
      	
                   
      Rate
      Period 3 Capitation Rates

                
	
                  1

                	
                  
                    TANF
      Child>12 months

                  

                	 
      	
                  $
      100.83

                
	
                  2

                	
                  TANF
      child < 12 months

                	 
      	
                  $
      233.31

                
	
                   3

                	
                  TANF
      Adult

                	 	$
      309.01
	
                  4

                	
                  
                    Pregnant
      Woman

                  

                	 
      	
                  $
      415.81

                
	
                  5

                	
                  
                    Newborn
      < 12 months 

                  

                	 
      	
                  $
      557.33

                
	
                  6

                	
                  
                    Expansion
      Child>12 months

                  

                	 
      	
                  $
      108.44

                
	
                  7

                	
                  
                    Expansion
      child < 12 months 

                  

                	 
      	
                  $
      210.84

                
	
                  8

                	
                  
                    Federal
      Mandate child 

                  

                	 
      	
                  $
      78.91

                
	
                  9

                	
                  
                    Delivery
      Supplemental Payment

                  

                	 
      	
                  $
      3,443.04

                


        

      

      
         

        
           

          
            
              	 
      	
                      Service
      Area: LUBBOCK

                    	 
      	 
      
	 
      	
                      Rate
      Cell

                    	 
      	
                       
      Rate
      Period 3 Capitation Rates

                    
	
                      1

                    	
                      
                        TANF
      Child>12 months

                      

                    	 
      	
                      $
      103.87

                    
	
                      2

                    	
                      TANF
      child < 12 months

                    	 
      	
                      $
      316.70

                    
	
                       3

                    	
                      TANF
      Adult

                    	 	$
      449.00
	
                      4

                    	
                      
                        Pregnant
      Woman

                      

                    	 
      	
                      $
      854.19

                    
	
                      5

                    	
                      
                        Newborn
      < 12 months 

                      

                    	 
      	
                      $
      483.31

                    
	
                      6

                    	
                      
                        Expansion
      Child>12 months

                      

                    	 
      	
                      $
      116.71

                    
	
                      7

                    	
                      
                        Expansion
      child < 12 months 

                      

                    	 
      	
                      $
      164.41

                    
	
                      8

                    	
                      
                        Federal
      Mandate child 

                      

                    	 
      	
                      $
      88.87

                    
	
                      9

                    	
                      
                        Delivery
      Supplemental Payment

                      

                    	 
      	
                      $
      3,230.39

                    


            

          

           

           

          
            
              
                	 
      	
                        Service
      Area: NUECES

                      	 
      	 
      
	 
      	
                        Rate
      Cell

                      	 
      	
                         
      Rate
      Period 3 Capitation Rates

                      
	
                        1

                      	
                        
                          TANF
      Child>12 months

                        

                      	 
      	
                        $
      155.00

                      
	
                        2

                      	
                        TANF
      child < 12 months

                      	 
      	
                        $
      370.89

                      
	
                         3

                      	
                        TANF
      Adult

                      	 	$
      375.83
	
                        4

                      	
                        
                          Pregnant
      Woman

                        

                      	 
      	
                        $
      522.42

                      
	
                        5

                      	
                        
                          Newborn
      < 12 months 

                        

                      	 
      	
                        $
      948.77

                      
	
                        6

                      	
                        
                          Expansion
      Child>12 months

                        

                      	 
      	
                        $
      158.07

                      
	
                        7

                      	
                        
                          Expansion
      child < 12 months 

                        

                      	 
      	
                        $
      297.90

                      
	
                        8

                      	
                        
                          Federal
      Mandate child 

                        

                      	 
      	
                        $
      105.45

                      
	
                        9

                      	
                        
                          Delivery
      Supplemental Payment

                        

                      	 
      	
                        $
      3,203.82

                      


              

            

             

             

            
              
                
                  	 
      	
                          Service
      Area: TRAVIS

                        	 
      	 
      
	 
      	
                          Rate
      Cell

                        	 
      	
                           
      Rate
      Period 3 Capitation Rates

                        
	
                          1

                        	
                          
                            TANF
      Child>12 months

                          

                        	 
      	
                          $
      100.65

                        
	
                          2

                        	
                          TANF
      child < 12 months

                        	 
      	
                          $
      311.86

                        
	
                           3

                        	
                          TANF
      Adult

                        	 	$
      286.82
	
                          4

                        	
                          
                            Pregnant
      Woman

                          

                        	 
      	
                          $
      550.10

                        
	
                          5

                        	
                          
                            Newborn
      < 12 months 

                          

                        	 
      	
                          $
      836.20

                        
	
                          6

                        	
                          
                            Expansion
      Child>12 months

                          

                        	 
      	
                          $
      113.16

                        
	
                          7

                        	
                          
                            Expansion
      child < 12 months 

                          

                        	 
      	
                          $
      222.95

                        
	
                          8

                        	
                          
                            Federal
      Mandate child 

                          

                        	 
      	
                          $
      81.92

                        
	
                          9

                        	
                          
                            Delivery
      Supplemental Payment

                          

                        	 
      	
                          $
      3,247.49

                        


                

              

               

               

            

          

        

      

      STAR SSI
Administrative Fee: HHSC will pay a STAR HMO a monthly Administrative Fee
of $14.00 per SSI Beneficiary who voluntarily enrolls in the HMO in accordance
with Attachment A, “HHSC Uniform Managed Care Contract Terms and Conditions,”
Article 10.

       

      Delivery
Supplemental Payment:  See
Attachment A, “HHSC Uniform Managed Care Contract Terms and Conditions,” Article
10, for a description of the methodology for establishing the Delivery
Supplemental Payment for the STAR Program.

       

      x Medicaid STAR+PLUS HMO
Program

      Capitation:
See Attachment A, “HHSC Uniform Managed Care Contract Terms and Conditions,”
Article 10, for a description of the Capitation Rate-setting methodology and the
Capitation Payment requirements for the STAR+PLUS Program.  The
following Rate Cells and Capitation Rates will apply to Rate Period
3:

      


      
        	
                STAR+PLUS
      Service Area:  BEXAR

              	 
      
	 
      	
                Rate
      Cell

              	
                Rate
      Period 3  Capitation Rates

              
	
                1.

              	
                Medicaid
      Only Standard Rate

              	
                $
      526.51

              
	
                2.

              	
                Medicaid
      Only 1915(C) Nursing Facility Waiver Rate

              	
                $
      2,748.46

              
	
                3.

              	
                Dual
      Eligible Standard Rate

              	
                $
      287.26

              
	
                4.

              	
                Dual
      Eligible 1915(C) Nursing Facility Waiver Rate

              	
                $
      1,845.00

              
	
                5.

              	
                Nursing
      Facility – Medicaid Only

              	
                $
      526.51

              
	
                6.

              	
                Nursing
      Facility – Dual Eligible

              	
                $
      287.26

              


      

       

      
        	
                STAR+PLUS
      Service Area:  NUECES

              	 
      
	 
      	
                Rate
      Cell

              	
                Rate
      Period 3  Capitation Rates

              
	
                1.

              	
                Medicaid
      Only Standard Rate

              	
                $
      614.57

              
	
                2.

              	
                Medicaid
      Only 1915(C) Nursing Facility Waiver Rate

              	
                $
      2,487.20

              
	
                3.

              	
                Dual
      Eligible Standard Rate

              	
                $
      393.22

              
	
                4.

              	
                Dual
      Eligible 1915(C) Nursing Facility Waiver Rate

              	
                $
      1,672.29

              
	
                5.

              	
                Nursing
      Facility – Medicaid Only

              	
                $
      614.57

              
	
                6.

              	
                Nursing
      Facility – Dual Eligible

              	
                $
      393.22

              


      

      


       

      x CHIP HMO PROGRAM

      Capitation:
See Attachment A, “HHSC Uniform Managed Care Contract Terms and Conditions,”
Article 10, for a description of the Capitation Rate-setting methodology and the
Capitation Payment requirements for the CHIP Program. The following Rate Cells
and Capitation Rates will apply to Rate Period 3:

      


      
        	 
      	
                Service
      Area: BEXAR

              	 
      	 
      
	 
      	
                Rate
      Cell

              	 
      	
                 Rate Period 3 Capitation
      Rates

              
	
                1

              	
                <
      Age 1

              	 
      	
                $
      117.46

              
	
                2

              	
                Ages
      1 through 5

              	 
      	
                $
      114.44

              
	
                3

              	
                Ages
      6 through 14

              	 
      	
                $
      77.43

              
	
                4

              	
                Ages
      15 through 18

              	 
      	
                $
      90.66

              


      

       

       

      
        	 
      	
                Service
      Area: EL PASO

              	 
      	 
      
	 
      	
                Rate
Cell

              	 
      	
                 Rate Period 3 Capitation
      Rates

              
	
                1

              	
                <
      Age 1

              	 
      	
                $
      83.94

              
	
                2

              	
                Ages
      1 through 5

              	 
      	
                $
      82.60

              
	
                3

              	
                Ages
      6 through 14

              	 
      	
                $
      64.48

              
	
                4

              	
                Ages
      15 through 18

              	 
      	
                $
      76.34

              


      

       

       

      
        	 
      	
                Service
      Area: LUBBOCK

              	 
      	 
      
	 
      	
                Rate
      Cell

              	 
      	
                 Rate Period 3 Capitation
      Rates

              
	
                1

              	
                <
      Age 1

              	 
      	
                $
      87.45

              
	
                2

              	
                Ages
      1 through 5

              	 
      	
                $
      84.55

              
	
                3

              	
                Ages
      6 through 14

              	 
      	
                $
      62.56

              
	
                4

              	
                Ages
      15 through 18

              	 
      	
                $
      87.06

              


      

       

       

      
        	 
      	
                Service
      Area: NUECES

              	 
      	 
      
	 
      	
                Rate
      Cell

              	 
      	
                 Rate Period 3 Capitation
      Rates

              
	
                1

              	
                <
      Age 1

              	 
      	
                $
      125.81

              
	
                2

              	
                Ages
      1 through 5

              	 
      	
                $
      102.44

              
	
                3

              	
                Ages
      6 through 14

              	 
      	
                $
      75.46

              
	
                4

              	
                Ages
      15 through 18

              	 
      	
                $
      94.22

              


      

       

       

      
        	 
      	
                Service
      Area: TRAVIS

              	 
      	 
      
	 
      	
                Rate
      Cell

              	 
      	
                 Rate Period 3 Capitation
      Rates

              
	
                1

              	
                <
      Age 1

              	 
      	
                $
      85.36

              
	
                2

              	
                Ages
      1 through 5

              	 
      	
                $
      107.53

              
	
                3

              	
                Ages
      6 through 14

              	 
      	
                $
      72.61

              
	
                4

              	
                Ages
      15 through 18

              	 
      	
                $
      98.21

              


      

       

      Delivery
Supplemental Payment:  See
Attachment A, “HHSC Uniform Managed Care Contract Terms and Conditions,” Article
10, for a description of the methodology for establishing the Delivery
Supplemental Payment for the CHIP Program. The CHIP Delivery Supplemental
Payment is $3,100.00 for all Service Areas.

       

      x CHIP Perinatal
Program

      Capitation:
See Attachment A, “HHSC Uniform Managed Care Contract Terms and Conditions,”
Article 10, for a description of the Capitation Rate-setting methodology and the
Capitation Payment requirements for the CHIP Perinatal Program.

       

      
        	 
      	
                Service
      Area: BEXAR

              	 
      	 
      
	 
      	
                Rate
      Cell

              	 
      	
                 Rate Period 3 Capitation
      Rates

              
	
                1

              	
                Perinate
      Newborn 0% - 185%

              	 
      	
                $
      428.97

              
	
                2

              	
                Perinate
      Newborn 186% - 200%

              	 
      	
                $
      806.15

              
	
                3

              	
                Perinate
      0% - 185%

              	 
      	
                $
      548.95

              
	
                4

              	
                Perinate
      186% - 200%

              	 
      	
                $
      184.79

              


      

       

      
         

        
          	 
      	
                  Service
      Area: EL PASO

                	 
      	 
      
	 
      	
                  Rate
      Cell

                	 
      	
                   Rate Period 3 Capitation
      Rates

                
	
                  1

                	
                  Perinate
      Newborn 0% - 185%

                	 
      	
                  $
      313.90

                
	
                  2

                	
                  Perinate
      Newborn 186% - 200%

                	 
      	
                  $
      589.91

                
	
                  3

                	
                  Perinate
      0% - 185%

                	 
      	
                  $
      548.95

                
	
                  4

                	
                  Perinate
      186% - 200%

                	 
      	
                  $
      184.79

                


        

         

      

      
         

        
          	 
      	
                  Service
      Area: LUBBOCK

                	 
      	 
      
	 
      	
                  Rate
      Cell

                	 
      	
                   Rate Period 3 Capitation
      Rates

                
	
                  1

                	
                  Perinate
      Newborn 0% - 185%

                	 
      	
                  $
      265.31

                
	
                  2

                	
                  Perinate
      Newborn 186% - 200%

                	 
      	
                  $
      498.59

                
	
                  3

                	
                  Perinate
      0% - 185%

                	 
      	
                  $
      548.95

                
	
                  4

                	
                  Perinate
      186% - 200%

                	 
      	
                  $
      184.79

                


        

        
           

           

          
            	 
      	
                    Service
      Area: NUECES

                  	 
      	 
      
	 
      	
                    Rate
      Cell

                  	 
      	
                     Rate Period 3 Capitation
      Rates

                  
	
                    1

                  	
                    Perinate
      Newborn 0% - 185%

                  	 
      	
                    $
      516.92

                  
	
                    2

                  	
                    Perinate
      Newborn 186% - 200%

                  	 
      	
                    $
      971.43

                  
	
                    3

                  	
                    Perinate
      0% - 185%

                  	 
      	
                    $
      548.95

                  
	
                    4

                  	
                    Perinate
      186% - 200%

                  	 
      	
                    $
      184.79

                  


          

          
             

             

            
              	 
      	
                      Service
      Area: TRAVIS

                    	 
      	 
      
	 
      	
                      Rate
      Cell

                    	 
      	
                       Rate Period 3 Capitation
      Rates

                    
	
                      1

                    	
                      Perinate
      Newborn 0% - 185%

                    	 
      	
                      $
      391.88

                    
	
                      2

                    	
                      Perinate
      Newborn 186% - 200%

                    	 
      	
                      $
      736.45

                    
	
                      3

                    	
                      Perinate
      0% - 185%

                    	 
      	
                      $
      548.95

                    
	
                      4

                    	
                      Perinate
      186% - 200%

                    	 
      	
                      $
      184.79

                    


            

          

        

      

       

      Delivery
Supplemental Payment:  See
Attachment A, “HHSC Uniform Managed Care Contract Terms and Conditions,” Article
10, for a description of the methodology for establishing the Delivery
Supplemental Payment for the CHIP Perinatal Program.  The CHIP
Perinatal Delivery Supplemental Payment is $3,100.00 for Perinates between 186%
and 200% of the Federal Poverty Level for all Service Areas.

       

       

      
        	
                Part
      9: Contract Attachments:

              
	 
      


      

      
        Modifications
to Part 9 of the HHSC Managed Care Contract document, “Contract Attachments,”
are italicized below:

        A: HHSC
Uniform Managed Care Contract Terms & Conditions - Version 1.10 is replaced with
Version 1.11

        B: Scope
of Work/Performance Measures – Version 1.10 is replaced with
Version 1.11 for all attachments, except if noted.

            B-1: HHSC RFP
529-04-272, Sections 6-9

            B-2: Covered
Services

            B-2.1
STAR+PLUS Covered Services

            B-2.2 CHIP
Perinatal Program Covered Services

            B-3:
Value-added Services

            B-3.1
STAR+PLUS Value-added Services

            B-3.2 CHIP
Perinatal Program Value-added Services

            B-4:
Performance Improvement Goals

            B-4.1 SFY
2008 Performance Improvement Goals

            B-5:
Deliverables/Liquidated Damages Matrix

            B-6: Map of
Counties with STAR and CHIP HMO Program Service Areas

            B-6.1
STAR+PLUS Service Areas

            B-6.2 CHIP
Perinatal Program Service Areas

            B-7:
STAR+PLUS Attendant Care Enhanced Payment Methodology

        C: HMO’s
Proposal and Related Documents

            C-1: HMO’s
Proposal

            C-2: HMO
Supplemental Responses

            C-3: Agreed
Modifications to HMO’s Proposal

      

       

      
        	
                Part
      10: Special Provision for Nueces Service Area

              
	 
      


      

       

      
        Attachment
A, Section 10.04 is amended to include sub-part (b) as follows:

        (b) In
addition to the reasons set forth in Section 10.04(a), the Parties expressly
understand and agree that HHSC may, at any time, unilaterally adjust the Rate
Period 2 STAR Program Capitation Rates for the Nueces Service Area. HHSC is
entitled to unilaterally adjust such rates, prospectively and/or
retrospectively, if it determines that: (1) the cumulative Rate Period 2
Encounter Data for all HMOs in the Nueces Service Area does not support the
Capitation Rates; or (2) economic factors in the Nueces Service Area
significantly and measurably impact providers or the delivery of Covered
Services to Members. For adjustments made pursuant to this Section 10.04(b),
HHSC will provide written notice at least ten (10) Business Days before: (1) the
effective date of a prospective adjustment; (2) offsetting Capitation Payments
to recover retrospective adjustments. Any adjustments to the Rate Period 2
Capitation Rates must meet the actuarial soundness requirements of Attachment A,
Section 10.03, “Certification of Capitation Rates.”

      

       

      
        	
                Part
      11:  Signatures:

              
	
                The
      Parties have executed this Contract Amendment in their capacities as
      stated below with authority to bind their organizations on the dates set
      forth by their signatures.  By signing this Amendment, the
      Parties expressly understand and agree that this Amendment is hereby made
      part of the Contract as though it were set out word for word in the
      Contract.

                 

                Texas
      Health and Human Services Commission

                /s/
      Charles E. Bell, M.D.

                Charles
      E. Bell, M.D.

                Deputy
      Executive Commissioner for Health Services

                Date:
      8/29/08

                 

                Superior
      HealthPlan, Inc.

                /s/
      Thomas Wise

                By:  Thomas
      Wise

                Title:
      President and CEO

                Date:
      8/07/08

              


      

    

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      Responsible
Office: HHSC Office of General Counsel (OGC)  

      Subject: Attachment A -- HHSC Uniform
Managed Care Contract Terms & Conditions Version 1.11

       

      Texas Health & Human Services
Commission 

      


      Uniform
Managed Care Contract Terms & Conditions 

      Version
1.11

       

      DOCUMENT
HISTORY LOG

      
        	
                STATUS1

              	
                DOCUMENT
      REVISION2

              	
                EFFECTIVE
      DATE

              	
                DESCRIPTION3

              
	
                Baseline

              	
                n/a

              	 
      	
                Initial
      version of the Uniform Managed Care Contract Terms &
      Conditions

              
	
                Revision

              	
                1.1

              	
                June
      30, 2006

              	
                Revised
      version of the Uniform Managed Care Contract Terms & Conditions that
      includes provisions applicable to MCOs participating in the STAR+PLUS
      Program. 

                 

                Article
      2, “Definitions,” is amended to add or modify the following
      definitions:  1915(c) Nursing Facility Waiver; Community-based
      Long Term Care Services; Court-ordered Commitment; Default Enrollment;
      Dual Eligibles; Eligibles; Functionally Necessary Covered Services; HHSC
      Administrative Services Contractor; HHSC HMO Programs or HMO Programs;
      Medicaid HMOs; Medical Assistance Only; Member; Minimum Data Set For Home
      Care (MSD-HC); Nursing Facility Cost Ceiling; Nursing Facility Level of
      Care; Outpatient Hospital Service; Qualified and Disabled Working
      Individual (QDWI); Qualified Medicare Beneficiary; Service Coordination;
      Service Coordinator; Specified Low-income Medicare Beneficiary (SMBL);
      STAR+PLUS or STAR+PLUS Program; STAR+PLUS HMO; Supplemental Security
      Income (SSI). 

                 

                Article
      4, “Contract Administration and Management,” is amended to add Sections
      4.02(a)(12) and 4.04.1, relating to the STAR+PLUS Service Coordinator.
      

                 

                Article
      8, “Amendments and Modifications,” Section 8.06 is amended to clarify that
      CMS must approve all amendments to STAR and STAR+PLUS HMO contracts.
      

                 

                Article
      10, “Terms and Conditions of Payment,” Section 10.05.1 is added to include
      the Capitation Rate structure provisions relating to STAR+PLUS. Section
      10.11 is modified to apply only to STAR and CHIP.  Section
      10.11.1 is added to include the Experience Rebate provisions relating to
      STAR+PLUS.

              
	
                Revision

              	
                1.2

              	
                September
      1, 2006

              	
                Revised
      version of the Uniform Managed Care Contract Terms & Conditions that
      includes provisions applicable to MCOs participating in the STAR and CHIP
      Programs. 

                 

                Section
      4.04(a) is amended to change the reference from “Texas Board of Medical
      Examiners” to “Texas Medical Board”. 

                 

                Article
      5 is amended to clarify the following sections: 5.02(e)(5), regarding
      disenrollment of Members; 5.02(i), regarding disenrollment of foster care
      children; and 5.04(b), regarding CHIP eligibility and enrollment for
      babies of CHIP Members

              


      

      
      

       

      
        	
                STATUS1

              	
                DOCUMENT
      REVISION2

              	
                EFFECTIVE
      DATE

              	
                DESCRIPTION3

              
	 
      	 
      	 
      	
                Article
      10 is amended to clarify the following sections: 10.01(d), regarding the
      fixed monthly Capitation Rate components; 10.10(c), regarding updating the
      state system for Members who become eligible for SSI.  Section
      10.17 is added regarding recoupment for federal
      disallowance.  

                 

                Article
      17 is amended to clarify the following section: 17.01, naming HHSC as an
      additional insured.

              
	
                Revision

              	
                1.3

              	
                September
      1, 2006

              	
                Article
      2 is amended to modify and add the following definitions to include the
      CHIP Perinatal Program- Appeal, CHIP Perinatal Program, CHIP Perinatal
      HMO, CHIP Perinate, CHIP Perinate Newborn, Covered Services, Complaint,
      Delivery Supplemental Payment, Eligibles, Experience Rebate, HHSC
      Administrative Services Contractor, Major Population Group, Member,
      Optional Service Area, and Service Management. 

                 

                Article
      5 is amended to add the following sections: 5.04.1 CHIP Perinatal
      eligibility and enrollment; 5.05(c) CHIP Perinatal HMOs. 

                 

                Article
      10 is amended to apply to the CHIP Perinatal Program. Section 10.06(a) is
      amended to add the Capitation Rates Structure for CHIP Perinates and CHIP
      Perinate Newborns.  Section 10.06(e) is added to include a
      description of the rate-setting methodology for the CHIP Perinatal
      Program. 10.09(b) is modified to include CHIP Perinatal Program; Section
      10.11 is amended to add the CHIP Perinatal Program to the STAR and CHIP
      Experience Rebate.  Section 10.12(c) amended to clarify cost
      sharing for the CHIP Perinatal Program.

              
	
                Revision

              	
                1.4

              	
                September,
      1 2006

              	
                Contract
      amendment did not revise Attachment A HHSC Uniform Managed Care Terms and
      Conditions

              
	
                Revision

              	
                1.5

              	
                January
      1, 2007

              	
                Revised
      version of the Uniform Managed Care Contract Terms & Conditions that
      includes provisions applicable to MCOs participating in the STAR,
      STAR+PLUS, CHIP, and CHIP Perinatal Programs. 

                 

                Section
      5.04(a) is amended to clarify the period of CHIP continuous coverage.
      

                 

                Section
      5.04.1 is amended to clarify the process for a CHIP Perinatal Newborn to
      move into CHIP at the end of the 12­month CHIP Perinatal Program
      eligibility. 

                 

                Section
      5.08 is added to include STAR+PLUS special default
      language.  

                 

                Section
      10.06.1 is amended to correct the FPL percentages for CHIP Perinates and
      CHIP Perinate Newborns. 

                 

                Section
      17.01 is amended to clarify the insurance requirements for the HMOs and
      Network Providers and to remove the insurance requirements for
      Subcontractors.

              


      

      
      

       

      
        	
                STATUS1

              	
                DOCUMENT
      REVISION2

              	
                EFFECTIVE
      DATE

              	
                DESCRIPTION3

              
	 
      	 
      	 
      	
                Section
      17.02(b) is added to clarify that a separate Performance Bond is not
      needed for the CHIP Perinatal Program.

              
	
                Revision

              	
                1.6

              	
                February
      1, 2007

              	
                Contract
      amendment did not revise Attachment A HHSC Uniform Managed Care Terms and
      Conditions

              
	
                Revision

              	
                1.7

              	
                July
      1, 2007

              	
                Article
      2 is modified to correct and align definition for “Clean Claim” with the
      UMCM. 

                 

                Section
      4.08(c) is modified to add a cross-reference to new Attachment B-1,
      Section 8.1.1.2. 

                 

                Section
      5.05(a), Medicaid HMOs, is amended to clarify provisions regarding
      enrollment into Medicaid Managed Care from Medicaid Fee-for-Service while
      in the hospital, changing HMOs while in the hospital, and addressing which
      HMO is responsible for professional and hospital charges during the
      hospital stay. 

                 

                New
      Section 10.05.1 (c) is added to clarify capitation payments (delays in
      payment and levels of capitation) for Members certified to receive
      STAR+PLUS Waiver Services. 

                 

                Section
      10.06.1 is modified to include the CHIP Perinatal pass through for
      delivery physician services for women under 185% FPL. 

                 

                Section
      10.11 is modified to include treatment of the new Incentives and
      Disincentives (within the Experience Rebate
      determination);  additionally, several clarifications are added
      with respect to the continuing accrual of any unpaid interest, etc.
      

                 

                Section
      10.11.1 is modified to include treatment of the new Incentives and
      Disincentives (within the Experience Rebate determination); additionally,
      several clarifications are added with respect to the continuing accrual of
      any unpaid interest, etc.

              
	
                Revision

              	
                1.8

              	
                September
      1, 2007

              	
                Article
      2 is modified to add definitions for Migrant Farmworker and FWC as a
      result of the Frew litigation corrective action plans. 

                 

                Article
      2 is modified to reflect legislative changes required by SB 10 to the
      definition for Value-added Services. 

                 

                New
      Section
      5.03.1 is added to clarify the enrollment process for infants born to
      pregnant women in STAR+PLUS. 

                 

                Section
      5.04 is modified to reflect legislative changes required by HB 109.
      

                 

                Section
      10.18 is added to clarify the required pass through of physician rate
      increases for all programs to comply with HHSC
  directives.

              


      

      
      

       

      
        	
                STATUS1

              	
                DOCUMENT
      REVISION2

              	
                EFFECTIVE
      DATE

              	
                DESCRIPTION3

              
	
                Revision

              	
                1.9

              	
                December
      1, 2007

              	
                Section
      10.11(d) is modified to increase the Experience rebate loss carry forward
      from 1 year to 2 years. 

                 

                Section
      10.11(e) is modified to eliminate the plan's responsibility to submit the
      actuarial certification on the 90 day FSR. 

                 

                Section
      10.11.1 (d) is modified to increase the Experience rebate loss carry
      forward from 1 year to 2 years. 

                 

                Section
      10.11.1 (e) is modified to eliminate the plan's responsibility to submit
      the actuarial certification on the 90 day FSR.

              
	 Revision    	 1.10	 March
      1, 2008	
                Article
      2 is modified to remove the word “administrative” from the definition for
      Allowable Expenses”. 

                 

                Article
      2 is modified to update the definition for Affiliate. 

                 

                Section
      4.08 is modified to provide consistency of language in sections
      4.08(b)(3), and to obligate the HMOs to provide HHSC with copies of
      amended Subcontracts.  

                 

                Section
      7.05 is modified to update the requirements regarding with state and
      federal anti-discrimination laws. 

                 

                Section
      10.06.1 is modified to clarify the CHIP Perinatal pass through for
      delivery physician services for women under 185% FPL. 

                 

                Section
      10.11 (b) is modified to change the heading in the table from Experience
      Rebate as a % of Revenues to Pre-tax Income as a % of Revenues
      

                 

                Section
      10.11 (c) (1) is modified to remove the word “administrative” from the
      title of UMCM chapter reference. 

                 

                Section
      10.11 (e) (4) is modified to remove the word “administrative” from the
      title of UMCM chapter reference. 

                 

                Section
      10.11.1 (b) is modified to establish new STAR+PLUS rebate brackets for
      Rate Period 2 and after. 

                 

                Section
      10.11.1 (c) (1) is modified to remove the word “administrative” from the
      title of UMCM chapter reference.

              
	 Revision    	 1.11	 September
      1, 2008	
                Article
      2 is modified to add definitions for Discharge and Transfer.

                 

                Article
      2 is modified to remove the “Pediatric and Family” qualifier from Advanced
      Practice Nurses in the definition for PCP.

                 

                Section
      5.02 is modified to clarify that only Medicaid HMOs have a limited right
      to request that a Member be disenrolled.

                 

                Section
      5.03 is modified to clarify that newborns must remain in their  mother’s
      Medicaid HMO for at least 90 days following the date of birth, unless the
      mother request s a plan change.

                 

                Section
      5.05(a), is modified to clarify provisions regarding enrollment into
      Medicaid Managed Care from Medicaid Fee-for-Service while in the hospital
      and changing HMOs while in the hospital.

                 

                Section
      5.05(c) is modified to clarify the span of coverage for CHIP Perinate
      Newborns who are in the hospital on the effective date of
      disenrollment.

                 

                Section
      05.07.1 is added to establish a special temporary STAR default process for
      service areas with HMOs that did not contract with HHSC prior to September
      1, 2006.

                 

                Section
      05.08.1 is added to establish a special temporary STAR+PLUS default
      process for service areas with HMOs that did not contract with HHSC prior
      to September 1, 2006.

                 

                Section
      09.06 is added to require the HMOs to notify HHSC of legal and other
      proceedings, and related events.

                 

                Section
      10.11 (e) is modified to clarify the settlement process.

                 

                Section
      10.11 (f) is modified to require the payment of interest on any Experience
      Rebate unpaid 35 days after the due date for the 90-day FSR
      Report.

                 

                Section
      10.11.1 (e) is modified to reference the process defined in Sections 10.11
      (e) and (f).

                 

                Section
      10.11.1 (f) is deleted as part of the Section 10.11.1 (e) alignment with
      the process defined in Sections 10.11 (e) and (f).

                 

                Section
      10.11.2 is added to institute the STAR, CHIP, CHIP Perinatal, and
      STAR+PLUS Administrative Expense Cap.

                 

                Section
      10.12 (b) is modified to address federal CHIP regulations.

                 

                Section
      11.07 is modified to remove extraneous word.

              
	
                1  Status
      should be represented as “Baseline” for initial issuances, “Revision” for
      changes to the Baseline version, and “Cancellation” for withdrawn versions
      2 Revisions should
      be numbered in accordance according to the version of the issuance and
      sequential numbering of the revision—e.g., “1.2” refers to the first
      version of the document and the second revision. 3  Brief
      description of the changes to the document made in the
      revision.

              


      

      
      

      


      Responsible
Office: HHSC Office of General Counsel (OGC)  Subject: Attachment A -- HHSC Uniform
Managed Care Contract Terms & Conditions Version 1.9

      TABLE OF
CONTENTS

      
         

         

          Article
1.
Introduction...................................................................................................................................
2

          Section
1.01
Purpose......................................................................................................................................
2 

          Section
1.02 Risk-based contract.
...................................................................................................................
2 

          Section
1.03
Inducements...............................................................................................................................
2 

          Section
1.04 Construction of the Contract.
......................................................................................................
2 

          Section
1.05 No implied authority.
...................................................................................................................
3 

          Section
1.06 Legal Authority.
...........................................................................................................................
3

          Article
2. Definitions
......................................................................................................................................
3

          Article
3. General Terms &
Conditions.......................................................................................................15

          Section
3.01 Contract
elements.....................................................................................................................15


          Section
3.02 Term of the Contract.
.................................................................................................................15


          Section
3.03 Funding.
.....................................................................................................................................15


          Section
3.04 Delegation of authority.
..............................................................................................................16

          Section
3.05 No waiver of sovereign immunity.
..............................................................................................16


          Section
3.06 Force
majeure...........................................................................................................................16


          Section
3.07
Publicity.....................................................................................................................................16


          Section
3.08 Assignment.
...............................................................................................................................16


          Section
3.09 Cooperation with other vendors and prospective vendors.
........................................................16 

          Section
3.10 Renegotiation and reprocurement rights.
...................................................................................17


          Section
3.11 RFP errors and
omissions.........................................................................................................17


          Section
3.12 Attorneys’ fees.
..........................................................................................................................17


          Section
3.13 Preferences under service
contracts.........................................................................................17


          Section
3.14 Time of the
essence..................................................................................................................17


          Section
3.15
Notice........................................................................................................................................17

          Article
4. Contract Administration &  Management
...................................................................................17

          Section
4.01 Qualifications, retention and replacement of HMO employees.
.................................................17 

          Section
4.02 HMO’s Key
Personnel...............................................................................................................17


          Section
4.03 Executive
Director.....................................................................................................................18


          Section
4.04 Medical Director.
........................................................................................................................18


          Section
4.04.1 STAR+PLUS Service Coordinator
..........................................................................................19


          Section
4.05 Responsibility for HMO personnel and
Subcontractors.............................................................19


          Section
4.06 Cooperation with HHSC and state administrative agencies.
......................................................19 

          Section
4.07 Conduct of HMO
personnel.......................................................................................................20


          Section
4.08
Subcontractors..........................................................................................................................20


          Section
4.09 HHSC’s ability to contract with Subcontractors.
.........................................................................21


          Section
4.10 HMO Agreements with Third
Parties.........................................................................................21

          Article
5. Member Eligibility &
Enrollment.................................................................................................22

          Section
5.01 Eligibility
Determination.............................................................................................................22


          Section
5.02 Member Enrollment &
Disenrollment.........................................................................................22


          Section
5.03 STAR enrollment for pregnant women and
infants....................................................................22


          Section
5.04 CHIP eligibility and enrollment.
..................................................................................................23


          Section
5.05 Span of Coverage
......................................................................................................................23


          Section
5.06 Verification of Member Eligibility.
...............................................................................................24


          Section
5.07 Special Temporary STAR Default Process
................................................................................24


          Section
5.08 Special Temporary STAR+PLUS Default
Process....................................................................25

          Article
6. Service Levels & Performance Measurement
............................................................................25

          Section
6.01 Performance
measurement.......................................................................................................25

          Article
7. Governing Law &
Regulations....................................................................................................25

          Section
7.01 Governing law and venue.
.........................................................................................................25


          Section
7.02 HMO responsibility for compliance with laws and
regulations...................................................25

          Section
7.03 TDI licensure/ANHC certification and
solvency.........................................................................26

          Section
7.04 Immigration Reform and Control Act of 1986.
............................................................................26

          Section
7.05 Compliance with state and federal anti-discrimination laws.
......................................................26

          Section
7.06 Environmental protection laws.
..................................................................................................27

          Section
7.07 HIPAA.
.......................................................................................................................................27

          Article
8. Amendments &
Modifications.....................................................................................................28

          Section
8.01 Mutual agreement.
.....................................................................................................................28


          Section
8.02 Changes in law or
contract........................................................................................................28


          Section
8.03 Modifications as a remedy.
........................................................................................................28


          Section
8.04 Modifications upon renewal or extension of
Contract................................................................28


          Section
8.05 Modification of HHSC Uniform Managed Care Manual.
.............................................................28 

          Section
8.06 CMS approval of Medicaid amendments
...................................................................................28

          Section
8.07 Required compliance with amendment and modification procedures.
.......................................28

          Article
9. Audit & Financial Compliance
.....................................................................................................28

          Section
9.01 Financial record retention and
audit..........................................................................................28


          Section
9.02 Access to records, books, and
documents................................................................................29


          Section
9.03 Audits of Services, Deliverables and
inspections......................................................................29


          Section
9.04 SAO Audit
..................................................................................................................................29


          Section
9.05 Response/compliance with audit or inspection findings.
............................................................30

          Section 9.06 Notification of Legal and Other Proceedings, and
Related Events............................................30

          Article
10. Terms & Conditions of
Payment...............................................................................................30

          Section
10.01 Calculation of monthly Capitation
Payment.............................................................................30


          Section
10.02 Time and Manner of
Payment.................................................................................................30

          Section
10.03 Certification of Capitation
Rates..............................................................................................31


          Section
10.04 Modification of Capitation
Rates..............................................................................................31


          Section
10.05 STAR Capitation
Structure......................................................................................................31

          Section
10.05.1STAR+PLUS Capitation Structure.
........................................................................................31


          Section
10.06 CHIP Capitation Rates
Structure.............................................................................................32


          Section
10.07 HMO input during rate setting
process....................................................................................33


          Section
10.08 Adjustments to Capitation Payments.
......................................................................................33

          Section
10.09 Delivery Supplemental Payment for CHIP, CHIP Perinatal and STAR HMOs.
........................33 

          Section
10.10 Administrative Fee for SSI
Members.......................................................................................34


          Section
10.11 STAR, CHIP, and CHIP Perinatal Experience
Rebate............................................................34

          Section
10.11.1 STAR+PLUS Experience
Rebate.........................................................................................36

          Section
10.12 Payment by Members.
.............................................................................................................39


          Section
10.13 Restriction on assignment of fees.
...........................................................................................40


          Section
10.14 Liability for taxes.
.....................................................................................................................40

          Section
10.15 Liability for employment-related charges and benefits.
............................................................40 

          Section
10.16 No additional
consideration.....................................................................................................40

          Section
10.17 Federal
Disallowance.............................................................................................................40

          Section
10.18 Required Pass Through of Physician Rate Increases
..............................................................41

          Article
11. Disclosure & Confidentiality  of Information
............................................................................41

          Section
11.01
Confidentiality..........................................................................................................................41

          Section
11.02 Disclosure of HHSC’s Confidential
Information.......................................................................42


          Section
11.03 Member
Records.....................................................................................................................42

          Section
11.04 Requests for public
information...............................................................................................42


          Section
11.05 Privileged Work
Product..........................................................................................................42

          Section
11.06 Unauthorized acts.
...................................................................................................................43

          Section
11.07 Legal
action.............................................................................................................................43

          Article
12. Remedies & Disputes
.................................................................................................................43

          Section
12.01 Understanding and
expectations.............................................................................................43


          Section
12.02 Tailored remedies.
...................................................................................................................43

          Section
12.03 Termination by HHSC.
.............................................................................................................45

           Section
12.04 Termination by
HMO...............................................................................................................47

          Section
12.05 Termination by mutual
agreement...........................................................................................47


          Section
12.06 Effective date of
termination....................................................................................................47

          Section
12.07 Extension of termination effective date.
...................................................................................47


          Section
12.08 Payment and other provisions at Contract
termination............................................................47


          Section
12.09 Modification of Contract in the event of remedies.
...................................................................48


          Section
12.10 Turnover
assistance................................................................................................................48

          Section
12.11 Rights upon termination or expiration of Contract.
...................................................................48


          Section
12.12 HMO responsibility for associated costs.
.................................................................................48

          Section
12.13 Dispute resolution.
...................................................................................................................48

          Section
12.14 Liability of
HMO.......................................................................................................................49

          Article
13. Assurances & Certifications
......................................................................................................49

          Section
13.01 Proposal certifications.
.............................................................................................................49


          Section
13.02 Conflicts of
interest..................................................................................................................49

          Section
13.03 Organizational conflicts of interest.
..........................................................................................49


          Section
13.04 HHSC personnel recruitment
prohibition.................................................................................50


          Section
13.05 Anti-kickback
provision............................................................................................................50

          Section
13.06 Debt or back taxes owed to State of
Texas.............................................................................50


          Section
13.07 Certification regarding status of license, certificate, or permit.
.................................................50 

          Section
13.08 Outstanding debts and
judgments...........................................................................................50

          Article
14. Representations &
Warranties..................................................................................................50

          Section
14.01 Authorization.
...........................................................................................................................50


          Section
14.02 Ability to perform.
.....................................................................................................................50


          Section
14.03 Minimum Net Worth.
................................................................................................................50


          Section
14.04 Insurer
solvency......................................................................................................................51

          Section
14.05 Workmanship and performance.
..............................................................................................51


          Section
14.06 Warranty of deliverables.
.........................................................................................................51

          Section
14.07 Compliance with Contract.
.......................................................................................................51

          Section
14.08 Technology Access
..................................................................................................................51

          Article
15. Intellectual Property
...................................................................................................................52

          Section
15.01 Infringement and
misappropriation..........................................................................................52


          Section
15.02
Exceptions...............................................................................................................................52

          Section
15.03 Ownership and
Licenses.........................................................................................................52

          Article
16. Liability
........................................................................................................................................53

          Section
16.01 Property
damage.....................................................................................................................53


          Section
16.02 Risk of
Loss.............................................................................................................................53


          Section
16.03 Limitation of HHSC’s Liability.
..................................................................................................53

          Article
17. Insurance &
Bonding.................................................................................................................53

          Section
17.01 Insurance
Coverage................................................................................................................53


          Section
17.02 Performance Bond.
..................................................................................................................55


          Section
17.03 TDI Fidelity
Bond.....................................................................................................................55

           

           

        

      

      Article 1. Introduction


      Section 1.01 Purpose.

      The
purpose of this Contract is to set forth the terms and conditions for the HMO’s
participation as a managed care organization in one or more of the HMO Programs
administered by HHSC.  Under the terms of this Contract, HMO will
provide comprehensive health care services to qualified Program recipients
through a managed care delivery system.

      Section 1.02 Risk-based
contract.

      This is a
Risk-based contract.

      Section 1.03 Inducements.

      In making
the award of this Contract, HHSC relied on HMO’s assurances of the
following:

      


      (1) HMO
is an established health maintenance organization that arranges for the delivery
of health care services, is currently licensed as such in the State of Texas and
is fully authorized to conduct business in the Service Areas;

      


      (2) HMO
and the HMO Administrative Service Subcontractors have the skills,
qualifications, expertise, financial resources and experience necessary to
provide the Services and Deliverables described in the RFP, HMO’s Proposal, and
this Contract in an efficient, cost-effective manner, with a high degree of
quality and responsiveness, and has performed similar services for other public
or private entities;

      


      (3) HMO
has thoroughly reviewed, analyzed, and understood the RFP, has timely raised all
questions or objections to the RFP, and has had the opportunity to review and
fully understand HHSC’s current program and operating environment for the
activities that are the subject of the Contract and the needs and requirements
of the State during the Contract term;

      


      (4) HMO
has had the opportunity to review and understand the State’s stated objectives
in entering into this Contract and, based on such review and understanding, HMO
currently has the capability to perform in accordance with the terms and
conditions of this Contract;

      


      (5) HMO
also has reviewed and understands the risks associated with the HMO Programs as
described in the RFP, including the risk of non-appropriation of
funds.

      


      Accordingly,
on the basis of the terms and conditions of this Contract, HHSC desires to
engage HMO to perform the Services and provide the Deliverables described in
this Contract under the terms and conditions set forth in this
Contract.

       

       Section
1.04  Construction
of the Contract.

       

      (a) Scope
of Introductory Article.

       

      The
provisions of any introductory article to the Contract are intended to be a
general introduction and are not intended to expand the scope of the Parties’
obligations under the Contract or to alter the plain meaning of the terms and
conditions of the Contract.

      


      (b)
References to the “State.” References in the Contract to the “State” shall mean
the State of Texas unless otherwise specifically indicated and shall be
interpreted, as appropriate, to mean or include HHSC and other agencies of the
State of Texas that may participate in the administration of the HMO Programs,
provided, however, that no provision will be interpreted to include
any entity other than HHSC as the contracting agency.

      


      (c)
Severability.  If any provision of this Contract is construed to be
illegal or invalid, such interpretation will not affect the legality or validity
of any of its other provisions. The illegal or invalid provision will be deemed
stricken and deleted to the same extent and effect as if never incorporated
in this Contract, but all other provisions will remain in full force and
effect.

       

      (d)
Survival of terms. Termination or expiration of this Contract for any
reason
will not release either Party from any liabilities or obligations set forth in
this Contract that:

      


      (1) The
Parties have expressly agreed shall survive any such termination or expiration;
or

      


      (2) Arose
prior to the effective date of termination and remain to be performed or by
their nature would be intended to be applicable following any such termination
or expiration.

       

      (e)
Headings. The article, section and paragraph headings in this Contract are for
reference and convenience only and may
not be considered in the interpretation of this Contract.

      


      (f)
Global drafting conventions.

      


      (1) The
terms “include,” “includes,” and “including” are terms of inclusion, and where
used in this Contract, are deemed to be followed by the words “without
limitation.”

      


      (2) Any
references to “sections,” “appendices,” “exhibits” or “attachments” are deemed
to be references to sections, appendices, exhibits or attachments to this
Contract.

      


      (3) Any
references to laws, rules, regulations, and manuals in this Contract are deemed
references to these documents as amended, modified, or supplemented from time to
time during the term of this Contract.

      


       

      Section 1.05 No implied
authority.

      The
authority delegated to HMO by HHSC is limited to the terms of this Contract.
HHSC is the state agency designated by the Texas Legislature to administer the
HMO Programs, and no other agency of the State grants HMO any authority related
to this program unless directed through HHSC.  HMO may not rely upon
implied authority, and specifically is not delegated authority under this
Contract to:

      (1) make
public policy;

      


      (2)
promulgate, amend or disregard administrative regulations or program policy
decisions made by State and federal agencies responsible for administration of
HHSC Programs; or

      


      (3)
unilaterally communicate or negotiate with any federal or state agency or the
Texas Legislature on behalf of HHSC regarding the HHSC Programs.

      


      HMO is
required to cooperate to the fullest extent possible to assist HHSC in
communications and negotiations with state and federal governments and agencies
concerning matters relating to the scope of the Contract and the HMO Program(s),
as directed by HHSC.

       

      Section 1.06 Legal Authority.

      


      (a) HHSC
is authorized to enter into this Contract under Chapters 531 and 533, Texas
Government Code; Section 2155.144, Texas Government Code; and/or Chapter 62,
Texas Health & Safety Code. HMO is authorized to enter into this Contract
pursuant to the authorization of its governing board or controlling owner or
officer.

      


      (b) The
person or persons signing and executing this Contract on behalf of the Parties,
or representing themselves as signing and executing this Contract on behalf of
the Parties, warrant and guarantee that he, she, or they have been duly
authorized to execute this Contract and to validly and legally bind the Parties
to all of its terms, performances, and provisions.

      


      Article
2. Definitions

      As used
in this Contract, the following terms and conditions shall have the meanings
assigned below:

       

      1915(c)
Nursing Facility Waiver means the HHSC waiver program that provides home
and community based services to aged and disabled adults as cost-effective
alternatives to institutional care in nursing homes.

       

      Abuse
means provider practices that are inconsistent with sound fiscal, business, or
medical practices and result in an unnecessary cost to the Medicaid or CHIP
Program, or in reimbursement for services that are not Medically Necessary or
that fail to meet professionally recognized standards for health care. It also
includes Member practices that result in unnecessary cost to the Medicaid or
CHIP Program.

       

      Account
Name means the name of the individual who lives with the child(ren) and
who applies for the Children’s Health Insurance Program coverage on behalf of
the child(ren).

       

      Action
(Medicaid only) means:

      


      (1) the
denial or limited authorization of a requested Medicaid service, including the
type or level of service;

      


      (2) the
reduction, suspension, or termination of a previously authorized
service;

      


      (3) the
denial in whole or in part of payment for service;

      


      (4) the
failure to provide services in a timely manner;

      


      (5) the
failure of an HMO to act within the timeframes set forth in the Contract and 42
C.F.R.
§438.408(b); or

       

      (6) for a
resident of a rural area with only one HMO, the denial of a Medicaid Members’
request to obtain services outside of the Network.

       

      An
Adverse Determination is one type of Action. 

       

      Acute
Care means preventive care, primary care, and other medical care provided
under the direction of a physician for a condition having a relatively short
duration.  

       

      Acute
Care Hospital means a hospital that provides
acute care services 

       

      Adjudicate
means to deny or pay a clean claim. 

       

      Administrative
Services see HMOAdministrative
Services. 

       

      Administrative
Services Contractor see HHSC Administrative Services Contractor.


       

      Adverse
Determination means a determination by an HMO or Utilization Review agent
that the Health Care Services furnished, or proposed to be furnished to a
patient, are not Medically Necessary or not appropriate. 

       

      Affiliate
means any
individual or entity that meets any of the following
criteria:  1) owns or holds more than a five percent (5%) interest in
the HMO (either directly, or through one or more intermediaries);  2)
in which the HMO owns or holds more than a five percent (5%) interest (either
directly, or through one or more intermediaries);  3) any parent
entity or subsidiary entity of the HMO, regardless of the organizational
structure of the entity;  4) any entity that has a common parent with
the HMO (either directly, or through one or more intermediaries);  5)
any entity that directly, or indirectly through one or more intermediaries,
controls, or is controlled by, or is under common control with, the
HMO;  or, 6) any entity that would be considered to be an affiliate by
any Securities and Exchange Commission (SEC) or Internal Revenue Service (IRS)
regulation, Federal Acquisition
Regulations (FAR), or by another applicable regulatory
body.

       

      Agreement or Contract
means this formal, written, and legally enforceable contract and amendments
thereto between the Parties. 

       

      Allowable
Expenses means all expenses related to the Contract between HHSC and the
HMO that are incurred during the Contract Period, are not reimbursable or
recovered from another source, and that conform with the HHSC Uniform Managed
Care Manual’s “Cost Principles for Expenses.”

       

      AAP
means the American Academy of Pediatrics.

       

      Approved
Non-Profit Health Corporation (ANHC) means an organization formed in
compliance with Chapter 844 of the Texas Insurance Code and licensed by TDI. See
also HMO.

       

      Appeal
(Medicaid only) means the formal process by which a Member or his or her
representative request a review of the HMO’s Action, as defined
above.

       

      Appeal
(CHIP and CHIP Perinatal Program only) means the formal process by which
a Utilization Review agent addresses Adverse Determinations.

       

      Auxiliary
Aids and Services includes:

       

      (1)
qualified interpreters or other effective methods of making aurally delivered
materials understood by persons with hearing impairments;

      


      (2) taped
texts, large print, Braille, or other effective methods to ensure visually
delivered materials are available to individuals with visual impairments;
and

      


      (3) other
effective methods to ensure that materials (delivered both aurally and visually)
are available to those with cognitive or other Disabilities affecting
communication.

      


      Behavioral
Health Services means Covered Services for the treatment of mental,
emotional, or chemical dependency disorders.

       

      Benchmark
means a target or standard based on historical data or an
objective/goal.

       

      Business
Continuity Plan or BCP means a plan that provides for a quick and smooth
restoration of MIS operations after a disruptive event.  BCP includes
business impact analysis, BCP development, testing, awareness, training, and
maintenance.  This is a day-to-day plan.

       

      Business
Day means any day other than a Saturday, Sunday, or a state or federal
holiday on which HHSC’s offices are closed, unless the context clearly indicates
otherwise.

       

      CAHPS
means the Consumer Assessment of Health Plans Survey. This survey is
conducted annually by the EQRO.

       

      Call
Coverage means arrangements made by a facility or an attending physician
with an appropriate level of health care provider who agrees to be available on
an as-needed basis to provide medically appropriate services for routine, high
risk, or Emergency Medical Conditions or Emergency Behavioral Health Conditions
that present without being scheduled at the facility or when the attending
physician is unavailable.

       

      Capitation
Rate means a fixed predetermined fee paid by HHSC to the HMO each month
in accordance with the Contract, for each enrolled

      Member in
a defined Rate Cell, in exchange for the HMO arranging for or providing a
defined set of Covered Services to such a Member, regardless of the amount of
Covered Services used by the enrolled Member.

       

      Capitation
Payment means the aggregate amount paid by HHSC to the HMO on a monthly
basis for the provision of Covered Services to enrolled Members in accordance
with the Capitation Rates in the Contract.

       

      Case Head
means the head of the household that is applying for
Medicaid.

       

      C.F.R.
means the Code of Federal Regulations. 

       

      Chemical
Dependency Treatment means treatment provided for a chemical dependency
condition by a Chemical Dependency Treatment facility, chemical dependency
counselor or hospital. 

       

      Children’s
Health Insurance Program or CHIP
means the
health insurance program authorized and funded pursuant to Title XXI, Social
Security Act (42 U.S.C. §§
1397aa-1397jj) and administered by HHSC.

       

      Child (or
Children) with Special Health Care Needs (CSHCN) means a child (or children)
who:

      


      (1)
ranges in age from birth up to age nineteen (19) years;

      


      (2) has a
serious ongoing illness, a complex chronic condition, or a disability that has
lasted or is anticipated to last at least twelve (12) continuous months or
more;

      


      (3) has
an illness, condition or disability that results (or without treatment would be
expected to result) in limitation of function, activities, or social roles in
comparison with accepted pediatric age-related milestones in the general areas
of physical, cognitive, emotional, and/or social growth and/or
development;

      


      (4)
requires regular, ongoing therapeutic intervention and evaluation by
appropriately trained health care personnel; and

      


      (5) has a
need for health and/or health-related services at a level significantly above
the usual for the child’s age.

      


      CHIP HMO
Program, or CHIP Program, means the State of Texas program in which HHSC
contracts with HMOs to provide, arrange for, and coordinate Covered Services for
enrolled CHIP Members.

       

      CHIP
HMOs means HMOs participating in the CHIP HMO Program.

       

      CHIP
Perinatal HMOs means HMOs participating in the CHIP Perinatal
Program.

       

      CHIP
Perinatal Program means the State of Texas program in which HHSC
contracts with HMOs to provide, arrange for, and coordinate Covered Services for
enrolled CHIP Perinate and CHIP Perinate Newborn Members.  Although
the CHIP Perinatal
Program is part of the CHIP Program, for Contract administration purposes it is
identified independently in this Contract. An HMO must specifically contract
with HHSC as a CHIP Perinatal HMO in order to participate in this part of the
CHIP Program.

       

      CHIP
Perinate means a CHIP Perinatal Program Member identified prior to
birth.

       

      CHIP
Perinate Newborn means a CHIP Perinate who has been born
alive.

       

      Chronic
or Complex Condition means a physical, behavioral, or developmental
condition which may have no known cure and/or is progressive and/or can be
debilitating or fatal if left untreated or under-treated.

       

      Clean
Claim means a claim submitted by a physician or provider for medical care
or health care services rendered to a Member, with the data necessary for the
MCO or subcontracted claims processor to adjudicate and accurately report the
claim. A Clean Claim must meet all requirements for accurate and complete data
as defined in the appropriate 837-(claim type) encounter guides as
follows:

      


      (1) 837
Professional Combined Implementation Guide

      


      (2) 837
Institutional Combined Implementation Guide

      


      (3) 837
Professional Companion Guide

      


      (4) 837
Institutional Companion Guide

      


      The HMO
may not require a physician or provider to submit documentation that conflicts
with the requirements of Texas Administrative Code, Title 28, Part 1, Chapter
21, Subchapters C and T.

       

      CMS
means the Centers for Medicare and Medicaid Services, formerly known as the
Health Care Financing Administration (HCFA), which is the federal agency
responsible for administering Medicare and overseeing state administration of
Medicaid and CHIP.

       

      COLA
means the Cost of Living Adjustment.

       

      Community-based
Long Term Care Services means services provided to STAR+PLUS Members in
their home or other community based settings necessary to provide assistance
with activities of daily living to allow the Member to remain in the most
integrated setting possible. Community-based Long-term Care includes services
available to all STAR+PLUS Members as well as those services available only to
STAR+PLUS Members who qualify under the 1915(c) Nursing Facility Waiver
services.

       

      Community
Resource Coordination Groups (CRCGs) means a statewide system of local
interagency groups, including both public and private

      providers,
which coordinate services for ”multi-need” children and youth. CRCGs develop
individual service plans for children and adolescents whose needs can be met
only through interagency cooperation. CRCGs address Complex Needs in a model
that promotes local decision-making and ensures that children receive the
integrated combination of social, medical and other services needed to address
their individual problems.

       

      Complainant
means a Member or a treating provider or other individual designated to
act on behalf of the Member who filed the Complaint.

       

      Complaint (CHIP and CHIP Perinatal Programs
only) means any dissatisfaction, expressed by a Complainant, orally or in
writing to the HMO, with any aspect of the HMO’s operation, including, but not
limited to, dissatisfaction with plan administration, procedures related to
review or Appeal of an Adverse Determination, as defined in Texas Insurance
Code, Chapter 843, Subchapter G; the denial, reduction, or termination of a
service for reasons not related to medical necessity; the way a service is
provided; or disenrollment decisions.  The term does not include
misinformation that is resolved promptly by supplying the appropriate
information or clearing up the misunderstanding to the satisfaction of the CHIP
Member.

       

      Complaint
(Medicaid only) means an expression of dissatisfaction expressed by a
Complainant, orally or in writing to the HMO, about any matter related to the
HMO other than an Action. As provided by 42 C.F.R. §438.400, possible subjects
for Complaints include, but are not limited to, the quality of care of services
provided, and aspects of interpersonal relationships such as rudeness of a
provider or employee, or failure to respect the Medicaid Member’s
rights.

       

      Complex
Need means a condition or situation resulting in a need for coordination
or access to services beyond what a PCP would normally provide, triggering the
HMO's determination that Care Coordination is required.

       

      Comprehensive
Care Program: See definition for Texas Health Steps.

       

      Confidential
Information means any communication or record (whether oral, written,
electronically stored or transmitted, or in any other form) consisting
of:

      


      (1)
Confidential Client information, including HIPAA-defined protected health
information;

      


      (2) All
non-public budget, expense, payment and other financial
information;

      


      (3) All
Privileged Work Product;

      


      (4) All
information designated by HHSC or any other State agency as confidential, and
all information designated as confidential under the Texas
Public Information Act, Texas Government Code, Chapter 552;

      


      (5) The
pricing, payments, and terms and conditions of the Contract, unless disclosed
publicly by HHSC or the State; and

      


      (6)
Information utilized, developed, received, or maintained by HHSC, the HMO, or
participating State agencies for the purpose of fulfilling a duty or obligation
under this Contract and that has not been disclosed publicly.

      


      Consumer-Directed
Services means the Member or his legal guardian is the employer of and
retains control over the hiring, management, and termination of an individual
providing personal assistance or respite.

       

      Continuity
of Care means care provided to a Member by the same PCP or specialty
provider to ensure that the delivery of care to the Member remains stable, and
services are consistent and unduplicated.

       

      Contract
or Agreement
means this formal, written, and legally enforceable contract and amendments
thereto between the Parties.

       

      Contract
Period or Contract
Term means the Initial Contract Period plus any and all Contract
extensions.

       

      Contractor
or HMO
means the HMO that is a party to this Contract and is an insurer licensed by TDI
as an HMO or as an ANHC formed in compliance with Chapter 844 of the Texas
Insurance Code.

       

      Core
Service Area (CSA) means the core set Service Area counties defined by
HHSC for the STAR and/or CHIP HMO Programs in which Eligibles will be required
to enroll in an HMO. (See Attachment B-6 to the HHSC Managed Care Contract
document for detailed information on the Service Area counties.)

       

      Copayment
(CHIP only) means the amount that a Member is required to pay when
utilizing certain benefits within the health care plan.  Once the
copayment is made, further payment is not required by the Member.

       

      Corrective
Action Plan means the detailed written plan that may be required by HHSC
to correct or resolve a deficiency or event causing the assessment of a remedy
or damage against HMO.

       

      Court-Ordered
Commitment means a commitment of a STAR, STAR+PLUS or CHIP Member to a
psychiatric facility for treatment ordered by a court of law pursuant to the
Texas Health and Safety Code, Title VII Subtitle C.

       

      Covered
Services means Health Care Services the HMO must arrange to provide to
Members, including all services required by the Contract and state and federal
law, and all Value-added Services negotiated by the Parties (see Attachments B-2, B­2.1, B-2.2 and
B-3 of the HHSC Managed
Care Contract relating to “Covered
Services” and “Value­added Services”).  Covered Services include
Behavioral Health Services.

       

      Credentialing
means the process of collecting, assessing, and validating qualifications
and other relevant information pertaining to a health care provider to determine
eligibility and to deliver Covered Services.

       

      Cultural
Competency means the ability of individuals and systems to provide
services effectively to people of various cultures, races, ethnic backgrounds,
and religions in a manner that recognizes, values, affirms, and respects the
worth of the individuals and protects and preserves their dignity.

       

      Date of
Disenrollment means the last day of the last month for which HMO receives
payment for a Member.

       

      Day
means a calendar day unless specified otherwise.

       

      Default
Enrollment means the process established by HHSC to assign a mandatory
STAR, STAR+PLUS, or CHIP Perinate enrollee who has not selected an MCO to an
MCO.

       

      Deliverable
means a written or recorded work product or data prepared, developed, or
procured by HMO as part of the Services under the Contract for the use or
benefit of HHSC or the State of Texas.

       

      Delivery
Supplemental Payment means a one­time per pregnancy supplemental
payment for STAR, CHIP and CHIP Perinatal HMOs.

       

      DADS
means the Texas Department of Aging and Disability Services or its
successor agency (formerly Department of Human Services).

       

      DSHS
means the Texas Department of State Health Services or its successor agency
(formerly Texas Department of Health and Texas Department of Mental Health and
Mental Retardation).

      
         

        Discharge
means a formal release of a Member from an Inpatient Hospital stay when
the need for continued care at an inpatient level has concluded. Movement or
Transfer from one Acute Care Hospital or Long Term Care Hospital /facility and
readmission to another within 24 hours for continued treatment is not a
discharge under this Contract.

      

       

      Disease
Management means a system of coordinated healthcare interventions and
communications for populations with conditions in which patient self-care
efforts are significant.

       

      Disproportionate
Share Hospital (DSH) means a hospital that
serves a higher than average number of Medicaid and other low-income patients
and receives additional reimbursement from the State.

       

      Disabled
Person or Person with Disability means a person under sixty-five (65)
years of age, including a child, who qualifies for Medicaid services because of
a disability.

       

      Disability
means a physical or mental impairment that substantially limits one or more of
an individual’s major life activities, such as caring for oneself, performing
manual tasks, walking, seeing,

      hearing,
speaking, breathing, learning, and/or working.

       

      Disability-related
Access means that facilities are readily accessible to and usable by
individuals with disabilities, and that auxiliary aids and services are provided
to ensure effective communication, in compliance with Title III of the Americans
with Disabilities Act.

       

      Disaster
Recovery Plan means the document developed by the HMO that outlines
details for the restoration of the MIS in the event of an emergency or
disaster.

       

      DSM-IV
means the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition, which is the
American Psychiatric Association’s official classification of behavioral health
disorders.

       

      Dual
Eligibles means Medicaid recipients who are also eligible for
Medicare.

       

      ECI
means Early Childhood Intervention, a federally mandated program for infants and
children under the age of three with or at risk for developmental delays and/or
disabilities. The federal ECI regulations are found at 34 §C.F.R. 303.1 et seq. The State ECI rules
are found at 25 TAC §621.21 et
seq.

       

      EDI
means electronic data interchange.

       

      Effective
Date means the effective date of this Contract, as specified in the HHSC
Managed Care Contract document.

       

      Effective
Date of Coverage means the first day of the month for which the HMO has
received payment for a Member.

       

      Eligibles
means individuals residing in one of the Service Areas and eligible to enroll in
a STAR, STAR+PLUS, CHIP, or CHIP Perinatal HMO, as applicable.

       

      Emergency
Behavioral Health Condition means any condition, without regard to the
nature or cause of the condition, which in the opinion of a prudent layperson
possessing an average knowledge of health and medicine:

      


      (1)
requires immediate intervention and/or medical attention without which Members
would present an immediate danger to themselves or others, or

      


      (2) which
renders Members incapable of controlling, knowing or understanding the
consequences of their actions.

      


      Emergency
Services means covered inpatient and outpatient services furnished by a
provider that is qualified to furnish such services under the Contract and that
are needed to evaluate or stabilize an Emergency Medical Condition and/or an
Emergency Behavioral Health Condition, including Post-stabilization Care
Services.

       

      Emergency
Medical Condition means a medical condition manifesting itself by acute
symptoms of recent onset and 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 care could
result in:

      


      (1)
placing the patient’s health in serious jeopardy;

      


      (2)
serious impairment to bodily functions;

      


      (3)
serious dysfunction of any bodily organ or part;

      


      (4)
serious disfigurement; or

      


      (5) in
the case of a pregnant women, serious jeopardy to the health of
a  woman or her unborn child.

      


      Encounter
means a Covered Service or group of Covered Services delivered by a Provider to
a Member during a visit between the Member and Provider. This also includes
Value-added Services.

       

      Encounter
Data means data elements from Fee-for-Service claims or capitated
services proxy claims that are submitted to HHSC by the HMO in accordance with
HHSC’s required format for Medicaid and CHIP HMOs.

       

      Enrollment
Report/Enrollment File means the daily or monthly list of Eligibles that
are enrolled with an HMO as Members on the day or for the month the report is
issued.

       

      EPSDT
means the federally mandated Early and Periodic Screening, Diagnosis and
Treatment program contained at 42 U.S.C. 1396d(r). The name has been changed to
Texas Health Steps (THSteps) in the State of Texas.

       

      Exclusive
Provider Organization (EPO) means the vendor contracted with HHSC to
operate the CHIP EPO in Texas.

       

      Expansion
Area means a county or Service Area that has not previously provided
healthcare to HHSC’s HMO Program Members utilizing a managed care
model.

       

      Expansion
Children means children who are generally at least one, but under age 6,
and live in a family whose income is at or below 133 percent of the federal
poverty level (FPL).  Children in this coverage group have either
elected to bypass TANF or are not eligible for TANF in Texas.

       

      Experience
Rebate means the portion of the HMO’s net income before taxes that is
returned to the State in accordance with Section 10.11 for the STAR, CHIP and
CHIP Perinatal Programs and 10.11.1 for the STAR+PLUS Program (“Experience
Rebate”).

       

      Expedited
Appeal means an appeal to the HMO in which the decision is required
quickly based on the Member's health status, and the amount of time

      necessary
to participate in a standard appeal could jeopardize the Member's life or health
or ability to attain, maintain, or regain maximum function.

       

      Expiration
Date means the expiration date of this Contract, as specified in HHSC’s
Managed Care Contract document.

       

      External
Quality Review Organization (EQRO) means the entity that contracts with
HHSC to provide external review of access to and quality of healthcare provided
to Members of HHSC’s HMO Programs.

       

      Fair
Hearing means the process adopted and implemented by HHSC in 25 T.A.C.
Chapter 1, in compliance with federal regulations and state rules relating to
Medicaid Fair Hearings.

       

      Farmworker
Child (FWC) means a child under age 21 of a Migrant
Farmworker.

       

      Fee-for-Service
means the traditional Medicaid Health Care Services payment system under
which providers receive a payment for each unit of service according to rules
adopted pursuant to Chapter 32, Texas Human Resources Code.

       

      Force
Majeure Event means any failure or delay in performance of a duty by a
Party under this Contract that is caused by fire, flood, hurricane, tornadoes,
earthquake, an act of God, an act of war, riot, civil disorder, or any similar
event beyond the reasonable control of such Party and without the fault or
negligence of such Party.

       

      FQHC
means a Federally Qualified Health Center, certified by CMS to meet the
requirements of §1861(aa)(3) of the Social Security Act as a federally qualified
health center,  that is enrolled as a provider in the Texas Medicaid
program.

       

      FPL
means the Federal Poverty Level.

       

      Fraud
means an intentional deception or misrepresentation made by a person with the
knowledge that the deception could result in some unauthorized benefit to
himself or some other person. It includes any act that constitutes fraud under
applicable
federal or state law.

       

      FSR
means Financial Statistical Report.

       

      Functionally
Necessary Covered Services means Community-based Long Term Care services
provided to assist STAR+PLUS Members with activities of daily living based on a
functional assessment of the Member’s activities of daily living and a
determination of the amount of supplemental supports necessary for the STAR+PLUS
Member to remain independent or in the most integrated setting
possible.

       

      Habilitative
and Rehabilitative Services means Health Care Services described in Attachment B-2 that may be
required by children who fail to reach (habilitative) or have lost
(rehabilitative) age appropriate developmental milestones.

       

      Health
Care Services means the Acute Care, Behavioral Health Care and
health-related services that an enrolled population might reasonably require in
order to be maintained in good health.

       

      Health
and Human Services Commission or HHSC
means the administrative agency within the executive department of Texas state
government established under Chapter 531, Texas Government Code, or its
designee, including, but not limited to, the HHS Agencies.

       

      Health-related
Materials are materials developed by the HMO or obtained from a third
party relating to the prevention, diagnosis or treatment of a medical
condition.

       

      HEDIS,
the Health Plan Employer Data and Information Set, is a registered trademark
of NCQA. HEDIS is a set of standardized performance measures designed to
reliably compare the performance of managed health care plans. HEDIS is
sponsored, supported and maintained by NCQA.

       

      HHS
Agency means the Texas health and human service agencies subject to
HHSC’s oversight under Chapter 531, Texas Government Code, and their successor
agencies.

       

      HHSC
Administrative Services Contractor (ASC) means an entity performing HMO
administrative services functions, including member enrollment functions, for
STAR, STAR+PLUS, CHIP, or CHIP Perinatal HMO Programs under contract with
HHSC.

       

      HHSC HMO
Programs or HMO Programs mean the STAR, STAR+PLUS, CHIP, and CHIP
Perinatal HMO Programs.

       

      HHSC
Uniform Managed Care Manual means the manual published by or on behalf of
HHSC that contains policies and procedures required of all HMOs participating in
the HHSC Programs.

       

      HIPAA
means the Health Insurance Portability and Accountability Act of 1996,
P.L. 104-191 (August 21, 1996), as amended or modified.

       

      HMO
or Contractor
means the HMO that is a party to this Contract, and is either:

      


      (1) an
insurer licensed by TDI as a Health Maintenance Organization in accordance with
Chapter 843 of the Texas Insurance Code, or

      


      (2) a
certified Approved Non-Profit Health Corporation (ANHC) formed in compliance
with Chapter 844 of the Texas Insurance Code.

      


      HMO
Administrative Services means the performance of services or functions,
other than the direct delivery of Covered Services, necessary for the management
of the delivery of and payment for Covered Services, including but not limited
to Network, utilization, clinical and/or quality management, service
authorization, claims

      processing,
management information systems operation and reporting.

       

       

      HMO’s
Service Area means all the counties included in any HHSC-defined Core or
Optional Service Area, as applicable to each HMO Program and within which the
HMO has been selected to provide HMO services.

       

      Home and
Community Support Services Agency or HCSS means an entity licensed to
provide home health, hospice, or personal assistance services provided to
individuals in their own home or independent living environment as prescribed by
a physician or individualized service plan. Each HCSS must provide clients with
a plan of care that includes specific services the agency agrees to perform. The
agencies are licensed and monitored by DADS or its successor.

       

      Hospital
means a licensed public or private institution as defined by Chapter 241, Texas
Health and Safety Code, or in Subtitle C, Title 7, Texas Health and Safety
Code.

       

      ICF-MR
means an intermediate care facility for the mentally retarded.

       

      Individual
Family Service Plan (IFSP) means the plan for services required by the
Early Childhood Intervention (ECI) Program and developed by an interdisciplinary
team.

       

      Initial
Contract Period means the Effective Date of the Contract through August
31, 2008.

       

      Inpatient
Stay means at least a 24-hour stay in a facility licensed to provide
hospital care.

       

      JCAHO
means Joint Commission on Accreditation of Health Care
Organizations.

       

      Joint
Interface Plan (JIP) means a document used to communicate basic system
interface information. This information includes: file structure, data elements,
frequency, media, type of file, receiver and sender of the file, and file I.D.
The JIP must include each of the HMO’s interfaces required to conduct business
under this Contract. The JIP must address the coordination with each of the
HMO’s interface partners to ensure the development and maintenance of the
interface; and the timely transfer of required data elements between contractors
and partners.

       

      Key HMO
Personnel means the critical management and technical positions
identified by the HMO in accordance with Article 4.

       

      Linguistic
Access means translation and interpreter services, for written and spoken
language to ensure effective communication. Linguistic access includes sign
language interpretation, and the provision of other auxiliary aids and services
to persons with disabilities.

       

      Local
Health Department means a local health department established pursuant to
Health and Safety

      Code,
Title 2, Local Public Health Reorganization Act §121.031.

       

      Local
Mental Health Authority (LMHA) means an entity within a specified region
responsible for planning, policy development, coordination, and resource
development and allocation and for supervising and ensuring the provision of
mental health care services to persons with mental illness in one or more local
service areas.

       

      Major
Population Group means any population, which represents at least 10% of
the Medicaid, CHIP, and/or CHIP Perinatal Program population in any of the
counties in the Service Area served by the HMO.

       

      Material
Subcontractor or Major
Subcontractor means any entity that contracts with the HMO for all or
part of the HMO Administrative Services, where the value of the subcontracted
HMO Administrative Service(s) exceeds $100,000, or is reasonably expected to
exceed $100,000, per State Fiscal Year.  Providers in the HMO’s
Provider Network are not Material Subcontractors.

       

       Mandated
or Required Services means services that a state is required to offer to
categorically needy clients under a state Medicaid plan.

       

      Marketing
means any communication from the HMO to a Medicaid or CHIP Eligible who is not
enrolled with the HMO that can reasonably be interpreted as intended to
influence the Eligible to:

      (1)
enroll with the HMO; or

      (2) not
enroll in, or to disenroll from, another MCO.

       

      Marketing
Materials means materials that are produced in any medium by or on behalf
of the HMO and can reasonably be interpreted as intending to market to potential
Members.  Health-related Materials are not Marketing
Materials.

       

      MCO
means managed care organization. 

       

      Medicaid
means the medical assistance entitlement program authorized and funded pursuant
to Title XIX, Social Security Act (42 U.S.C. §1396 et seq.) and administered by
HHSC. 

       

      Medicaid
HMOs
means contracted HMOs participating in STAR and/or STAR+PLUS. 

       

      Medical
Assistance Only  (MAO) means a person that does not receive SSI
benefits but qualifies financially and functionally for limited Medicaid
assistance. 

       

      Medical
Home means a PCP or specialty care Provider who has accepted the
responsibility for providing accessible, continuous, comprehensive and
coordinated care to Members participating in a HHSC HMO Program. 

       

      Medically
Necessary means:

       

      (1)
Non-behavioral health related Health Care Services that are:

      


      (a)
reasonable and necessary to prevent illnesses or medical conditions, or provide
early screening, interventions, and/or treatments for conditions that cause
suffering or pain, cause physical deformity or limitations in function, threaten
to cause or worsen a handicap, cause illness or infirmity of a Member, or
endanger life;

      


      (b)
provided at appropriate facilities and at the appropriate levels of care for the
treatment of a Member’s health conditions;

      


      (c)
consistent with health care practice guidelines and standards that are endorsed
by professionally recognized health care organizations or governmental
agencies;

      


      (d)
consistent with the diagnoses of the conditions;

      


      (e) no
more intrusive or restrictive than necessary to provide a proper balance of
safety, effectiveness, and efficiency;

      


      (f) are
not experimental or investigative; and

      


      (g) are
not primarily for the convenience of the Member or Provider; and

      


      (2)
Behavioral Health Services that are:

      


      (a) are
reasonable and necessary for the diagnosis or treatment of a mental health or
chemical dependency disorder, or to improve, maintain, or prevent deterioration
of functioning resulting from such a disorder;

      


      (b) are
in accordance with professionally accepted clinical guidelines and standards of
practice in behavioral health care;

      


      (c) are
furnished in the most appropriate and least restrictive setting in which
services can be safely provided;

      


      (d) are
the most appropriate level or supply of service that can safely be
provided;

      


      (e) could
not be omitted without adversely affecting the Member’s mental and/or physical
health or the quality of care rendered;

      


      (f) are
not experimental or investigative; and

       

      (g) are
not primarily for the convenience of the
Member or Provider. 

       

      Member
means a person who:

      (1) is
entitled to benefits under Title XIX of the Social Security Act and Medicaid, is
in a Medicaid eligibility category included in the STAR or STAR+PLUS Program,
and is enrolled in the
STAR or STAR+PLUS Program and the HMO’s
STAR or STAR+PLUS HMO;

      


      (2) is
entitled to benefits under Title XIX of the Social Security Act and Medicaid, is
in a Medicaid eligibility category included as a voluntary participant in the
STAR or STAR+PLUS Program, and is enrolled in the STAR or STAR+PLUS Program and
the HMO’s STAR or STAR+PLUS HMO;

      


      (3) has
met CHIP eligibility criteria and is enrolled in the HMO’s CHIP HMO;
or

      


      (4) has
met CHIP Perinatal Program eligibility criteria and is enrolled in the HMO’s
CHIP Perinatal Program.

      


      Member
Materials means all written materials produced or authorized by the HMO
and distributed to Members or potential members containing information
concerning the HMO Program(s).  Member Materials include, but are not
limited to, Member ID cards, Member handbooks, Provider directories, and
Marketing Materials.

       

      Member
Month means one Member enrolled with the HMO during any given month. The
total Member Months for each month of a year comprise the annual Member
Months.

       

      Member(s)
with Special Health Care Needs (MSHCN) includes a Child or
Children with a Special Health Care Need (CSHCN) and any adult Member
who:

      


      (1) has a
serious ongoing illness, a Chronic or Complex Condition, or a Disability that
has lasted or is anticipated to last for a significant period of time,
and

      


      (2)
requires regular, ongoing therapeutic intervention and evaluation by
appropriately trained health care personnel.

      


      Migrant
Farmworker means a migratory agricultural worker, generally defined as an
individual whose principal employment is in agriculture on a seasonal basis, who
has been so employed within the last twenty-four months, and who establishes for
the purposes of such employment a temporary abode.

       

      Minimum
Data Set for Home Care (MDS-HC) means the assessment instrument included
in the Uniform Managed Care
Manual that is used to collect data such as health, social support and
service use information on persons receiving long term care services outside of
an institutional setting.

       

      MIS
means Management Information System.

       

      National
Committee for Quality Assurance (NCQA) means the independent organization
that accredits HMOs, managed behavioral health organizations, and accredits and
certifies disease management programs. HEDIS and the Quality Compass are
registered trademarks of NCQA.

       

      Net
Income before Taxes means an aggregate excess of Revenues over Allowable
Expenses.

       

      Network
or Provider Network means all Providers that have a contract with the
HMO, or any Subcontractor, for the delivery of Covered Services to the HMO’s
Members under the Contract.

       

      Network
Provider or Provider means an appropriately credentialed and licensed
individual, facility, agency, institution, organization or other entity, and its
employees and subcontractors, that has a contract with the HMO for the delivery
of Covered Services to the HMO’s Members.

       

      Non-capitated
Services means those Medicaid services identified in Attachment B-1,
Section 8.2.2.8.

       

      Non-provider
Subcontracts means contracts between the HMO and a third party that
performs a function, excluding delivery of health care services, that the HMO is
required to perform under its Contract with HHSC.

       

      Nursing
Facility Cost Ceiling means the annualized cost of serving a client in a
nursing facility. A per diem cost is established for each Medicaid nursing
facility resident based on the level of care needed.  This level of
care is referred to as the Texas Index for Level of Effort or the TILE
level.   The per diem cost is annualized to achieve the nursing
facility ceiling.

       

      Nursing
Facility Level of Care means the determination that the level of care
required to adequately serve a STAR+PLUS Member is at or above the level of care
provided by a nursing facility.

       

      OB/GYN
means obstetrician-gynecologist.

       

      Open
Panel means Providers who are accepting new patients for the HMO
Program(s) served.

       

      Operational
Start Date means the first day on which an HMO is responsible for
providing Covered Services to Members of an HMO Program in a Service Area in
exchange for a Capitation Payment under the Contract.  The Operational
Start Date may vary per HMO Program and Service Area.  The Operational
Start Date(s) applicable to this Contract are set forth in the HHSC Managed Care Contract
document.

       

      Optional
Service Area (OSA) means an HHSC defined county or counties, contiguous
to a CSA, in which CHIP or CHIP Perinatal HMOs provide health care coverage to
CHIP Eligibles. The CHIP or CHIP Perinatal HMO must serve the associated Core
Service Area in order to provide coverage in the OSA. The HHSC Managed Care Contract
document includes OSAs, if applicable.

       

      Operations
Phase means the period of time when HMO is responsible for providing the
Covered Services and all related Contract functions for a Service
Area.  The Operations Phase begins on the

      Operational
Start Date, and may vary by HMO Program and Service Area.

       

      Outpatient
Hospital Services means diagnostic, therapeutic, and rehabilitative
services that are provided to Members in an organized medical facility, for less
than a 24-hour period, by or under the direction of a physician. To distinguish
between the types of services being billed, hospitals must indicate a
three-digit type of bill (TOB) code in block 4 of the UB-92 claim form. Most
commonly for hospitals, this code will be 131 for an outpatient hospital
claims.

       

      Out-of-Network
(OON) means an appropriately licensed individual, facility, agency,
institution, organization or other entity that has not entered into a contract
with the HMO for the delivery of Covered Services to the HMO’s
Members.

       

      Parties
means HHSC and HMO, collectively.

       

      Party
means either HHSC or HMO, individually.

       

      Pended
Claim means a claim for payment, which requires additional information
before the claim can be adjudicated as a clean claim.

       

      Population
Risk Group means a distinct group of members identified by age, age
range, gender, type of program, or eligibility category.

       

      Post-stabilization
Care Services means Covered Services, related to an Emergency Medical
Condition that are provided after a Medicaid Member is stabilized in order to
maintain the stabilized condition, or, under the circumstances described in 42
§§C.F.R. 438.114(b)&(e) and 42 C.F.R. §422.113(c)(iii) to improve or resolve
the Medicaid Member’s condition.

       

      Primary
Care Physician or Primary Care Provider (PCP) means a physician or
provider who has agreed with the HMO to provide a Medical Home to Members and
who is responsible for providing initial and primary care to patients,
maintaining the continuity of patient care, and initiating referral for
care.

      Provider
types that can be PCPs are from any of the following practice areas: General
Practice, Family Practice, Internal Medicine, Pediatrics, Obstetrics/Gynecology
(OB/GYN), Advanced Practice Nurses (APNs) and Physician Assistants (when
practicing under the supervision of a physician specializing in Family Practice,
Internal Medicine, Pediatrics or Obstetrics/Gynecology who also qualifies as a
PCP under this contract), Federally Qualified Health Centers (FQHCs), Rural
Health Clinics (RHCs) and similar community clinic s; and specialist physicians
who are willing to provide a Medical Home to selected Members with special needs
and conditions.

       

      Proposal
means the proposal submitted by the HMO in response to the
RFP.

       

      Provider
or Network Provider means an appropriately credentialed and licensed
individual, facility, agency, institution, organization or other entity, and its
employees and subcontractors, that has a contract with the HMO for the delivery
of Covered Services to the HMO’s Members.

       

      Provider
Contract means a contract entered into by a direct provider of health
care services and the HMO or an intermediary entity.

       

      Provider
Network or Network means all Providers that have contracted with the HMO
for the applicable HMO Program.

       

      Proxy
Claim Form means a form submitted by Providers to document services
delivered to Members under a capitated arrangement. It is not a claim for
payment.

       

      Public
Health Entity means a HHSC Public Health Region, a Local Health
Department, or a hospital district.

       

      Public
Information means information that:

      


      (1) Is
collected, assembled, or maintained under a law or ordinance or in connection
with the transaction of official business by a governmental body or for a
governmental body; and

      


      (2) The
governmental body owns or has a right of access to.

      


      Qualified
and Disabled Working Individual (QDWI) means an individual whose only
Medicaid benefit is payment of the Medicare Part A premium.

       

      Qualified
Medicare Beneficiary (QMB) means a Medicare beneficiary
whose only Medicaid benefits are payment of Medicare premiums, deductibles, and
coinsurance for individuals who are entitled to Medicare Part A, whose income
does not exceed 100% of the federal poverty level, and whose resources do not
exceed twice the resource limit of the SSI program.

       

      Quality
Improvement means a system to continuously examine, monitor and revise
processes and systems that support and improve administrative and clinical
functions.

       

      Rate
Cell means a Population Risk Group for which a Capitation Rate has been
determined.

       

      Rate
Period 1 means the period of time beginning on the Operational Start Date
and ending on August 31, 2007.

       

      Rate
Period 2 means the period of time beginning on September 1, 2007 and
ending on August 31, 2008.

       

      Real-Time
Captioning (also known as CART, Communication Access Real-Time
Translation) means a process by which a trained individual uses a shorthand
machine, a computer, and real-time translation software to type and
simultaneously translate spoken language into text on a computer screen.
Real Time Captioning is provided for individuals who are deaf, have hearing
impairments, or have unintelligible speech. It is usually used to interpret
spoken English into text English but may be used to translate other spoken
languages into text.

       

      Readiness
Review means the assurances made by a selected HMO and the examination
conducted by HHSC, or its agents, of HMO’s ability, preparedness, and
availability to fulfill its obligations under the Contract.

       

      Request
for Proposals or RFP
means the procurement solicitation instrument issued by HHSC under which this
Contract was awarded and all RFP addenda, corrections or modifications, if
any.

       

      Revenue
means all managed care revenue received by the HMO pursuant to this Contract
during the Contract Period, including retroactive adjustments made by HHSC. This
would include any funds earned on Medicaid or CHIP managed care funds such as
investment income, earned interest, or third party administrator earnings from
services to delegated Networks.

       

      Risk
means the potential for loss as a result of expenses and costs of the HMO
exceeding payments made by HHSC under the Contract.

       

      Routine
Care means health care for covered preventive and medically necessary
Health Care Services that are non-emergent or non-urgent.

       

      Rural
Health Clinic (RHC) means an entity that meets all of the requirements
for designation as a rural health clinic under 1861(aa)(1) of the Social
Security Act and approved for participation in the Texas Medicaid
Program.

       

      Service
Coordination means a specialized care management service that is
performed by a Service Coordinator and that includes but is not limited
to:

      


      (1)
identification of needs, including physical health, mental health services and
for STAR+PLUS Members, long term support services,

      


      (2)
development of a Service Plan to address those identified needs;

      


      (3)
assistance to ensure timely and a coordinated access to an array of providers
and Covered Services;

      


      (4)
attention to addressing unique needs of Members; and

      


      (5)
coordination of Plan services with social and other services delivered outside
the Plan, as necessary and appropriate.

      


      Service
Coordinator means the person with primary responsibility for providing
service coordination and care management to STAR+PLUS Members.

       

      Scope of
Work means the description of Services and Deliverables specified in this
Contract, the RFP, the HMO’s Proposal, and any agreed modifications to these
documents.

       

      SDX
means State Data Exchange.

       

      SED
means severe emotional disturbance as determined by a Local Mental Health
Authority.

       

      Service
Area means the counties included in any HHSC-defined Core and Optional
Service Area as applicable to each HMO Program.

       

      Service
Management is an administrative service in the STAR, CHIP and CHIP
Perinatal Programs performed by the HMO to facilitate development of a Service
Plan and coordination of services among a Member’s PCP, specialty providers and
non-medical providers to ensure Members with Special Health Care Needs and/or
Members needing high-cost treatment have access to, and appropriately utilize,
Medically Necessary Covered Services, Non­capitated Services, and other
services and supports.

       

      Service
Plan (SP) means an individualized plan developed with and for Members
with Special Health Care Needs, including persons with disabilities or chronic
or complex conditions.  The SP includes, but is not limited to, the
following:

      (1) the
Member’s history;

      


      (2)
summary of current medical and social needs and concerns;

      


      (3) short
and long term needs and goals;

      


      (4) a
list of services required, their frequency, and

      


      (5) a
description of who will provide such services.

      


      The
Service Plan should incorporate as a component of the plan the Individual Family
Service Plan (IFSP) for members in the Early Childhood Intervention (ECI)
Program

      The
Service Plan may include information for services outside the scope of covered
benefits such as how to access affordable, integrated housing.

       

      Services
means the tasks, functions, and responsibilities assigned and delegated
to the HMO under this Contract.

       

      Significant
Traditional Provider or STP (for Medicaid) means primary care providers
and long-term care providers, identified by HHSC as having provided a
significant level of care to Fee-for-Service clients. Disproportionate Share
Hospitals (DSH) are also Medicaid STPs.

       

      Significant
Traditional Provider or STP (for CHIP) means primary care providers
participating in the CHIP HMO Program prior to May 2004, and Disproportionate
Share Hospitals (DSH).

       

      Skilled
Nursing Facility Services (CHIP only)  Services provided in a
facility that provides nursing or rehabilitation services and Medical supplies
and use of appliances and equipment furnished by the facility.

       

      Software
means all operating system and applications software used by the HMO to provide
the Services under this Contract.

       

      SPMI
means severe and persistent mental illness as determined by the Local
Mental Health Authority.

       

      Specialty
Hospital means any inpatient hospital that is not a general Acute Care
hospital.

       

      Specialty
Therapy means physical therapy, speech therapy or occupational
therapy.

       

      Specified
Low-Income Medicare Beneficiary (SLMB) means a Medicare beneficiary whose
only Medicaid benefit is payment of the Medicare Part B premium.

       

      SSA
means the Social Security Administration.

       

      SSI
Administrative Fee means the monthly per member per month fee paid to an
HMO to provide administrative services to manage the healthcare of the HMO’s
voluntary SSI beneficiaries. These services are described in more detail under
Section 10.10 of
this document.   

       

      Stabilize
means to provide such medical care as to assure within reasonable medical
probability that no deterioration of the condition is likely to result from, or
occur from, or occur during discharge, transfer, or admission of the Member.


       

      STAR+PLUS
or STAR+PLUS Program means the State of Texas Medicaid managed care
program in which HHSC contracts with HMOs to provide, arrange, and coordinate
preventive, primary, acute and long term care Covered Services to adult persons
with disabilities and elderly persons age 65 and over who qualify for Medicaid
through the SSI program and/or the MAO program. Children under age 21, who
qualify for Medicaid through the SSI

      program,
may voluntarily participate in the STAR+PLUS program.

       

      STAR+PLUS
HMOs means contracted HMOs participating in the STAR+PLUS
Program.

       

      State
Fiscal Year (SFY) means a 12-month period beginning on September 1 and
ending on August 31 the following year.

       

      Subcontract
means any agreement between the HMO and other party to fulfill the requirements
of the Contract.

       

      Subcontractor
means any individual or entity, including an Affiliate, that has entered
into a Subcontract with HMO.

       

      Subsidiary
means an Affiliate controlled by such person or entity directly or
indirectly through one or more intermediaries.

       

      Supplemental
Security Income (SSI) means a Federal income supplement program funded by
general tax revenues (not Social Security taxes) designed to help aged, blind
and disabled people with little or no income by providing cash to meet basic
needs for food, clothing and shelter.

       

      T.A.C.
means Texas Administrative Code. 

       

      TDD
means telecommunication device for the deaf. It is interchangeable with the term
Teletype machine
or TTY.

       

      TDI
means the Texas Department of Insurance.

       

      Temporary
Assistance to Needy Families (TANF) means the federally funded program
that provides assistance to single parent families with children who meet the
categorical requirements for aid. This program was formerly known as the Aid to
Families with Dependent Children (AFDC) program.

       

      Texas
Health Network (THN) is the name of the Medicaid primary care case
management program in Texas.

       

      Texas
Health Steps (THSteps) is the name adopted by the State of Texas for the
federally mandated Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
program. It includes the State’s Comprehensive Care Program extension to EPSDT,
which adds benefits to the federal EPSDT requirements contained in 42 U.S.C.
§1396d(r), and defined and codified at 42 C.F.R. §§440.40 and 441.56-62. HHSC’s
rules are contained in 25 T.A.C., Chapter 33 (relating to Early and Periodic
Screening, Diagnosis and Treatment).

       

      Texas
Medicaid Bulletin means the bi-monthly update to the Texas Medicaid
Provider Procedures Manual.

       

      Texas
Medicaid Provider Procedures Manual means the policy and procedures
manual published by or on behalf of HHSC that contains policies and procedures
required of all health care providers who participate in the Texas Medicaid
program. The manual is published annually and is updated bi­monthly by the
Texas Medicaid Bulletin.

       

      Texas
Medicaid Service Delivery Guide means an attachment to the Texas Medicaid
Provider Procedures Manual.

       

      Third
Party Liability (TPL) means the legal responsibility of another
individual or entity to pay for all or part of the services provided to Members
under the Contract (see 1 TAC §354.2301 et seq., relating to Third
Party Resources).

       

      Third
Party Recovery (TPR) means the recovery of payments on behalf of a Member
by HHSC or the HMO from an individual or entity with the legal responsibility to
pay for the Covered Services.

       

      TP
40 means Type Program 40, which is a Medicaid program eligibility type
assigned to pregnant women under 185% of the federal poverty level
(FPL).

       

      TP
45 means Type Program 45, which is a Medicaid program eligibility code
assigned to newborns (under 12 months of age) who are born to mothers who are
Medicaid eligible at the time of the child’s birth.

       

      
        Transfer
means the movement of the Member from one Acute Care Hospital or Long
Term Care Hospital/facility and readmission to another Acute Care Hospital or
Long Term Care Hospital/facility within 24 hours for continued
treatment.

      

       

      Transition
Phase includes all activities the HMO is required to perform between the
Contract Effective Date and the Operational Start Date for a Service
Area.

       

      Turnover
Phase includes all activities the HMO is required to perform in order to
close out the Contract and/or transition Contract activities and operations for
a Service Area to HHSC or a subsequent contractor.

       

      Turnover
Plan means the written plan developed by HMO, approved by HHSC,
to be employed during the Turnover Phase. The Turnover Plan describes HMO’s
policies and procedures that will assure:

      


      (1) The
least disruption in the delivery of Health Care Services to those Members who
are enrolled with the HMO during the transition to a subsequent health
plan;

      


      (2)
Cooperation with HHSC and the subsequent health plan in notifying Members of the
transition and of their option to select a new plan, as requested and in the
form required or approved by HHSC; and

      


      (3)
Cooperation with HHSC and the subsequent health plan in transferring information
to the subsequent health plan, as requested and in the form required or approved
by HHSC.

      


      URAC
/American Accreditation Health Care Commission means the independent
organization that accredits Utilization Review functions and offers a variety of
other accreditation and certification programs for health care
organizations.

       

      Urgent
Behavioral Health Situation means a behavioral health condition that
requires attention and assessment within twenty-four (24) hours but which does
not place the Member in immediate danger to himself or herself or others and the
Member is able to cooperate with treatment.

       

      Urgent
Condition means a health condition including an Urgent Behavioral Health
Situation that is not an emergency but is severe or painful enough to cause a
prudent layperson, possessing the average knowledge of medicine, to believe that
his or her condition requires medical treatment evaluation or treatment within
twenty-four (24) hours by the Member’s PCP or PCP designee to prevent serious
deterioration of the Member’s condition or health.

       

      Utilization
Review means the system for retrospective, concurrent, or prospective
review of the medical necessity and appropriateness of Health Care Services
provided, being provided, or proposed to be provided to a Member.  The
term does not include elective requests for clarification of
coverage.

       

      Value-added
Services means additional services for coverage beyond those specified in
Attachments B-2, B-2.1, and B-2.2.  Value-added Services may be actual
Health Care Services,  benefits, or positive incentives that HHSC
determines will promote healthy lifestyles and improve health outcomes among
Members.  Value-added Services that promote healthy lifestyles should
target specific weight loss, smoking cessation, or other programs approved by
HHSC. Temporary phones, cell phones, additional transportation benefits, and
extra home health services may be Value-added Services, if approved by
HHSC.  Best practice approaches to delivering Covered Services are not
considered Value-added Services.

       

      Waste
means practices that are not cost-efficient.

       

      Article
3. General Terms & Conditions

      Section 3.01 Contract
elements.

      


      (a)
Contract documentation. The Contract between the Parties will consist of
the HHSC
Managed Care Contract document and all attachments and amendments.

      


      (b) Order
of documents. In the event of any conflict or contradiction between or among the
contract documents, the documents
shall control in the following order of precedence:

      


      (1) The
final executed HHSC Managed
Care Contract document, and all amendments thereto;

      


      (2) HHSC
Managed Care Contract Attachment A – “HHSC’s Uniform
Managed Care Contract Terms and Conditions,” and all amendments
thereto;

      


      (3) HHSC
Managed Care Contract Attachment B – “Scope of
Work/Performance Measures,” and all attachments and amendments
thereto;

      


      (4) The
HHSC Uniform Managed Care
Manual, and all attachments and amendments thereto;

      


      (5) HHSC
Managed Care Contract Attachment C-3 – “Agreed
Modifications to HMO’s Proposal;”

      


      (6) HHSC
Managed Care Contract Attachment C-2, “HMO
Supplemental Responses,” and

      


      (7) HHSC
Managed Care Contract

       

      Attachment C-1 – “HMO’s
Proposal.”  

       

      Section
3.02 Term of the
Contract.

      The term
of the Contract will begin on the Effective Date and will conclude on the
Expiration Date. The Parties may renew the Contract for an additional period or
periods, but the Contract Term may not exceed a total of eight (8)
years.  All reserved contract extensions beyond the Expiration Date
will be subject to good faith negotiations between the Parties and mutual
agreement to the extension(s).

       

      Section 3.03 Funding.

      This
Contract is expressly conditioned on the availability of state and federal
appropriated funds. HMO will have no right of action against HHSC in the event
that HHSC is unable to perform its obligations under this Contract as a result
of the suspension, termination, withdrawal, or failure of funding to HHSC or
lack of sufficient funding of HHSC for any activities or functions contained
within the scope of this Contract. If funds become unavailable, the provisions
of Article 12 (“Remedies
and Disputes”) will apply. HHSC will use all reasonable efforts to ensure that
such funds are available, and will negotiate in good faith with HMO to resolve
any HMO claims for payment that represent accepted Services or Deliverables that
are pending at the time funds become unavailable.  HHSC shall make
best efforts to provide reasonable written advance notice to HMO upon learning
that funding for this Contract may be unavailable.

       

      Section 3.04 Delegation of
authority.

      Whenever,
by any provision of this Contract, any right, power, or duty is imposed or
conferred on HHSC, the right, power, or duty so imposed or conferred is
possessed and exercised by the Commissioner unless any such right, power, or
duty is specifically delegated to the duly appointed agents or employees of
HHSC. The Commissioner will reduce any such delegation of authority to writing
and provide a copy to HMO on request.

       

      Section 3.05 No waiver of sovereign
immunity.

      The
Parties expressly agree that no provision of this Contract is in any way
intended to constitute a waiver by HHSC or the State of Texas of any immunities
from suit or from liability that HHSC or the State of Texas may have by
operation of law.

       

      Section 3.06 Force majeure.

      Neither
Party will be liable for any failure or delay in performing its obligations
under the Contract if such failure or delay is due to any cause beyond the
reasonable control of such Party, including, but not limited to, unusually
severe weather, strikes, natural disasters, fire, civil disturbance, epidemic,
war, court order, or acts of God.  The existence of such causes of
delay or failure will extend the period of

      performance
in the exercise of reasonable diligence until after the causes of delay or
failure have been removed.  Each Party must inform the other in
writing with proof of receipt within five (5) Business Days of the existence of
a force majeure event or otherwise waive this right as a defense.

       

      Section 3.07 Publicity.

      


      (a) HMO
may use the name of HHSC, the State of Texas, any HHS Agency, and the name of
the HHSC HMO Program in any media release, public announcement, or public
disclosure relating to the Contract or its subject matter only if, at least
seven (7) calendar days prior to distributing the material, the HMO submits the
information to HHSC for review and comment. If HHSC has not responded within
seven

      


      (7)
calendar days, the HMO may use the submitted information.  HHSC
reserves the right to object to and require changes to the publication if, at
HHSC’s sole discretion, it determines that the publication does not accurately
reflect the terms of the Contract or the HMO’s performance under the Contract.
..

      


      (b) HMO
will provide HHSC with one (1) electronic copy of any information described in
Subsection 3.07(a) prior to public release.  HMO will provide
additional copies, including hard copies, at the request of HHSC.

      


      (c) The
requirements of Subsection 3.07(a) do not apply to:

      


      (1)
proposals or reports submitted to HHSC, an administrative agency of the State of
Texas, or a governmental agency or unit of another state or the federal
government;

      


      (2)
information concerning the Contract’s terms, subject matter, and estimated
value:

      


      (a) in
any report to a governmental body to which the HMO is required by law to report
such information, or

      


      (b) that
the HMO is otherwise required by law to disclose; and

      


      (3)
Member Materials (the HMO must comply with the Uniform Managed Care
Manual’s provisions regarding the review and approval of Member
Materials).

      


      Section 3.08 Assignment.

      (a)
Assignment by HMO. HMO shall not assign all or any portion of its rights under
or interests in the Contract or delegate any of its duties without prior written
consent of HHSC. Any written request for assignment or delegation must be
accompanied by written acceptance of the assignment or delegation by the
assignee or delegation by the delegate.  Except where otherwise agreed
in writing by HHSC, assignment or delegation will not release HMO
from

      its
obligations pursuant to the Contract. An HHSC-approved Material Subcontract will
not be considered

      to be an
assignment or delegation for purposes of this section.

      


      (b)
Assignment by HHSC. HMO understands and agrees HHSC may in one or more
transactions assign, pledge, transfer, or hypothecate the
Contract.  This assignment will only be made
to another State agency or a non-State agency that is contracted to perform
agency support.

      


      (c)
Assumption. Each party to whom a transfer is made (an "Assignee") must assume
all or any part of HMO’S or HHSC's interests in the Contract, the product, and
any documents executed with respect to the Contract, including,
without limitation, its obligation for all or any portion of the purchase
payments, in whole or in part.

       

      Section 3.09 Cooperation with other vendors and
prospective vendors.

      HHSC may
award supplemental contracts for work related to the Contract, or any portion
thereof.  HMO will reasonably cooperate with such other vendors, and
will not commit or permit any act that may interfere with the performance of
work by any other vendor.

       

      Section 3.10 Renegotiation and reprocurement
rights.

      


      (a)
Renegotiation of Contract terms. Notwithstanding anything in the Contract to the
contrary, HHSC may at any time during the term of the Contract exercise the
option to notify HMO that HHSC has elected to renegotiate certain terms of the
Contract. Upon HMO’s receipt of any notice pursuant to this Section, HMO and
HHSC will undertake good faith negotiations of the subject terms of the
Contract, and may
execute an amendment to the Contract in accordance with Article 8.

      


      (b)
Reprocurement of the services or procurement of additional
services.

      


      Notwithstanding
anything in the Contract to the contrary, whether or not HHSC has accepted or
rejected HMO’s Services and/or Deliverables provided during any period of the
Contract, HHSC may at any time issue requests for proposals or offers to other
potential contractors for performance of any portion of the Scope of Work
covered by the Contract or Scope of Work similar or comparable to the Scope of
Work performed by HMO under the Contract.

      


      (c)
Termination rights upon reprocurement. If HHSC elects to procure the Services or
Deliverables or any portion of the Services or Deliverables from another vendor
in accordance with this
Section, HHSC will have the termination rights set forth in Article 12 (“Remedies and
Disputes”). 

       

      Section
3.11
RFP errors and omissions.

      HMO will
not take advantage of any errors and/or omissions in the RFP or the resulting
Contract. HMO must
promptly notify HHSC of any such errors and/or omissions that are
discovered.

       

      Section 3.12 Attorneys’ fees.

      In the
event of any litigation, appeal, or other legal action to enforce any provision
of the Contract, HMO agrees to pay all reasonable expenses of such action,
including attorneys' fees and costs, if HHSC is the prevailing
Party.

       

      Section 3.13 Preferences under service
contracts.

      HMO is
required in performing the Contract to purchase products and materials produced
in the State of Texas when they are available at a price and time comparable to
products and materials produced outside the State.

       

      Section 3.14 Time of the
essence.

      In
consideration of the need to ensure uninterrupted and continuous HHSC HMO
Program performance, time is of the essence in the performance of the Scope of
Work under the Contract.

       

      Section 3.15 Notice

      


      (a) Any
notice or other legal communication required or permitted to be made or given by
either Party pursuant to the Contract will be in writing and in English, and
will be deemed to have been given:

      


      (1) Three
(3) Business Days after the date of mailing if sent by registered or certified
U.S. mail, postage prepaid, with return receipt requested;

      


      (2) When
transmitted if sent by facsimile, provided a confirmation of transmission is
produced by the sending machine; or

      


      (3) When
delivered if delivered personally or sent by express courier
service.

      


      (b) The
notices described in this Section may not be sent by electronic
mail.

      


      (c) All
notices must be sent to the Project Manager identified in the HHSC Managed Care Contract
document.  In addition, legal notices must be sent to the Legal
Contact identified in the HHSC
Managed Care Contract document.

      


      (d)
Routine communications that are administrative in nature will be provided in a
manner agreed to by the Parties.

      


      Article
4. Contract Administration & Management

      Section 4.01 Qualifications, retention and
replacement
of HMO employees.

      HMO
agrees to maintain the organizational and administrative capacity and
capabilities to carry out all duties and responsibilities under this
Contract.  The personnel HMO assigns to perform the duties and
responsibilities under this Contract will be properly trained and qualified for
the functions they are to perform. Notwithstanding transfer or turnover of
personnel,
HMO remains obligated to perform all duties and responsibilities under this
Contract without degradation and in accordance with the terms of this
Contract.

       

      Section 4.02 HMO’s Key
Personnel.

      (a)
Designation of Key Personnel. HMO must designate key management and technical
personnel who will be assigned to the Contract. For the purposes of this
requirement, Key Personnel are those with management responsibility or principal
technical responsibility for the following functional
areas for each HMO Program included within the scope of the
Contract:

      


      (1)
Member Services;

      


      (2)
Management Information Systems;

      


      (3)
Claims Processing,

       

      (4)
Provider Network Development and Management;

      


      (5)
Benefit Administration and Utilization and Care Management;

      


      (6)
Quality Improvement;

      


      (7)
Behavioral Health Services;

      


      (8)
Financial Functions;

      


      (9)
Reporting;

      


      (10)
Executive Director(s) for applicable HHSC HMO Program(s) as defined in Section 4.03 (“Executive
Director”);

      


      (11)
Medical Director(s) for applicable HHSC HMO
Program(s) as defined in Section 4.04 (“Medical
Director”); and

      


      (12)
STAR+PLUS Service Coordinators for STAR+PLUS HMOs as defined in Section 4.04.1 (“STAR+PLUS
Service Coordinator.”)

      


      (b)
Support and Replacement of Key Personnel. The HMO must maintain, throughout the
Contract Term, the ability to supply its Key Personnel with the required
resources necessary to meet Contract requirements and comply with applicable
law. The HMO must ensure project continuity by timely replacement of Key
Personnel, if necessary, with a sufficient number of persons having the
requisite skills, experience and other qualifications.  Regardless of
specific personnel changes, the HMO must maintain the overall level of
expertise, experience, and skill reflected in the Key HMO Personnel
job descriptions and qualifications included in the HMO’s proposal.

      


      (c)
Notification of replacement of Key Personnel. HMO must notify HHSC within
fifteen (15) Business Days of any change in Key Personnel. Hiring or replacement
of Key Personnel must conform to all Contract requirements. If HHSC determines
that a
satisfactory working relationship cannot be established between certain Key
Personnel and HHSC, it
will notify the HMO in writing.  Upon receipt of HHSC’s notice, HHSC
and HMO will attempt to resolve HHSC’s concerns on a mutually agreeable
basis.

       

       

      Section 4.03 Executive
Director.

      


      (a) The
HMO must employ a qualified individual to serve as the Executive Director for
its HHSC HMO Program(s). Such Executive Director must be employed full-time by
the HMO, be primarily dedicated to HHSC HMO Program(s), and must hold a Senior
Executive or Management position in the HMO’s organization, except that the HMO
may propose an alternate structure for the Executive Director position, subject
to HHSC’s prior review and written approval.

      


      (b) The
Executive Director must be authorized and empowered to represent the HMO
regarding all matters pertaining to the Contract prior to such representation.
The Executive Director must act as liaison between the HMO and the HHSC and must
have responsibilities that include, but are not limited to, the
following:

      


      (1)
ensuring the HMO’s compliance with the terms of the Contract, including securing
and coordinating resources necessary for such compliance;

      


      (2)
receiving and responding to all inquiries and requests made by HHSC related to
the Contract, in the time frames and formats specified by HHSC. Where
practicable, HHSC must consult with the HMO to establish time frames and formats
reasonably acceptable to the Parties;

      


      (3)
attending and participating in regular HHSC HMO Executive Director meetings or
conference calls;

      


      (4)
attending and participating in regular HHSC Regional Advisory Committees (RACs)
for managed care (the Executive Director may designate key personnel to attend a
RAC if the Executive Director is unable to attend);

      


      (5)
making best efforts to promptly resolve any issues identified either by the HMO
or HHSC that may arise and are related to the Contract;

      


      (6)
meeting with HHSC representative(s) on a periodic or as needed basis to review
the HMO’s performance and resolve issues, and

      


      (7)
meeting with HHSC at the time and place requested by HHSC, if HHSC determines
that the HMO is not in compliance with the requirements of the
Contract.

       

       Section 4.04  Medical
Director.


      (a) The
HMO must have a qualified individual to serve as the Medical Director for its
HHSC HMO Program(s). The Medical Director must be currently licensed in Texas
under the Texas Medical Board as an M.D.
or D.O. with no restrictions or other licensure limitations. The Medical
Director must comply with the requirements of 28 T.A.C. §11.1606 and all
applicable federal and state statutes and regulations.

      


      (b) The
Medical Director, or his or her physician designee meeting the same Contract
qualifications that apply to the Medical Director, must be available by
telephone 24 hours a day, seven days a week, for Utilization Review decisions.
The Medical Director, and his/her designee, must either possess expertise with
Behavioral Health Services, or ready access to such expertise to ensure timely
and appropriate medical decisions for Members, including after regular business
hours.

      


      (c) The
Medical Director, or his or her physician designee meeting the same Contract
qualifications that apply to the Medical Director, must be authorized and
empowered to represent the HMO regarding clinical issues, Utilization Review and
quality of care inquiries. The Medical Director, or his or her physician
designee, must exercise independent medical judgment in all decisions relating
to medical necessity. The HMO must ensure that its decisions relating to medical
necessity are not adversely influenced by fiscal management decisions. HHSC may
conduct reviews of decisions relating to medical necessity upon reasonable
notice.

      


      Section 4.04.1 STAR+PLUS Service
Coordinator

      


      (a)
STAR+PLUS HMOs must employ as Service Coordinators persons experienced in
meeting the needs of people with disabilities, old and young, and vulnerable
populations who have Chronic or Complex Conditions. A Service Coordinator must
have an undergraduate and/or graduate degree in social work or a related field,
or be a Registered Nurse, Licensed Vocational Nurse, Advanced Nurse
Practitioner, or a Physician Assistant.

      


      (b) The
STAR+PLUS HMO must monitor the Service Coordinator’s workload and performance to
ensure that he or she is able to perform all necessary Service Coordination
functions for the STAR+PLUS Members in a timely manner.

      


      (c) The
Service Coordinator must be responsible for working with the Member or his or
her representative, the PCP and other Providers to develop a seamless package of
care in which primary, Acute Care, and long-term care service needs are met
through a single, understandable, rational plan. Each Member’s Service Plan must
also be well coordinated with the Member’s family and community support systems,
including Independent Living Centers, Area Agencies on Aging and Mental
Retardation Authorities. The Service Plan should be agreed to and signed by the
Member or the Member’s representative to indicate agreement with the plan. The
plan should promote consumer direction and self-determination and may include
information for services
outside the scope of Covered Services such as how to access affordable,
integrated housing. For dual eligible Members, the STAR+PLUS HMO is responsible
for meeting the Member’s Community Long- term Care Service needs.

       

      (d) The
STAR+PLUS HMO must empower its Service Coordinators to authorize the provision
and delivery of Covered Services, including Community Long-term Care Covered
Services.

       

      Section 4.05 Responsibility for HMO personnel and
Subcontractors.

      


      (a) HMO’s
employees and Subcontractors will not in any sense be considered employees of
HHSC or the State of Texas, but will be considered for all purposes as the HMO’s
employees or its Subcontractor’s employees, as applicable.

      


      (b)
Except as expressly provided in this Contract, neither HMO nor any of HMO’s
employees or Subcontractors may act in any sense as agents or representatives of
HHSC or the State of Texas.

      


      (c) HMO
agrees that anyone employed by HMO to fulfill the terms of the Contract is an
employee of HMO and remains under HMO’s sole direction and control. HMO assumes
sole and full responsibility for its acts and the acts of its employees and
Subcontractors.

      


      (d) HMO
agrees that any claim on behalf of any person arising out of employment or
alleged employment by the HMO  (including, but not limited to, claims
of discrimination against HMO, its officers, or its agents) is the sole
responsibility of HMO and not the responsibility of HHSC.  HMO will
indemnify and hold harmless the State from any and all claims asserted against
the State arising out of such employment or alleged employment by the
HMO.  HMO understands that any person who alleges a claim arising out
of employment or alleged employment by HMO will not be entitled to any
compensation, rights, or benefits from HHSC (including, but not limited to,
tenure rights, medical and hospital care, sick and annual/vacation leave,
severance pay, or retirement benefits).

      


      (e) HMO
agrees to be responsible for the following in respect to its
employees:

      


      (1)
Damages incurred by HMO’s employees within the scope of their duties under the
Contract; and

      


      (2)
Determination of the hours to be worked and the duties to be performed by HMO’s
employees.

      


      (f) HMO
agrees and will inform its employees and Subcontractor(s) that there is no right
of subrogation, contribution, or indemnification against HHSC for any duty owed
to them by HMO pursuant to this Contract or any judgment rendered against the
HMO. HHSC’s liability to the HMO’s employees, agents
and Subcontractors, if any, will be governed by the Texas Tort Claims Act, as
amended or modified (TEX.
CIV. PRACT. & REM. CODE §101.001et
seq.).

       

      (g) HMO
understands that HHSC does not assume liability for the actions of, or judgments
rendered against, the HMO, its employees, agents or
Subcontractors.  HMO agrees that it has no right to indemnification or
contribution from HHSC for any such judgments rendered against HMO or its
Subcontractors.

       

      Section 4.06 Cooperation with HHSC and
stateadministrative agencies.

      


      (a)
Cooperation with Other MCOs. HMO agrees to reasonably cooperate with and work
with the other MCOs in the HHSC HMO Programs, Subcontractors, and third-party
representatives as requested by HHSC. To the extent permitted by HHSC’s
financial and personnel resources, HHSC agrees to reasonably cooperate with HMO
and to use its best efforts to ensure that other
HHSC contractors reasonably cooperate with the HMO.

      


      (b)
Cooperation with state and federal administrative agencies.

      


      HMO must
ensure that HMO personnel will cooperate with HHSC or other state or federal
administrative agency personnel at no charge to HHSC for purposes relating to
the administration of HHSC programs including, but not limited to the following
purposes:

      


      (1) The
investigation and prosecution of fraud, abuse, and waste in the HHSC
programs;

      


      (2)
Audit, inspection, or other investigative purposes; and

      


      (3)
Testimony in judicial or quasi-judicial proceedings relating to the Services
and/or Deliverables under this Contract or other delivery of information to HHSC
or other agencies’ investigators or legal staff.

      


      Section 4.07 Conduct of HMO
personnel.

      


      (a) While
performing the Scope of Work, HMO’s personnel and Subcontractors
must:

      


      (1)
Comply with applicable State rules and regulations and HHSC’s requests regarding
personal and professional conduct generally applicable to the service locations;
and

      


      (2)
Otherwise conduct themselves in a businesslike and professional
manner.

      


      (b) If
HHSC determines in good faith that a particular employee or Subcontractor is not
conducting himself or herself in accordance with this Contract, HHSC may provide
HMO with notice and documentation concerning such conduct.  Upon
receipt of such notice, HMO must promptly investigate the
matter and take appropriate action that may include:

       

      (1)
Removing the employee from the project;

      


      (2)
Providing HHSC with written notice of such removal; and

      


      (3)
Replacing the employee with a similarly qualified individual acceptable to
HHSC.

       

      (c)
Nothing in the Contract will prevent HMO, at the request of HHSC, from replacing
any personnel who are not adequately performing their assigned responsibilities
or who, in the reasonable opinion of HHSC’s Project Manager, after consultation
with HMO, are unable to work effectively with the members of the HHSC’s staff.
In such event, HMO will provide replacement personnel with equal or greater
skills and qualifications as soon as reasonably
practicable.  Replacement of Key Personnel will be subject to HHSC
review. The Parties will work together in the event of any such replacement so
as not to disrupt the overall project schedule.

      


      (d) HMO
agrees that anyone employed by HMO to fulfill the terms of the Contract remains
under HMO’s sole direction and control.

      


      (e) HMO
shall have policies regarding disciplinary action for all employees who have
failed to comply with federal and/or state laws and the HMO’s standards of
conduct, policies and procedures, and Contract requirements.  HMO
shall have policies regarding disciplinary action for all employees who have
engaged in illegal or unethical conduct.

      


      Section 4.08 Subcontractors.

       

      (a) HMO
remains fully responsible for the obligations, services, and functions performed
by its Subcontractors to the same extent as if such obligations, services, and
functions were performed by HMO’s employees, and for purposes of this Contract
such work will be deemed work performed by HMO.  HHSC reserves the
right to require the replacement of any Subcontractor found by HHSC to be
unacceptable and unable to meet the requirements of the Contract, and to object
to the selection of a Subcontractor.

      


      (b) HMO
must:

      
        


        (1)
actively monitor the quality of care and services, as well as the quality of
reporting data, provided under a Subcontract;

        


        (2)
notify HHSC in writing at least 60 days prior to reprocurement of services
provided by any Material Subcontractor;

        


        (3)
notify HHSC in writing within three (3) Business Days after making a
decision  to terminate all or part of a Subcontract with a Material
Subcontractor or upon receiving notification from the Material Subcontractor of
its intent to terminate all or part of such Subcontract;

        


        (4)
notify HHSC in writing within one (1) Business Day of making a decision to enter
into a Subcontract with a new Material Subcontractor, or a new Subcontract for
newly procured services of an existing Material Subcontractor; and

        


        (5)
provide HHSC with a copy of TDI filings of delegation
agreements.

      

       

      (c)
During the Contract Period, Readiness Reviews by HHSC or its designated agent
may occur if:

      


      (1) a new
Material Subcontractor is employed by HMO;

      


      (2) an
existing Material Subcontractor provides services in a new Service
Area;

      


      (3) an
existing Material Subcontractor provides services for a new HMO
Program;

      


      (4) an
existing Material Subcontractor changes locations or changes its MIS and or
operational functions;

      


      (5) an
existing Material Subcontractor changes one or more of its MIS subsystems,
claims processing or operational functions; or

      


      (6) a
Readiness Review is requested by HHSC. The
HMO must submit information required by HHSC for each proposed Material
Subcontractor as indicated in Attachment B-1, Section 7.
Refer to Attachment B-1,
Sections 8.1.1.2 and 8.1.18 for additional
information regarding HMO Readiness Reviews during the Contract
Period.

      


      (d) HMO
must not disclose Confidential Information of HHSC or the State of Texas to a
Subcontractor unless and until such Subcontractor has agreed in writing to
protect the confidentiality of such Confidential Information in the manner
required of HMO under this Contract.

      


      (e)HMO
must identify any Subcontractor that is a subsidiary or entity formed after the
Effective Date of the Contract, whether or not an Affiliate of HMO, substantiate
the proposed Subcontractor’s ability to perform the subcontracted Services, and
certify to HHSC that no loss of service will occur as a result of the
performance of such Subcontractor.  The HMO will assume responsibility
for all contractual responsibilities whether or not the HMO performs them.
Further, HHSC considers the HMO to be the sole point of contact with regard to
contractual matters, including payment of any and all charges resulting from the
Contract.

      


      (f)
Except as provided herein, all Subcontracts must be in writing and must provide
HHSC the right to examine the Subcontract and all Subcontractor records relating
to the Contract and the Subcontract.  This requirement does not apply
to agreements with utility or mail service providers.

       

      (g) A
Subcontract whereby HMO receives rebates, recoupments, discounts, payments, or
other consideration from a Subcontractor (including without limitation
Affiliates) pursuant to or related to the execution of this Contract must be in
writing and must provide HHSC the right to examine the Subcontract and all
records relating to such consideration.

      


      (h) All
Subcontracts described in subsections (f) and (g) must show the dollar amount,
the percentage of money, or the value of any consideration that HMO pays to or
receives from the Subcontractor.

      


      (i) HMO must
submit a copy of each Material Subcontract executed prior to the Effective Date
of the Contract to HHSC no later than thirty (30) days after the Effective Date
of the Contract.  For Material Subcontracts executed or amended after
the Effective Date of the Contract, HMO must submit a copy to HHSC no later than
five (5) Business Days after execution or amendment.


      (j)
Network Provider Contracts must include the mandatory provisions included in the
HHSC Uniform Managed Care
Manual.

      


      (k) HHSC
reserves the right to reject any Subcontract or require changes to any
provisions that do not comply with the requirements or duties and
responsibilities of this Contract or create significant barriers for HHSC in
monitoring compliance with this Contract.

      


      Section 4.09 HHSC’s ability to contract
withSubcontractors.

       

      The HMO
may not limit or restrict, through a covenant not to compete, employment
contract or other contractual arrangement, HHSC’s ability to contract with
Subcontractors or former employees of the HMO.

       

      Section 4.10 HMO Agreements with Third
Parties

      


      (a) If
the HMO intends to report compensation paid to a third party (including without
limitation an Affiliate) as an Allowable Expense under this Contract, and the
compensation paid to the third party exceeds $100,000, or is reasonably
anticipated to exceed $100,000, in a State Fiscal Year, then the HMO’s agreement
with the third party must be in writing.  The agreement must provide
HHSC the right to examine the agreement and all records relating to the
agreement.

      


      (b) All
agreements whereby HMO receives rebates, recoupments, discounts, payments, or
other consideration from a third party (including without limitation Affiliates)
pursuant to or related to the execution of this Contract, must be in writing and
must provide HHSC the right to examine the agreement and all records relating to
such consideration.

      


      (c) All
agreements described in subsections (a) and (b) must show the dollar amount, the
percentage of money,
or the value of any consideration that HMO pays to or receives from the third
party.

      


      (d) HMO
must submit a copy of each third party agreement described in subsections (a)
and (b) to HHSC. If the third party agreement is entered into prior to the
Effective Date of the Contract, HMO must submit a copy no later than thirty (30)
days after the Effective Date of the Contract.  If the third party
agreement is executed after the Effective Date of the Contract, HMO must submit
a copy no later than five (5)
Business Days after execution. 

       

      (e) For
third party agreements valued under $100,000 per State Fiscal Year that are
reported as Allowable Expenses, the HMO must maintain financial records and data
sufficient to verify the accuracy of such expenses in accordance with the
requirements of Article
9.

      


      (f) HHSC
reserves the right to reject any third party agreement or require changes to any
provisions that do not comply with the requirements or duties and
responsibilities of this Contract or create significant barriers for HHSC in
monitoring compliance with this Contract.

      


      (g) This
section shall not apply to Provider Contracts, or agreements with utility or
mail service providers.

      


      Article
5. Member Eligibility & Enrollment

       

      Section 5.01 Eligibility
Determination

      The State
or its designee will make eligibility determinations for each of the HHSC HMO
Programs.

       

      Section 5.02 Member Enrollment &
Disenrollment.

      


      (a) The
HHSC Administrative Services Contractor will enroll and disenroll eligible
individuals in the HMO Program. To enroll in an HMO, the Member’s permanent
residence must be located within the HMO’s Service Area. The HMO is not allowed
to induce or accept disenrollment from a Member. The HMO must refer the Member
to the HHSC Administrative Services Contractor.

      


      (b) HHSC
makes no guarantees or representations to the HMO regarding the number of
eligible Members who will ultimately be enrolled into the HMO or the length of
time any such enrolling Members remain enrolled with the HMO beyond the minimum
mandatory enrollment periods established for each HHSC HMO Program.

      


      (c) The
HHSC Administrative Services Contractor will electronically transmit to the HMO
new Member information and change information applicable to active
Members.

      


      (d) As
described in the following Sections, depending on the HMO Program, special
conditions may also apply to enrollment and span of coverage for the
HMO.

       

      (e) A
Medicaid HMO has a limited right to request a Member be disenrolled from HMO
without the Member’s consent. HHSC must approve any HMO request for
disenrollment of a Member for cause. HHSC may permit disenrollment of a Member
under the following circumstances:

      


      (1)
Member misuses or loans Member’s HMO membership card to another person to obtain
services.

      


      (2)
Member is disruptive, unruly, threatening or uncooperative to the extent that
Member’s membership seriously impairs HMO’s or Provider’s ability to provide
services to Member or to obtain new Members, and Member’s behavior is not caused
by a physical or behavioral health condition.

      


      (3)
Member steadfastly refuses to comply with managed care restrictions (e.g.,
repeatedly using emergency room in combination with refusing to allow HMO to
treat the underlying medical condition).

      


      (4) HMO
must take reasonable measures to correct Member behavior prior to requesting
disenrollment. Reasonable measures may include providing education and
counseling regarding the offensive acts or behaviors.

      


      (5) For
STAR+PLUS HMOs, under limited conditions, the HMO may request disenrollment of
members who are totally dependent on a ventilator or who have been diagnosed
with End Stage Renal Disease.

      


      (f) HHSC
must notify the Member of HHSC’s decision to disenroll the Member if all
reasonable measures have failed to remedy the problem.

      


      (g) If
the Member disagrees with the decision to disenroll the Member from HMO, HHSC
must notify the Member of the availability of the Complaint procedure and, for
Medicaid Members, HHSC’s Fair Hearing process.

      


      (h) HMO
cannot request a disenrollment based on adverse change in the member’s health
status or utilization of services that are Medically Necessary for treatment of
a member’s condition.

      


      (i) Upon implementation of the
Comprehensive Healthcare Program for Foster Care, STAR and CHIP Members taken
into conservatorship by the Department of Family and Protective Services (DFPS)
will be disenrolled effective the date of conservatorship.

      


      Section 5.03 STAR enrollment for pregnant women
and infants.

      (a) The
HHSC Administrative Services Contractor will retroactively enroll some pregnant
Members in a Medicaid HMO based on their date of eligibility.

       

      (b) The
HHSC Administrative Services Contractor will enroll newborns born to Medicaid
eligible mothers who are enrolled in a STAR HMO in the same HMO for at least 90
days following the date of birth, unless the mother requests a plan change as a
special exception.  The Administrative Service Contractor will
consider such requests on a case-by­case basis. The HHSC Administrative
Services Contractor will retroactively, to date of birth, enroll newborns in the
applicable STAR HMO.

       

      Section 5.03.1
Enrollment for infants born to pregnant women in STAR+PLUS.

      If a
newborn is born to a Medicaid-eligible mother enrolled in a STAR+PLUS HMO, the
HHSC Administrative Service Contractor will enroll the newborn into that HMO’s
STAR HMO product, if one exists. All rules related to STAR newborn enrollment
will apply to the newborn. If the STAR+PLUS HMO does not have a STAR product but
the newborn is eligible for STAR, the newborn will be enrolled in traditional
Fee-for-Service Medicaid, and given the opportunity to select a STAR
HMO.

       

      Section 5.04 CHIP eligibility and
enrollment.

      (a) Term
of coverage.  The Administrative Services Contractor determines CHIP
eligibility on behalf of HHSC. The Administrative

      Services
Contractor will enroll and disenroll eligible individuals into and out of
CHIP.  CHIP Members with an Effective Date of Coverage on

      or after
September 1, 2007 will have twelve (12) months of coverage.  CHIP
Members with an Effective Date of Coverage prior to September 1, 2007 will be
required to re-enroll in the CHIP Program at the end of their six month coverage
period, at which point they will have a new Effective Date of Coverage and
twelve (12) months of coverage.

      


      (b)
Pregnant Members and Infants.

      


      (1) The
HHSC Administrative Contractor will refer pregnant CHIP Members, with the
exception of Legal Permanent Residents and other legally qualified aliens barred
from Medicaid due to federal eligibility restrictions, to Medicaid for
eligibility determinations. Those CHIP Members who are determined to be Medicaid
Eligible will be disenrolled from HMO’s CHIP plan. Medicaid coverage will be
coordinated to begin after CHIP eligibility ends to avoid gaps in health care
coverage.

      


      (2) In
the event the HMO remains unaware of a Member’s pregnancy until delivery, the
delivery will be covered by CHIP.  Babies are automatically enrolled
in the mother’s CHIP health plan at birth with CHIP eligibility and
re-enrollment following the timeframe as that of the mother. The HHSC
Administrative Services Contractor will then set the Member’s eligibility
expiration date at the later of (1) the end of the second month following the
month of the baby’s birth or
(2) the Member’s original eligibility expiration date.

       

       Section
5.04.1  CHIP
Perinatal eligibility, enrollment, and disenrollment


      (a) The
HHSC Administrative Contractor will electronically transmit to the HMO new CHIP
Perinate Member information based on the appropriate CHIP Perinate or CHIP
Perinate Newborn Rate Cell.  There is no waiting period for CHIP
Perinatal Program Members.

      


      (b) CHIP
Perinate Newborns are eligible for 12 months continuous enrollment, beginning
with the month of enrollment as a CHIP Perinate (month of enrollment plus 11
months).  A CHIP Perinate Newborn will maintain coverage in his or her
CHIP Perinatal health plan.

      


      (c) If
only one CHIP Perinatal HMO operates in a Service Area, HHSC will automatically
enroll a prospective member in that CHIP Perinatal HMO.  If multiple
CHIP Perinatal HMOs offer coverage in the Service Area, HHSC will send an
enrollment packet to the prospective Member’s household.  If the
household of a prospective member does not make a selection within 15 calendar
days, the HHSC Administrative Services Contractor will notify the household that
the prospective member has been assigned to a CHIP Perinatal HMO (“Default
Enrollment”).  When this occurs the household has 30 calendar days to
select another CHIP Perinatal HMO for the Member.

      


      (d)
HHSC’s Administrative Services Contractor will assign prospective members to
CHIP Perinatal HMOs in a Service Area in a rotational basis. Should HHSC
implement one or more administrative rules governing the Default Enrollment
processes, such administrative rules will take precedence over the Default
Enrollment process set forth herein.

      


      (e) When
a member of a household enrolls in the CHIP Perinatal Program, all traditional
CHIP members in the household will be disenrolled from their current health
plans and prospectively enrolled in the CHIP Perinatal Program Member’s health
plan.  All members of the household must remain in the same health
plan through the end of the CHIP Perinatal Program Member’s enrollment
period.

      


      (f) In
the 10th month
of the CHIP Perinate Newborn’s coverage, the family will receive a CHIP renewal
form.  The family must complete and submit the renewal form, which
will be pre-populated to include the CHIP Perinate Newborn’s and the CHIP
Program Members’ information.  Once the child’s CHIP Perinatal Program
coverage expires, the child will be added to his or her siblings’ existing CHIP
program case.

      


      Section 5.05 Span of Coverage

      


      
        (a)
Medicaid HMOs.

         

        (1) Open
Enrollment.

        HHSC will
conduct continuous open enrollment for Medicaid Eligibles and the HMO must
accept all persons who choose to enroll as Members in the HMO or who are
assigned as Members in the HMO by HHSC, without regard to the Member’s health
status or any other factor.

         

        (2)
Enrollment of New Medicaid Eligibles.

        Persons
who become eligible for Medicaid during an Inpatient Stay in a Hospital will not
be enrolled in a Medicaid HMO until discharged from the Hospital, with the
following exceptions: (1) Members retroactively enrolled in STAR in accordance
with Section 5.03, “STAR Enrollment of Pregnant Women and Infants,” and (2) all
Medicaid-eligible newborns. If a Member is enrolled in a Medicaid HMO during an
Inpatient Stay under either of these exceptions, the Medicaid HMO will be
responsible for all Covered Services, including Hospital facility charges,
beginning on the Effective Date of Coverage.

         

        (3)
Movement between STAR or STAR+PLUS HMOs.

        A Member
cannot change from a STAR or STAR+PLUS HMO to a different STAR or STAR+PLUS HMO
during an Inpatient Stay in a Hospital.

         

        (4)
Movement from a Medicaid Fee-for-Service or PCCM Program to a STAR or STAR+PLUS
HMO.

        A
Medicaid recipient can move from the Medicaid Fee-for-Service or PCCM program
into a STAR or STAR+PLUS HMO during an Inpatient Stay in a Hospital. Except as
provided in subpart (a)(2), responsibility for claims incurred during the
Inpatient Stay will be divided as follows: (1) the Medicaid Fee-for-Service
program will continue to pay allowable Hospital facility charges until the
earlier of the date of Discharge or loss of Medicaid eligibility; and (2)
beginning on the Effective Date of Coverage, the STAR or STAR+PLUS HMO will pay
for all other Covered Services.

         

        (5)
Movement from a STAR or STAR+PLUS HMO to the STAR Health MCO.

        A
Medicaid recipient can move from the STAR or STAR+PLUS program into the STAR
Health Program during an Inpatient Stay. In such cases, responsibility for
claims incurred during the Inpatient stay will be divided as follows: (1) the
STAR or STAR+PLUS HMO will continue to pay Hospital facility charges for Covered
Services until the earlier of the date of Discharge or loss of Medicaid
eligibility, and (2) beginning on the Effective Date of Coverage, the STAR
Health MCO will pay for all other Covered Services.

         

        (6)
Responsibility for Costs Incurred After Loss of Medicaid
Eligibility.

        Medicaid
HMOs are not responsible for services incurred on or after the effective date of
loss of Medicaid eligibility.

         

        (7)
Reenrollment after Temporary Loss of Medicaid Eligibility.

        Members
who are disenrolled because they are temporarily ineligible for Medicaid will be
automatically re-enrolled into the same health plan, if available. Temporary
loss of eligibility is defined as a period of six months or less.

         

        (b) CHIP
HMOs.

        If a CHIP
Member’s Effective Date of Coverage occurs while the CHIP Member is confined in
a hospital, HMO is responsible for the CHIP Member’s costs of Covered Services
beginning on the Effective Date of Coverage. If a CHIP Member is disenrolled
while the CHIP Member is confined in a hospital, HMO’s responsibility for the
CHIP Member’s costs of Covered Services terminates on the Date of
Disenrollment.

         

        (c) CHIP
Perinatal HMOs.

        If a CHIP Perinate’s Effective Date of
Coverage occurs while the CHIP Perinate is confined in a Hospital, HMO is
responsible for the CHIP Perinate’s costs of Covered Services beginning on the
Effective Date of Coverage. If a CHIP Perinate is disenrolled while confined in
a Hospital, the HMO’s responsibility for the CHIP Perinate’s costs of Covered
Services terminates on the Date of Disenrollment. If a CHIP Perinate Newborn is
disenrolled while confined in a Hospital, the HMO’s responsibility for the CHIP
Perinate Newborn’s costs of Covered Services terminates on: (1) the effective
date of Medicaid eligibility, if the CHIP Perinate Newborn is disenrolled from
the CHIP Perinatal Program based on a determination of Medicaid eligibility, or
(2) on the Date of Disenrollment, if the CHIP Perinate Newborn is disenrolled
from the CHIP Perinatal Program for any other reason.

      

       

      Section 5.06 Verification of Member
Eligibility.

      Medicaid
MCOs are prohibited from entering into an agreement to share information
regarding their Members with an external vendor that provides verification of
Medicaid recipients’ eligibility to Medicaid providers.  All such
external vendors must contract with the State and obtain eligibility information
from the State.

       

      Section 5.07 Special Temporary STAR Default
Process

      


      (a) STAR
HMOs that did not contract with HHSC prior to the Effective Date of the Contract
to provide Medicaid Health Care Services will be assigned a limited number of
Medicaid-eligibles, who have not actively made a STAR HMO choice, for a finite
period.  The number will vary by Service Area as set forth
below.  To the extent possible, the special default assignment will be
based on each eligible’s prior history with a PCP and geographic proximity to a
PCP.

      


      (b) For
the Bexar, Dallas, El Paso, Harris, Tarrant, and Travis Service Areas, the
special default process will begin with the Operational Start Date and conclude
when the HMO has achieved an enrollment of 15,000 mandatory STAR members, or at
the end of six months, whichever comes first.

      


      (c) For
the Lubbock Service Area, the special default process will begin with the
Operational Start Date and conclude when the HMO has achieved an enrollment of
5,000 mandatory STAR members, or at the end of six months, whichever comes
first.

      


      (d)
Special default periods may be extended for one or more Service Areas if
consistent with HHSC administrative rules.

      


      (e) This
Section does not apply to the Nueces Service Area.

       

      
        Section 5.07.1 Special Temporary STAR Default
Process – Rate Period 3

         

        In the
Bexar, Dallas, Harris, Lubbock, and Tarrant STAR Service Areas, HHSC will
implement a temporary default assignment for enrollees who have not actively
made an HMO choice. HHSC will assign these enrollees equally among all HMOs in a
Program Service Area. This temporary default process will be effective for
monthly enrollments from October 2008 to March 2009, after which time HHSC will
reinstate the standard enrollment process based on HMO elective choice
percentages.

      

       

      Section 5.08 Special Temporary STAR+PLUS Default
Process

      


      (a)
STAR+PLUS HMOs that did not contract with HHSC to provide STAR+PLUS services in
Harris County prior to the Effective Date of the Contract will be assigned a
limited number of STAR+PLUS Medicaid-eligibles in Harris County, who have not
actively made a STAR+PLUS HMO choice, for a finite period. To the extent
possible, the special default assignment will be based on each eligible's prior
history with a PCP and geographic proximity to a PCP.

      


      (b) For
the Harris Service Area, the special default process will begin on the
Operational Start Date. All defaults for Harris County will be awarded to the
new HMO during the special default process. The special default process will
conclude at the end of the first 6-month period following the Operational Start
Date, or when the HMO has achieved a total enrollment of 8,000 STAR+PLUS Members
for the entire Harris Service Area (includes Harris and Harris Contiguous
counties), whichever comes first.

      


      (c) The
special default process will apply to Harris County only. The Harris Contiguous
counties will follow the standard default process.

      


      (d) This
Section does not apply to the Bexar, Nueces or Travis Service Areas for
STAR+PLUS.

       

      
        Section 5.08.1 Special Temporary STAR+PLUS Default
Process – Rate Period 3

        In the
Harris STAR+PLUS Service Area, HHSC will implement a temporary default
assignment for enrollees who have not actively made an HMO choice. HHSC will
assign these enrollees equally among all HMOs in a Program Service Area. This
temporary default process will be effective for monthly enrollments from October
2008 to March 2009, after which time HHSC will reinstate the standard enrollment
process based on HMO elective choice percentages.

      

       

      Article
6. Service Levels & Performance Measurement

       

      Section 6.01 Performance
measurement.

      Satisfactory
performance of this Contract will be measured by:

      


      (a)
Adherence to this Contract, including all representations and
warranties;

      


      (b)
Delivery of the Services and Deliverables described in Attachment
B;

      


      (c)
Results of audits performed by HHSC or its representatives in accordance with
Article 9 (“Audit and
Financial Compliance”);

      


      (d)
Timeliness, completeness, and accuracy of required reports; and

      


      (e)
Achievement of performance measures developed by HMO and HHSC and as modified
from time to time by written agreement during the term of this
Contract.

      


       

      Article
7. Governing Law & Regulations

       

      Section 7.01 Governing law and
venue.

      This
Contract is governed by the laws of the State of Texas and interpreted in
accordance with Texas law.  Provided HMO first complies with the
procedures set forth in Section
12.13 (“Dispute Resolution,”) proper venue for claims arising from this
Contract will be in the State District Court of Travis County,
Texas.

       

      Section 7.02 HMO responsibility for compliance
with
laws and regulations.

      


      (a) HMO
must comply, to the satisfaction of HHSC, with all provisions set forth in this
Contract, all applicable provisions of state and federal laws, rules,
regulations, federal waivers, policies and guidelines, and any court-ordered
consent decrees, settlement agreements, or other court orders that govern the
performance of the Scope of Work including, but not limited to:

      


      (1)
Titles XIX and XXI of the Social Security Act;

      


      (2)
Chapters 62 and 63, Texas Health and Safety Code;

      


      (3)
Chapters 531 and 533, Texas Government Code;

      


      (4) 42
C.F.R. Parts 417 and 457, as applicable;

      


      (5) 45
C.F.R. Parts 74 and 92;

      


      (6) 48
C.F.R. Part 31, or OMB Circular A-122, based on whether the entity is for-profit
or nonprofit;

      


      (7) 1
T.A.C. Part 15, Chapters 361, 370, 391, and 392; and

      


      (8) all
State and Federal tax laws, State and Federal employment laws, State and Federal
regulatory requirements, and licensing provisions.

      


      (b) The
Parties acknowledge that the federal and/or state laws, rules, regulations,
policies, or guidelines, and court-ordered consent decrees, settlement
agreements, or other court orders that affect the performance of the Scope of
Work may change from time to time or be added, judicially interpreted, or
amended by competent authority.  HMO acknowledges that the HMO
Programs will be subject to continuous change during the term of the Contract
and, except as provided in Section 8.02, HMO has provided for or will provide
for adequate resources, at no additional charge to HHSC, to reasonably
accommodate such changes.  The Parties further acknowledge that HMO
was selected, in part, because of its expertise, experience, and knowledge
concerning applicable Federal and/or state laws, regulations, policies, or
guidelines that affect the performance of the Scope of Work.  In
keeping with HHSC’s reliance on this knowledge and expertise, HMO is responsible
for identifying the impact of changes in applicable Federal or state legislative
enactments and regulations that affect the performance of the Scope of Work or
the State’s use of the Services and Deliverables. HMO must timely notify HHSC of
such changes and must work with HHSC to identify the impact of such changes on
how the State uses the Services and Deliverables.

      


      (c) HHSC
will notify HMO of any changes in applicable law, regulation, policy, or
guidelines that HHSC becomes aware of in the ordinary course of its
business.

      


      (d) HMO
is responsible for any fines, penalties, or disallowances imposed on the State
or HMO arising from any noncompliance with the laws and regulations relating to
the delivery of the Services or Deliverables by the HMO, its Subcontractors or
agents.

      


      (e) HMO
is responsible for ensuring each of its employees, agents or Subcontractors who
provide Services under the Contract are properly licensed, certified, and/or
have proper permits to perform any activity related to the
Services.

      


      (f) HMO
warrants that the Services and Deliverables will comply with all applicable
Federal, State, and County laws, regulations, codes, ordinances, guidelines, and
policies.  HMO will indemnify HHSC from and against any losses,
liability, claims, damages, penalties, costs, fees, or expenses arising from or
in connection with HMO’s failure to comply with or violation of any such law,
regulation, code, ordinance, or policy.

      


      Section 7.03 TDI licensure/ANHC certification and
solvency.

      


      (a)
Licensure HMO must be either licensed by the TDI as an HMO or a certified ANHC
in all counties for the Service
Areas included within the scope of the Contract.

      


      (b)
Solvency HMO must maintain compliance with the Texas Insurance Code and rules
promulgated and administered by the TDI requiring a fiscally sound
operation.  HMO must have a plan and take appropriate measures to
ensure adequate provision against the risk of insolvency as required by
TDI.

      


      Such
provision must be adequate to provide for the following in the event of
insolvency:

      


      (1)
continuation of benefits, until the time of discharge, to Members who are
confined on the date of insolvency in a Hospital or other inpatient
facility;

      


      (2)
payment to unaffiliated health care providers and affiliated health care
providers whose agreements do not contain member “hold harmless” clauses
acceptable to TDI, and

      


      (3)
continuation of benefits for the duration of the Contract period for which HHSC
has paid a Capitation Payment.

      


      Provision
against the risk of insolvency must be made by establishing adequate reserves,
insurance or other guarantees in full compliance with all financial requirements
of TDI.

       

      Section 7.04 Immigration Reform and Control Act
of 1986.

      HMO shall
comply with the requirements of the Immigration Reform and Control Act of 1986
and the Immigration Act of 1990 (8 U.S.C. §1101, et seq.) regarding employment
verification and retention of verification forms for any individual(s) hired on
or after November 6, 1986, who will perform any labor or services under this
Contract.

       

      Section 7.05 Compliance with state and federal
anti-discrimination laws.

       

      
        (a) HMO
agrees to comply with state and federal anti-discrimination laws, including
without limitation:

         

      

      
        (1) Title
VI of the Civil Rights Act of 1964 (42 U.S.C.
§2000d et
seq.);

        


        (2)
Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. §794);

        


        (3)
Americans with Disabilities Act of 1990 (42 U.S.C.
§12101 et
seq.);

        


        (4) Age
Discrimination Act of 1975 (42 U.S.C. §§6101-6107);

        


        (5) Title
IX of the Education Amendments of 1972 (20 U.S.C. §§1681-1688);

        


        (6) Food
Stamp Act of 1977 (7 U.S.C. §200 et seq.); and

        


        (7) The
HHS agency’s administrative rules, as set forth in the Texas Administrative
Code, to the extent applicable to this Agreement.

        


        HMO
agrees to comply with all amendments to the above-referenced laws, and all
requirements imposed by the regulations issued pursuant to these laws. These
laws provide in part that no persons in the United States may, on the grounds of
race, color, national origin, sex, age, disability, political beliefs, or
religion, be excluded from participation in or denied any aid, care, service or
other benefits provided by Federal or State funding, or otherwise be subjected
to discrimination.

        


        (b) HMO
agrees to comply with Title VI of the Civil Rights Act of 1964, and its
implementing regulations at 45 C.F.R. Part 80 or 7 C.F.R. Part 15, prohibiting a
contractor from adopting and implementing policies and procedures that exclude
or have the effect of excluding or limiting the participation of clients in its
programs, benefits, or activities on the basis of national origin. Applicable
state and federal civil rights laws require contractors to provide alternative
methods for ensuring access to services for applicants and recipients who cannot
express themselves fluently in English. HMO agrees to ensure that its policies
do not have the effect of excluding or limiting the participation of persons in
its programs, benefits, and activities on the basis of national origin. HMO also
agrees to take reasonable steps to provide services and information, both orally
and in writing, in appropriate languages other than English, in order to ensure
that persons with limited English proficiency are effectively informed and can
have meaningful access to programs, benefits, and activities.

        


        (c) HMO
agrees to comply with Executive Order 13279, and its implementing regulations at
45 C.F.R. Part 87 or 7 C.F.R. Part 16. These provide in part that any
organization that participates in programs funded by direct financial assistance
from the United States Department of Agriculture or the United States Department
of Health and Human Services shall not, in providing services, discriminate
against a program beneficiary
or prospective program beneficiary on the basis of religion or religious
belief.

        
          


          (d) Upon
request, HMO will provide HHSC Civil Rights Office with copies of all of the
HMO’s civil rights policies and procedures.

          


          (e) HMO
must notify HHSC’s Civil Rights Office of any civil rights complaints received
relating to its performance under this Agreement. This notice must be delivered
no more than ten (10) calendar days after receipt of a complaint. Notice
provided pursuant to this section must be directed to:

          


          HHSC
Civil Rights Office 

          701 W. 51
Street, Mail Code W206  

          Austin,
Texas 78751  

          Phone
Toll Free: (888) 388-6332  

          Phone:
(512) 438-4313  

          TTY Toll
Free: (877) 432-7232 

          Fax:
(512) 438-5885.

        

      

       

      Section 7.06 Environmental protection
laws.

      HMO shall
comply with the applicable provisions of federal environmental protection laws
as described in this Section:

      


      (a)
Pro-Children Act of 1994. HMO shall comply with the Pro-Children Act of 1994 (20
U.S.C. §6081 et seq.),
as applicable, regarding
the provision of a smoke-free workplace and promoting the non-use of all tobacco
products.

      


      (b)
National Environmental Policy Act of 1969. HMO shall comply with any applicable
provisions relating to the institution of environmental quality control measures
contained in the National Environmental Policy Act of 1969 (42 U.S.C. §4321
et seq.) and Executive Order
11514 (“Protection and Enhancement of Environmental Quality”).

      


      (c) Clean
Air Act and Water Pollution Control Act regulations.

      


      HMO shall
comply with any applicable provisions relating to required notification of
facilities violating the requirements of Executive Order 11738 (“Providing for
Administration of the Clean Air Act and the Federal Water Pollution Control Act
with Respect to Federal Contracts, Grants, or Loans”).

      


      (d) State
Clean Air Implementation Plan. HMO shall comply with any applicable provisions
requiring conformity of federal actions to State (Clean Air)
Implementation Plans under §176(c) of the Clean Air Act of 1955, as amended (42
U.S.C. §740 et
seq.).

      


      (e) Safe
Drinking Water Act of 1974. HMO shall comply with applicable provisions relating
to the protection of underground sources of drinking water under the Safe
Drinking Water Act of 1974, as
amended (21 U.S.C. § 349; 42 U.S.C. §§ 300f to 300j-9).

       

      Section 7.07 HIPAA.

      HMO shall
comply with applicable provisions of HIPAA. This includes, but is not limited
to, the requirement that the HMO’s MIS system comply with applicable certificate
of coverage and data specification and reporting requirements promulgated
pursuant to HIPAA. HMO must comply with HIPAA EDI requirements.

       

      Article
8. Amendments & Modifications

       

      Section 8.01 Mutual
agreement.

      This
Contract may be amended at any time by mutual agreement of the
Parties.  The amendment must be in writing and signed by individuals
with authority to bind the Parties.

       

      Section 8.02 Changes in law or
contract.

      If
Federal or State laws, rules, regulations, policies or guidelines are adopted,
promulgated, judicially interpreted or changed, or if contracts are entered or
changed, the effect of which is to alter the ability of either Party to fulfill
its obligations under this Contract, the Parties will promptly negotiate in good
faith appropriate modifications or alterations to the Contract and any
schedule(s) or attachment(s) made a part of this Contract. Such modifications or
alterations must be in writing and signed by individuals with authority to bind
the parties, equitably adjust the terms and conditions of this Contract, and
must be limited to those provisions of this Contract affected by the
change.

       

      Section 8.03 Modifications as a
remedy.

      This
Contract may be modified under the terms of Article 12 ( “Remedies and
Disputes”).

       

      Section 8.04 Modifications upon renewal or
extension of Contract.

      


      (a) If
HHSC seeks modifications to the Contract as a condition of any Contract
extension, HHSC’s notice to HMO will specify those modifications to the Scope of
Work, the Contract pricing terms, or other Contract terms and
conditions.

      


      (b) HMO
must respond to HHSC’s proposed modification within the timeframe specified by
HHSC, generally within thirty (30) days of receipt.  Upon receipt of
HMO’s response to the proposed modifications, HHSC may enter into negotiations
with HMO to arrive at mutually agreeable Contract amendments. In the event that
HHSC determines that the Parties will be unable to reach agreement on mutually
satisfactory contract modifications, then HHSC will provide written notice to
HMO of its intent not to extend the Contract beyond the Contract Term then in
effect.

      


      Section 8.05 Modification of HHSC Uniform Managed
Care Manual.

       

      (a) HHSC
will provide HMO with at least thirty (30) days
advance written notice before implementing a substantive and material change in
the HHSC Uniform Managed Care Manual (a change that materially and substantively
alters the HMO’s ability to fulfill its obligations under the
Contract).  The Uniform Managed Care Manual, and all modifications
thereto made during the Contract Term, are incorporated by reference into this
Contract.  HHSC will provide HMO with a reasonable amount of time to
comment on such changes, generally at least ten (10) Business
Days.  HHSC is not required to provide advance written notice of
changes that are not material and substantive in nature, such as corrections of
clerical errors or policy clarifications.

      


      (b) The
Parties agree to work in good faith to resolve disagreements concerning material
and substantive
changes to the HHSC Uniform Managed Care Manual.  If the Parties are
unable to resolve issues relating to material and substantive changes, then
either Party may terminate the agreement in accordance with Article 12 (“Remedies and
Disputes”).

       

      (c)
Changes will be effective on the date specified in HHSC’s written notice, which
will not be earlier than the HMO’s response deadline, and such changes will be
incorporated into the HHSC Uniform Managed Care Manual.  If the HMO
has raised an objection to a material and substantive change to the HHSC Uniform
Managed Care Manual and submitted a notice of termination in accordance with
Section 12.04(d), HHSC
will not enforce the policy change during the period of time between the receipt
of the notice and the date of Contract termination.

       

      Section 8.06 CMS approval of Medicaid
amendments

      The
implementation of amendments, modifications, and changes to STAR and STAR+PLUS
HMO contracts is subject to the approval of the Centers for Medicare and
Medicaid Services (“CMS.”)

       

      Section 8.07 Required compliance with amendment
and modification procedures.

      No
different or additional services, work, or products will be authorized or
performed except as authorized by this Article.  No waiver of any
term, covenant, or condition of this Contract will be valid unless executed in
compliance with this Article.  HMO will not be entitled to payment for
any services, work or products that are not authorized by a properly executed
Contract amendment or modification.

       

      Article
9. Audit & Financial Compliance

      Section 9.01 Financial record retention and
audit.

      HMO
agrees to maintain, and require its Subcontractors to maintain, supporting
financial information and documents that are adequate to ensure that payment is
made and the Experience Rebate is calculated in accordance with applicable
Federal and State requirements, and are sufficient to ensure the accuracy and
validity of HMO invoices. Such documents, including all original claims forms,
will be maintained and retained by HMO or its Subcontractors for a period of
five (5) years after the Contract Expiration Date or until the resolution of all
litigation, claim, financial management review or audit pertaining to this
Contract, whichever is longer.

       

      Section 9.02 Access to records, books, and
documents.

      (a) Upon
reasonable notice, HMO must provide, and cause its Subcontractors to provide,
the officials and entities identified in this Section with prompt, reasonable,
and adequate access to any records,

      books,
documents, and papers that are related to the performance of the Scope of
Work.

      


      (b) HMO
and its Subcontractors must provide the access described in this Section upon
HHSC’s request.  This request may be for, but is not limited to, the
following purposes:

      


      (1)
Examination;

      


      (2)
Audit;

      


      (3)
Investigation;

      


      (4)
Contract administration; or

      


      (5) The
making of copies, excerpts, or transcripts.

      


      (c) The
access required must be provided to the following officials and/or
entities:

      


      (1) The
United States Department of Health and Human Services or its
designee;

      


      (2) The
Comptroller General of the United States or its designee;

      


      (3) HMO
Program personnel from HHSC or its designee;

      


      (4) The
Office of Inspector General;

      


      (5) Any
independent verification and validation contractor or quality assurance
contractor acting on behalf of HHSC;

      


      (6) The
Office of the State Auditor of Texas or its designee;

      


      (7) A
State or Federal law enforcement agency;

      


      (8) A
special or general investigating committee of the Texas Legislature or its
designee; and

      


      (9) Any
other state or federal entity identified by HHSC, or any other entity engaged by
HHSC.

      


      (d) HMO
agrees to provide the access described wherever HMO maintains such books,
records, and supporting documentation.  HMO further agrees to provide
such access in reasonable comfort and to provide any furnishings, equipment, and
other conveniences deemed reasonably necessary to fulfill the purposes described
in this Section.  HMO will require its Subcontractors to provide
comparable access and accommodations.

      


      Section 9.03 Audits of Services, Deliverables and
inspections.

      (a) Upon
reasonable notice from HHSC, HMO will provide, and will cause its Subcontractors
to provide, such auditors and inspectors as HHSC may from time to time
designate, with access to:

       

      (1) HMO
service locations, facilities, or installations; and

       

      (2) HMO
Software and Equipment.

      


      (b) The
access described in this Section will be for the purpose of examining, auditing,
or investigating:

      


      (1) HMO’s
capacity to bear the risk of potential financial losses;

      


      (2) the
Services and Deliverables provided;

      


      (3) a
determination of the amounts payable under this Contract;

      


      (4)
detection of fraud, waste and/or abuse; or

      


      (5) other
purposes HHSC deems necessary to perform its regulatory function and/or enforce
the provisions of this Contract.

      


      (c) HMO
must provide, as part of the Scope of Work, any assistance that such auditors
and inspectors reasonably may require to complete such audits or
inspections.

      


      (d) If,
as a result of an audit or review of payments made to the HMO, HHSC discovers a
payment error or overcharge, HHSC will notify the HMO of such error or
overcharge.  HHSC will be entitled to recover such funds as an offset
to future payments to the HMO, or to collect such funds directly from the HMO.
HMO must return funds owed to HHSC within thirty (30) days after receiving
notice of the error or overcharge, or interest will accrue on the amount
due.  HHSC will calculate interest at the Department of Treasury’s
Median Rate (resulting from the Treasury’s auction of 13-week bills) for the
week in which liability is assessed. In the event that an audit reveals that
errors in reporting by the HMO have resulted in errors in payments to the HMO or
errors in the calculation of the Experience Rebate, the HMO will indemnify HHSC
for any losses resulting from such errors, including the cost of
audit.

      


      Section 9.04 SAO Audit

      The HMO
understands that acceptance of funds under this Contract acts as acceptance of
the authority of the State Auditor’s Office (“SAO”), or any successor agency, to
conduct an investigation in connection with those funds.  The HMO
further agrees to cooperate fully with the SAO or its successor in the conduct
of the audit or investigation, including providing all records
requested.  The HMO will ensure that this clause concerning the
authority to audit funds received indirectly by Subcontractors through HMO and
the requirement to cooperate is included in any Subcontract it awards, and in
any third party agreements described in Section 4.10
(a-b).

       

      Section 9.05 Response/compliance with audit or
inspection findings.

      (a) HMO
must take action to ensure its or a Subcontractor’s compliance with or
correction of any finding of noncompliance with any law, regulation, audit
requirement, or generally accepted accounting principle relating to the Services
and Deliverables or any other
deficiency contained in any audit, review, or inspection conducted under this
Article.  This action will include HMO’S delivery to HHSC, for HHSC’S
approval, a Corrective Action Plan that addresses deficiencies identified in any
audit(s), review(s), or inspection(s) within thirty (30) calendar days of the
close of the audit(s), review(s), or inspection(s).

      


      (b) HMO
must bear the expense of compliance with any finding of noncompliance under this
Section that is:

      


      (1)
Required by Texas or Federal law, regulation, rule or other audit requirement
relating to HMO's business;

      


      (2)
Performed by HMO as part of the Services or Deliverables; or

      


      (3)
Necessary due to HMO's noncompliance with any law, regulation, rule or audit
requirement imposed on HMO.

      


      (c) As
part of the Scope of Work, HMO must provide to HHSC upon request a copy of those
portions of HMO's and its Subcontractors' internal audit reports relating to the
Services and Deliverables provided to HHSC under the Contract.

       

      
        Section 9.06 Notification of Legal and Other
Proceedings, and Related Events.

        The HMO
must notify HHSC of all proceedings, actions, and events as specified in the
Uniform Managed Care Manual, Chapter 5.8, “Report of Legal and Other
Proceedings, and Related Events.”

         

      

      Article
10. Terms & Conditions of Payment

      Section 10.01 Calculation of monthly Capitation
Payment.

      


      (a) This
is a Risk-based contract.  For each applicable HMO Program, HHSC will
pay the HMO fixed monthly Capitation Payments based on the number of eligible
and enrolled Members. HHSC will calculate the monthly Capitation Payments by
multiplying the number of Members by each applicable Member Rate
Cell.  In consideration of the Monthly Capitation Payment(s), the HMO
agrees to provide the Services and Deliverables described in this
Contract.

      


      (b) HMO
will be required to provide timely financial and statistical information
necessary in the Capitation Rate determination process.  Encounter
Data provided by HMO must conform to all HHSC requirements. Encounter Data
containing non­compliant information, including, but not limited to,
inaccurate client or member identification numbers, inaccurate provider
identification numbers, or diagnosis or procedures codes insufficient to
adequately describe the diagnosis or medical procedure performed, will not be
considered in the HMO’s experience for rate-setting purposes.

      


      (c)
Information or data, including complete and accurate Encounter Data, as
requested by HHSC for rate-setting purposes, must be provided to HHSC: (1)
within thirty (30) days of receipt of the letter from HHSC requesting the
information or data; and (2) no later than March 31st of each
year.

      


      (d) The
fixed monthly Capitation Rate consists of the following components:

       

      (1) an
amount for Health Care Services

      


      (2) an
amount for administering the program,

      


      (3) an
amount for the HMO’s Risk margin,  and

      


      (4) with
respect to the Medicaid program, pass
through funds for high-volume providers. Capitation Rates for each HMO Program
may vary by Service Area and MCO.  HHSC will employ or retain
qualified actuaries to perform data analysis and calculate the Capitation Rates
for each Rate Period.

       

      (e) HMO
understands and expressly assumes the risks associated with the performance of
the duties and responsibilities under this Contract, including the failure,
termination or suspension of funding to HHSC, delays or denials of required
approvals, and cost overruns not reasonably attributable to HHSC.

       

      Section 10.02 Time and Manner of
Payment.

      


      (a)
During the Contract Term and beginning after the Operational Start Date, HHSC
will pay the monthly Capitation Payments by the 10th Business Day of each
month.

      


      (b) The
HMO must accept Capitation Payments by direct deposit into the HMO’s
account.

      


      (c) HHSC
may adjust the monthly Capitation Payment to the HMO in the case of an
overpayment to the HMO, for Experience Rebate amounts due and unpaid, and if
money damages are assessed in accordance with Article 12 (“Remedies and
Disputes”).

      


      (d)
HHSC’s payment of monthly Capitation Payments is subject to availability of
federal and state appropriations. If appropriations are not available to pay the
full monthly Capitation Payment, HHSC may:

      


      (1)
equitably adjust Capitation Payments for all participating Contractors, and
reduce scope of service requirements as appropriate in accordance with Article 8, or

       

      (2)
terminate the Contract in accordance with Article 12 (“Remedies and
Disputes”). 

       

      Section
10.03 Certification of
Capitation Rates.

      HHSC will
employ or retain a qualified actuary to certify the actuarial soundness of the
Capitation Rates contained in this Contract.  HHSC will also employ or
retain a qualified actuary to certify all revisions or modifications to the
Capitation Rates.

       

      Section 10.04 Modification of Capitation
Rates.

      The
Parties expressly understand and agree that the agreed Capitation Rates are
subject to modification in accordance with Article 8 (“Amendments and
Modifications,”) if changes in state

      or
federal laws, rules, regulations or policies affect the rates or the actuarial
soundness of the rates.  HHSC will provide the HMO notice of a
modification to the Capitation Rates 60 days prior to the effective date of the
change, unless HHSC determines that circumstances warrant a shorter notice
period.  If the HMO does not accept the rate change, either Party may
terminate the Contract in accordance with Article 12 (“Remedies and
Disputes”).

       

      Section 10.05 STAR Capitation
Structure.

       

      (a) STAR
Rate Cells. STAR Capitation Rates are defined on a per Member
per month basis by Rate Cells and Service Areas. STAR Rate Cells
are:

      


      (1) TANF
adults;

      


      (2) TANF
children over 12 months of age;

       

      (3)
Expansion children over 12 months of age;

      


      (4)
Newborns less than or equal to 12 months of age;

      


      (5) TANF
children less than or equal to 12 months of age;

      


      (6)
Expansion children less than or equal to 12 months of age;

      


      (7)
Federal mandate children; and

      


      (8)
Pregnant women.

      


      (b) STAR
Capitation Rate development:

      


      (1)
Capitation Rates for Rate Periods 1 and 2 for Service Areas with historical STAR
Program participation.

      


      For
Service Areas where HHSC operated the STAR Program prior to the Effective Date
of this Contract, HHSC will develop base Capitation Rates by analyzing
historical STAR Encounter Data and financial data for the Service
Area.  This analysis will apply to all MCOs in the Service Area,
including MCOs that have no historical STAR Program participation in the Service
Area.  The analysis will include a review of historical enrollment and
claims experience information; any changes to Covered Services and covered
populations; rate changes specified by the Texas Legislature; and any other
relevant information. If the HMO participated in the STAR Program in the Service
Area prior to the Effective Date of this Contract, HHSC may modify the Service
Area base Capitation Rates using diagnosis-based risk adjusters to yield the
final Capitation Rates.

      


      (2)
Capitation Rates for Rate Periods 1 and 2 for Service Areas with no historical
STAR Program participation.

      


      For
Service Areas where HHSC has not operated the STAR Program prior to
the

      Effective
Date of this Contract, HHSC will establish base Capitation Rates for Rate
Periods 1 and 2 by analyzing Fee-for-Service claims data for the Service
Area.  This analysis will include a review of historical enrollment
and claims experience information; any changes to Covered Services and covered
populations; rate changes specified by the Texas Legislature; and any other
relevant information.

       

      (3)
Capitation Rates for subsequent Rate Periods for Service Areas with no
historical STAR Program participation.

      For
Service Areas where HHSC has not operated the STAR Program prior to the
Effective Date of this Contract, HHSC will establish base Capitation Rates for
the Rate Periods following Rate Period 2 by analyzing historical STAR Encounter
Data and financial data for the Service Area.  This analysis will
include a review of historical enrollment and claims experience information; any
changes to Covered Services and covered populations; rate changes specified by
the Texas Legislature; and any other relevant information.

       

      (c)
Acuity adjustment. HHSC may evaluate and implement an acuity adjustment
methodology, or alternative reasonable methodology, that appropriately
reimburses the HMO for acuity and cost differences that deviate from that of the
community average, if HHSC in its sole discretion determines that such a
methodology is reasonable and appropriate.  The community average is a
uniform rate for all HMOs in a Service Area, and is determined by combining all
the experience for all HMOs in a
Service Area to get an average rate for the Service Area. Value-added Services
will not be included in the rate-

      setting
process.

       

      Section 10.05.1STAR+PLUS Capitation
Structure.

      (a)
STAR+PLUS Rate Cells.  STAR+PLUS Capitation Rates are defined on a per
Member per month basis by Rate Cells.

       

      STAR+PLUS
Rate Cells are based on client category as follows:

      


      (1)
Medicaid Only Standard Rate

      


      (2)
Medicaid Only 1915 (c) Nursing Facility Waiver Rate

      


      (3) Dual
Eligible Standard Rate

      


      (4) Dual
Eligible 1915(c) Nursing Facility Waiver Rate

      


      (5)
Nursing Facility – Medicaid only

      


      (6)
Nursing Facility - Dual Eligible

      


      These
Rate Cells are subject to change after Rate Period 2.

      


      (b)
STAR+PLUS Capitation Rates  For All Service Areas, HHSC will establish
base Capitation Rates by Service Area based on fee-for­service experience in
the counties included in the Service Area. For the base Capitation Rate in the
Harris Service Area, the encounter data from existing STAR+PLUS plans in Harris
County will be blended with the fee-for-service experience from the balance of
counties in the Harris Service Area. HHSC may adjust the base Capitation Rate by
the HMO’s Case Mix Index to yield the final Capitation Rates. HHSC reserves the
right to trend forward these rates
until sufficient Encounter Data is available to base Capitation Rates on
Encounter Data.

      


      (c) Delay
in Increased Capitation Level for Certain Members Receiving Waiver
Services

      


      Once a
current HMO Member has been certified to receive STAR+PLUS Waiver (SPW)
services, there is a two-month delay before the HMO will begin receiving the
higher capitation payment.

      Non-Waiver
Members who qualify for STAR+PLUS based on eligibility for SPW services and
Waiver recipients who transfer from another region will not be subject to this
two-month delay in the increased capitation payment.

      All SPW
recipients will be registered into Service Authorization System Online
(SASO).  The Premium Payment System (PPS) will process data from the
SASO system in establishing a Member’s correct capitation payment.

       

      Section 10.06 CHIP Capitation Rates
Structure.

       

      (a) CHIP
Rate Cells. CHIP Capitation Rates are defined on a per Member per month basis by
the Rate Cells applicable to a
Service Area.  CHIP Rate Cells are based on the Member’s age group as
follows:

      


      (1) under
age one (1);

      


      (2) ages
one (1) through five (5);

      


      (3) ages
six (6) through fourteen (14); and

      


      (4) ages
fifteen (15) through eighteen (18).

      


      (b) CHIP
Capitation Rate development:   HHSC will establish base
Capitation Rates by analyzing Encounter Data and financial data for each Service
Area.  This analysis will include a review of historical enrollment
and claims experience information; any changes to Covered Services and covered
populations; rate changes specified by the Texas Legislature; and any other
relevant information.  HHSC may modify the Service Area base
Capitation

      Rate
using diagnosis based risk adjusters to yield the final Capitation
Rates.

       

      (c)
Acuity adjustment. HHSC may evaluate and implement an acuity adjustment
methodology, or alternative reasonable methodology, that appropriately
reimburses the HMO for acuity and cost differences that deviate from that of the
community average, if HHSC in its sole discretion determines that such a
methodology is reasonable and appropriate.  The community average is a
uniform rate for all HMOs in a Service Area, and is determined by combining all
the experience for all HMOs in a
Service Area to get an average rate for the Service Area.

      


      (d)
Value-added Services will not be included in the rate-setting
process.

       

      Section
10.06.1 CHIP Perinatal Program
Capitation Structure.


      
        (a) CHIP
Perinatal Program Rate Cells. CHIP Perinatal Capitation Rates are defined on a
per Member per month basis by the Rate Cells applicable to a Service
Area.  CHIP Perinatal Rate

        Cells are
based on the Member’s birth status and household income as follows:

        


        (1) CHIP
Perinate 0% - 185% of FPL;

        


        (2) CHIP
Perinate 186% - 200% of FPL;

        


        (3) CHIP
Perinate Newborn 0% - 185% of FPL;

        


        and 4)
CHIP Perinate Newborn 186% - 200% of FPL.

        


        (b) CHIP
Perinatal Program Capitation Rate Development

        


        (1) Until
such time as adequate encounter data is available to set rates, CHIP Perinatal
Program capitation rates will be established based on experience from comparable
populations in the Medicaid Fee-for-Service and STAR programs.  This
analysis will include: a review of historical enrollment and claims experience
information; changes to 

          Covered
Services and covered populations; rate changes specified by the Texas
Legislature; and any other relevant information.  HHSC may modify the
Service Area based Capitation Rate using diagnosis-based risk adjusters to yield
the final Capitation Rates.

          


          (2)
Effective 4/1/07, on a prospective basis, the monthly Capitation Rate for CHIP
Perinate Members at or below 185% of the Federal Poverty Level (FPL)has been
increased. All physicians involved in a labor with delivery for CHIP Perinate
Members at or below 185% FPL will share in the increase.  For services
provided on or after April 1, 2007 to CHIP Perinate Members, the HMO must
increase its fee schedule in effect on March 31, 2007 by at least 26.1% for the
procedure codes related to labor with delivery. The HMO’s Chief Executive
Officer will attest that the HMO has appropriately increased physician fees as
required above.  HHSC will perform sample audits to verify payments to
physicians are in accordance with this Contract requirement.

          


          (c)
Value-added Services will not be included in the rate-setting
process.

        

      

      


      Section 10.07 HMO input during rate setting
process.

      


      (1) In
Service Areas with historical STAR or CHIP Program participation, HMO must
provide certified Encounter Data and financial data as prescribed in HHSC’s Uniform Managed Care
Manual. Such information may include, without limitation: claims lag
information by Rate Cell, capitation expenses, and stop loss reinsurance
expenses.  HHSC may request clarification or for additional financial
information from the HMO.  HHSC will notify the HMO of the deadline
for submitting a response, which will include a reasonable amount of time for
response.

      


      (2) HHSC
will allow the HMO to review and comment on data used by HHSC to determine base
Capitation Rates.  In Service Areas with no historical STAR Program
participation, this will include Fee-for-Service data for Rate Periods 1 and
2.  HHSC will notify the HMO of deadline for submitting comments,
which will include a reasonable amount of time for response.  HHSC
will not consider comments received after the deadline in its rate
analysis.

      


      (3)
During the rate setting process, HHSC will conduct at least two (2) meetings
with the HMO.  HHSC may conduct the meetings in person, via
teleconference, or by another method deemed appropriate by
HHSC.  Prior to the first meeting, HHSC will provide the HMO with
proposed Capitation Rates. During the first meeting, HHSC will describe the
process used to generate the proposed Capitation Rates, discuss major changes in
the rate setting process, and receive input from the HMO.  HHSC will
notify the HMO of the deadline for submitting comments, which will include a
reasonable amount of time to review and comment on the proposed Capitation Rates
and rate setting process.  After reviewing such comments, HHSC will
conduct a second meeting to discuss the final Capitation Rates and changes
resulting from HMO comments, if any.

      


      Section 10.08 Adjustments to Capitation
Payments.

      


      (a)
Recoupment.

      


      HHSC may
recoup a payment made to the HMO for a Member if:

      


      (1) the
Member is enrolled into the HMO in error, and the HMO provided no Covered
Services to the Member during the month for which the payment was
made;

      


      (2) the
Member moves outside the United States, and the HMO has not provided Covered
Services to the Member during the month for which the payment was
made;

      


      (3) the
Member dies before the first day of the month for which the payment was made;
or

       

      (4) a
Medicaid Member’s eligibility status or program type is changed, corrected as a
result of error, or is retroactively adjusted.

      


      (b)
Appeal of recoupment. The HMO may appeal the recoupment or adjustment of
capitations in the above circumstances using the
HHSC dispute resolution process set forth in Section 12.13, (“Dispute
Resolution”). 

       

      Section
10.09 Delivery
Supplemental Payment for CHIP,
CHIP Perinatal and STAR HMOs.

      


      (a) The
Delivery Supplemental Payment (DSP) is a function of the average delivery cost
in each Service Area.  Delivery costs include facility and
professional charges.

      


      (b) CHIP
and STAR HMOs will receive a Delivery Supplemental Payment (DSP) from HHSC for
each live or stillbirth by a Member. CHIP Perinatal HMOs will receive a DSP from
HHSC for each live or stillbirth by a mother of a CHIP Perinatal Program Member
in the 186% to 200% FPL (measured at the time of enrollment in the CHIP
Perinatal Program).   CHIP Perinatal HMOs will not receive a DSP
from HHSC for a live or stillbirth by the mother of a CHIP Perinatal Program
Member in the 100%-185% FPL.  For STAR, CHIP and CHIP Perinatal
Program HMOs, the one-time DSP payment is made in the amount identified in the
HHSC Managed Care Contract
document regardless of whether there is a single birth or there are
multiple births at time of delivery.  A delivery is the birth of a
live born infant, regardless of the duration of the pregnancy, or a stillborn
(fetal death) infant of twenty (20) weeks or more of gestation.  A
delivery does not include a spontaneous or induced abortion, regardless of the
duration of the pregnancy.

      


      (c) HMO
must submit a monthly DSP Report as described in Attachment B-1, Section 8 to
the HHSC Managed Care Contract
document, in the format prescribed in HHSC’s Uniform Managed Care
Manual.

      


      (d) HHSC
will pay the Delivery Supplemental Payment within twenty (20) Business Days
after receipt of a complete and accurate report from the HMO.

      


      (e) The
HMO will not be entitled to Delivery Supplemental Payments for deliveries that
are not reported to HHSC within 210 days after the date of delivery, or within
thirty (30) days from the date of discharge from the hospital for the stay
related to the delivery, whichever is later.

      


      (f) HMO
must maintain complete claims and adjudication disposition documentation,
including paid and denied amounts for each delivery. The HMO must submit the
documentation to HHSC within five

      


      (5)
Business Days after receiving a request for such information from
HHSC.

      


      Section 10.10 Administrative Fee for SSI
Members

      


      (a)
Administrative Fee. STAR HMOs will receive a monthly fee for administering
benefits to each SSI Beneficiary who voluntarily enrolls in the HMO (a
“Voluntary SSI Member”), in the amount identified in the HHSC Managed Care Contract
document. The HHSC will pay for Health Care Services for such Voluntary SSI
Members under the Medicaid Fee-for-Services program.  SSI
Beneficiaries in all Service Areas except Nueces may voluntarily participate in
the

      


      STAR
Program; however, HHSC reserves the right to discontinue such voluntary
participation.

      


      (b)
Administrative services and functions.

      


      (1) HMO
must perform the same administrative services and functions for Voluntary SSI
Members as are performed for other Members under this contract. These
administrative services and functions include, but are not limited
to:

      


      (i) prior
authorization of services;

      


      (ii) all
Member services functions, including linguistic services and Member materials in
alternative formats for the blind and disabled;

      


      (iii)
health education;

      


      (iv)
utilization management using HHSC Administrative Services Contractor encounter
data to provide service management and appropriate interventions;

      


      (v)
quality assessment and performance improvement activities;

      


      (vi)
coordination to link Voluntary SSI Members with applicable community resources
and Non­capitated services.

      


      (2) HMO
must require Network Providers to submit claims for health and health-related
services to the HHSC Administrative Services Contractor for claims adjudication
and payment.

      


      (3) HMO
must provide services to Voluntary SSI Members within the HMO’s Network unless
necessary services are unavailable within Network. HMO must also allow referrals
to Out-of-Network providers if necessary services are not available within the
HMO’s Network. Records must be forwarded
to Member’s PCP following a referral visit.

      


      (c)
Members who become eligible for SSI A Member’s SSI status is effective the date
the State’s eligibility system identifies the Member as Type Program 13 (TP13).
On this effective date, the Member becomes a voluntary STAR
enrollee.  The State is responsible for updating the State's
eligibility system within 45 days of official notice of the Member’s
Federal SSI eligibility by the Social Security Administration
(SSA).

       

      Section 10.11 STAR, CHIP, and CHIP Perinatal
Experience Rebate

       

      (a) HMO’s
duty to pay. At the end of each Rate Year beginning with Rate Year 1, the HMO
must pay an Experience Rebate for the STAR, CHIP, and CHIP Perinatal Programs to
HHSC if the HMO’s Net Income before Taxes is greater than 3% of the total
Revenue for the period.  The Experience Rebate is calculated in
accordance with the tiered rebate method set forth below based on the
consolidated Net Income before Taxes for all of the HMO’s STAR, CHIP, and CHIP
Perinatal Service Areas included within the scope of the Contract, as measured
by any positive amount on the
Financial-Statistical Report (FSR) as reviewed and confirmed by
HHSC.

      


      (b)
Graduated Experience Rebate Sharing Method.

       

      
        	
                Pre-tax
      Income as a % of Revenues

              	
                HMO
      Share

              	
                HHSC
      Share

              
	
                <
      3%

              	
                100%

              	
                0%

              
	
                >
      3% and < 7%

              	
                75%

              	
                25%

              
	
                >
      7% and < 10%

              	
                50%

              	
                50%

              
	
                >
      10% and < 15%

              	
                25%

              	
                75%

              
	
                >
      15%

              	
                0%

              	
                100%

              


      

      
      

      


      HHSC and
the HMO will share the Net Income before Taxes for the STAR, CHIP, and CHIP
Perinatal Programs as follows, unless HHSC provides the HMO an Experience Rebate
Reward in accordance with Section 6 of Attachment B-1 to the HHSC Managed Care Contract
document and HHSC’s Uniform
Managed Care Manual:

      


      (1) The
HMO will retain all Net Income before Taxes that is equal to or less than 3% of
the total Revenues received by the HMO.

      


      (2) HHSC
and the HMO will share that portion of the Net Income before Taxes that is over
3% but less than or equal to 7% of the total Revenues received with 75% to the
HMO and 25% to HHSC.

      


      (3) HHSC
and the HMO will share that portion of the Net Income before Taxes that is over
7% but less than or equal to 10% of the total Revenues received with 50% to the
HMO and 50% to HHSC.

      


      (4) HHSC
and the HMO will share that portion of the Net Income before Taxes that is over
10% but less than or equal to 15% of the total Revenues received with 25% to the
HMO and 75% to HHSC.

      


      (5) HHSC
will be paid the entire portion of the Net Income before Taxes that exceeds 15%
of the total Revenues.

       

      (c) Net
income before taxes.

      


      (1) The
HMO must compute the Net Income before Taxes in accordance with the HHSC Uniform Managed Care Manual’s
“Cost Principles for Expenses” and “FSR Instructions for Completion”
and applicable federal regulations. The Net Income before Taxes will be
confirmed by HHSC or its agent for the Rate Year relating to all revenues and
expenses incurred pursuant to the Contract. HHSC reserves the right to modify
the “Cost Principles for
Expenses” and “FSR
Instructions for Completion” found in HHSC’s Uniform Managed Care
Manual in accordance with Section 8.05.

      


      (2) For
purposes of calculating Net Income before Taxes, the following items are not
Allowable Expenses:

      


      (i) the
payment of an Experience Rebate;

      


      (ii) any
interest expense associated with late or underpayment of the Experience
Rebate;

      


      (iii)
financial incentives, including without limitation the Quality Challenge Award
described in Attachment B-1, Section 6.3.2.3; and

      


      (iv)
financial disincentives, including without limitation: the Performance-based
Capitation Rate described in Attachment B-1, Section 6.3.2.2; and the liquidated
damages described in Attachment B-5.

      


      (3)
Financial incentives are true net bonuses and shall not be reduced by the
potential increased Experience Rebate payments.  Financial
disincentives are true net disincentives, and shall not be offset in whole or
part by potential decreases in Experience Rebate payments.

      


      (4) For
FSR reporting purposes, financial incentives incurred shall not be reported as
an increase in Revenues or as an offset to costs, and any award of such will not
increase reported income.  Financial disincentives incurred shall not
be included as reported expenses, and shall not reduce reported
income.  The reporting or recording of any of these incurred items
will be done on a memo basis, which is below the income line, and will be listed
as separate items.

      


      (d) Carry
forward of prior Rate Year losses. Losses incurred by a STAR, CHIP, or CHIP
Perinatal HMO for one Rate Year may be carried forward to the next Rate Year,
and applied as an offset against a STAR, CHIP, or CHIP Perinatal Experience
Rebate. Prior losses may be carried forward for two Rate Years for this
purpose.  If the HMO offsets a loss against another STAR, CHIP, or
CHIP Perinatal Service Area, only that portion of the loss that
was not used as an offset may be carried forward to the next Rate Year. Losses
incurred by a

      STAR,
CHIP, CHIP Perinatal HMO cannot be offset against the STAR+PLUS
Program.

      


      (e)
Settlements for payment.

       

      
        (1) There
may be one or more HMO payment(s) of the State share of the Experience Rebate on
income generated for a given State Fiscal Year under the STAR, CHIP, and CHIP
Perinatal Programs. The first scheduled payment (the “Primary Settlement”) will
equal 100% of the State share of the Experience Rebate as derived from the FSR,
and will be paid on the same day the 90-day FSR Report is submitted to
HHSC.

        The
“Primary Settlement,” as utilized herein, refers strictly to what should be paid
with the 90-day FSR, and does not refer to the first instance in which an HMO
may tender a payment. For example, an HMO may submit a 90-day FSR indicating no
Experience Rebate is due, but then submit a 334-day FSR with a higher income and
a corresponding Experience Rebate payment. In such case, this initial payment
would be subsequent to the Primary Settlement.

         

        (2) The
next scheduled payment will be an adjustment to the Primary Settlement, if
required, and will be paid on the same day that the 334-day FSR Report is
submitted to HHSC if the adjustment is a payment from the HMO to HHSC. Section
10.11(f) describes the interest expenses associated with any payment after the
Primary Settlement.

        An HMO
may make non-scheduled payments at any time to reduce the accumulation of
interest under Section 10.11(f). HHSC may require an adjusted FSR and/or
Experience Rebate calculation form in connection with any such non-scheduled
payment.

         

        (3) HHSC
or its agent may audit or review the FSRs. If HHSC determines that corrections
to the FSRs are required, based on an HHSC audit/review or other documentation
acceptable to HHSC, then HHSC will make final adjustments. Any payment
resulting from an audit or final adjustment will be due from the HMO within 30
days of the earlier of:

        (i) the
date of the management representation letter resulting from the audit;
or

        (ii) the
date of any invoice issued by HHSC.

        Payment
within this 30-day timeframe will not relieve the HMO of any interest payment
obligation that may exist under Section 10.11(f).

         

        (4) In
the event that any Experience Rebates and/or corresponding interest payments
owed to the State are not paid by the required due dates, then HHSC may offset
such amounts from any future Capitation Payments, or collect such sums directly
from the HMO. HHSC may adjust the Experience Rebate if HHSC determines the HMO
has paid amounts for goods or services that are not reasonable, necessary, and
allowable in accordance with the HHSC Uniform Managed Care Manual’s
“Cost Principles for Expenses,” the HHSC “FSR Instructions for Completion,”
the Federal Acquisition Regulations (FAR), or other applicable federal or
state regulations. HHSC has final authority in auditing and determining the
amount of the Experience Rebate.

      

       

      
        
          (f)
Interest on Experience Rebate.

           

          (1)
Interest on any
Experience Rebate owed to HHSC will be charged beginning 35 days after
the due date of the Primary Settlement, as described in Section 10.11(e)(1).
Thus, any Experience Rebate due or paid on or after the Primary Settlement will
accrue interest starting at 35 days after the due date for the 90-day FSR
Report. For example, any Experience Rebate payment (s) made in conjunction with
the 334-day FSR, or as a result of audit findings, will accrue interest back to
35 days after the due-date for submission of the 90-day FSR.

          The HMO
has the option of preparing an additional FSR based on 120 days of claims
run-out (a “120- day FSR”). If a 120-day FSR, and an Experience Rebate payment
based on it, are received by HHSC before the interest commencement date above,
then such a payment would be counted as part of the Primary
Settlement.

           

          (2) If an
audit or adjustment determines a downward revision of income after an interest
payment has previously been required for the same State Fiscal Year, then HHSC
will recalculate the interest and, if necessary, issue a full or partial refund
or credit to the HMO.

           

          (3) Any
interest obligations that are incurred pursuant to Section 10.11 that are not
timely paid will be subject to accumulation of interest as well, at the same
rate as applicable to the underlying Experience Rebate.

           

          (4) All
interest assessed pursuant to Section 10.11 will continue to accrue until such
point as a payment is received by HHSC, at which point interest on the amount
received will stop accruing. If a balance remains at that point that is subject
to interest, then the balance will continue to accrue interest. If interim
payments are made, then any interest that may be due will only be charged on
amounts for the time period during which they remained unpaid. By way of example
only, if $100,000 is subject to interest commencing on a given day, and a
payment is received for $75,000 45 days after the start of interest, then the
$75,000 will be subject to 45 days of interest, and the $25,000 balance will
continue to accrue interest until paid. The accrual of interest as defined under
Section 10.11 (f) will not stop during any period of dispute. If a dispute is
resolved in the HMO’s favor, then interest will only be assessed on the revised
unpaid amount.

           

          (5) If
the HMO incurs an interest obligation pursuant to Section 10.11 for an
Experience Rebate payment due on or after September 1, 2008, HHSC will assess
such interest at 12% per annum, compounded daily. If any interest rate
stipulated hereunder is found by a court of competent jurisdiction to be outside
the range deemed legal and enforceable, then in such specific case the rate
hereunder will be adjusted as little as possible so as to be deemed legal and
enforceable.

           

          (6) Any
such interest expense incurred pursuant to Section 10.11 is not an Allowable
Expense for reporting purposes on the FSR.

        

      

       

      Section 10.11.1 STAR+PLUS Experience
Rebate

      


      (a) HMO’s
duty to pay. At the end of each Rate Year beginning with Rate Year 1, the HMO
must pay an Experience Rebate to HHSC for the STAR+PLUS Program if the HMO
produces a positive Net Income in STAR+PLUS. The STAR+PLUS Experience Rebate is
calculated in accordance with the tiered rebate method set forth below based on
the consolidated Net Income before Taxes for all of the HMO’s STAR+PLUS Service
Areas included within the scope of the Contract, as measured by any positive
amount on the
Financial-Statistical Report (FSR) as reviewed and confirmed by
HHSC.

      


      (b)
Graduated STAR+PLUS Experience Rebate Sharing Method.

      
        1) Rate
Period 1.

        
          	
                  Pre-tax
      Income as
      a % of Revenues

                	
                  HMO
      Share

                	
                  HHSC
      Share

                
	
                  <
      3%

                	
                  50%

                	
                  50%

                
	
                  >
      3%

                	
                  75%

                	
                  25%

                


        

        
        

        


        For Rate
Period 1, HHSC and the HMO will share the Net Income before Taxes for the
STAR+PLUS Program as follows, unless HHSC provides the HMO an Experience Rebate
Reward in accordance with Section 6 of Attachment B-1 to the HHSC Managed Care Contract
document and HHSC’s Uniform
Managed Care Manual:

        


        (i) HHSC
and the STAR+PLUS HMO will share that portion of the Net Income before Taxes
that is equal to or less than 3% of the total STAR+PLUS Revenues received with
50% to the HMO and 50% to HHSC.

        


        (ii) HHSC
and the STAR+PLUS HMO will share that portion of the Net Income before Taxes
that is over 3% of the total STAR+PLUS Revenues received with 75% to the HMO and
25% to HHSC.

        


        (2) Rate
Period 2

        


        
          	
                  Pre-tax
      Income as a % of Revenues

                	
                  HMO
      Share

                	
                  HHSC
      Share

                
	
                  <
      2%

                	
                  100%

                	
                  0%

                
	
                  >
      2% and ≤ 6%

                	
                  75%

                	
                  25%

                
	
                  >
      6% and ≤ 10%

                	
                  50%

                	
                  50%

                
	
                  >
      10% and ≤ 15%

                	
                  25%

                	
                  75%

                
	
                  >
      15%

                	
                  0%

                	
                  100%

                


        

        
        

        


        For Rate Period 2 and
after, HHSC and the HMO will share the Net Income before Taxes for the STAR+PLUS
Program as follows, unless HHSC provides
the HMO an Experience Rebate Reward in accordance with Section 6 of Attachment B-1 to the HHSC Managed Care Contract
document and HHSC’s Uniform
Managed Care Manual:

         

        
          (1) The
STAR+PLUS HMO will retain all the Net Income before Taxes that is equal to or
less than 2% of the total STAR+PLUS Revenues received by the HMO.

          


          (2) HHSC
and the STAR+PLUS HMO will share that portion of the Net Income before Taxes
that is over 2% and less than or equal to 6% of the total STAR+PLUS Revenues
received with 75% to the HMO and 25% to HHSC.

          


          (3) HHSC
and the STAR+PLUS HMO will share that portion of the Net Income before Taxes
that is over 6% and less than or equal to 10% of the total STAR+PLUS Revenues
received with 50% to the HMO and 50% to HHSC.

          


          (4) HHSC
and the STAR+PLUS HMO will share that portion of the Net Income before Taxes
that is over 10% and less than or equal to 15% of the total STAR+PLUS Revenues
received with 25% to the HMO and 75% to HHSC.

          


          (5) HHSC
will be paid the entire portion of the Net Income before Taxes that exceeds 15%
of the total Revenues.

        

         

      

      (c) Net
income before taxes. 1) The HMO must compute the Net Income before Taxes in
accordance with the HHSC
Uniform Managed Care Manual’s “Cost Principles for Expenses” and “FSR Instructions for Completion”
and applicable federal regulations. The Net Income before Taxes will be
confirmed by HHSC or its agent for the Rate Year relating to all revenues
and expenses incurred pursuant to the Contract. HHSC reserves the right to
modify the “Cost Principles for Expenses”
and “FSR Instructions
for Completion” found in HHSC’s Uniform Managed Care
Manual in accordance with Section 8.05.

      


      (2) For
purposes of calculating Net Income before Taxes, the following items are not
Allowable Expenses:

      


      (i) the
payment of an Experience Rebate;

      


      (ii) any
interest expense associated with late or underpayment of the Experience
Rebate;

      


      (iii)
financial incentives, including without limitation the Quality Challenge Award
described in Attachment B-1, Section 6.3.2.3, and the STAR+PLUS Hospital
Inpatient Incentive Shared Savings Award described in Attachment B-1, Section
6.3.2.5.2; and

      


      (iv)
financial disincentives, including without limitation: the Performance-based
Capitation Rate described in Attachment B-1, Section 6.3.2.2; the STAR+PLUS
Hospital Inpatient Disincentive Administrative Fee at Risk described in
Attachment B-1, Section 6.3.2.5.1; and the liquidated damages described in
Attachment B-5.

      


      (3)
Financial incentives are true net bonuses and shall not be reduced by the
potential increased Experience Rebate payments.  Financial
disincentives are true net disincentives, and shall not be offset in whole or
part by potential decreases in Experience Rebate payments.

      


      (4) For
FSR reporting purposes, financial incentives incurred shall not be reported as
an increase in Revenues or as an offset to costs, and any award of such will not
increase reported income.

      


      Financial
disincentives incurred shall not be included as reported expenses, and shall not
reduce reported income.  The reporting or recording of any of these
incurred items will be done on a memo basis, which is below the income line, and
will be listed as separate items.

      


      (d) Carry
forward of prior Rate Year losses. Losses incurred by a STAR+PLUS HMO for one
Rate Year may be carried forward to the next Rate Year, and applied as an offset
against a STAR+PLUS Experience Rebate.  Prior losses may be carried
forward for two Rate Years for this purpose.  If the HMO offsets a
loss against another STAR+PLUS Service Area, only that portion of the loss that
was not used as an offset may be carried forward to the next Rate
Year. Losses incurred by a STAR+PLUS HMO cannot be offset against the STAR or
CHIP Programs.

      


      
        (e)
Settlements for payment; interest.

        The
processes applied to STAR, CHIP, and CHIP Perinatal Programs under Sections
10.11 (e) and (f) will also be applied to STAR+PLUS, with all applicable
references to the STAR, CHIP, and CHIP Perinatal Programs replaced with
STAR+PLUS. Any interest accruing under Section 10.11(f) for the STAR, CHIP, CHIP
and CHIP Perinatal Programs will be separate and apart from interest accruing
for the STAR+PLUS Program.

      

       

      
        Section 10.11.2 STAR, CHIP, CHIP
Perinatal Program, and STAR+PLUS Administrative Expense Cap.

         

        (a)
General requirement.

        Effective
with SFY 2009, the calculation methodology of Experience Rebates described in
Sections 10.11 and 10.11.1 will be adjusted by an Administrative Expense Cap
(“Admin Cap.”) The Admin Cap is a calculated maximum amount of administrative
expense dollars (corresponding to a given FSR) that can be deducted from
Revenues for purposes of determining income subject to the Experience Rebate.
While Administrative Expenses may be limited by the Admin Cap to determine
Experience Rebates, all valid Allowable Expenses will continue to be reported on
the Financial Statistical Reports (FSRs). Thus, the Admin Cap does not impact
FSR reporting, but may impact any associated Experience Rebate
calculation.

         

        Commencing
with the Primary Settlement for SFY 2009, and for all pre and post-audit FSRs
thereafter, the calculation of any corresponding Experience Rebate due will be
subject to limitations on total deductible administrative expenses.

         

        Such
limitations will be calculated as follows: (EML note: the proposed language
appears to relate to calculation methodology, so I moved it to (b).

         

        (b)
Calculation methodology.

        HHSC will
determine the administrative expense component of the applicable Capitation Rate
structure for each Program and Service Area prior to each applicable Rate
Period. At the conclusion of a Rate Period, HHSC will apply that predetermined
administrative expense component against the HMO’s actually incurred number of
Member Months and aggregate premiums received (monthly Capitation Payments plus
Delivery Supplemental Payments), to determine the specific Admin Cap, in
aggregate dollars, for a given HMO, Service Area, and Program.

         

        For SFY
2009 only, the Admin Cap methodology will include the application of an
adjustment factor of 1.05. This factor will have the effect of increasing the
Admin Cap. Section 10.11.2(d) demonstrates how HHSC will apply the adjustment
factor.

         

        (c) Data
sources.

        In
determining the amount of Experience Rebate payment to include in the Primary
Settlement (or in conjunction with any subsequent payment or settlement), the
HMO will need to make the appropriate calculation, in order to assess the
impact, if any, of the Admin Cap.

        


        
          	
                  (1) The total premiums
      paid by HHSC (earned by the HMO), and corresponding Member Months, will be
      taken from the relevant FSR (or audit report) for the Rate
      Period.

                


        

        


        
          	
                  (2) There are two
      components of the administrative expense portion of the Capitation Rate
      structure: the percentage rate to apply against the total premiums paid
      (the “percentage of premium” within the administrative expenses), and, the
      dollar rate per Member Month (the “fixed amount” within the administrative
      expenses). These will be taken from the supporting details associated with
      the official notification of final Capitation Rates, as supplied by HHSC.
      This notification is sent to the HMOs during the annual rate setting
      process via email, labeled as “the final rate exhibits for your health
      plan.” The email has one or more spreadsheet files attached, which are
      particular to the given HMO. The spreadsheet(s) show the fixed amount and
      percentage of premium components for the administrative component of the
      Capitation Rate.

                


        

         

        The
components of the administrative expense portion of the Capitation Rate can also
be found on HHSC’s Medicaid website, under “Rate Analysis for Managed Care
Services.” Under each Program, there is a separate Rate Setting document for
each Rate Period that describes the development of the Capitation Rates. Within
each such document, there is a section entitled “Administrative Fees,” where it
refers to “the amount allocated for administrative expenses.”

         

        In cases
where the administrative expense portion of the Capitation Rate refers to “the
greater of (a) [one set of factors], and (b) [another set of factors],” then the
Admin Cap will be calculated each way, and the larger of the two results will be
the Admin Cap utilized for the determination of any Experience Rebates
due.

         

        (d)
Separate calculations, by FSR.

        Each HMO
will have a separate Admin Cap for each Program and each Service Area in which
it participates. This will require calculating a separate Admin Cap
corresponding to each FSR (for annual, or complete period, versions of FSRs
only). All administrative expenses reported on an FSR in excess of the
calculated corresponding Admin Cap will be subtracted from the total Allowable
Expense in the Experience Rebate calculation of income for that Program and
Service Area, subject to any consolidation or offset that may apply, as
described in Section 10.11.2(d).

         

        By way of
example only, HHSC will calculate the Admin Cap for a Rate Period as
follows:

        


        
          	
                  1.
      Multiply the predetermined administrative expense rate structure “fixed
      amount,” or dollar rate per Member Month (for example, $11.00), by the
      actual number of Member Months for the Program and Service Area during the
      Rate Period (for example, 70,000):

                


        

        


        
          	
                   
      

                	
                  •
      $11.00 x 70,000 = $770,000.

                


        

        


        
          	
                  2.
      Multiply the predetermined percent of premiums in the administrative
      expense rate structure (for example, 5.75%), by the actual aggregate
      premiums earned for the Program and Service Area during the Rate Period
      (for example, $6,000,000).

                


        

        


        
          	
                   
      

                	
                  •
      5.75% x $6,000,000 = $345,000.

                


        

        


        
          	
                  3.
      For SFY 2009, add the totals of items 1-2 and multiply the sum by the
      adjustment factor of 1.05. To this product, add applicable premium taxes
      and maintenance taxes (for example, $112,000), to determine the Admin Cap
      for the Program and Service Area:

                


        

        


        
          	
                   
      

                	
                  •
      1.05($770,000 + $345,000) + $112,000 =
  $1,282,750.

                


        

        


        
          	
                  In
      this example, $1,282,750 would be the Admin Cap for a single Program in a
      given Service Area for an HMO in a particular Rate
  Period.

                


        

         

        4. For
other SFY 2010 and beyond, add the totals of items 1-2, plus applicable premium
taxes and maintenance taxes (for example, $112,000), to determine the Admin Cap
for the Program and Service Area:

        


        
          	
                   
      

                	
                  •
      $770,000 + $345,000 + $112,000 =
$1,227,000.

                


        

        


        
          	
                  In
      this example, $1,227,000 would be the Admin Cap for a single Program in a
      given Service Area for an HMO in a particular Rate
  Period.

                


        

         

        (e)
Consolidation and offsets.

        STAR,
CHIP, and CHIP Perinatal Program results will be consolidated, but STAR+PLUS
Program results will be calculated on a stand-alone basis. For a given HMO,
total incurred administrative expenses, as reported on the FSRs for the HMO’s
Service Areas and/or Programs (excluding STAR+PLUS), will be summed, and
compared to the total Admin Caps for the HMO’s various Service Areas and
Programs (excluding STAR+PLUS). Thus, a STAR, CHIP, or CHIP Perinatal HMO that
exceeds its Admin Cap limit in one or more Service Areas or Programs, but does
not exceed the Admin Cap in another Service area or Program, may have an offset.
Similarly, within STAR+PLUS, HMOs operating in multiple Service Areas will
likewise consolidate STAR+PLUS Service Area FSR administrative expense results,
and compare that to consolidated STAR+PLUS Admin Caps. The net impact of the
Admin Cap across relevant FSRs will be applied to the Experience Rebate
calculation.

         

        (f)
Impact on Loss carry-forward.

        For
Experience Rebate calculation purposes, the calculation of any loss
carry-forward, as described in Sections 10.11(d) and 10.11.1(d), will be based
on the allowable pre-tax loss as determined under the Admin Cap.

         

        (g) HMOs
entering a Service Delivery Area or Program.

        If an HMO
enters a new Service Area or offers a Program that it did not offer in the prior
contract year, it will be exempt from the Admin Cap for those Service Areas and
Programs for a period of time to be determined by HHSC, up to the first 12
months of operations.

         

        (h)
Service Delivery Areas with only one HMO in a Program.

        In
Service Areas operating with only one HMO for a Program, HHSC may, at its sole
discretion, revise the Admin Cap if its application would create an undue
hardship on the HMO.

         

        (i)
Unforeseen events.

        If, in
HHSC’s sole discretion, it determines that unforeseen events have created
significant hardships for one or more HMOs, HHSC may revise or temporarily
suspend the Admin Cap as it deems necessary.

      

       

      Section 10.12 Payment by
Members.

      (a)
Medicaid HMOs Medicaid HMOs and their Network Providers are prohibited from
billing or collecting any amount from a Member for Health Care Services covered
by this Contract. HMO must inform Members of costs for

      non-covered
services, and must require its Network Providers to:

       

      (1)
inform Members of costs for non-covered services prior to rendering such
services; and

       

      (2)
obtain a signed Private Pay form from such Members.

      


      (b) CHIP
HMOs.

       

      
        (1)
Families that meet the enrollment period cost share limit requirement must
report it to the HHSC Administrative Services Contractor. The HHSC
Administrative Service Contractor notifies the HMO that a family’s cost share
limit has been reached. Upon notification from the HHSC Administrative Services
Contractor that a family has reached its cost-sharing limit for the term of
coverage, the HMO will generate and mail to the CHIP Member a new Member ID card
within five days, showing that the CHIP Member’s cost-sharing obligation for
that term of coverage has been met. No cost-sharing may be collected from these
CHIP Members for the balance of their term of coverage.

         

        (2)
Providers are responsible for collecting all CHIP Member co-payments at the time
of service. Co-payments that families must pay vary according to their income
level.

         

        (3)
Co-payments do not apply, at any income level, to Covered Services that qualify
as well-baby and well-child care services, as defined by 42 C.F.R.
§457.520.

         

        (4)
Except for costs associated with unauthorized non-emergency services provided to
a Member by Out-of-Network providers and for non-covered services, the
co-payments outlined in the CHIP Cost Sharing Table in the HHSC Uniform Managed Care Manual
are the only amounts that a provider may collect from a CHIP-eligible
family. As required by 42 C.F.R. §457.515, this includes, without limitation,
Emergency Services that are provided at an Out-of-Network facility. Cost sharing
for such Emergency Services is limited to the co-payment amounts set forth in
the CHIP Cost Sharing Table.

         

        (5)
Federal law prohibits charging premiums, deductibles, coinsurance, co-payments,
or any other cost-sharing to CHIP Members of Native Americans or Alaskan
Natives. The HHSC Administrative Services Contractor will notify the HMO of CHIP
Members who are not subject to cost-sharing requirements. The HMO is responsible
for educating Providers regarding the cost-sharing waiver for this
population.

         

        (6) An
HMO’s monthly Capitation Payment will not be reduced for a family’s failure to
make its CHIP premium payment. There is no relationship between the per
Member/per month amount owed to the HMO for coverage provided during a month and
the family’s payment of its CHIP premium obligation for that
month.

      

    

    
      


      (c) CHIP
Perinatal HMOs Cost-sharing does not apply to CHIP Perinatal Program
Members.  The exemption from cost-sharing applies
through the end of the original 12-month enrollment period.

       

      Section 10.13 Restriction on assignment of
fees.

      During
the term of the Contract, HMO may not, directly or indirectly, assign to any
third party any beneficial or legal interest of the HMO in or to any payments to
be made by HHSC pursuant to this Contract. This restriction does not apply to
fees paid to Subcontractors.

       

      Section 10.14 Liability for
taxes.

      HHSC is
not responsible in any way for the payment of any Federal, state or local taxes
related to or incurred in connection with the HMO’s performance of this
Contract. HMO must pay and discharge any and all such taxes, including any
penalties and interest. In addition, HHSC is exempt from Federal excise taxes,
and will not pay any personal property taxes or income taxes levied on HMO or
any taxes levied on employee wages.

       

      Section 10.15 Liability for
employment-relatedcharges and benefits.

      HMO will
perform work under this Contract as an independent contractor and not as agent
or representative of HHSC. HMO is solely and exclusively liable for payment of
all employment-related charges incurred in connection with the performance of
this Contract, including but not limited to salaries, benefits, employment
taxes, workers compensation benefits, unemployment insurance and benefits, and
other insurance or fringe benefits for Staff.

       

      Section 10.16 No additional
consideration.

      


      (a) HMO
will not be entitled to nor receive from HHSC any additional consideration,
compensation, salary, wages, charges, fees, costs, or any other type of
remuneration for Services and Deliverables provided under the Contract, except
by properly authorized and executed Contract amendments.

      


      (b) No
other charges for tasks, functions, or activities that are incidental or
ancillary to the delivery of the Services and Deliverables will be sought from
HHSC or any other state agency, nor will the failure of HHSC or any other party
to pay for such incidental or ancillary services entitle the HMO to withhold
Services and Deliverables due under the Agreement.

      


      (c) HMO
will not be entitled by virtue of the Contract to consideration in the form of
overtime, health insurance benefits, retirement benefits, disability retirement
benefits, sick leave, vacation time, paid holidays, or other paid leaves of
absence of any type or kind whatsoever.

      


      Section 10.17 Federal
Disallowance

      If the
federal government recoups money from the state for expenses and/or costs that
are deemed unallowable by the federal government, the state has the right to, in
turn, recoup payments made to the HMOs for these same expenses and/or costs,
even if they had not been previously disallowed by the state and were incurred
by the HMO, and any such expenses and/or costs would then be deemed unallowable
by the state.  If the state retroactively recoups money from the HMOs
due to a federal disallowance, the state will recoup the entire amount paid to
the HMO for the federally disallowed expenses and/or costs, not just the federal
portion.

       

      Section 10.18 Required Pass Through of Physician
Rate Increases

      


      (a)
Effective September 1, 2007, all HMOs participating in the STAR, STAR+PLUS, CHIP
and CHIP Perinatal Programs are required to adjust their physician fee schedules
to reflect the physician rate increases funded through Legislative
Appropriations during the 80th Regular
Legislative Session.  The HMOs are required to pass on all
appropriated targeted physician rate increases to physicians serving their
Members.

      


      (b) The
Medicaid Fee Schedule in effect on September 1, 2007 (the “updated Medicaid Fee
Schedule”) will include the legislatively-mandated physician rate increases
based on the age of the Member, under 21 and over 21. The HMO must pay the
appropriate rate for the age of the Member on the date of service.

      


      (c) If,
under the terms of a Network Provider contract in place prior to September 1,
2007, the HMO pays for physician services based on the Medicaid Fee Schedule,
then the HMO must pay for physician services provided on or after September 1,
2007 based on the updated Medicaid Fee Schedule.

      


      (d) If,
under the terms of a Network Provider contract in place prior to September 1,
2007, the HMO pays for physician services based on a percentage of the Medicaid
Fee Schedule, then the HMO must pay for physician services provided on or after
September 1, 2007 based on the same percentage of the updated Medicaid Fee
Schedule.  By way of example only, if prior to September 1, 2007, the
HMO paid for physician services at110% of the Medicaid Fee Schedule, then the
HMO will pay for physician services provided on or after September 1, 2007 at
110% of the updated Medicaid Fee Schedule.

      


      (e) If,
under the terms of a Network Provider contract in place prior to September 1,
2007, the HMO uses benchmarks other than the Medicaid Fee Schedule (e.g. rates
that are a percentage of Medicare) to pay for physician services, then for
physician services provided on or after September 1, 2007, the HMO must increase
its rates by 25% for services to Members under 21 and by 10% for Members age 21
and over.  The HMO must provide HHSC with a copy of both the prior and
new Network Provider agreements and demonstrate how the new rates are 125% or
110%, depending on the age of the Member, of the former rates.

      


      (f) The
HMO’s Chief Executive Officer will attest that the HMO has appropriately
increased physician reimbursements as required above.  HHSC will
perform sample audits to verify payments to physicians are in accordance with
this Contract requirement.

      


      Article
11. Disclosure & Confidentiality of Information

      Section 11.01 Confidentiality.

      


      (a) HMO
and all Subcontractors, consultants, or agents under the Contract must treat all
information that is obtained through performance of the Services under the
Contract, including, but not limited to, information relating to applicants or
recipients of HHSC Programs as Confidential Information to the extent that
confidential treatment is provided under law and regulations.

      


      (b) HMO
is responsible for understanding the degree to which information obtained
through performance of this Contract is confidential under State and Federal
law, regulations, or administrative rules.

      


      (c) HMO
and all Subcontractors, consultants, or agents under the Contract may not use
any information obtained through performance of this Contract in any manner
except as is necessary for the proper discharge of obligations and securing of
rights under the Contract.

      


      (d) HMO
must have a system in effect to protect all records and all other documents
deemed confidential under this Contract maintained in connection with the
activities funded under the Contract. Any disclosure or transfer of Confidential
Information by HMO, including information required by HHSC, will be in
accordance with applicable law. If the HMO receives a request for information
deemed confidential under this Contract, the HMO will immediately notify HHSC of
such request, and will make reasonable efforts to protect the information from
public disclosure.

      


      (e) In
addition to the requirements expressly stated in this Section, HMO must comply
with any policy, rule, or reasonable requirement of HHSC that relates to the
safeguarding or disclosure of information relating to Members, HMO’S operations,
or HMO’s performance of the Contract.

      


      (f) In
the event of the expiration of the Contract or termination of the Contract for
any reason, all Confidential Information disclosed to and all copies thereof
made by the HMOI shall be returned to HHSC or, at HHSC’s option, erased or
destroyed.  HMO shall provide HHSC certificates evidencing such
destruction.

      


      (g) The
obligations in this Section shall not restrict any disclosure by the HMO
pursuant to any applicable law, or by order of any court or government agency,
provided that the HMO shall give prompt notice to HHSC of such
order.

      


      (h) With
the exception of confidential Member information, Confidential Information shall
not be afforded the protection of the Contract if such data was:

       

      (1)
Already known to the receiving Party without restrictions at the time of its
disclosure by the furnishing Party;

      


      (2)
Independently developed by the receiving Party without reference to the
furnishing Party’s Confidential Information;

      


      (3)
Rightfully obtained by the other Party without restriction from a third party
after its disclosure by the furnishing Party;

      


      (4)
Publicly available other than through the fault or negligence of the other
Party; or

      


      (5)
Lawfully released without restriction to anyone.

       

      Section 11.02 Disclosure of HHSC’s Confidential
Information.

      


      (a) HMO
will immediately report to HHSC any and all unauthorized disclosures or uses of
HHSC’s Confidential Information of which it or its Subcontractor(s),
consultant(s), or agent(s) is aware or has knowledge.  HMO
acknowledges that any publication or disclosure of HHSC’s Confidential
Information to others may cause immediate and irreparable harm to HHSC and may
constitute a violation of State or federal laws.  If HMO, its
Subcontractor(s), consultant(s), or agent(s) should publish or disclose such
Confidential Information to others without authorization, HHSC will immediately
be entitled to injunctive relief or any other remedies to which it is entitled
under law or equity.  HHSC will have the right to recover from HMO all
damages and liabilities caused by or arising from HMO’s, its Subcontractors’,
consultants’, or agents’ failure to protect HHSC’s Confidential
Information.  HMO will defend with counsel approved by HHSC, indemnify
and hold harmless HHSC from all damages, costs, liabilities, and expenses
(including without limitation reasonable attorneys’ fees and costs) caused by or
arising from HMO’s or its Subcontractors’, consultants’ or agents’ failure to
protect HHSC’s Confidential Information.  HHSC will not unreasonably
withhold approval of counsel selected by the HMO.

      


      (b) HMO
will require its Subcontractor(s), consultant(s), and agent(s) to comply with
the terms of this provision.

      


      Section 11.03 Member Records

      


      (a) HMO
must comply with the requirements of state and federal laws, including the HIPAA
requirements set forth in Section 7.07, regarding the
transfer of Member Records.

      


      (b) If at
any time during the Contract Term this Contract is terminated, HHSC may require
the transfer of Member Records, upon written notice to HMO, to another entity,
as consistent with federal and state laws and applicable releases.

      


      (c) The
term “Member Record” for this Section means only those administrative,
enrollment, case management
and other such records maintained by HMO and is not intended to include patient
records maintained by participating Network Providers.

       

      Section 11.04 Requests for public
information.

      


      (a) HHSC
agrees that it will promptly notify HMO of a request for disclosure of
information filed in accordance with the Texas Public Information Act, Chapter
552 of the Texas Government Code, that consists of the HMO’S confidential
information, including without limitation, information or data to which HMO has
a proprietary or commercial interest.  HHSC will deliver a copy of the
request for public information to HMO.

      


      (b) With
respect to any information that is the subject of a request for disclosure, HMO
is required to demonstrate to the Texas Office of Attorney General the specific
reasons why the requested information is confidential or otherwise excepted from
required public disclosure under law.  HMO will provide HHSC with
copies of all such communications.

      


      (c) To
the extent authorized under the Texas Public Information Act, HHSC agrees to
safeguard from disclosure information received from HMO that the HMO believes to
be confidential information.  HMO must clearly mark such information
as confidential information or provide written notice to HHSC that it considers
the information confidential.

      


      Section 11.05 Privileged Work
Product.

      


      (a) HMO
acknowledges that HHSC asserts that privileged work product may be prepared in
anticipation of litigation and that HMO is performing the Services with respect
to privileged work product as an agent of HHSC, and that all matters related
thereto are protected from disclosure by the Texas Rules of Civil Procedure,
Texas Rules of Evidence, Federal Rules of Civil Procedure, or Federal Rules of
Evidence.

      


      (b) HHSC
will notify HMO of any privileged work product to which HMO has or may have
access.  After the HMO is notified or otherwise becomes aware that
such documents, data, database, or communications are privileged work product,
only HMO personnel, for whom such access is necessary for the purposes of
providing the Services, may have access to privileged work product.

      


      (c) If
HMO receives notice of any judicial or other proceeding seeking to obtain access
to HHSC’s privileged work product, HMO will:

      


      (1)
Immediately notify HHSC; and

      


      (2) Use
all reasonable efforts to resist providing such access.

      


      (d) If
HMO resists disclosure of HHSC’s privileged work product in accordance with this
Section, HHSC will, to the extent authorized under Civil Practices and Remedies
Code or other applicable State law, have the right and duty to:

       

      (1)
represent HMO in such resistance;

      


      (2) to
retain counsel to represent HMO; or

      


      (3) to
reimburse HMO for reasonable attorneys' fees and expenses incurred in resisting
such access.

       

      (e) If a
court of competent jurisdiction orders HMO to produce documents, disclose data,
or otherwise breach the confidentiality obligations imposed in the Contract, or
otherwise with respect to maintaining the confidentiality, proprietary nature,
and secrecy of privileged work product, HMO will not be liable for breach of
such obligation.

       

      Section 11.06 Unauthorized
acts.

      Each
Party agrees to:

      


      (1)
Notify the other Party promptly of any unauthorized possession, use, or
knowledge, or attempt thereof, by any person or entity that may become known to
it, of any HHSC Confidential Information or any information identified by the
HMO as confidential or proprietary;

      


      (2)
Promptly furnish to the other Party full details of the unauthorized possession,
use, or knowledge, or attempt thereof, and use reasonable efforts to assist the
other Party in investigating or preventing the reoccurrence of any unauthorized
possession, use, or knowledge, or attempt thereof, of Confidential
Information;

      


      (3)
Cooperate with the other Party in any litigation and investigation against third
Parties deemed necessary by such Party to protect its proprietary rights;
and

      


      (4)
Promptly prevent a reoccurrence of any such unauthorized possession, use, or
knowledge such information.

      


      Section 11.07 Legal action.

      Neither
party may commence any legal action or proceeding in respect to any unauthorized
possession, use, or knowledge, or attempt thereof by any person or entity of
HHSC’s Confidential Information or information identified by the HMO as
confidential or proprietary, which action or proceeding identifies the other
Party information without such Party’s consent.

       

      Article
12. Remedies & Disputes

      Section 12.01 Understanding and
expectations.

      The
remedies described in this Section are directed to HMO’s timely and responsive
performance of the Services and production of Deliverables, and the creation of
a flexible and responsive relationship between the Parties.  The HMO
is expected to meet or exceed all HHSC objectives and standards, as set forth in
the Contract.  All areas of responsibility and all Contract
requirements will be subject to performance evaluation by
HHSC.  Performance reviews may be conducted
at the discretion of HHSC at any time and may relate to any responsibility
and/or requirement.  Any and all responsibilities and/or requirements
not fulfilled may be subject to remedies set forth in the Contract.

       

      Section 12.02 Tailored
remedies.

      


      (a)
Understanding of the Parties. HMO agrees and understands that HHSC may pursue
tailored contractual remedies for noncompliance with the Contract.  At
any time and at its discretion, HHSC may impose or pursue one or more remedies
for each item of noncompliance and will determine remedies on a case-by-case
basis.  HHSC’s pursuit or non-pursuit of a tailored remedy
does not
constitute a waiver of any other remedy that HHSC may have at law or
equity.

      


      (b)
Notice and opportunity to cure for non-material breach.

      


      (1) HHSC
will notify HMO in writing of specific areas of HMO performance that fail to
meet performance expectations, standards, or schedules set forth in the
Contract, but that, in the determination of HHSC, do not result in a material
deficiency or delay in the implementation or operation of the
Services.

      


      (2) HMO
will, within five (5) Business Days (or another date approved by HHSC) of
receipt of written notice of a non-material deficiency, provide the HHSC Project
Manager a written response that:

      


      (A)
Explains the reasons for the deficiency, HMO’s plan to address or cure the
deficiency, and the date and time by which the deficiency will be cured;
or

      


      (B) If
HMO disagrees with HHSC’s findings, its reasons for disagreeing with HHSC’s
findings.

      


      (3) HMO’s
proposed cure of a non-material deficiency is subject to the approval of HHSC.
HMO’s repeated commission of non-material deficiencies or repeated failure to
resolve any such deficiencies may be regarded by HHSC as a material deficiency
and entitle HHSC to pursue any other remedy provided in the Contract or any
other appropriate remedy HHSC may have at law or equity.

      


      (c)
Corrective action plan.

      


      (1) At
its option, HHSC may require HMO to submit to HHSC a written plan (the
“Corrective Action Plan”) to correct or resolve a material breach of this
Contract, as determined by HHSC.

      


      (2) The
Corrective Action Plan must provide:

      


      (A) A
detailed explanation of the reasons for the cited deficiency;

      


      (B) HMO’s
assessment or diagnosis of the cause; and

      


      (C) A
specific proposal to cure or resolve the deficiency.

       

      (3) The
Corrective Action Plan must be submitted by the deadline set forth in HHSC’s
request for a Corrective Action Plan.  The Corrective Action Plan is
subject to approval by HHSC, which will not unreasonably be
withheld.

      


      (4) HHSC
will notify HMO in writing of HHSC’s final disposition of HHSC’s
concerns.  If HHSC accepts HMO’s proposed Corrective Action Plan, HHSC
may:

      


      (A)
Condition such approval on completion of tasks in the order or priority that
HHSC may reasonably prescribe;

      


      (B)
Disapprove portions of HMO’s proposed Corrective Action Plan; or

      


      (C)
Require additional or different corrective action(s).

      


      Notwithstanding
the submission and acceptance of a Corrective Action Plan, HMO remains
responsible for achieving all written performance criteria.

      


      (5)
HHSC’s acceptance of a Corrective Action Plan under this Section will
not:

      


      (A)
Excuse HMO’s prior substandard performance;

      


      (B)
Relieve HMO of its duty to comply with performance standards; or

      


      (C)
Prohibit HHSC from assessing additional tailored remedies or pursuing other
appropriate remedies for continued substandard performance.

      


      (d)
Administrative remedies.

      


      (1) At
its discretion, HHSC may impose one or more of the following remedies for each
item of material noncompliance and will determine the scope and severity of the
remedy on a case-by-case basis:

      


      (A)
Assess liquidated damages in accordance with Attachment B-5 to the HHSC Managed Care Contract,
“Liquidated Damages Matrix;”

      


      (B)
Conduct accelerated monitoring of the HMO. Accelerated monitoring includes more
frequent or more extensive monitoring by HHSC or its agent;

      


      (C)
Require additional, more detailed, financial and/or programmatic reports to be
submitted by HMO;

      


      (D)
Decline to renew or extend the Contract;

      


      (E)
Appoint temporary management;

      


      (F)
Initiate disenrollment of a Member or Members;

      


      (G)
Suspend enrollment of Members;

      


      (H)
Withhold or recoup payment to HMO;

      


      (I)
Require forfeiture of all or part of the HMO’s bond; or

      


      (J)
Terminate the Contract in accordance with Section 12.03, (“Termination
by HHSC”).

       

      (2) For
purposes of the Contract, an item of material noncompliance means a specific
action of HMO that:

      


      (A)
Violates a material provision of the Contract;

      


      (B) Fails
to meet an agreed measure of performance; or

      


      (C)
Represents a failure of HMO to be reasonably responsive to a reasonable request
of HHSC relating to the Services for information, assistance, or support within
the timeframe specified by HHSC.

      


      (3) HHSC
will provide notice to HMO of the imposition of an administrative remedy in
accordance with this Section, with the exception of accelerated monitoring,
which may be unannounced.  HHSC may require HMO to file a written
response in accordance with this Section.

      


      (4) The
Parties agree that a State or Federal statute, rule, regulation, or Federal
guideline will prevail over the provisions of this Section unless the statute,
rule, regulation, or guidelines can be read together with this Section to give
effect to both.

      


      (e)
Damages.

      


      (1) HHSC
will be entitled to actual and consequential damages resulting from the HMO’S
failure to comply with any of the terms of the Contract.  In some
cases, the actual damage to HHSC or State of Texas as a result of HMO’S failure
to meet any aspect of the responsibilities of the Contract and/or to meet
specific performance standards set forth in the Contract are difficult or
impossible to determine with precise accuracy.  Therefore, liquidated
damages will be assessed in writing against and paid by the HMO in accordance
with and for failure to meet any aspect of the responsibilities of the Contract
and/or to meet the specific performance standards identified by the HHSC in
Attachment B-5 to the HHSC
Managed Care Contract, “Deliverables/Liquidated Damages Matrix.”
Liquidated damages will be assessed if HHSC determines such failure is the fault
of the HMO (including the HMO’S Subcontractors and/or consultants) and is not
materially caused or contributed to by HHSC or its agents.  If at any
time, HHSC determines the HMO has not met any aspect of the responsibilities of
the Contract and/or the specific performance standards due to mitigating
circumstances, HHSC reserves the right to waive all or part of the liquidated
damages.  All such waivers must be in writing, contain the reasons for
the waiver, and be signed by the appropriate executive of HHSC.

       

      (2) The
liquidated damages prescribed in this Section are not intended to be in the
nature of a penalty, but are intended to be reasonable estimates of HHSC’s
projected financial loss and damage resulting from the HMO’s nonperformance,
including financial loss as a result of project delays.  Accordingly,
in the event HMO fails to perform in accordance with the Contract, HHSC may
assess liquidated damages as provided in this Section.

      


      (3) If
HMO fails to perform any of the Services described in the Contract, HHSC may
assess liquidated damages for each occurrence of a liquidated damages event, to
the extent consistent with HHSC's tailored approach to remedies and Texas
law.

      


      (4) HHSC
may elect to collect liquidated damages:

      


      (A)
Through direct assessment and demand for payment delivered to HMO;
or

      


      (B) By
deduction of amounts assessed as liquidated damages as set-off against payments
then due to HMO or that become due at any time after assessment of the
liquidated damages. HHSC will make deductions until the full amount payable by
the HMO is received by HHSC.

      


      (f)
Equitable Remedies

      


      (1) HMO
acknowledges that, if HMO breaches (or attempts or threatens to breach) its
material obligation under this Contract, HHSC may be irreparably
harmed.  In such a circumstance, HHSC may proceed directly to court to
pursue equitable remedies.

      


      (2) If a
court of competent jurisdiction finds that HMO breached (or attempted or
threatened to breach) any such obligations, HMO agrees that without any
additional findings of irreparable injury or other conditions to injunctive
relief, it will not oppose the entry of an appropriate order compelling
performance by HMO and restraining it from any further breaches (or attempted or
threatened breaches).

      


      (g)
Suspension of Contract

      


      (1) HHSC
may suspend performance of all or any part of the Contract if:

      


      (A) HHSC
determines that HMO has committed a material breach of the
Contract;

      


      (B) HHSC
has reason to believe that HMO has committed, assisted in the commission of
Fraud, Abuse, Waste, malfeasance, misfeasance, or nonfeasance by any party
concerning the Contract;

      


      (C) HHSC
determines that the HMO knew, or should have known of, Fraud, Abuse, Waste,
malfeasance, or nonfeasance by any party concerning the Contract, and the HMO
failed to take appropriate action; or

      


      (D) HHSC
determines that suspension of the Contract in whole or in part is in the best
interests of the State of Texas or the HHSC Programs.

       

      (2) HHSC
will notify HMO in writing of its intention to suspend the Contract in whole or
in part.  Such notice will:

       

      (A) Be
delivered in writing to HMO;

      


      (B)
Include a concise description of the facts or matter leading to HHSC’s decision;
and

      


      (C)
Unless HHSC is suspending the contract for convenience, request a Corrective
Action Plan from HMO or describe actions that HMO may take to avoid the
contemplated suspension of the Contract.

      


      Section 12.03 Termination by
HHSC.

      This
Contract will terminate upon the Expiration Date. In addition, prior to
completion of the Contract Term, all or a part of this Contract may be
terminated for any of the following reasons:

      


      (a)
Termination in the best interest of HHSC. HHSC may terminate the Contract
without cause at any time when, in its sole discretion, HHSC determines that
termination is in the best interests of the State of Texas.  HHSC will
provide reasonable advance written notice of the termination, as it deems
appropriate under the circumstances.  The termination
will be effective on the date specified in HHSC’s notice of
termination.

      


      (b)
Termination for cause. HHSC reserves the right to terminate this

      


      Contract,
in whole or in part, upon the following conditions:

      (1) Assignment for the benefit of
creditors, appointment of receiver, or
inability to pay debts. HHSC may terminate this Contract at any time if
HMO:

      


      (A) Makes
an assignment for the benefit of its creditors;

      


      (B)
Admits in writing its inability to pay its debts generally as they become due;
or

      


      (C)
Consents to the appointment of a receiver, trustee, or liquidator of HMO or of
all or any part of its property.

      


      (2) Failure to adhere to laws, rules,
ordinances, or orders. HHSC may
terminate this Contract if a court of competent jurisdiction finds HMO failed to
adhere to any laws, ordinances, rules, regulations or orders of any public
authority having jurisdiction and such violation prevents or substantially
impairs performance of HMO’s duties
under this Contract.  HHSC will provide at least thirty (30) days
advance written notice of such termination.

       

      (3)
Breach of
confidentiality. HHSC may terminate this Contract at any time if HMO
breaches confidentiality laws with respect
to the Services and Deliverables provided under this Contract.

       

      (4) Failure to maintain adequate
personnel or resources. HHSC may
terminate this Contract if, after providing notice and an opportunity to
correct, HHSC determines that HMO has failed to supply personnel or resources
and such failure results in HMO’s inability to fulfill its duties under this
Contract. HHSC will provide at least thirty (30) days advance written notice of
such termination.

      


      (5) Termination for gifts and
gratuities.

      


      (A) HHSC
may terminate this Contract at any time following the determination by a
competent judicial or quasi-judicial authority and HMO’s exhaustion of all legal
remedies that HMO, its employees, agents or representatives have either offered
or given any thing of value to an officer or employee of HHSC or the State of
Texas in violation of state law.

      


      (B) HMO
must include a similar provision in each of its Subcontracts and shall enforce
this provision against a Subcontractor who has offered or given any thing of
value to any of the persons or entities described in this Section, whether or
not the offer or gift was in HMO’s behalf.

      


      (C)
Termination of a Subcontract by HMO pursuant to this provision will not be a
cause for termination of the Contract unless:

      


      (1) HMO
fails to replace such terminated Subcontractor within a reasonable time;
and

      


      (2) Such
failure constitutes cause, as described in this Subsection
12.03(b).

      


      (D) For
purposes of this Section, a “thing of value” means any item of tangible or
intangible property that has a monetary value of more than $50.00 and includes,
but is not limited to, cash, food, lodging, entertainment, and charitable
contributions.  The term does not include contributions to holders of
public office or candidates for public office that are paid and reported in
accordance with State and/or Federal law.

      


      (6) Termination for non-appropriation of
funds. Notwithstanding
any other provision of this
Contract, if funds for the continued fulfillment
of this Contract by HHSC are at any time
not forthcoming or are insufficient, through
failure of any entity to appropriate funds or
otherwise, then HHSC will have the right to
terminate this Contract at no additional
cost and with no penalty whatsoever
by giving prior written notice documenting
the lack of funding.  HHSC will provide
at least thirty (30) days advance written
notice of such termination.  HHSC will use
reasonable efforts to ensure appropriated
funds are available.

      


      (7) Judgment and
execution.

      


      (A) HHSC
may terminate the Contract at any time if judgment for the payment of money in
excess of $500,000.00 that is not covered by insurance, is rendered by any court
or governmental body against HMO, and HMO does not:

      


      (1)
Discharge the judgment or provide for its discharge in accordance with the terms
of the judgment;

      


      (2)
Procure a stay of execution of the judgment within thirty (30) days from the
date of entry thereof; or

      


      (3)
Perfect an appeal of such judgment and cause the execution of such judgment to
be stayed during the appeal, providing such financial reserves as may be
required under generally accepted accounting principles.

      


      (B) If a
writ or warrant of attachment or any similar process is issued by any court
against all or any material portion of the property of HMO, and such writ or
warrant of attachment or any similar process is not released or bonded within
thirty (30) days after its entry, HHSC may terminate the Contract in accordance
with this Section.

      


      (8) Termination for
insolvency.

      


      (A) HHSC
may terminate the Contract at any time if HMO:

      


      (1) Files
for bankruptcy;

      


      (2)
Becomes or is declared insolvent, or is the subject of any proceedings related
to its liquidation, insolvency, or the appointment of a receiver or similar
officer for it;

      


      (3) Makes
an assignment for the benefit of all or substantially all of its creditors;
or

      


      (4)
Enters into an Contract for the composition, extension, or readjustment of
substantially all of its obligations.

       

      (B) HMO
agrees to pay for all reasonable expenses of HHSC including the cost of counsel,
incident to:

      


      (1) The
enforcement of payment of all obligations of the HMO by any action or
participation in, or in connection with a case or proceeding under Chapters 7,
11, or 13 of the United States Bankruptcy Code, or any successor
statute;

      


      (2) A
case or proceeding involving a receiver or other similar officer duly appointed
to handle the HMO's business; or

      


      (3) A
case or proceeding in a State court initiated by HHSC when previous collection
attempts have been unsuccessful.

      


      (9) Termination for HMO’S material
breach of the Contract.

      


      HHSC will
have the right to terminate the Contract in whole or in part if HHSC determines,
at its sole discretion, that HMO has materially breached the
Contract.  HHSC will provide at least thirty (30) days advance written
notice of such termination.

       

      Section 12.04 Termination by
HMO.

      


      (a)
Failure to pay. HMO may terminate this Contract if HHSC fails to pay the HMO
undisputed charges when due as required under this
Contract.  Retaining premium, recoupment, sanctions, or penalties that
are allowed under this Contract or that result from the HMO’s failure to perform
or the HMO’s default under the terms of this Contract is not cause for
termination.  Termination for failure to pay does not release HHSC
from the obligation to pay undisputed charges for services provided prior to the
termination date. If HHSC fails to pay undisputed charges when due, then the HMO
may submit a notice of intent to terminate for failure to pay in accordance with
the requirements of Subsection
12.04(d). If HHSC pays all undisputed amounts then due within thirty
(30)­days after receiving the notice of intent to terminate, the HMO
cannot proceed with termination of the Contract under this Article.

      


      (b)
Change to HHSC Uniform Managed Care  Manual.

      


      HMO may
terminate this agreement if the Parties are unable to resolve a dispute
concerning a material and substantive change to the HHSC Uniform Managed Care
Manual (a change that materially and substantively alters the HMO’s ability to
fulfill its obligations under the Contract).  HMO must submit a notice
of intent to terminate due to a material and substantive change in the HHSC
Uniform Managed Care Manual no later than thirty (30) days after the effective
date of the policy change.  HHSC will not enforce the policy change
during the period of time

      between
the receipt of the notice of intent to terminate and the effective date of
termination.

      


      (c)
Change to Capitation Rate. If HHSC proposes a modification to the Capitation
Rate that is unacceptable to the HMO, the HMO may terminate the
Contract.  HMO must submit a written notice of intent to terminate due
to a change in the Capitation Rate no later than thirty (30) days after HHSC’s
notice of the proposed change. HHSC will not enforce the rate change during the
period of time
between the receipt of the notice of intent to terminate and the effective date
of termination.

      


      (d)
Notice of intent to terminate.

      


      In order
to terminate the Contract pursuant to this Section, HMO must give HHSC at least
ninety (90) days
written notice of intent to terminate.  The termination date will be
calculated as the last day of the month following ninety (90) days from the date
the notice of intent to terminate is received by HHSC.

      


      Section 12.05 Termination by mutual
agreement.

      This
Contract may be terminated by mutual written agreement of the
Parties.

       

      Section 12.06 Effective date of
termination.

      Except as
otherwise provided in this Contract, termination will be effective as of the
date specified in the notice of termination.

       

      Section 12.07 Extension of termination effective
date.

      The
Parties may extend the effective date of termination one or more times by mutual
written agreement.

       

      Section 12.08 Payment and other provisions
atContract termination.

      


      (a) In
the event of termination pursuant to this Article, HHSC will pay the Capitation
Payment for Services and Deliverables rendered through the effective date of
termination.  All pertinent provisions of the Contract will form the
basis of settlement.

      


      (b) HMO
must provide HHSC all reasonable access to records, facilities, and
documentation as is required to efficiently and expeditiously close out the
Services and Deliverables provided under this Contract.

      


      (c) HMO
must prepare a Turnover Plan, which is acceptable to and approved by
HHSC.  The Turnover Plan will be implemented during the time period
between receipt of notice and the termination date.

      


      Section 12.09 Modification of Contract in the
event of remedies.

       HHSC
may propose a modification of this Contract in response to the imposition of a
remedy under this Article. Any modifications under this Section must be
reasonable, limited to the matters causing the exercise of a remedy, in writing,
and executed
in accordance with Article
8. HMO must negotiate such proposed modifications in good
faith.

       

      Section 12.10 Turnover
assistance.

      Upon
receipt of notice of termination of the Contract by HHSC, HMO will provide any
turnover assistance reasonably necessary to enable HHSC or its designee to
effectively close out the Contract and move the work to another vendor or to
perform the work itself.

       

      Section 12.11 Rights upon termination or
expiration of Contract.

      In the
event that the Contract is terminated for any reason, or upon its expiration,
HHSC will, at HHSC's discretion, retain ownership of any and all associated work
products, Deliverables and/or documentation in whatever form that they
exist.

       

      Section 12.12 HMO responsibility for associated
costs.

      If HHSC
terminates the Contract for Cause, the HMO will be responsible to HHSC for all
reasonable costs incurred by HHSC, the State of Texas, or any of its
administrative agencies to replace the HMO.  These costs include, but
are not limited to, the costs of procuring a substitute vendor and the cost of
any claim or litigation that is reasonably attributable to HMO’s failure to
perform any Service in accordance with the terms of the Contract

       

      Section 12.13 Dispute
resolution.

      


      (a)
General agreement of the Parties. The Parties mutually agree that the interests
of fairness, efficiency, and good business practices are best served when the
Parties employ all reasonable and informal means to resolve any dispute under
this Contract. The Parties express their mutual commitment to using all
reasonable and informal means of
resolving disputes prior to invoking a remedy provided elsewhere in this
Section.

      


      (b) Duty
to negotiate in good faith. Any dispute that in the judgment of any Party to
this Contract may materially or substantially affect the performance of any
Party will be reduced to writing and delivered to the other Party. The Parties
must then negotiate in good faith and use every reasonable effort to resolve
such dispute and the Parties shall not resort to any formal proceedings unless
they have reasonably determined that a negotiated resolution is not possible.
The resolution of any dispute disposed of by Contract between the Parties shall
be reduced to
writing and delivered to all Parties within ten (10) Business Days.

      


      (c)
Claims for breach of Contract.

      


      (1) General requirement. HMO’s
claim for breach of this Contract will be resolved in accordance with the
dispute resolution process established by HHSC in
accordance with Chapter 2260, Texas Government Code.

      


      (2) Negotiation of claims. The
Parties expressly agree that the HMO’s claim for breach of this Contract that
the Parties cannot resolve in the ordinary course of business or through the use
of all reasonable and informal means will be submitted to the negotiation
process provided in Chapter 2260, Subchapter B, Texas Government
Code.

      


      (A) To
initiate the process, HMO must submit written notice to HHSC that specifically
states that HMO invokes the provisions of Chapter 2260, Subchapter B, Texas
Government Code.  The notice must comply with the requirements of
Title 1, Chapter 392, Subchapter B of the Texas Administrative
Code.

      


      (B) The
Parties expressly agree that the HMO’s compliance with Chapter 2260, Subchapter
B, Texas Government Code, will be a condition precedent to the filing of a
contested case proceeding under Chapter 2260, Subchapter C, of the Texas
Government Code.

      


      (3) Contested case proceedings.
The contested case process provided in Chapter 2260, Subchapter C, Texas
Government Code, will be HMO’s sole and exclusive process for seeking a remedy
for any and all alleged breaches of contract by HHSC if the Parties are unable
to resolve their disputes under Subsection (c)(2) of this Section.

      


      The
Parties expressly agree that compliance with the contested case process provided
in Chapter 2260, Subchapter C, Texas Government Code, will be a condition
precedent to seeking consent to sue from the Texas Legislature under Chapter
107, Civil Practices & Remedies Code. Neither the execution of this Contract
by HHSC nor any other conduct of any representative of HHSC relating to this
Contract shall be considered a waiver of HHSC’s sovereign immunity to
suit.

      


      (4) HHSC rules. The submission,
processing and resolution of HMO’s claim is governed by the rules adopted by
HHSC pursuant to Chapter 2260, Texas Government Code, found at Title 1, Chapter
392, Subchapter B of the Texas Administrative Code.

      


      (5) HMO’s duty to perform.
Neither the occurrence of an event constituting an alleged breach of contract
nor the pending status of any claim for breach of contract is grounds for the
suspension of performance, in whole or in part, by HMO of any duty or obligation
with respect to the performance of this Contract. Any changes to the Contract as
a result of a dispute resolution will be implemented in accordance with Article 8 (“Amendments and
Modifications”).

      


      Section 12.14 Liability of
HMO.

      


      (a) HMO
bears all risk of loss or damage to HHSC or the State due to:

      


      (1)
Defects in Services or Deliverables;

      


      (2)
Unfitness or obsolescence of Services or Deliverables; or

      


      (3) The
negligence or intentional misconduct of HMO or its employees, agents,
Subcontractors, or representatives.

      


      (b) HMO
must, at the HMO’s own expense, defend with counsel approved by HHSC, indemnify,
and hold harmless HHSC and State employees, officers, directors, contractors and
agents from and against any losses, liabilities, damages, penalties, costs,
fees, including without limitation reasonable attorneys' fees, and expenses from
any claim or action for property damage, bodily injury or death, to the extent
caused by or arising from the negligence or intentional misconduct of the HMO
and its employees, officers, agents, or Subcontractors.  HHSC will not
unreasonably withhold approval of counsel selected by HMO.

      


      (c) HMO
will not be liable to HHSC for any loss, damages or liabilities attributable to
or arising from the failure of HHSC or any state agency to perform a service or
activity in connection with this Contract.

      


      Article
13. Assurances & Certifications

      Section 13.01 Proposal
certifications.

      HMO
acknowledges its continuing obligation to comply with the requirements of the
following certifications contained in its Proposal, and will immediately notify
HHSC of any changes in circumstances affecting these
certifications:

      


      (1)
Federal lobbying;

      


      (2)
Debarment and suspension;

      


      (3) Child
support; and

      


      (4)
Nondisclosure statement.

      


      Section 13.02 Conflicts of
interest.

      


      (a)
Representation. HMO agrees to comply with applicable state and federal laws,
rules, and regulations regarding conflicts of interest in the performance of its
duties under this Contract. HMO warrants that it has no interest and will not
acquire any direct or indirect interest that

      


      would
conflict in any manner or degree with its performance under this
Contract.

      


      (b)
General duty regarding conflicts of interest. HMO will establish safeguards to
prohibit employees from using their positions for a purpose that constitutes or
presents the appearance of personal
or organizational conflict of interest, or personal gain. HMO will operate with
complete independence
and objectivity without actual, potential or apparent conflict of interest with
respect to the activities conducted under this Contract with the State of
Texas.

       

      Section 13.03 Organizational conflicts of
interest.

      (a)
Definition. An organizational conflict of interest is a set of facts or
circumstances, a relationship, or other situation under which a HMO, or a
Subcontractor has past, present, or currently planned personal or financial
activities or interests that either directly or indirectly:

      


      (1)
Impairs or diminishes the HMO’s, or Subcontractor’s ability to render impartial
or objective assistance or advice to HHSC; or

      


      (2)
Provides the HMO or Subcontractor an unfair competitive advantage in future HHSC
procurements (excluding the award of this Contract).

      


      


      (b)
Warranty. Except as otherwise disclosed and approved by HHSC prior to the
Effective Date of the Contract, HMO warrants that, as of the Effective Date and
to the best of its knowledge and belief, there are no relevant facts or
circumstances that could give rise to an organizational conflict of interest
affecting this Contract. HMO affirms that it has neither given, nor intends to
give, at any time hereafter, any economic opportunity, future employment, gift,
loan, gratuity, special discount, trip, favor, or service to a public servant or
any employee or representative of same, at any time during the procurement
process or in connection
with the procurement process except as allowed under relevant state and federal
law.

      


      (c)
Continuing duty to disclose.

      


      (1) HMO
agrees that, if after the Effective Date, HMO discovers or is made aware of an
organizational conflict of interest, HMO will immediately and fully disclose
such interest in writing to the HHSC project manager.  In addition,
HMO must promptly disclose any relationship that might be perceived or
represented as a conflict after its discovery by HMO or by HHSC as a potential
conflict.  HHSC reserves the right to make a final determination
regarding the existence of conflicts of interest, and HMO agrees to abide by
HHSC’s decision.

      


      (2) The
disclosure will include a description of the action(s) that HMO has taken or
proposes to take to avoid or mitigate such conflicts.

      


      (d)
Remedy. If HHSC determines that an organizational conflict of interest exists,
HHSC may, at its discretion, terminate the Contract pursuant to Subsection 12.03(b)(9). If HHSC
determines that HMO was aware of an organizational conflict of interest before
the award
of this Contract and did not disclose the conflict to the contracting officer,
such nondisclosure will be considered a material breach of the
Contract.  Furthermore, such breach may be submitted to the Office of
the Attorney General, Texas Ethics Commission, or appropriate State or Federal
law enforcement officials for further action.

       

      (e) Flow
down obligation. HMO must include the provisions of this Section in all
Subcontracts for work to be performed similar to the service provided by HMO,
and the terms

      "Contract,"
"HMO," and "project manager" modified appropriately to preserve the State's
rights.

       

      Section 13.04 HHSC personnel recruitment
prohibition.

      HMO has
not retained or promised to retain any person or company, or utilized or
promised to utilize a consultant that participated in HHSC’s development of
specific criteria of the RFP or who participated in the selection of the HMO for
this Contract. Unless
authorized in writing by HHSC, HMO will not recruit or employ any HHSC
professional or technical personnel who have worked on projects relating to the
subject matter of this Contract, or who have had any influence on decisions
affecting the subject matter of this Contract, for two (2) years following the
completion of this Contract.

       

      Section 13.05 Anti-kickback
provision.

      HMO
certifies that it will comply with the Anti-Kickback Act of 1986, 41 U.S.C.
§51-58 and Federal Acquisition Regulation 52.203-7, to the extent
applicable.

       

      Section 13.06 Debt or back taxes owed to State of
Texas.

      In
accordance with Section 403.055 of the Texas Government Code, HMO agrees that
any payments due to HMO under the Contract will be first applied toward any debt
and/or back taxes HMO owes State of Texas.  HMO further agrees that
payments will be so applied until such debts and back taxes are paid in
full.

       

      Section 13.07 Certification regarding status of
license, certificate, or permit.

      Article
IX, Section 163 of the General Appropriations Act for the 1998/1999 state fiscal
biennium prohibits an agency that receives an appropriation under either Article
II or V of the General Appropriations Act from awarding a contract with the
owner, operator, or administrator of a facility that has had a license,
certificate, or permit revoked by another Article II or V agency. HMO certifies
it is not ineligible for an award under this provision.

       

      Section 13.08 Outstanding debts and
judgments.

      HMO
certifies that it is not presently indebted to the State of Texas, and that HMO
is not subject to an

      outstanding
judgment in a suit by State of Texas against HMO for collection of the balance.
For purposes of this Section, an indebtedness is any amount sum of money that is
due and owing to the State of Texas and is not currently under dispute. A false
statement regarding HMO’s status will be treated as a material breach of this
Contract and may be grounds for termination at the option of HHSC.

       

      Article
14. Representations & Warranties

      Section 14.01 Authorization.

      


       (a)
The execution, delivery and performance of this Contract has been duly
authorized by HMO and no additional approval, authorization or consent of any
governmental or regulatory agency is required to be obtained in order for HMO to
enter into this Contract and perform its obligations under this
Contract.

      


      (b) HMO
has obtained all licenses, certifications, permits, and authorizations necessary
to perform the Services under this Contract and currently is in good standing
with all regulatory agencies that regulate any or all aspects of HMO’s
performance of this Contract. HMO will maintain all required certifications,
licenses, permits, and authorizations during the term of this
Contract.

      


      Section 14.02 Ability to
perform.

       HMO
warrants that it has the financial resources to fund the capital expenditures
required under the Contract without advances by HHSC or assignment of any
payments by HHSC to a financing source.

       

      Section 14.03 Minimum Net
Worth.

      The HMO
has, and will maintain throughout the life of this Contract, minimum net worth
to the greater of (a) $1,500,000; (b) an amount equal to the sum of twenty-five
dollars ($25) times the number of all enrollees including Members; or (c) an
amount that complies with standards adopted by TDI. Minimum net worth means the
excess total admitted assets over total liabilities, excluding liability for
subordinated debt issued in compliance with Chapter 843 of the Texas Insurance
Code.

       

      Section 14.04 Insurer
solvency.

      


      (a) The
HMO must be and remain in full compliance with all applicable state and federal
solvency requirements for basic-service health maintenance organizations,
including but not limited to, all reserve requirements, net worth standards,
debt-to-equity ratios, or other debt limitations. In the event the HMO fails to
maintain such compliance, HHSC, without limiting any other rights it may have by
law or under the Contract, may terminate the Contract.

      


      (b) If
the HMO becomes aware of any impending changes to its financial or business
structure that could adversely impact its compliance with the

      


      requirements
of the Contract or its ability to pay its debts as they come due, the HMO must
notify HHSC immediately in writing.

      (c) The
HMO must have a plan and take appropriate measures to ensure adequate provision
against the risk of insolvency as required by TDI. Such provision must be
adequate to provide for the following in the event of insolvency:

      


      (1)
continuation of Covered Services, until the time of discharge, to Members who
are confined on the date of insolvency in a hospital or other inpatient
facility;

      


      (2)
payments to unaffiliated health care providers and affiliated healthcare
providers whose Contracts do not contain Member “hold harmless” clauses
acceptable to the TDI;

      


      (3)
continuation of Covered Services for the duration of the Contract Period for
which a capitation has been paid for a Member;

      


      (4)
provision against the risk of insolvency must be made by establishing adequate
reserves, insurance or other guarantees in full compliance with all financial
requirements of TDI and the Contract.

      


       Should
TDI determine that there is an immediate risk of insolvency or the HMO is unable
to provide Covered Services to its Members, HHSC, without limiting any other
rights it may have by law, or under the Contract, may terminate the
Contract.

       

      Section 14.05 Workmanship and
performance.

      


      (a) All
Services and Deliverables provided under this Contract will be provided in a
manner consistent with the standards of quality and integrity as outlined in the
Contract.

      


      (b) All
Services and Deliverables must meet or exceed the required levels of performance
specified in or pursuant to this Contract.

      


      (c) HMO
will perform the Services and provide the Deliverables in a workmanlike manner,
in accordance with best practices and high professional standards used in
well-managed operations performing services similar to the services described in
this Contract.

      


      Section 14.06 Warranty of
deliverables.

      HMO
warrants that Deliverables developed and delivered under this Contract will meet
in all material respects the specifications as described in the Contract during
the period following its acceptance by HHSC, through the term of the Contract,
including any subsequently negotiated by HMO and HHSC. HMO will promptly repair
or replace any such Deliverables not in compliance with this warranty at no
charge to HHSC.

       

      Section 14.07 Compliance with
Contract.

      HMO will
not take any action substantially or materially inconsistent with any of the
terms and conditions set forth in this Contract without the express written
approval of HHSC.

       

      Section 14.08 Technology
Access

      


      (a) HMO
expressly acknowledges that State funds may not be expended in connection with
the purchase of an automated information system unless that system meets certain
statutory requirements relating to accessibility by persons with visual
impairments.  Accordingly, HMO represents and warrants to HHSC that
this technology is capable, either by virtue of features included within the
technology or because it is readily adaptable by use with other technology,
of:

      


      (1)
Providing equivalent access for effective use by both visual and non-visual
means;

      


      (2)
Presenting information, including prompts used for interactive communications,
in formats intended for non-visual use; and

      


      (3) Being
integrated into networks for obtaining, retrieving, and disseminating
information used by individuals who are not blind or visually
impaired.

      


      (b) For
purposes of this Section, the phrase "equivalent access" means a substantially
similar ability to communicate with or make use of the technology, either
directly by features incorporated within the technology or by other reasonable
means such as assistive devices or services that would constitute reasonable
accommodations under the Americans with Disabilities Act or similar State or
Federal laws.  Examples of methods by which equivalent access may be
provided include, but are not limited to, keyboard alternatives to mouse
commands and other means of navigating graphical displays, and customizable
display appearance.

      


      (c) In
addition, all technological solutions offered by the HMO must comply with the
requirements of  Texas Government Code §531.0162.  This
includes, but is not limited to providing technological solutions that meet
federal accessibility standards for persons with disabilities, as
applicable.

      


      Article
15. Intellectual Property

      Section 15.01 Infringement and
misappropriation.

      


      (a) HMO
warrants that all Deliverables provided by HMO will not infringe or
misappropriate any right of, and will be free of any claim of, any third person
or entity based on copyright, patent, trade secret, or other intellectual
property rights.

      


      (b) HMO
will, at its expense, defend with counsel approved by HHSC, indemnify, and hold
harmless HHSC, its employees, officers, directors, contractors, and
agents from and against any losses, liabilities, damages, penalties, costs,
fees, including without limitation reasonable attorneys’ fees and expenses, from
any claim or action against HHSC that is based on a claim of breach of the
warranty set forth in the preceding paragraph.  HHSC will promptly
notify HMO in writing of the claim, provide HMO a copy of all information
received by HHSC with respect to the claim, and cooperate with HMO in defending
or settling the claim.  HHSC will not unreasonably withhold, delay or
condition approval of counsel selected by the HMO.

       

      (c) In
case the Deliverables, or any one or part thereof, is in such action held to
constitute an infringement or misappropriation, or the use thereof is enjoined
or restricted or if a proceeding appears to HMO to be likely to be brought, HMO
will, at its own expense, either:

      


      (1)
Procure for HHSC the right to continue using the Deliverables; or

      


      (2)
Modify or replace the Deliverables to comply with the Specifications and to not
violate any intellectual property rights.

      


      If
neither of the alternatives set forth in (1) or (2) above are available to the
HMO on commercially reasonable terms, HMO may require that HHSC return the
allegedly infringing Deliverable(s) in which case HMO will refund all amounts
paid for all such Deliverables.

       

      Section 15.02 Exceptions.

      HMO is
not responsible for any claimed breaches of the warranties set forth in Section
15.01 to the extent caused by:

      


      (a)
Modifications made to the item in question by anyone other than HMO or its
Subcontractors, or modifications made by HHSC or its contractors working at
HMO’s direction or in accordance with the specifications; or

      


      (b) The
combination, operation, or use of the item with other items if HMO did not
supply or approve for use with the item; or

      


      (c)
HHSC’s failure to use any new or corrected versions of the item made available
by HMO.

      


      Section 15.03 Ownership and
Licenses

      


      (a)
Definitions.

      


      For
purposes of this Section 15.03, the following terms have the meanings set forth
below:

      


      (1)
“Custom
Software” means any software developed by the HMO: for HHSC; in
connection with the Contract; and with funds received from HHSC.  The
term does not include HMO Proprietary Software or Third Party
Software.

      


      (2)
“HMO
Proprietary Software” means software:

      


      (i)
developed by the HMO prior to the Effective Date of the Contract, or (ii)
software developed by the HMO after the
Effective Date of the Contract that is not developed: for HHSC; in connection
with the Contract; and with funds received from HHSC.

      


      (3)
“Third
Party Software” means software that is: developed for general commercial
use; available to the public; or not developed for HHSC.  Third Party
Software includes without limitation: commercial off-the-shelf software;
operating system software; and application software, tools, and
utilities.

      


      (b)
Deliverables. The Parties agree that any Deliverable, including without
limitation the Custom Software, will be the exclusive property of
HHSC.

      


      (c)
Ownership rights.

      


      (1) HHSC
will own all right, title, and interest in and to its Confidential Information
and the Deliverables provided by the HMO, including without limitation the
Custom Software and associated documentation.  For purposes of this
Section 15.03, the Deliverables will not include HMO Proprietary Software or
Third Party Software.  HMO will take all actions necessary and
transfer ownership of the Deliverables to HHSC, including, without limitation,
the Custom Software and associated documentation prior to Contract
termination.

      


      (2) HMO
will furnish such Deliverables, upon request of HHSC, in accordance with
applicable State law. All Deliverables, in whole and in part, will be deemed
works made for hire of HHSC for all purposes of copyright law, and copyright
will belong solely to HHSC. To the extent that any such Deliverable does not
qualify as a work for hire under applicable law, and to the extent that the
Deliverable includes materials subject to copyright, patent, trade secret, or
other proprietary right protection, HMO agrees to assign, and hereby assigns,
all right, title, and interest in and to Deliverables, including without
limitation all copyrights, inventions, patents, trade secrets, and other
proprietary rights therein (including renewals thereof) to HHSC.

      


      (3) HMO
will, at the expense of HHSC, assist HHSC or its nominees to obtain copyrights,
trademarks, or patents for all such Deliverables in the United States and any
other countries.  HMO agrees to execute all papers and to give all
facts known to it necessary to secure United States or foreign country
copyrights and patents, and to transfer or cause to transfer to HHSC all the
right, title, and interest in and to such Deliverables. HMO also agrees not to
assert any moral rights under applicable copyright law with regard to such
Deliverables.

      


      (d)
License Rights HHSC will have a royalty-free and non-exclusive license to access
the HMO Proprietary Software and associated
documentation during the term of the Contract. HHSC will also have ownership
and

      unlimited
rights to use, disclose, duplicate, or publish all information and data
developed, derived, documented, or furnished by HMO under or resulting from the
Contract.  Such data will include all results, technical information,
and materials developed for and/or obtained by HHSC from HMO in the performance
of the Services hereunder, including but not limited to all reports, surveys,
plans, charts, recordings (video and/or sound), pictures, drawings, analyses,
graphic representations, computer printouts, notes and memoranda, and documents
whether finished or unfinished, which result from or are prepared in connection
with the Services performed as a result of the Contract.

      


      (e)
Proprietary Notices HMO will reproduce and include HHSC’s copyright and other
proprietary notices and product identifications
provided by HMO on such copies, in whole or in part, or on any form of the
Deliverables.

      


      (f) State
and Federal Governments In accordance with 45 C.F.R. §95.617, all appropriate
State and Federal agencies will have a royalty-free, nonexclusive, and
irrevocable license to reproduce, publish, translate, or otherwise use, and to
authorize others to use for Federal Government purposes all materials, the
Custom Software and modifications thereof, and associated documentation
designed, developed, or installed with federal financial participation under the
Contract, including but not limited to those materials covered by copyright, all
software
source and object code, instructions, files, and documentation.

       

      Article
16. Liability

      Section 16.01 Property damage.

      


      (a) HMO
will protect HHSC’s real and personal property from damage arising from HMO’s,
its agent’s, employees’ and Subcontractors’ performance of the Contract, and HMO
will be responsible for any loss, destruction, or damage to  HHSC’s
property that results from or is caused by HMO’s, its agents’, employees’ or
Subcontractors’ negligent or wrongful acts or omissions.  Upon the
loss of, destruction of, or damage to any property of HHSC, HMO will notify the
HHSC Project Manager thereof and, subject to direction from the Project Manager
or her or his designee, will take all reasonable steps to protect that property
from further damage.

      


      (b) HMO
agrees to observe and encourage its employees and agents to observe safety
measures and proper operating procedures at HHSC sites at all
times.

      


      (c) HMO
will distribute a policy statement to all of its employees and agents that
directs the employee or agent to promptly report to HHSC or to HMO any special
defect or unsafe condition encountered while on HHSC premises.  HMO
will promptly report to HHSC any
special defect or an unsafe condition it encounters or otherwise learns
about.

       

      Section 16.02 Risk of Loss.

      During
the period Deliverables are in transit and in possession of HMO, its carriers or
HHSC prior to being accepted by HHSC, HMO will bear the risk of loss or damage
thereto, unless such loss or damage is caused by the negligence or intentional
misconduct of HHSC. After HHSC accepts a Deliverable, the risk of loss or damage
to the Deliverable will be borne by HHSC, except loss or damage attributable to
the negligence or intentional misconduct of HMO’s agents, employees or
Subcontractors.

       

      Section 16.03 Limitation of HHSC’s
Liability.

      HHSC WILL
NOT BE LIABLE FOR ANY INCIDENTAL, INDIRECT, SPECIAL, OR CONSEQUENTIAL DAMAGES
UNDER CONTRACT, TORT (INCLUDING NEGLIGENCE), OR OTHER LEGAL
THEORY.  THIS WILL APPLY REGARDLESS OF THE CAUSE OF ACTION AND EVEN IF
HHSC HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.

      HHSC’S
LIABILITY TO HMO UNDER THE CONTRACT WILL NOT EXCEED THE TOTAL CHARGES TO BE PAID
BY HHSC TO HMO UNDER THE CONTRACT, INCLUDING CHANGE ORDER PRICES AGREED TO BY
THE PARTIES OR OTHERWISE ADJUDICATED.

      HMO’s
remedies are governed by the provisions in Article 12.

       

      Article
17. Insurance & Bonding

      Section 17.01 Insurance
Coverage.

      (a)
Statutory and General Coverage

      HMO will
maintain the following insurance coverage.

      


      (1)
Standard Worker's Compensation Insurance coverage;

      


      (2)
Automobile Liability;

      


      (3)
Comprehensive Liability Insurance including Bodily Injury coverage of
$100,000.00 per each occurrence and Property Damage Coverage of $25,000.00 per
each occurrence; and

      


      (4)
General Liability Insurance of at least $1,000,000.00 per occurrence and
$5,000,000.00 in the aggregate.

      


      If HMO’s
current Comprehensive General Liability insurance coverage does not meet the
above stated requirements, HMO will obtain excess liability insurance to
compensate for the difference in the coverage amounts.

      


      (b)
Professional Liability Coverage.

      


      (1) HMO
must maintain, or cause its Network Providers to maintain, Professional
Liability Insurance for each Network Provider of $100,000.00 per occurrence and
$300,000.00 in the aggregate, or the limits required by the hospital at which
the Network Provider has admitting privileges.

      


      (2) HMO
must maintain an Umbrella Professional Liability Insurance Policy for the
greater of $3,000,000.00 or an amount (rounded to the nearest $100,000.00) that
represents the number of Members enrolled in the HMO in the first month of the
applicable State Fiscal Year multiplied by $150.00, not to exceed
$10,000,000.00.

      


      (c)
General Requirements for All Insurance Coverage

      


      (1)
Except as provided herein, all exceptions to the Contract’s insurance
requirements must be approved in writing by HHSC. HHSC’s written approval is not
required in the following situations:

      


      (A) An
HMO or a Network Provider is not required to obtain the insurance coverage
described in Section 17.01 if the HMO or Network Provider qualifies as a state
governmental unit or municipality under the Texas Tort Claims Act, and is
required to comply with, and subject to the provisions of, the Texas Tort Claims
Act.

      


      (B) An
HMO may waive the Professional Liability Insurance requirement described in
Section 17.01(b)(1) for a Network Provider of Community-based Long Term Care
Services.  An HMO may not waive this requirement if the Network
Provider provides other Covered Services in addition to Community-based Long
Term Care Services, or if a Texas licensing entity requires the Network Provider
to carry such Professional Liability coverage.   An HMO that
waives the Professional Liability Insurance requirement for a Network Provider
pursuant to this provision is not required to obtain such coverage on behalf of
the Network Provider.

      


      (2) HMO
or the Network Provider is responsible for any and all deductibles stated in the
insurance policies.

      


      (3)Insurance
coverage must be issued by insurance companies authorized to conduct business in
the State of Texas.

      


      (4)
Insurance coverage must name HHSC as an additional insured with the following
exceptions: Standard Workers’ Compensation Insurance maintained by the HMO,
and

      


      Professional
Liability Insurance maintained by Network Providers.

      


      (5)
Insurance coverage kept by the HMO must be maintained throughout the Term of the
Contract, and until HHSC’s final acceptance of all Services and Deliverables.
Failure to maintain such insurance coverage will constitute a material breach of
this Contract.

      


      (6) With
the exception of Professional Liability Insurance maintained by Network
Providers, the insurance policies described in this Section must have extended
reporting periods of two years.  When policies are renewed or
replaced, the policy retroactive date must coincide with, or precede, the
Contract Effective Date.

      


      (7) With
the exception of Professional Liability Insurance maintained by Network
Providers, the insurance policies described in this Section must provide that
prior written notice to be given to HHSC at least thirty (30) calendar days
before coverage is substantially changed, canceled, or
non-renewed.  HMO must submit a new coverage binder to HHSC to ensure
no break in coverage.

      


      (8) The
Parties expressly understand and agree that any insurance coverages and limits
furnished by HMO will in no way expand or limit HMO’s liabilities and
responsibilities specified within the Contract documents or by applicable
law.

      


      (9) HMO
expressly understands and agrees that any insurance maintained by HHSC will
apply in excess of and not contribute to insurance provided by HMO under the
Contract.

      


      (10) If
HMO, or its Network Providers, desire additional coverage, higher limits of
liability, or other modifications for its own protection, HMO or its Network
Providers will be responsible for the acquisition and cost of such additional
protection.  Such additional protection will not be an Allowable
Expense under this Contract.

      


      (d) Proof
of Insurance Coverage

       

      (1)
Except as provided in Section 17.01(d)(2), the HMO must furnish the HHSC Project
Manager original Certificates of Insurance evidencing the required insurance
coverage on or before the Effective Date of the Contract.  If
insurance coverage is renewed during the Term of the Contract, the HMO must
furnish the HHSC Project Manager renewal certificates of insurance, or such
similar evidence, within five (5) Business Days of renewal.  The
failure of HHSC to obtain such evidence from HMO will not be deemed to be a
waiver by HHSC and HMO will remain under continuing obligation to maintain and
provide proof of insurance coverage.

       

      (2) The
HMO is not required to furnish the HHSC Project Manager proof of Professional
Liability Insurance maintained by Network Providers on or before the Effective
Date of the Contract, but must provide such information upon HHSC’s request
during the Term of the Contract.

       

      Section 17.02 Performance
Bond.

      


      (a)
Beginning on the Operational Start Date of the Contract, and each year
thereafter, the HMO must obtain a performance bond with a one (1) year
term.  The performance bond must continue to be in effect for one (1)
year following the expiration of the one (1) year term.  HMO must
obtain and maintain the annual performance bonds in the form prescribed by HHSC
and approved by TDI, naming HHSC as Obligee, securing HMO’s faithful performance
of the terms and conditions of this Contract. The annual performance bonds must
comply with Chapter 843 of the Texas Insurance Code and 28 T.A.C.
§11.1805.  The annual performance bond(s) must be issued in the amount
of $100,000.00 for each applicable HMO Program within each Service Area that the
HMO covers under this Contract. All performance bonds must be issued by a surety
licensed by TDI, and specify cash payment as the sole remedy.  HMO
must deliver the initial performance bond to HHSC prior to the Operational Start
Date of the Contract, and each renewal performance bond prior to the first day
of the State Fiscal Year.

      


      (b) Since
the CHIP Perinatal Program is a sub­program of the CHIP Program, neither a
separate performance bond for the CHIP Perinatal Program nor a combined
performance bond for the CHIP and CHIP Perinatal Programs is
required.  The same bond that the HMO obtains for its CHIP Program
within a particular Service Area also will cover the HMO’s CHIP Perinatal
Program, if applicable, in that same Service Area.

      


      Section 17.03 TDI Fidelity
Bond

      The HMO
will secure and maintain throughout the life of the Contract a fidelity bond in
compliance with Chapter 843 of the Texas Insurance Code and 28 T.A.C.
§11.1805.  The HMO must promptly provide HHSC with copies of the bond
and any amendments or renewals thereto.

       

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      Subject: Attachment B-1 - HHSC
Joint Mediciad/CHIP HMO RFP, Section 6

      
        	
                DOCUMENT
      HISTORY LOG

              
	
                STATUS1

              	
                DOCUMENT

                REVISION2

              	
                EFFECTIVE

                DATE

              	
                DESCRIPTION3

              
	
                Baseline

              	
                n/a

              	 
      	
                Initial
      version Attachment B-1, Section 6

              
	
                Revision

              	
                1.1

              	
                June
      30, 2006

              	
                Revised
      version of the Attachment B-1, Section 6, that includes provisions
      applicable to MCOs participating in the STAR+PLUS Program.

                Section
      6.3.2.1, Experience Rebate Reward, is modified to delete references to the
      selected performance indicators and the Quality Challenge
      Pool.

                Section
      6.3.2.2, Performance-Based Capitation Rate, is modified to include
      STAR+PLUS and to add Additional STAR+PLUS Performance Indicators. Section
      6.3.2.3, Quality Challenge Award, is modified to include STAR+PLUS.
      Section 6.3.2.5, STAR+PLUS Hospital Inpatient Performance Based
      Capitation Rate: Hospital Inpatient Stay Cost Incentives and
      Disincentives, is added.

                Section
      6.3.2.5.1, STAR+PLUS Hospital Inpatient Disincentive – Administrative
      Fee at Risk, is added.

                Section
      6.3.2.5.2, STAR+PLUS Hospital Inpatient Incentive – Shared Savings
      Award, is added.

              
	
                Revision

              	
                1.2

              	
                September
      1, 2006

              	
                Revised
      version of the Attachment B-1, Section 6, that includes provisions
      applicable to MCOs participating in the STAR and CHIP
      Programs.

                Section
      6.3.2.2, Performance-Based Capitation Rate, modifies the standard
      performance indicator for the Behavioral Health Hotline to change the
      maximum abandonment rate from 5% to 7% (except in the Dallas Core Service
      Area).

                Section
      6.3.2.3, Quality Challenge Award, is modified to reflect the new start
      date for the Quality Challenge Award, which will not be implemented until
      State Fiscal Year 2008.

              
	
                Revision

              	
                1.3

              	
                September
      1, 2006

                 

              	
                Revised
      version of the Attachment B-1, Section 6, that includes provisions
      applicable to MCOs participating in the CHIP Perinatal
      Program.

                Section
      6.3.2.1 modified to clarify that the Experience Rebate Reward incentive
      may apply to the CHIP Perinatal Program at a later date.

                Section
      6.3.2.2 modified to clarify that the Performance-based Capitation Rate
      will not apply for the CHIP Perinatal Program in SFY
  2007.

              
	
                Revision

              	
                1.4

              	
                September
      1, 2006

              	
                Contract
      amendment did not revise Attachment B-1 Section 6 – Premium Payment,
      Incentives, and Disincentives

              
	
                Revision

              	
                1.5

              	
                January
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-1 Section 6 – Premium Payment,
      Incentives, and Disincentives

              
	
                Revision

              	
                1.6

              	
                February
      1, 2007

              	
                Revised
      version of the Attachment B-1, Section 6, that includes provisions
      applicable to MCOs participating in the STAR+PLUS Program.

                Section
      6.3.2.5 is modified to clarify the months included in Rate Period
      1.

              
	
                Revision

              	
                1.7

              	
                July
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-1 Section 6 – Premium Payment,
      Incentives, and Disincentives

              
	
                Revision

              	
                1.8

              	
                September
      1, 2007

              	
                Section
      6.3 is modified as a result of SB 10 legislation and the Frew litigation
      to prohibit HMOs from passing down financial disincentives or sanctions to
      providers.

                Section
      6.3.1.1 is modified as a result of the Frew litigation to allow HHSC to
      post information regarding poor HMO performance on the HHSC
      website.

                Section
      6.3.2.2 is modified to clarify language regarding the Performance
      Indicator Dashboard and the reapportionment of points for the 1% at-risk
      premium.

                Section
      6.3.2.3 is modified as a result of the Frew litigation to clarify
      language.

                New
      Section 6.3.2.6 is added as a result of the Frew litigation to clarify
      requirements for additional incentives and
  disincentives.

              
	
                Revision

              	
                1.9

              	
                December
      1, 2007

              	
                Section 6.3.2.3 is modified to
      outline the calculation methodology for STAR, STAR+PLUS, and
      CHIP.

              
	Revision   	1.10	 March
      1, 2008	Contract
      amendment did not revise Attachment B-1 Section 6 - Premium Payment,
      Incentives, and Disincentives.
	Revision     	1.11	 September
      1, 2008	Contract
      amendment did not revise Attachment B-1 Section 6 - Premium Payment,
      Incentives, and Disincentives.
	
                1  Status
      should be represented as “Baseline” for initial issuances, “Revision” for
      changes to the Baseline version, and “Cancellation” for withdrawn
      versions

                2 
       Revisions should be numbered in accordance according to the
      version of the issuance and sequential numbering of the revision—e.g.,
      “1.2” refers to the first version of the document and the second
      revision.

                3  Brief
      description of the changes to the document made in the
      revision.

              


      

      
      

      


      


      


      
        	
                6.
      Premium Payment, Incentives, and
Disincentives

              


      

      This
section documents how the Capitation Rates are developed and describes
performance incentives and disincentives related to HHSC’s value-based
purchasing approach.  For further information, HMOs should refer to
the HHSC Uniform Managed Care
Contract Terms and Conditions.

       

      Under the
HMO Contracts, health care coverage for Members will be provided on a fully
insured basis. The HMO must provide the Services and Deliverables, including
Covered Services to enrolled Members in order for monthly Capitation Payments to
be paid by HHSC. Attachment B-1, Section 8 includes the HMO’s
financial responsibilities regarding out-of-network Emergency Services and
Medically Necessary Covered Services not available through Network
Providers.

      


      
        	
                6.1
      Capitation Rate Development

              


      

      


      Refer to
Attachment A, HHSC Uniform Managed Care Contract
Terms & Conditions, Article 10, “Terms & Conditions of Payment,”
for information concerning Capitation Rate development.

      


      
        	
                6.2
      Financial Payment Structure and
Provisions

              


      

      


      HHSC will
pay the HMO monthly Capitation Payments based on the number of eligible and
enrolled Members. HHSC will calculate the monthly Capitation Payments by
multiplying the number of Member Months times the applicable monthly Capitation
Rate by Member Rate Cell. The HMO must provide the Services and Deliverables,
including Covered Services to Members, described in the Contract for monthly
Capitation Payments to be paid by HHSC.

       

      The HMO
must understand and expressly assume the risks associated with the performance
of the duties and responsibilities under the Contract, including the failure,
termination, or suspension of funding to HHSC, delays or denials of required
approvals, cost of claims incorrectly paid by the HMO, and cost overruns not
reasonably attributable to HHSC. The HMO must further agree that no other
charges for tasks, functions, or activities that are incidental or ancillary to
the delivery of the Services and Deliverables will be sought from HHSC or any
other state agency, nor will the failure of HHSC or any other party to pay for
such incidental or ancillary services entitle the HMO to withhold Services or
Deliverables due under the Contract.

      


      
        	
                6.2.1
      Capitation Payments

              


      

      


      The HMO
must refer to the HHSC Uniform
Managed Care Contract Terms & Conditions for information and Contract
requirements on the:

       

      1) Time and Manner of
Payment,

      2) Adjustments to Capitation
Payments,

      3) Delivery Supplemental Payment,
and

      4) Experience Rebate.


      
        	
                6.3
      Performance Incentives and
Disincentives

              


      

      
      

       

      HHSC
introduces several financial and non-financial performance incentives and
disincentives through this Contract. These incentives and disincentives are
subject to change by HHSC over the course of the Contract Period. The
methodologies required to implement these strategies will be refined by HHSC
after collaboration with contracting HMOs through a new incentives workgroup to
be established by HHSC.  HMO is prohibited from passing down financial
disincentives and/or sanctions imposed on the HMO to health care providers,
except on an individual basis and related to the individual provider’s
inadequate performance.

      


      
        	
                6.3.1
      Non-financial Incentives

              


      

      


      
        	
                6.3.1.1
      Performance Profiling

              


      

      


      HHSC
intends to distribute information on key performance indicators to HMOs on a
regular basis, identifying an HMO’s performance, and comparing that performance
to other HMOs, and HHSC standards and/or external Benchmarks. HHSC will
recognize HMOs that attain superior performance and/or improvement by
publicizing their achievements. For example, HHSC may post information
concerning exceptional performance on its website, where it will be available to
both stakeholders and members of the public. Likewise, HHSC may post its final
determination regarding poor performance or HMO peer group performance
comparisons on its website, where it will be available to both stakeholders and
members of the public.

      


      
        	
                6.3.1.2
      Auto-assignment Methodology for Medicaid
HMOs

              


      

      
      

       

      HHSC may
also revise its auto-assignment methodology during the Contract Period for new
Medicaid Members who do not select an HMO (Default Members). The new assignment
methodology would reward those HMOs that demonstrate superior performance and/or
improvement on one or more key dimensions of performance. In establishing the
assignment methodology, HHSC will employ a subset of the performance indicators
contained within the Performance Indicator
Dashboard. At present, HHSC intends to recognize those HMOs that exceed
the minimum geographic access standards defined within Attachment B-1, Section 8 and the
Performance Indicator Dashboard. HHSC may also use its assessment of HMO
performance on annual quality improvement goals (described in Attachment B-1, Section 8) in
developing the assignment methodology. The methodology would disproportionately
assign Default Members to the HMO(s) in a given Service Area that performed
comparably favorably on the selected performance indicators.

       

      HHSC
anticipates that it will not implement a performance-based auto-assignment
algorithm before September 1, 2007. HHSC will invite HMO comments on potential
approaches prior to implementation of the new performance-based auto-assignment
algorithm.

      


      


      
        	
                6.3.2
      Financial Incentives and
Disincentives

              


      

      


      
        	
                6.3.2.1
      Experience Rebate Reward

              


      

      


      HHSC
historically has required HMOs to provide HHSC with an Experience Rebate (see
the Uniform Managed Care
Contract Terms and Conditions, Article 10.11) when there has been an
aggregate excess of Revenues over Allowable Expenses. During the Contract
Period, should the HMO experience an aggregate excess of Revenues over Allowable
Expenses across STAR and CHIP HMO Programs and Service Areas, HHSC will allow
the HMO to retain that portion of the aggregate excess of Revenues over
Allowable Expenses that is equal to or less than 3.5% of the total Revenue for
the period should the HMO demonstrate superior performance on selected
performance indicators.  The retention of 3.5% of revenue exceeds the
retention of 3.0% of revenue that would otherwise be afforded to a HMO without
demonstrated superior performance on these performance indicators relative to
other HMOs. HHSC will develop the methodology for determining the level of
performance necessary for an HMO to retain the additional 0.5% of revenue after
consultation with HMOs. The finalized methodology will be added to the Uniform Managed Care
Manual.

       

      HHSC will
calculate the Experience Rebate Reward after it has calculated the HMO’s at-risk
Capitation Rate payment, as described below in Section 6.3.2.2. HHSC will
calculate whether a HMO is eligible for the Experience Rebate Reward prior to
the 90-day Financial Statistical Report (FSR) filing.

       

      HHSC
anticipates that it will not implement the incentive for Rate Period 1 of the
Contract.  HHSC will invite HMO comments on potential approaches prior
to implementation of the new performance-based Experience Rebate
Reward.  HHSC may also implement this incentive option for the
STAR+PLUS and CHIP Perinatal programs in the future.

       

      6.3.2.2
Performance-Based Capitation Rate

      Beginning
in State Fiscal Year 2007 of the Contract, HHSC will place each STAR and CHIP
HMO at risk for 1% of the Capitation Rate(s). Beginning in State Fiscal Year
2008 of the Contract, HHSC will also place each STAR+PLUS HMO at risk for 1% of
the Capitation Rate(s).  HHSC retains the right to vary the percentage
of the Capitation Rate placed at risk in a given Rate Period.  HHSC
will not place CHIP Perinatal HMOs at risk for 1% of the Capitation Rate(s) in
State Fiscal Year 2007, but reserves this right in subsequent State Fiscal
Years.

       

      As noted
in Section 6.2, HHSC will pay the HMO monthly Capitation Payments based on the
number of eligible and enrolled Members. HHSC will calculate the monthly
Capitation Payments by multiplying the number of Member months times the
applicable monthly Capitation Rate by Member rate cell.  At the end of
each Rate Period, HHSC will evaluate if the HMO has demonstrated that it has
fully met the performance expectations for which the HMO is at
risk.  Should the HMO fall short on some or all of the performance
expectations, HHSC will adjust a future monthly Capitation Payment by an
appropriate portion of the 1% at-risk amount.  HMOs will be able to
earn variable percentages up to 100% of the 1% at-risk Capitation Rate. HHSC’s
objective is that all HMOs achieve performance levels that enable them to
receive the full at-risk amount.

      


      HHSC will
determine the extent to which the HMO has met the performance expectations by
assessing the HMO’s performance for each applicable HMO Program relative to
performance targets for the rate period. HHSC will conduct separate accounting
for each HMO Program’s at-risk Capitation Rate amount.

       

      HHSC will
identify no more than 10 at-risk performance indicators for each HMO Program.
Some of the performance indicators will be standard across the HMO Programs
while others may apply to only one of the HMO Programs.

       

      HHSC’s
at-risk performance indicators may include some or all of the following
measures. The specific performance indicators, periods of data collection, and
associated points are detailed in the HHSC Uniform Managed Care Manual.
The minimum percentage targets identified in this section were developed
based, in part, on the HHSC HMO Program objective of ensuring access to care and
quality of care, past performance of the HHSC HMOs, and performance of Medicaid
and CHIP HMOs nationally on HEDIS and CAHPS measures of plan performance. The Performance Indicator
Dashboard includes a more detailed listing of performance indicators by
Program and is included in the HHSC Uniform Managed Care
Manual.

       

      Standard
Performance Indicators:

      


      
        	
                 
      

              	
                1. 98% of
      Clean Claims are properly Adjudicated within 30 calendar
    days.

              


      

      


      
        	
                 
      

              	
                2. The
      Member Services Hotline abandonment rate does not exceed
    7%.

              


      

      


      
        	
                 
      

              	
                3. The
      Behavioral Health Hotline abandonment rate does not exceed 7%.1

              


      

      


      
        	
                 
      

              	
                4. The
      Provider Services Hotline abandonment rate does not exceed
    7%.

              


      

      


      Additional
STAR Performance Indicators

      


      
        	
                 
      

              	
                1. 90% of
      child Members have access to at least one child-appropriate PCP with an
      Open Panel within 30 miles travel
distance.

              


      

      


      
        	
                 
      

              	
                2. 90% of
      adult Members have access to at least one adult-appropriate PCP with an
      Open Panel within 30 miles travel
distance.

              


      

      


      
        	
                 
      

              	
                3. 36% of
      age-qualified child Members receive six or more well-child visits (in the
      first 15 months of life.

              


      

      


      
        	
                 
      

              	
                4. 56% of
      age-qualified child Members receive at least one well-child visit in the
      3rd, 4th, 5th, or 6th year of life.

              


      

      


      
        	
                 
      

              	
                5. 72% of
      pregnant women Members receive a prenatal care visit in the first
      trimester or within 42 days of
enrollment.

              


      

      


      Additional
CHIP Performance Indicators

      


      
        	
                 
      

              	
                1. 90% of
      child Members have access to at least one child-appropriate PCP with an
      Open Panel within 30 miles travel
distance.

              


      

      
        	
                 
      

              	
                2. 90% of
      child Members have access to at least one otolaryngologist (ENT) within 75
      miles travel distance.

              


      

      
        	
                 
      

              	
                3. 56% of
      age-qualified child Members receive at least one well-child visit in the
      3rd, 4th, 5th, or 6th year of life

              


      

      
        	
                 
      

              	
                4. 38% of
      adolescents receive an annual well
visit.

              


      

      
        	
                 
      

              	
                1
      Will not apply in the Dallas Core Service Area.  Points will be
      allocated proportionately over the remaining standard performance
      indicators.

              


      

       

      Additional
STAR+PLUS Performance Indicators

      


      
        	
                 
      

              	
                1. 57% of
      adult Members report no problem with delays in getting approval from the
      HMO

              


      

      


      
        	
                 
      

              	
                2. 90% of
      adult Members have access to at least one adult-appropriate PCP with an
      Open Panel within 30 miles travel
distance

              


      

      


      
        	
                 
      

              	
                3. 62% of
      adult Members report no problem in getting a referral to a Specialty
      Physician

              


      

      


      
        	
                 
      

              	
                4. 47% of
      adult Members report no problem getting needed Special
      Therapy  (physical therapy, occupational therapy, and speech
      therapy) from the HMO

              


      

      


      
        	
                 
      

              	
                5. 57% of
      adult Members report no problem getting needed Behavioral Health Services
      from the HMO

              


      

      


      Failure
to timely provide HHSC with necessary data related to the calculation of the
performance indicators will result in HHSC’s assignment of a zero percent
performance rate for each related performance indicator.

       

      For any
Member survey-based indicators that are included in the 1% at-risk premium
that yield
response rates deemed by HHSC to be too low to yield credible data, HHSC will
reapportion points across the remaining measures.

       

      Actual
plan rates will be rounded to the nearest whole number. HHSC will calculate
performance assessment for the at-risk portion of the capitation payments by
summing all earned points and converting them to a percentage.  For
example, an HMO that earns 92 points will earn 92% of the at-risk Capitation
Rate.  HHSC will apply the premium assessment of 8% of the at-risk
Capitation Rate as a reduction to the monthly Capitation Payment ninety days
after the end of the contract period.

       

      HMOs will
report actual Capitation Payments received on the Financial Statistical Report
(FSR). Actual Capitation Payments received include all of the at-risk Capitation
Payment paid to the HMO.  Any performance assessment based on
performance for a contract period will appear on the second final (334-day) FSR
for that contract period.

       

      HHSC will
evaluate the performance-based Capitation Rate methodology annually in
consultation with HMOs. HHSC may then modify the methodology it deems necessary
and appropriate to motivate, recognize, and reward HMOs for
performance.  The methodologies for Rate Periods 1 and 2 will be
included in the HHSC Uniform
Managed Care Manual.

      


      
        	
                6.3.2.3
      Quality Challenge Award

              


      

      


      Data
collection for the Quality Challenge Award will begin on September 1, 2006;
however, the Quality Challenge Award will not be implemented until State Fiscal
Year 2008. Should one or more HMOs be unable to earn the full amount of the
performance-based at-risk portion of the Capitation Rate, HHSC will reallocate
the funds through the HMO Program’s Quality Challenge Award.  HHSC
will use these funds to reward HMOs that demonstrate superior clinical quality,
service delivery, access to care, and/or Member satisfaction. HHSC will
determine the number of HMOs that will receive Quality Challenge Award funds
annually based on the amount of the funds to be reallocated.  Separate
Quality Challenge Award payments will be made for each of the HMO
Programs.

      


      As with
the performance-based Capitation Rate, each HMO will be evaluated separately for
each HMO Program.  HHSC intends to evaluate HMO performance annually
on some combination of performance indicators in order to determine which HMOs
demonstrate superior performance.  In no event will a distribution
from the Quality Challenge Award, plus any other incentive payments made in
accordance with the HMO Contract, when combined with the Capitation Rate
payments, exceed 105% of the Capitation Rate payments to an HMO.

       

      Information
about the data collection period to be used and each indicator that will be
considered for any specific time period can be found in the HHSC Uniform Managed Care
Manual.

       

      HHSC will
calculate the HMOs’ degree of compliance with the Quality Challenge Award
indicators based on Encounter Data and other information supplied by the
HMOs.  Failure to provide timely and accurate information will result
in HHSC’s assignment of a zero percent performance rate for each applicable
Quality Challenge Award indicator.

       

      HHSC will
evaluate the Quality Challenge Award methodology annually in consultation with
HMOs. HHSC will make methodology modifications annually as it deems necessary
and appropriate to motivate, recognize, and reward HMOs for superior performance
based on available Quality Challenge Award funds and/or other performance
incentives applicable to the award.  HHSC will include the Quality
Challenge Award methodology and any modifications in the HHSC Uniform Managed Care
Manual.

       

      6.3.2.4  Remedies
and Liquidated Damages

      All areas
of responsibility and all requirements in the Contract will be subject to
performance evaluation by HHSC. Any and all responsibilities or requirements not
fulfilled may have remedies and HHSC will assess either actual or liquidated
damages. Refer to Attachment A,
HHSC Uniform Managed Care Contract Terms and Conditions and Attachment B-5 for performance
standards that carry liquidated damage values.

      


      
        	
                6.3.2.5
      STAR+PLUS Hospital Inpatient Performance-Based Capitation Rate: Hospital
      Inpatient Stay Cost Incentives &
  Disincentives

              


      

      


      Effective
as of the STAR+PLUS Operational Start Date, HHSC will place at-risk a portion of
the HMO’s Medicaid-Only Capitation Rate. Settlements for Inpatient Stay costs
will be calculated by the State after the end of each State Fiscal Year (SFY)
using three (3) months of completed Hospital paid data for the preliminary
settlement and 11 months of completed data for the final settlement. The SFY
2006 Fee-for-Service (FFS) Inpatient Hospital per-member-per-month (PMPM) rate
will be projected for Rate Period 1 (February 1, 2007 through August 31, 2007)
for the first settlement. Adjustments for the projection will include trending
and risk adjustment.  The base and final inpatient hospital PMPM rate
will be calculated separately for each HMO, Service Area, and Rate Cell. Harris
County is excluded from the Harris Service Area calculations.

      


      6.3.2.5.1
STAR+PLUS Hospital Inpatient Disincentive - Administrative Fee at
Risk

      HHSC has
assumed that STAR+PLUS HMOs will achieve a 22% reduction in projected FFS
Hospital Inpatient Stay costs, for the Medicaid-Only population, through the
implementation of the STAR+PLUS model.  HMOs achieving savings beyond
22% will be eligible for the STAR+PLUS Shared Savings Award described in Section 6.3.2.5.2. The HMO
will be at-risk for savings less than 22%.

       

      The
maximum risk to the HMO will be equal to 50% of the difference between 15%
Hospital inpatient savings and 22% Hospital inpatient savings. The disincentive
for savings above 15%, but still less than 22% will be equal to 50% of the
difference between the level of achieved savings and 22%. HHSC retains the right
to vary the disincentive percentage in a given Rate Period by Contract
amendment.

      


      
        	
                6.3.2.5.2
      STAR+PLUS Hospital Inpatient Incentive – Shared Savings
    Award

              


      

      


      HMOs that
exceed the 22% reduction in Inpatient Stay costs incurred by STAR+PLUS Members
specified in Section
6.3.2.5.1 will be eligible to obtain a 20% share of the savings achieved
beyond the 22% target. HHSC will determine the extent to which the HMO has met
and exceeded the performance expectation in the manner described within Section
6.3.2.5.  Should HHSC determine that the HMO exceeded the 22%
target, HHSC will adjust a future monthly Capitation Payment upward by 20% of
the calculated savings. This shared savings award is limited to 5% of the HMO’s
capitation in accordance with Federal Balance Budget Act requirements and is
calculated off of total of STAR+PLUS Capitation Payment. An HMO will be subject
to contractual remedies and determined ineligible for the award, if a HHSC audit
reveals that the HMO has inappropriately averted Medically Necessary Inpatient
Stay admissions and potentially endangered Member safety.

      


      
        	
                6.3.2.6
      Additional Incentives and
Disincentives

              


      

      


      HHSC will
evaluate all performance-based incentives and disincentive methodologies
annually and in consultation from the HMOs.  HHSC may then modify the
methodologies as needed, as funds become available, or as mandated by court
decree, statute, or rule in an effort to motivate, recognize, and reward HMOs
for performance.

       

      Information
about the data collection period to be used, performance indicators selected or
developed, or HMO ranking methodologies used for any specific time period will
be found in the HHSC Uniform
Managed Care Manual.

       

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    
      Subject: Attachment B-1 - HHSC
Joint Mediciad /CHIP HMO RFP, Section 7


      
        	
                DOCUMENT
      HISTORY LOG

              
	
                STATUS1

              	
                DOCUMENT

                REVISION2

              	
                EFFECTIVE

                DATE

              	
                DESCRIPTION3

              	 
      
	
                 

                Baseline

                 

              	
                 

                n/a

                 

              	 
      	
                 

                Initial
      version Attachment B-1, Section 7

                 

              	 
      
	
                Revision

              	
                1.1

              	
                June
      30, 2006

              	
                Revised
      version of the Attachment B-1, Section 7, that includes provisions
      applicable to MCOs participating in the STAR+PLUS Program.

                 

                Sections
      7.1 to 7.3 modified to include STAR+PLUS.

                 

              	 
      
	
                Revision

              	
                1.2

              	
                September
      1, 2006

              	
                Revised
      version of the Attachment B-1, Section 7, that includes provisions
      applicable to MCOs participating in the STAR and CHIP
      Programs.

                 

                Section
      7.3.1.7, Operations Readiness, changes reference from “Operational Date”
      to “Effective Date.”

                 

              	 
      
	
                Revision

              	
                1.3

              	
                September
      1, 2006

              	
                Revised
      version of the Attachment B-1, Section 7, that includes provisions
      applicable to MCOs participating in the CHIP Perinatal
      Program.

                Sections
      7.2, 7.3, and 7.3.1.2 through 7.3.1.7 modified to include the CHIP
      Perinatal Program.

              	 
      
	
                Revision

              	
                1.4

              	
                September
      1, 2006

              	
                Contract
      amendment did not revise Attachment B-1 Section 7 – Transition Phase
      Requirements

              	 
      
	
                Revision

              	
                1.5

              	
                January
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-1 Section 7 – Transition Phase
      Requirements

              	 
      
	
                Revision

              	
                1.6

              	
                February
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-1 Section 7 – Transition Phase
      Requirements

              	 
      
	
                Revision

              	
                1.7

              	
                July
      1, 2007

              	
                Section
      7.3.1.9 is modified to add a cross-reference to Attachment B-1, Sections
      8.1.1.2 and 8.1.18.

              	 
      
	
                Revision

              	
                1.8

              	
                September
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-1 Section 7 – Transition Phase
      Requirements

              	 
      
	
                Revision

              	
                1.9

              	
                December
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-1 Section 7 – Transition Phase
      Requirements

              	 
      
	Revision	1.10	March
      1, 2008	Contract
      amendment did not revise Attachment B-1 Section 7 – Transition Phase
      Requirements	 
	Revision    	1.11	September
      1, 2008	Contract
      amendment did not revise Attachment B-1 Section 7 – Transition Phase
      Requirements	 
	
                 

                1  Status
      should be represented as “Baseline” for initial issuances, “Revision” for
      changes to the Baseline version, and “Cancellation” for withdrawn
      versions

                2
      Revisions should be numbered in accordance according to the version
      of the issuance and sequential numbering of the revision—e.g., “1.2”
      refers to the first version of the document and the second
      revision.

                3  Brief
      description of the changes to the document made in the
      revision.

              


      

      
      

      


      


      


      
        	
                 
      

              	
                7.
      Transition Phase Requirements

              


      

      


      
        	
                 
      

              	
                7.1
      Introduction

              


      

      This
Section presents the scope of work for the Transition Phase of the Contract,
which includes those activities that must take place between the time of
Contract award and the Operational Start Date.

       

      The
Transition Phase will include a Readiness Review of each HMO, which must be
completed successfully prior to a HMO’s Operational Start Date for each
applicable HMO Program. HHSC may, at its discretion, postpone the Operational
Start Date of the Contract for any such HMO that fails to satisfy all Transition
Phase requirements.

       

      If for
any reason, a HMO does not fully meet the Readiness Review prior to the
Operational Start Date, and HHSC has not approved a delay in the Operational
Start Date or approved a delay in the HMO’s compliance with the applicable
Readiness Review requirement, then HHSC shall impose remedies and either actual
or liquidated damages. If the HMO is a current HMO Contractor, HHSC may also
freeze enrollment into the HMO’s plan for any of its HMO Programs. Refer to
the HHSC Uniform Managed Care
Contract Terms and Conditions (Attachment A) and the Liquidated Damages Matrix
(Attachment B-5) for additional information.

      


      
        	
                 
      

              	
                7.2
      Transition Phase Scope for HMOs

              


      

      


      STAR,
STAR+PLUS and CHIP HMOs must meet the Readiness Review requirements established
by HHSC no later than 90 days prior to the Operational Start Date for each
applicable HMO Program. CHIP Perinatal HMOS must meet the Readiness Review
requirements established by HHSC not later than 60 days prior to the Operational
Start Date for the CHIP Perinatal Program.  HMO agrees to provide all
materials required to complete the readiness review by the dates established by
HHSC and its Contracted Readiness Review Vendor.

      


      
        	
                 
      

              	
                7.3
      Transition Phase Schedule and Tasks

              


      

      


      The
Transition Phase will begin after both Parties sign the Contract.  The
start date for the STAR and CHIP Transition Phase is November 15,
2005.  The start date for the STAR+PLUS Transition Phase is June 30,
2006. The start date for the CHIP Perinate Transition Phase is September 1,
2006.

       

      The
Transition Phase must be completed no later than the agreed upon Operational
Start Date(s) for each HMO Program and Service Area.   The HMO
may be subject to liquidated damages for failure to meet the agreed upon
Operational Start Date (see Attachment B-5).

       

      
        	
                 
      

              	
                7.3.1
      Transition Phase Tasks

              


      

      


      The HMO
has overall responsibility for the timely and successful completion of each of
the Transition Phase tasks.  The HMO is responsible for clearly
specifying and requesting information needed from HHSC, other HHSC contractors,
and Providers in a manner that does not delay the schedule or work to be
performed.

      


      
        	
                 
      

              	
                7.3.1.1
      Contract Start-Up and Planning

              


      

      


      HHSC and
the HMO will work together during the initial Contract start-up phase
to:

      


      
        	
                 
      

              	
                • define
      project management and reporting
standards;

              


      

      


      
        	
                 
      

              	
                • establish
      communication protocols between HHSC and the
  HMO;

              


      

      


      
        	
                 
      

              	
                • establish
      contacts with other HHSC
contractors;

              


      

      


      
        	
                 
      

              	
                • establish
      a schedule for key activities and milestones;
  and

              


      

      


      
        	
                 
      

              	
                • clarify
      expectations for the content and format of Contract
      Deliverables.

              


      

      


      The HMO
will be responsible for developing a written work plan, referred to as the
Transition/Implementation Plan, which will be used to monitor progress
throughout the Transition Phase. An updated and detailed Transition
/Implementation Plan will be due to HHSC.

      


      
        	
                 
      

              	
                7.3.1.2
      Administration and Key HMO
Personnel

              


      

      


      No later
than the Effective Date of the Contract, the HMO must designate and identify Key
HMO Personnel that meet the requirements in HHSC Uniform Managed Care Contract
Terms & Conditions, Article 4.  The HMO will supply HHSC
with resumes of each Key HMO Personnel as well as organizational information
that has changed relative to the HMO’s Proposal, such as updated job
descriptions and updated organizational charts, (including updated Management
Information System (MIS) job descriptions and an updated MIS staff
organizational chart), if applicable.  If the HMO is using a Material
Subcontractor(s), the HMO must also provide the organizational chart for such
Material Subcontractor(s).

       

      No later
than the Contract execution date, STAR+PLUS HMOs must update the information
above and provide any additional information as it relates to the STAR+PLUS
Program.

       

      No later
than the Contract execution date, CHIP Perinatal HMOs must update the
information above and provide any additional information as it relates to the
CHIP Perinatal Program.

      


      
        	
                 
      

              	
                7.3.1.3
      Financial Readiness Review

              


      

      


      In order
to complete a Financial Readiness Review, HHSC will require that HMOs update
information submitted in their proposals.  Note: STAR+PLUS and/or CHIP
Perinatal HMOs who have already submitted proposal updates for HHSC’s review for
STAR and/or CHIP, must either verify that the information has not changed and
that it applies to STAR+PLUS and/or the CHIP Perinatal
Program or provide updated information for STAR+PLUS by July 10, 2006 and for
the CHIP Perinatal Program by September 1, 2006. This information will include
the following:

       

      Contractor Identification
and Information

      


      
        	
                 
      

              	
                1. The
      Contractor’s legal name, trade name, or any other name under which the
      Contractor does business, if any.

              


      

      


      
        	
                 
      

              	
                2. The
      address and telephone number of the Contractor’s headquarters
      office.

              


      

      


      
        	
                 
      

              	
                3. A copy
      of its current Texas Department of Insurance Certificate of Authority to
      provide HMO or ANHC services in the applicable Service
      Area(s).  The Certificate of Authority must include all counties
      in the Service Area(s) for which the Contractor is proposing to serve HMO
      Members.

              


      

      


      
        	
                 
      

              	
                4. Indicate
      with a “Yes-HMO”, “Yes-ANHC” or “No” in the applicable cell(s) of the
      Column B of the following chart whether the Contractor is currently
      certified by TDI as an HMO or ANHC in all
      counties in each of the CSAs in which the Contractor proposes to
      participate in one or more of the HHSC HMO Programs. If the Contractor is
      not proposing to serve a CSA for a particular HMO Program, the Contractor
      should leave the applicable cells in the table
  empty.

              


      

       

      Table
2: TDI Certificate of Authority in Proposed HMO Program CSAs

       

      
        	
                Column
      A

              	
                Column
      B

              	
                Column
      C

              
	
                Core
      Service Area (CSA)

              	
                TDI
      Certificate of Authority

              	
                Counties/Partial
      Counties without a TDI Certificate of Authority

              
	
                Bexar

              	 
      	 
      
	
                Dallas

              	 
      	 
      
	
                El
      Paso

              	 
      	 
      
	
                Harris

              	 
      	 
      
	
                Lubbock

              	 
      	 
      
	
                Nueces

              	 
      	 
      
	
                Tarrant

              	 
      	 
      
	
                Travis

              	 
      	 
      
	
                Webb

              	 
      	 
      


      

      
      

      


      If the Contractor is
not
currently certified by TDI as an HMO or ANHC in any one or more counties in a
proposed CSA, the Contractor must identify such entire counties in Column C for
each CSA. For each county listed in Column C, the Contractor must document that
it applied to TDI for such certification of authority prior to the submission of
a Proposal for this RFP. The Contractor shall indicate the date that it applied
for such certification and the status of its application to get TDI
certification in the relevant counties in this section of its submission to
HHSC.

      


      
        	
                 
      

              	
                5. For
      Contractors serving any CHIP and CHIP Perinatal OSAs, indicate with a
      “Yes-HMO”, “Yes-ANHC” or “No” in the applicable cell(s) of the Column C of
      the following chart whether the Contractor is currently certified by TDI
      as an HMO or ANHC in the entire county in the OSA. If the Contractor is
      not proposing to serve an OSA, the Contractor should leave the applicable
      cells in the table empty.

              


      

      


      


      Table
3: TDI Certificate of Authority in Proposed HMO Program OSAs

      
        	
                CHIP
      Program

              
	
                Column
      A

              	
                Column
      B

              	
                Column
      C

              	 
      
	
                Core
      Service Area (CSA)

              	
                Affiliated
      CHIP OSA

              	
                TDI
      Certificate of Authority

              	 
      
	
                Bexar

              	 
      	 
      	 
      
	
                El
      Paso

              	 
      	 
      	 
      
	
                Harris

              	 
      	 
      	 
      
	
                Lubbock

              	 
      	 
      	 
      
	
                Nueces

              	 
      	 
      	 
      
	
                Travis

              	 
      	 
      	 
      


      

      
      

      


       

      
        	
                CHIP
      Perinatal Program

              
	
                Column
      A

              	
                Column
      B

              	
                Column
      C

              
	
                Core
      Service Area (CSA)

              	
                Affiliated
      CHIP OSA

              	
                TDI
      Certificate of Authority

              
	
                Bexar

              	 
      	 
      
	
                El
      Paso

              	 
      	 
      
	
                Harris

              	 
      	 
      
	
                Lubbock

              	 
      	 
      
	
                Nueces

              	 
      	 
      
	
                Travis

              	 
      	 
      


      

      
      

      


      For each
county listed in Column C, the Contractor must document that it applied to TDI
for such certification of authority prior to the submission of a Proposal for
this RFP. The Contractor shall indicate the date that it applied for such
certification and the status of its application to get TDI certification in the
relevant counties in this section of its submission to HHSC.

      


      
        	
                 
      

              	
                6. If the
      Contractor proposes to participate in STAR or STAR+PLUS and seeks to be
      considered as an organization meeting the requirements of Section
      §533.004(a) or (e) of the Texas Government Code, describe how the
      Contractor meets the requirements of §§533.004(a)(1), (a)(2), (a)(3), or
      (e) for each proposed Service
Areas.

              


      

      
        	
                 
      

              	
                7. The
      type of ownership (proprietary, partnership,
  corporation).

              


      

      
        	
                 
      

              	
                8. The
      type of incorporation (for profit, not-for-profit, or non-profit) and
      whether the Contractor is publicly or privately
  owned.

              


      

      
        	
                 
      

              	
                9. If the
      Contractor is an Affiliate or Subsidiary, identify the parent
      organization.

              


      

      
        	
                 
      

              	
                10. If any
      change of ownership of the Contractor’s company is anticipated during the
      12 months following the Proposal due date, the Contractor must describe
      the circumstances of such change and indicate when the change is likely to
      occur.

              


      

      
        	
                 
      

              	
                11. The
      name and address of any sponsoring corporation or others who provide
      financial support to the Contractor and type of support, e.g., guarantees,
      letters of credit, etc. Indicate if there are maximum limits of the
      additional financial support.

              


      

      
        	
                 
      

              	
                12. The
      name and address of any health professional that has at least a five
      percent financial interest in the Contractor and the type of financial
      interest.

              


      

      
        	
                 
      

              	
                13. The
      names of officers and directors.

              


      

      
        	
                 
      

              	
                14. The
      state in which the Contractor is incorporated and the state(s) in which
      the Contractor is licensed to do business as an HMO. The Contractor must
      also indicate the state where it is commercially domiciled, if
      applicable.

              


      

      
        	
                 
      

              	
                15. The
      Contractor’s federal taxpayer identification
  number.

              


      

      
        	
                 
      

              	
                16. The
      Contractor’s Texas Provider Identifier (TPI) number if the Contractor is
      Medicaid-enrolled in Texas.

              


      

      
        	
                 
      

              	
                17. Whether
      the Contractor had a contract terminated or not renewed for
      non-performance or poor performance within the past five years. In such
      instance, the Contractor must describe the issues and the parties
      involved, and provide the address and telephone number of the principal
      terminating party. The Contractor must also describe any corrective action
      taken to prevent any future occurrence of the problem leading to the
      termination.

              


      

      
        	
                 
      

              	
                18. A
      current Certificate of Good Standing issued by the Texas Comptroller of
      Public Accounts, or an explanation for why this form is not applicable to
      the Contractor.

              


      

      
        	
                 
      

              	
                19. Whether
      the Contractor has ever sought, or is currently seeking, National
      Committee for Quality Assurance (NCQA) or American Accreditation
      HealthCare Commission (URAC) accreditation status, and if it has or is,
      indicate:

              


      

      
        	
                 
      

              	
                • its
      current NCQA or URAC accreditation
status;

              


      

      


      
        	
                 
      

              	
                • if NCQA
      or URAC accredited, its accreditation term effective dates;
      and

              


      

      


      
        	
                 
      

              	
                • if not
      accredited, a statement describing whether and when NCQA or URAC
      accreditation status was ever denied the
  Contractor.

              


      

      


      Material Subcontractor
Information

      A
Material Subcontractor means any entity retained by the HMO to provide all or
part of the HMO Administrative Services where the value of the subcontracted HMO
Administrative Service(s) exceeds $100,000 per fiscal year. HMO Administrative
Services are those services or functions other than the direct delivery of
Covered Services necessary to manage the delivery of and payment for Covered
Services.  HMO Administrative Services include but are not limited to
Network, utilization, clinical and/or quality management, service authorization,
claims processing, Management Information System (MIS) operation and
reporting.  The term Material Subcontractor does not include Providers
in the HMO’s Provider Network.

       

      Contractors
must submit the following for each proposed Material Subcontractor, if
any:

      


      
        	
                 
      

              	
                1. A
      signed letter of commitment from each Material Subcontractor that states
      the Material Subcontractor’s willingness to enter into a Subcontractor
      agreement with the Contractor and a statement of work for activities to be
      subcontracted. Letters of Commitment must be provided on the Material
      Subcontractor’s official company letterhead and signed by an official with
      the authority to bind the company for the subcontracted work. The Letter
      of Commitment must state, if applicable, the company’s certified HUB
      status.

              


      

      
        	
                 
      

              	
                2. The
      Material Subcontractor’s legal name, trade name, or any other name under
      which the Material Subcontractor does business, if
  any.

              


      

      
        	
                 
      

              	
                3. The
      address and telephone number of the Material Subcontractor’s headquarters
      office.

              


      

      
        	
                 
      

              	
                4. The
      type of ownership (e.g., proprietary, partnership,
      corporation).

              


      

      
        	
                 
      

              	
                5. The
      type of incorporation (i.e., for profit, not-for-profit, or non-profit)
      and whether the Material Subcontractor is publicly or privately
      owned.

              


      

      
        	
                 
      

              	
                6. If a
      Subsidiary or Affiliate, the identification of the parent
      organization.

              


      

      
        	
                 
      

              	
                7. The
      name and address of any sponsoring corporation or others who provide
      financial support to the Material Subcontractor and type of support, e.g.,
      guarantees, letters of credit, etc. Indicate if there are maximum limits
      of the additional financial
support.

              


      

      
        	
                 
      

              	
                8. The
      name and address of any health professional that has at least a five
      percent (5%) financial interest in the Material Subcontractor and the type
      of financial interest.

              


      

      
        	
                 
      

              	
                9. The
      state in which the Material Subcontractor is incorporated, commercially
      domiciled, and the state(s) in which the organization is licensed to do
      business.

              


      

      
        	
                 
      

              	
                10. The
      Material Subcontractor’s Texas Provider Identifier if Medicaid-enrolled in
      Texas.

              


      

      
        	
                 
      

              	
                11. The
      Material Subcontractor’s federal taxpayer identification
      number.

              


      

      
        	
                 
      

              	
                12. Whether
      the Material Subcontractor had a contract terminated or not renewed for
      non-performance or poor performance within the past five
      years.  In such instance, the Contractor must describe the
      issues and the parties involved, and provide the address and telephone
      number of the principal terminating party. The Contractor must also
      describe any corrective action taken to prevent any future occurrence of
      the problem leading to the
termination.

              


      

      
        	
                 
      

              	
                13. Whether
      the Material Subcontractor has ever sought, or is currently seeking,
      National Committee for Quality Assurance (NCQA) or American Accreditation
      HealthCare Commission (URAC) accreditation or certification status, and if
      it has or is, indicate:

              


      

      
        	
                 
      

              	
                • its
      current NCQA or URAC accreditation or certification
  status;

              


      

      


      
        	
                 
      

              	
                • if NCQA
      or URAC accredited or certified, its accreditation or certification term
      effective dates; and

              


      

      


      
        	
                 
      

              	
                • if not
      accredited, a statement describing whether and when NCQA or URAC
      accreditation status was ever denied the Material
      Subcontractor.

              


      

      


      Organizational
Overview

      


      
        	
                 
      

              	
                1. Submit
      an organizational chart (labeled Chart A), showing the corporate structure
      and lines of responsibility and authority in the administration of the
      Bidder’s business as a health plan.

              


      

      


      
        	
                 
      

              	
                2. Submit
      an organizational chart (labeled Chart B) showing the Texas organizational
      structure and how it relates to the proposed Service Area(s), including
      staffing and functions performed at the local level. If Chart A represents
      the entire organizational structure, label the submission as Charts A and
      B.

              


      

      


      
        	
                 
      

              	
                3. Submit
      an organizational chart (labeled Chart C) showing the Management
      Information System (MIS) staff organizational structure and how it relates
      to the proposed Service Area(s) including staffing and functions performed
      at the local level.

              


      

      


      
        	
                 
      

              	
                4. If the
      Bidder is proposing to use a Material Subcontractor(s), the Bidder shall
      include an organizational chart demonstrating how the Material
      Subcontractor(s) will be managed within the Bidder’s Texas organizational
      structure, including the primary individuals at the Bidder’s organization
      and at each Material Subcontractor organization responsible for overseeing
      such Material Subcontract. This information may be included in Chart B, or
      in a separate organizational
chart(s).

              


      

      


      
        	
                 
      

              	
                5. Submit
      a brief narrative explaining the organizational charts submitted, and
      highlighting the key functional responsibilities and reporting
      requirements of each organizational unit relating to the Bidder’s proposed
      management of the HMO Program(s), including its management of any proposed
      Material Subcontractors.

              


      

      


      Other
Information

      


      
        	
                 
      

              	
                1. Briefly
      describe any regulatory action, sanctions, and/or fines imposed by any
      federal or Texas regulatory entity or a regulatory entity in another state
      within the last 3 years, including a description of any letters of
      deficiencies, corrective actions, findings of non-compliance, and/or
      sanctions. Please indicate which of these actions or fines, if any, were
      related to Medicaid or CHIP programs. HHSC may, at its option, contact
      these clients or regulatory agencies and any other individual or
      organization whether or not identified by the
  Contractor.

              


      

      


      
        	
                 
      

              	
                2. No
      later than ten (10) days after the Contract Effective Date, submit
      documentation that demonstrates that the HMO has secured the required
      insurance and bonds in accordance with TDI requirements and Attachment
      B-1, Section 8.

              


      

      


      
        	
                 
      

              	
                3. Submit
      annual audited financial statement for fiscal years 2004 and 2005 (2005 to
      be submitted no later than six months after the close of the fiscal
      year).

              


      

      


      
        	
                 
      

              	
                4. Submit
      an Affiliate Report containing a list of all Affiliates and for HHSC’s
      prior review and approval, a schedule of all transactions with Affiliates
      that, under the provisions of the Contract, will be allowable as expenses
      in the FSR Report for services provided to the HMO by the Affiliate. Those
      should include financial terms, a detailed description of the services to
      be provided, and an estimated amount that will be incurred by the HMO for
      such services during the Contract
Period.

              


      

      


      


      
        	
                 
      

              	
                7.3.1.4
      System Testing and Transfer of Data

              


      

      


      The HMO
must have hardware, software, network and communications systems with the
capability and capacity to handle and operate all MIS systems and subsystems
identified in Attachment
B-1, Section
8.1.18.  For example, the HMO’s MIS system must comply with the
Health Insurance Portability and Accountability Act of 1996 (HIPAA) as indicated
in Section
8.1.18.4.

       

      During
this Readiness Review task, the HMO will accept into its system any and all
necessary data files and information available from HHSC or its
contractors.  The HMO will install and test all hardware, software,
and telecommunications required to support the Contract.  The HMO will
define and test modifications to the HMO’s system(s) required to support the
business functions of the Contract.

       

      The HMO
will produce data extracts and receive all electronic data transfers and
transmissions. STAR and CHIP HMOs must be able to demonstrate the ability to
produce an EQRO (currently, Institute for Child Health Policy (ICHP)) encounter
file by April 1, 2006, and the 837-encounter file by August 1,
2006.  STAR+PLUS HMOs must be able to demonstrate the ability to
produce the STAR+PLUS encounter file by the STAR+PLUS Operational Start Date and
the 837- encounter file by September 1, 2007. CHIP Perinatal HMOs who have
already demonstrated the ability to produce an EQRO encounter file and
837-encounter file for the CHIP Program are not required to produce separate
files for the CHIP Perinatal Program.

       

      If any
errors or deficiencies are evident, the HMO will develop resolution procedures
to address problems identified.  The HMO will provide HHSC, or a
designated vendor, with test data files for systems and interface testing for
all external interfaces.  This includes testing of the required
telephone
lines for Providers and Members and any necessary connections to the HHSC
Administrative Services Contractor and the External Quality Review
Organization.  The HHSC Administrative Services Contractor will
provide enrollment test files to new HMOs that do not have previous HHSC
enrollment files. The HMO will demonstrate its system capabilities and adherence
to Contract specifications during readiness review.

      
         

      

      
        	
                 
      

              	
                7.3.1.5
      System Readiness Review

              


      

      


      The HMO
must assure that systems services are not disrupted or interrupted during the
Operations Phase of the Contract. The HMO must coordinate with HHSC and other
contractors to ensure the business and systems continuity for the processing of
all health care claims and data as required under this contract.

       

      The HMO
must submit to HHSC, descriptions of interface and data and process flow for
each key business processes described in Section 8.1.18.3, System-wide
Functions.

       

      The HMO
must clearly define and document the policies and procedures that will be
followed to support day-to-day systems activities. The HMO must develop, and
submit for State review and approval, the following information by December 14,
2005 for STAR and CHIP, by July 31, 2006 for STAR+PLUS:

      


      
        	
                 
      

              	
                1. Joint
      Interface Plan.

              


      

      


      
        	
                 
      

              	
                2. Disaster
      Recovery Plan

              


      

      


      
        	
                 
      

              	
                3. Business
      Continuity Plan

              


      

      


      
        	
                 
      

              	
                4. Risk
      Management Plan, and

              


      

      


      
        	
                 
      

              	
                5. Systems
      Quality Assurance Plan.

              


      

      


      Separate
plans are not required for CHIP Perinatal HMOs.

      


      
        	
                 
      

              	
                7.3.1.6
      Demonstration and Assessment of System
Readiness

              


      

      


      The HMO
must provide documentation on systems and facility security and provide evidence
or demonstrate that it is compliant with HIPAA. The HMO shall also provide HHSC
with a summary of all recent external audit reports, including findings and
corrective actions, relating to the HMO’s proposed systems, including any SAS70
audits that have been conducted in the past three years. The HMO shall promptly
make additional information on the detail of such system audits available to
HHSC upon request.

       

      In
addition, HHSC will provide to the HMO a test plan that will outline the
activities that need to be performed by the HMO prior to the Operational Start
Date of the Contract. The HMO must be prepared to assure and demonstrate system
readiness. The HMO must execute system readiness test cycles to include all
external data interfaces, including those with Material
Subcontractors.

       

      HHSC, or
its agents, may independently test whether the HMO’s MIS has the capacity to
administer the STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO business, as
applicable to the HMO. This Readiness Review of a HMO’s MIS may include a desk
review and/or an onsite
review.  HHSC may request from the HMO additional documentation to
support the provision of STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO
Services, as applicable to the HMO.  Based in part on the HMO’s
assurances of systems readiness, information contained in the Proposal,
additional documentation submitted by the HMO, and any review conducted by HHSC
or its agents, HHSC will assess the HMO’s understanding of its responsibilities
and the HMO’s capability to assume the MIS functions required under the
Contract.

      


      The HMO
is required to provide a Corrective Action Plan in response to any Readiness
Review deficiency no later than ten (10) calendar days after notification of any
such deficiency by HHSC. If the HMO documents to HHSC’s satisfaction that the
deficiency has been corrected within ten (10) calendar days of such deficiency
notification by HHSC, no Corrective Action Plan is required.

      


      
        	
                 
      

              	
                7.3.1.7
      Operations Readiness

              


      

      


      The HMO
must clearly define and document the policies and procedures that will be
followed to support day-to-day business activities related to the provision of
STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO Services, including
coordination with contractors.  The HMO will be responsible for
developing and documenting its approach to quality assurance.

      Readiness
Review. Includes all plans to be implemented in one or more Service Areas
on the anticipated Operational Start Date. At a minimum, the HMO shall, for each
HMO Program:

      


      
        	
                 
      

              	
                1. Develop
      new, or revise existing, operations procedures and associated
      documentation to support the HMO’s proposed approach to conducting
      operations activities in compliance with the contracted scope of
      work.

              


      

      
        	
                 
      

              	
                2. Submit
      to HHSC, a listing of all contracted and credentialed Providers, in a HHSC
      approved format including a description of additional contracting and
      credentialing activities scheduled to be completed before the Operational
      Start Date.

              


      

      
        	
                 
      

              	
                3. Prepare
      and implement a Member Services staff training curriculum and a Provider
      training curriculum.

              


      

      
        	
                 
      

              	
                4. Prepare
      a Coordination Plan documenting how the HMO will coordinate its business
      activities with those activities performed by HHSC contractors and the
      HMO’s Material Subcontractors, if any.  The Coordination Plan
      will include identification of coordinated activities and protocols for
      the Transition Phase.

              


      

      
        	
                 
      

              	
                5. Develop
      and submit to HHSC the draft Member Handbook, draft Provider Manual, draft
      Provider Directory, and draft Member Identification Card for HHSC’s review
      and approval. The materials must at a minimum meet the requirements
      specified in Section
      8.1.5 and include the
      Critical Elements to be defined in the HHSC Uniform Managed Care
      Manual.

              


      

      
        	
                 
      

              	
                6. Develop
      and submit to HHSC the HMO’s proposed Member complaint and appeals
      processes for Medicaid, CHIP, and CHIP Perinatal as applicable to the
      HMO’s Program participation.

              


      

      
        	
                 
      

              	
                7. Provide
      sufficient copies of the final Provider Directory to the HHSC
      Administrative Services Contractor in sufficient time to meet the
      enrollment schedule.

              


      

      
        	
                 
      

              	
                8. Demonstrate
      toll-free telephone systems and reporting capabilities for the Member
      Services Hotline, the Behavioral Health Hotline, and the Provider Services
      Hotline.

              


      

      
        	
                 
      

              	
                9. Submit
      a written Fraud and Abuse Compliance Plan to HHSC for approval no later
      than 30 days after the Contract Effective Date.  See Section 8.1.19, Fraud
      and Abuse, for the
      requirements of the plan, including new requirements for special
      investigation units. As part of the Fraud and Abuse Compliance Plan, the
      HMO shall:

              


      

      
        	
                 
      

              	
                • designate
      executive and essential personnel to attend mandatory training in fraud
      and abuse detection, prevention and reporting.  Executive and
      essential fraud and abuse personnel means HMO staff persons who supervise
      staff in the following areas:  data collection, provider
      enrollment or disenrollment, encounter data, claims processing,
      utilization review, appeals or grievances, quality assurance and
      marketing, and who are directly involved in the decision-making and
      administration of the fraud and abuse detection program within the
      HMO.  The training will be conducted by the Office of Inspector
      General, Health and Human Services Commission, and will be provided free
      of charge.  The HMO must schedule and complete training no later
      than 90 days after the Effective
Date.

              


      

      


      
        	
                 
      

              	
                • designate
      an officer or director within the organization responsible for carrying
      out the provisions of the Fraud and Abuse Compliance
  Plan.

              


      

      


      
        	
                 
      

              	
                • The HMO
      is held to the same requirements and must ensure that, if this function is
      subcontracted to another entity, the subcontractor also meets all the
      requirements in this section and the Fraud and Abuse section as stated in
      Attachment B-1, Section
      8.

              


      

      


      
        	
                 
      

              	
                • Note:
      STAR+PLUS HMOs who have already submitted and received HHSC’s approval for
      their Fraud and Abuse Compliance Plans must submit acknowledgement that
      the HMO’s approved Fraud and Abuse Compliance Plan also applies to the
      STAR+PLUS program, or submit a revised Fraud and Abuse Compliance Plan for
      HHSC’s approval, with an explanation of changes to be made to incorporate
      the STAR+PLUS program into the plan, by July 10,
  2006.

              


      

      


      
        	
                 
      

              	
                • CHIP
      Perinatal HMOs who have already submitted and received HHSC’s approval for
      their Fraud and Abuse Compliance Plans must submit acknowledgement that
      the HMO’s approved Fraud and Abuse Compliance Plan also applies to the
      CHIP Perinatal Program, or submit a revised Fraud and Abuse Compliance
      Plan for HHSC’s approval, with an explanation of changes to be made to
      incorporate the CHIP Perinatal program into the plan, by September 15,
      2006.

              


      

      


      
        	
                 
      

              	
                • Complete
      hiring and training of STAR+PLUS Service Coordination staff, no later than
      45 days prior to the STAR+PLUS Operational Start
  Date.

              


      

      


      During
the Readiness Review, HHSC may request from the HMO certain operating procedures
and updates to documentation to support the provision of STAR, STAR+PLUS, CHIP,
and/or CHIP Perinatal HMO Services.  HHSC will assess the HMO’s
understanding of its responsibilities and the HMO’s capability to assume the
functions required under the Contract, based in part on the HMO’s assurances of
operational readiness, information contained in the Proposal, and in Transition
Phase documentation submitted by the HMO.

       

      The HMO
is required to promptly provide a Corrective Action Plan and/or Risk Mitigation
Plan as requested by HHSC in response to Operational Readiness Review
deficiencies identified by the HMO or by HHSC or its agent.  The HMO
must promptly alert HHSC of deficiencies, and must correct a deficiency or
provide a Corrective Action Plan and/or Risk Mitigation Plan no later than ten
(10) calendar days after HHSC’s notification of deficiencies. If the Contractor
documents to HHSC’s satisfaction that the deficiency has been corrected within
ten (10) calendar days of such deficiency notification by HHSC, no Corrective
Action Plan is required.

      


      
        	
                 
      

              	
                7.3.1.8
      Assurance of System and Operational
Readiness

              


      

      


      In
addition to successfully providing the Deliverables described in Section 7.3.1, the HMO must
assure HHSC that all processes, MIS systems, and staffed functions are ready and
able to successfully assume responsibilities for operations prior to the
Operational Start Date. In particular, the HMO must assure that Key HMO
Personnel, Member Services staff, Provider Services staff, and MIS staff are
hired and trained, MIS systems and interfaces are in place and functioning
properly, communications procedures are in place, Provider Manuals have been
distributed, and that Provider training sessions have occurred according to the
schedule approved by HHSC.

      


      
        	
                 
      

              	
                7.3.1.9
      Post-Transition

              


      

      


      The HMO
will work with HHSC, Providers, and Members to promptly identify and resolve
problems identified after the Operational Start Date and to communicate to HHSC,
Providers, and Members, as applicable, the steps the HMO is taking to resolve
the problems.

       

      If a HMO
makes assurances to HHSC of its readiness to meet Contract requirements,
including MIS and operational requirements, but fails to satisfy requirements
set forth in this Section, or as otherwise required pursuant to the Contract,
HHSC may, at its discretion do any of the following in accordance with the
severity of the non-compliance and the potential impact on Members and
Providers:

      


      
        	
                 
      

              	
                1. freeze
      enrollment into the HMO’s plan for the affected HMO Program(s) and Service
      Area(s);

              


      

      


      
        	
                 
      

              	
                2. freeze
      enrollment into the HMO’s plan for all HMO Programs or for all Service
      Areas of an affected HMO Program;

              


      

      


      
        	
                 
      

              	
                3. impose
      contractual remedies, including liquidated damages;
  or

              


      

      


      
        	
                 
      

              	
                4. pursue
      other equitable, injunctive, or regulatory
  relief.

              


      

      


      Refer to
Attachment B-1, Sections
8.1.1.2 and 8.1.18 for additional
information regarding HMO Readiness Reviews during the Operations
Phase.

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    
      Subject: Attachment B-1 - HHSC
Joint Mediciad/CHIP HOM RFP, Section 8


      
        	
                DOCUMENT
      HISTORY LOG

              


      

      
      

       

      
        	
                STATUS1

              	
                DOCUMENT

                REVISION2

              	
                EFFECTIVE

                DATE

              	
                DESCRIPTION3

              	 
      
	
                 

                Baseline

                 

              	
                 

                n/a

                 

              	 
      	
                 

                Initial
      version Attachment B-1, Section 8

                 

              	 
      
	
                Revision

              	
                1.1

              	
                June
      30, 2006

              	
                Revised
      version of the Attachment B-1, Section 8, that includes provisions
      applicable to MCOs participating in the STAR+PLUS Program.

                 

                Section
      8.1.1.1, Performance Evaluation, is modified to include STAR+PLUS
      Performance Improvement Goals.

                 

                Section
      8.1.2, Covered Services, is modified to include Functionally Necessary
      Community Long-term Care Services for STAR+PLUS.

                 

                Section
      8.1.2.1 Value-Added Services, is modified to add language allowing for the
      HMO to distinguish between the Dual Eligible and non-Dual Eligible
      populations.

                 

                Section
      8.1.2.2 Case-by-Case Added Services, is modified to clarify for STAR+Plus
      members it is based on functionality.

                 

                Section
      8.1.3, Access to Care, is modified to include STAR+PLUS Functional
      Necessity and 1915(c) Nursing Facility Waiver clarifications.

                 

                Section
      8.1.4, Provider Network, is modified to include STAR+PLUS.

                 

                Section
      8.1.4.2, Primary Care Providers, is modified to include
      STAR+PLUS

                 

                Section
      8.1.4.8, Provider Reimbursement, is modified to include Functionally
      Necessary Long-term care services for STAR+PLUS.

                 

                Section
      8.1.7.7, Provider Profiling, is modified to include
STAR+PLUS.

                 

                Sections
      8.1.12 and 8.1.12.2, Services for People with Special Health Care Needs,
      are modified to include STAR+PLUS.

                 

                Section
      8.1.13, Service Management for Certain Populations, is modified to include
      STAR+PLUS.

                 

                Section
      8.1.14, Disease Management, is modified to include STAR+PLUS.

                 

                Section
      8.2, Additional Medicaid HMO Scope of Work, is modified to include
      STAR+PLUS.

                 

                Section
      8.3, Additional STAR+PLUS Scope of Work, is added.

                 

              	 
      
	
                Revision

              	
                1.2

              	
                September
      1, 2006

              	
                Revised
      version of Attachment B-1, Section 8, that includes provisions applicable
      to MCOs participating in the STAR and CHIP Programs.

                 

                Section
      8.1.1.1, Performance Evaluation, is modified to clarify that the HMOs
      goals are Service Area and Program specific; when the percentages for
      Goals 1 and 2 are to be negotiated; and when Goal 3 is to be
      negotiated.

                 

                Section
      8.1.2.1, Value-Added Services, is modified to add language allowing for
      the addition of two Value-added Services during the Transition Phase of
      the Contract and to clarify the effective dates for Value Added Services
      for the Transition Phase and the Operation Phase of the
      Contract.

                 

                Section
      8.1.3.2, Access to Network Providers, is modified to delete references to
      Open Panels.

                 

                Section
      8.1.4, Provider Network, is modified to clarify that “Out-of-Network
      reimbursement arrangements” with certain providers must be in
      writing.

                 

                Section
      8.1.5.1, Member Materials, is modified to clarify the date that the member
      ID card and the member handbook are to be sent to members.

                 

                Section
      8.1.5.6, Member Hotline, is modified to clarify the hotline performance
      requirements.

                 

                Section
      8.1.17.2, Financial Reporting Requirements, is modified to clarify that
      the Bonus Incentive Plan refers to the Employee Bonus Incentive
      Plan.  It has also been modified to clarify the reports and
      deliverable due dates and to change the name of the Claims Summary Lag
      Report and clarify that the report format has been moved to the Uniform
      Managed Care Manual.

                 

                Section
      8.1.18.5, Claims Processing Requirements, is modified to revise the claims
      processing requirements and move many of the specifics to the Uniform
      Managed Care Manual.

                 

                Section
      8.1.20, Reporting Requirements, is modified to clarify the reports and
      deliverable due dates.

                 

                Section
      8.1.20.2, Reports, is modified to delete the Claims Data Specifications
      Report, amend the All Claims Summary Report, and add two new
      provider-related reports to the contract.

                 

                Section
      8.2.2.10, Cooperation with Immunization Registry, is added to comply with
      legislation, SB 1188 sec. 6(e)(1), 79th
      Legislature, Regular Session, 2005.

                 

                Section
      8.2.2.11, Case Management for Children and Pregnant Women, is
      added.

                 Section
      8.2.5.1, Provider Complaints, is modified to include the 30-day
      resolution requirement.

                 

                Section
      8.2.10.2, Non-Reimbursed Arrangements with Local Public Health Entities,
      is modified to update the requirements and delete the requirement for an
      MOU.

                 

                Section
      8.2.11, Coordination with Other State Health and Human Services (HHS)
      Programs, is modified to update the requirements and delete the
      requirement for an MOU.

                 

                Section
      8.4.2, CHIP Provider Complaint and Appeals, is modified to include the
      30-day resolution requirement.

                 

              	 
      
	
                Revision

              	
                1.3

              	
                September
      1, 2006

              	
                Revised
      version of Attachment B-1, Section 8, that includes provisions applicable
      to MCOs participating in the CHIP Perinatal Program.

                Section
      8.1.1.1, Performance Evaluation, is modified to clarify that HHSC will
      negotiate and implement Performance Improvement Goals for the first full
      State Fiscal Year following the CHIP Perinatal Operational Start
      Date

                Section
      8.1.2, Covered Services is amended to: (a) clarify that Fee For Service
      will pay the Hospital costs for CHIP Perinate Newborns; (b) add a
      reference to new Attachment B-2.2 concerning covered services; (c) add
      CHIP Perinate references where appropriate.

                Section
      8.1.2.2 Case-by-Case Added Services, is modified to clarify that this does
      not apply to the CHIP Perinatal Program.

                Section
      8.1.3, Access to Care, is amended to include emergency services
      limitations.

                Section
      8.1.3.2, Access to Network Providers, is amended to include the Provider
      access standards for the CHIP Perinatal Program.

                Section
      8.1.4.2 Primary Care Providers, is modified to clarify the development of
      the PCP networks between the CHIP Perinates and the CHIP Perinate
      Newborns.

                Section
      8.1.4.6 Provider Manual, Materials and Training, modified to include the
      CHIP Perinatal Program

                Section
      8.1.4.9 Termination of Provider Contracts modified to include the CHIP
      Perinatal Program.

                Section
      8.1.5.2 Member Identification (ID) Card, modified to include the CHIP
      Perinatal Program.

                Section
      8.1.5.3 Member Handbook, modified to include the CHIP Perinatal
      Program.

                Section
      8.1.5.4 Provider Directory, modified to include the CHIP Perinatal
      Program.

                Section
      8.1.5.6 Member Hotline, modified to include the CHIP Perinatal
      Program.

                Section
      8.1.5.7 Member Education, modified to include the CHIP Perinatal
      Program.

                Section
      8.1.5.9 Member Complaint and Appeal Process, modified to include the CHIP
      Perinatal Program.

                Section
      8.1.7.7, Provider Profiling, is modified to include the CHIP Perinatal
      Program.

                Section
      8.1.12, Services for People with Special Health Care Needs, modified to
      clarify between CHIP Perinatal Program and CHIP Perinatal
      Newborn.

                Section
      8.1.13, Service Management for Certain Populations, modified to clarify
      the CHIP Perinatal Program.

                Section
      8.1.15, Behavioral Health (BH) Network and Services, modified to clarify
      between CHIP Perinatal and Perinate members.

                Section
      8.1.17.2, Financial Reporting Requirements, modified to include the CHIP
      Perinatal Program.

                Section
      8.1.18.3, System-wide Functions, modified to include the CHIP Perinatal
      Program.

                Section
      8.1.18.5, Claims Processing Requirements, modified to include the CHIP
      Perinatal Program.

                Section
      8.1.19, Fraud and Abuse, modified to include the CHIP Perinatal
      Program

                Section
      8.1.20.2, Provider Termination Report and Provider Network Capacity
      Report, is modified to include the CHIP Perinatal Program.

                Section
      8.5, Additional Scope of Work for CHIP Perinatal Program HMOs, is added to
      Attachment B-1.

              	 
      
	
                Revision

              	
                1.4

              	
                September
      1, 2006

              	
                Contract
      amendment did not revise Attachment B-1, Section 8-Operations Phase
      Requirements.

              	 
      
	
                Revision

              	
                1.5

              	
                January
      1, 2007

              	
                Revised
      version of the Attachment B-1, Section 8, that includes provisions
      applicable to MCOs participating in the STAR and STAR+PLUS
      Program.

                Section
      8.1.2 is modified to include a reference to STAR and STAR+PLUS covered
      services.

                Section
      8.1.20.2 is modified to update the references to the Uniform Managed Care
      Manual for the “Summary Report of Member Complaints and Appeals” and the
      “Summary Report of Provider Complaints.”

                Section
      8.2.2.5 is modified to require the Provider to coordinate with the
      Regional Health Authority.

                Section
      8.2.4 is amended to clarify cost settlements and encounter rates for
      Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)
      for STAR and STAR+PLUS service areas.

                Section
      8.3.2.4 is amended to clarify the timeframe for initial STAR+PLUS
      assessments. Section 8.3.3 is amended to: (1) clarify the use of the DHS
      Form

                2060;
      (2) require the HMO to complete the Individual Service Plan (ISP), Form
      3671 for each Member receiving 1915(c) Nursing Facility Waiver Services;
      (3) require HMOs to complete Form 3652 and Form 3671annually at
      reassessment; (4) allow the HMOs to administer the Minimum Data Set for
      Home Care (MDS-HC) instrument for non-waiver STAR+PLUS Members over the
      course of the first year of operation; (5) allow HMOs to submit other
      supplemental assessment instruments.

                Section
      8.3.4 is modified to include the criteria for participation in 1915(c)
      nursing facility waiver services.

                Section
      8.3.4.3 is amended to remove the six-month timeframe for Nursing Facility
      Cost Ceiling.  Deletes provision stating DADS Commissioner may
      grant exceptions in individual cases.

                Section
      8.3.5 is amended to delete the requirement that HMOs use the Consumer
      Directed Services option for the delivery of Personal Attendant Services.
      The new language provides HMOs with three options for delivering these
      services.  The options are described in the following new
      subsections: 8.3.5.1, Personal Attendant Services Delivery Option –
      Self-Directed Model; 8.3.5.2, Personal Attendant Services Delivery Option
      – Agency Model, Self-Directed; and 8.3.5.3, Personal Attendant Services
      Delivery Option – Agency Model.

                Section
      8.3.7.3 is modified to reflect the changes made by the HMO workgroup
      regarding enhanced payments for attendant care.  The section
      also includes a reference to new Attachment B-7, which contains the HMO’s
      methodology for implementing and paying the enhanced
    payments.

              	 
      
	
                Revision

              	
                1.6

              	
                February
      1, 2007

              	
                Revised
      version of the Attachment B-1, Section 8, that includes provisions
      applicable to MCOs participating in the STAR+PLUS and CHIP Perinatal
      Programs.

                Section
      8.1 is modified to clarify the Operational Start Date of the STAR+PLUS
      Program.

                Section
      8.1.3.2 is modified to allow exceptions to hospital access standards on a
      case-by-case basis only for HMOs participating in the CHIP Perinatal
      Program.

                Section
      8.3.3 is modified to clarify when the 12-month period begins for the
      STAR+PLUS HMOs to complete the MDS-HC instruments for non-1915(c) Nursing
      Facility Waiver Members who are receiving Community-based Long-term Care
      Services.

              	 
      
	
                Revision

              	
                1.7

              	
                July
      1, 2007

              	
                New
      Section 8.1.1.2 is added to require the HMOs to pay for any additional
      readiness reviews beyond the original ones conducted before the
      Operational Start Date.

                Section
      8.1.5.5 is modified to add a requirement that all HMOs must list Home
      Health Ancillary providers on their websites, with an indicator for
      Pediatric services.

                Section
      8.1.17.2 is modified to remove the requirement that the Claims Lag Report
      separate claims by service categories.

                Section
      8.1.18 is modified to update the cross-references to sections of the
      contract addressing remedies and damages and to add cross-references to
      sections of the contract addressing Readiness Reviews.

                Section
      8.1.18.5 is modified to require the HMO to make an electronic funds
      transfer payment process available when processing claims for Medically
      Necessary covered STAR+PLUS services.

                Section
      8.1.19 is modified to comply with a new federal law that requires entities
      that receive or make Medicaid payments of at least $5 million annually to
      educate employees, contractors and agents and to implement policies and
      procedures for detecting and preventing fraud, waste and
      abuse.

                Section
      8.1.20.2 is modified to require Provider Termination Reports for STAR+PLUS
      as required by the Dashboard.  The amendment also requires
      Claims Summary Reports be submitted by claim type.

                Section
      8.2.7.5 is modified to comply with the settlement agreement in the Alberto N.
      litigation.

                Section
      8.3.4.3 is modified to remove references to the cost cap for 1915(c)
      Nursing Facility Waiver services.

              	 
      
	
                Revision

              	
                1.8

              	
                September
      1, 2007

              	
                Section
      8.1.2.1 is modified to reflect legislative changes required by SB
      10.

                Section
      8.1.3.2 is modified to reflect legislative changes required by SB
      10.

                Section
      8.1.5.6 is modified to comply with the Frew litigation corrective action
      plans.

                New
      Section 8.1.5.6.1 is added to comply with the Frew litigation corrective
      action plans.

                Section
      8.1.5.7 is modified to comply with the Frew litigation corrective action
      plans.

                Section
      8.1.11 is modified to delete language included in error and to clarify the
      coverage for children in foster care.

                Section
      8.1.13 is added to comply with the Frew litigation corrective action
      plans.

                Section
      8.1.17.2 is modified to reflect legislative changes required by SB
      10.

                Section
      8.1.20.2 is modified to comply with the Frew litigation corrective action
      plans by adding two new reports: Medicaid Medical Check-ups Report and
      Medicaid FWC Report.

                Section
      8.2.2.3 is modified to comply with Frew litigation correction action
      plans.

                New
      Section 8.2.2.12 is added to comply with the Frew litigation correction
      action plans to enhance care for children of Migrant Farmworkers. Section
      8.2.4 is modified to clarify cost settlement requirements and

                encounter
      and payment reporting requirements for the Nueces Service Area and the
      STAR+PLUS Service Areas.

                Section
      8.2.7.4 is amended to reflect the new fair hearings process for Medicaid
      Members that will be effective 9/1/07.

                Section
      8.2.11 is modified to comply with the Frew litigation corrective action
      plans.

              	 
      
	
                Revision

              	
                1.9

              	
                December
      1, 2007

              	
                Section
      8.1.17.1 is modified to include provider contracts in the documentation
      HMOs must provide upon request and the timeframes in which documents must
      be provided.

                Section
      8.1.17.2 is modified to eliminate the plan's responsibility to submit the
      actuarial certification on the 90 day FSR.

                Section
      8.1.20.2 is modified to change the name of the Medicaid Medical Check-ups
      Report to the Medicaid Managed Care THSteps Medical Checkups Annual Report
      (90-Day FREW Report) and to clarify the term “not previously
      enrolled”.

                Section
      8.2.2.8 is modified to reflect changes as a result of the Alberto N
      litigation Second Partial Settlement Agreement.  Services for
      person under age 21 are being carved out of the STAR Program and provided
      through the Personal Care Services (PCS) benefit in traditional Medicaid
      Fee-for-Service.

                Section
      8.2.7.4 is modified to clarify the HMO’s role in filling out the request
      for Fair Hearing and to conform to Fair Hearings time
      requirements.

                Section
      8.2.12 is modified to remove the outdated reference to 42 C.F.R.
      434.28.

                Section
      8.3.4 is modified to specify that plan of care at initial determination
      must be 200% or less of nursing facility cost.

                Section
      8.3.5 is modified to clarify when the HMO must provide PAS information to
      Members receiving PAS services.

              	 
      
	Revision    	1.10    	March
      31, 2008	
                Section
      8.1.4.4 is modified to add language regarding expedited credentialing as
      required by HB 1594. 

                Section
      8.1.12.2 is modified to transfer the Medical Transportation Program back
      to HHSC. 

                Section
      8.1.17 is modified to add a reference to Federal Acquisition Regulations
      (“FAR”). 

                Section
      8.1.20.2 is modified to change the name of the Medicaid FWC Report to the
      Children of Migrant Farm Workers Annual Report (FWC Annual Report) Section
      8.2.4 is modified to include Municipal Health Department’s Public
      Clinics.
 	 
	Revision    	1.11	September
      1, 2008	
                Section
      8.1.4 is modified to reflect waiver requirements.

                Section
      8.1.4.2 is modified to remove the “Pediatric and Family” qualifier from
      Advanced Practice Nurses.

                Section
      8.1.4.7 is modified to require the HMOs to pay all reasonable costs for
      HHSC to conduct onsite monitoring of the HMO’s Provider Hotline
      functions.

                Section
      8.1.5.6 is modified to require the HMOs to pay all reasonable costs for
      HHSC to conduct onsite monitoring of the HMO’s Member Hotline
      functions.

                Section
      8.1.14 is modified to require the HMO to coordinate continuity of care for
      Members in Disease Management who change plans.

                Section
      8.1.15.3 is modified to clarify the first sentence.

                Section
      8.1.18.1 is modified to clarify encounter data submission
      requirements.

                Section
      8.1.18.2 is modified to require HMOs to follow applicable JIPs and
      required field submissions. This requirement has been moved from
      Attachment B-1, Section 8.1.20.2.

                Section
      8.1.20.2 is modified to require the HMOs to submit copies of all internal
      and external audit reports. The requirement to follow applicable JIPs and
      required field submissions has been moved to Attachment B-1, Section
      8.1.18.2.

                Section
      8.2.1 is modified to add a cross reference to Section 8.1.14 for specific
      requirements for Members transferring to and from the HMO’s DM
      Program.

                Section
      8.2.2.3.1 is added to require the HMO to educate THSteps providers on the
      availability of the Oral Evaluation and Fluoride Varnish (OEVS) Medicaid
      benefit.

                
                  Section
      8.2.4 is modified to require the HMOs to pay full encounter rates to RHCs
      on or after September 1, 2008.

                  Section
      8.2.7.2 is modified to align contract references to TDI’s
      recodification.

                  Section
      8.3.3 is modified to reflect current Waiver requirements and the
      conversion from the TILE to the RUG assessment instrument.

                  Section
      8.3.4.1 is modified to reflect the conversion from the TILE to the RUG
      assessment instrument.

                  Section
      8.3.4.2 is modified to reflect the conversion from the TILE to the RUG
      assessment instrument.

                  Section
      8.3.4.3 is modified to reflect current Waiver requirements and the
      conversion from the TILE to the RUG assessment
      instrument.

                

              	 
	
                 

                 1  Status
      should be represented as “Baseline” for initial issuances, “Revision” for
      changes to the Baseline version, and “Cancellation” for withdrawn
      versions

                2
      Revisions should be numbered in accordance according to the version
      of the issuance and sequential numbering of the revision—e.g., “1.2”
      refers to the first version of the document and the second
      revision.

                3  Brief
      description of the changes to the document made in the
      revision.

              


      

      
      

      


      
        Table of
Contents

        


        8.
OPERATIONS PHASE
REQUIREMENTS................................................8-11

        8.1
General Scope of
Work....................................................................................8-11

        8.1.1
Administration and Contract
Management..................................................8-11

        8.1.2
Covered
Services........................................................................................8-13

        8.1.3
Access to
Care............................................................................................8-16

        8.1.4
Provider
Network.........................................................................................8-20

        8.1.5
Member
Services.........................................................................................8-28

        8.1.6
Marketing and Prohibited
Practices.............................................................8-34

        8.1.7
Quality Assessment and Performance
Improvement..................................8-34

        8.1.8
Utilization
Management...............................................................................8-37

        8.1.9
Early Childhood Intervention
(ECI)..............................................................8-39

        8.1.10
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) -
Specific
Requirements..................................................................8-40

        8.1.11
Coordination with Texas Department of Family and Protective
Services..8-40

        8.1.12
Services for People with Special Health Care
Needs................................8-41

        8.1.13
Service Management for Certain
Populations...........................................8-43

        8.1.14
Disease Management
(DM).......................................................................8-43

        8.1.15
Behavioral Health (BH) Network and
Services..........................................8-44

        8.1.16
Financial Requirements for Covered
Services..........................................8-48

        8.1.17
Accounting and Financial Reporting
Requirements..................................8-48

        8.1.18
Management Information System
Requirements......................................8-52

        8.1.19
Fraud and
Abuse.......................................................................................8-56

        8.1.20
Reporting
Requirements............................................................................8-58

        8.2
Additional Medicaid HMO Scope of
Work......................................................8-62

        8.2.1
Continuity of Care and Out-of-Network
Providers.......................................8-62

        8.2.2
Provisions Related to Covered Services for Medicaid
Members.................8-63

        8.2.3
Medicaid Significant Traditional
Providers...................................................8-72

        8.2.4
Federally Qualified Health Centers (FQHCs) and Rural Health Clinics
(RHCs)...................................................................................................................8-73

        8.2.5
Provider Complaints and
Appeals...............................................................8-73

        8.2.6
Member Rights and
Responsibilities...........................................................8-74

        8.2.7
Medicaid Member Complaint and Appeal
System.......................................8-74

        8.2.8
Additional Medicaid Behavioral Health
Provisions......................................8-82

        8.2.9
Third Party Liability and
Recovery..............................................................8-83

        8.2.10
Coordination With Public Health
Entities...................................................8-84

        8.2.11
Coordination with Other State Health and Human Services (HHS)
Programs...................................................................................................................8-85

        8.2.12
Advance
Directives....................................................................................8-85

        8.3
Additional STAR+PLUS Scope of
Work.........................................................8-86

        8.3.1
Covered Community-Based Long-Term Care
Services..............................8-86

        8.3.2
Service
Coordination...................................................................................8-88

        8.3.3
STAR+PLUS Assessment
Instruments.......................................................8-93

        8.3.4
1915(c) Nursing Facility Waiver Service
Eligibility.......................................8-94

        8.3.5 Personal Attendant
Services.......................................................................8-95



        8.3.6
Community Based Long-term Care Service
Providers................................8-96

        8.4
Additional CHIP Scope of
Work......................................................................8-97

        8.4.1
CHIP Provider
Network...............................................................................8-97

        8.4.2
CHIP Provider Complaint and
Appeals.......................................................8-98

        8.4.3
CHIP Member Complaint and Appeal
Process...........................................8-98

        8.4.4
Dental Coverage for CHIP
Members...........................................................8-98

        8.5
Additional CHIP Perinatal Scope of
Work......................................................8-98

        8.5.1
CHIP Perinatal Provider
Network................................................................8-99

        8.5.2
CHIP Perinatal Program Provider Complaint and
Appeals.........................8-99

        8.5.3
CHIP Perinatal Program Member Complaint and Appeal
Process.............8-99



      
        	
                 
      

              	
                8.
      OPERATIONS PHASE REQUIREMENTS

              


      

       

      This
Section is designed to provide HMOs with sufficient information to understand
the HMOs' responsibilities. This Section describes scope of work requirements
for the Operations Phase of the Contract.

       

      Section 8.1
includes the general scope of work that applies to the STAR, STAR+PLUS, CHIP,
and CHIP Perinatal HMO Programs.

       

      Section 8.2
includes the additional Medicaid scope of work that applies only to the STAR and
STAR+PLUS HMOs.

       

      Section 8.3
includes the additional scope of work that applies only to STAR+PLUS
HMOs.

       

      Section 8.4
includes the additional scope of work that applies only to CHIP
HMOs.

       

      Section 8.5
includes the additional scope of work that applies only to CHIP Perinatal
HMOs.

       

      The
Section does not include detailed information on the STAR, STAR+PLUS, CHIP, and
CHIP Perinatal HMO Program requirements, such as the time frame and format for
all reporting requirements.  HHSC has included this information in the
Uniform
Managed Care Contract Terms and Conditions (Attachment A)
and the Uniform Managed Care
Manual. HHSC reserves the right to modify these documents as it deems
necessary using the procedures set forth in the Uniform Managed Care
Contract Terms and Conditions.

       

      
        	
                 
      

              	
                8.1
      General Scope of Work

              


      

       

      In each HMO Program Service Area, HHSC will select
HMOs for each HMO Program to provide health care services to Members. The
HMO must be licensed by the Texas Department of Insurance (TDI) as an HMO or an
ANHC in all zip codes in the respective Service Area(s).

       

      Coverage
for benefits will be available to enrolled Members effective on the Operational
Start Date. The Operational Start Date is September 1, 2006 for STAR and CHIP
HMOs, January 1, 2007 for CHIP Perinatal HMOs, and February 1, 2007 for the
STAR+PLUS HMOs.

       

      8.1.1  Administration
and Contract Management

      The HMO
must comply, to the satisfaction of HHSC, with (1) all provisions set forth in
this Contract, and (2) all applicable provisions of state and federal laws,
rules, regulations, and waivers.

      


      8.1.1.1
Performance Evaluation

      The HMO
must identify and propose to HHSC, in writing, no later than May 1st of each
State Fiscal Year (SFY) after the Operational Start Date, annual HMO Performance
Improvement Goals for the next fiscal year, as well as measures and time frames
for demonstrating that such goals are being met.  Performance
Improvement Goals must be based on HHSC priorities and identified opportunities
for improvement (see Attachment
B-4, Performance Improvement Goals). The Parties will negotiate such
Performance Improvement Goals, the measures that will be used to assess goal
achievement, and the time frames for completion, which will be incorporated into
the Contract. If HHSC and the HMO cannot agree on the Performance Improvement
Goals, measures, or time frames, HHSC will set the goals, measures, or time
frames.

       

      For State
Fiscal Year 2007, HHSC has established three overarching goals for each Program.
These overarching goals are as follows:

       

      Goal 1  (STAR and CHIP)
Improve Access to Primary Care Services for Members 

       

      Goal 2 (STAR and CHIP) Improve Access
to Behavioral Health Services for Members,

       

      Goal
3 (STAR Only) Improve Access to Clinically Appropriate Alternatives to
Emergency Room Services Outside of
Regular Office Hours 

                  (CHIP Only)  Improve
Current Member Understanding About the CHIP Benefit Renewal
Processes

      


      Note:  The HMO is
required to propose customized sub-goals specific to the HMO’s Service Areas and
Programs for all overarching goals.  The sub-goals must be approved by
HHSC as part of the negotiation process.

      The
specific percentages of expected achievement for each sub-goal will be
negotiated by HHSC and the HMO before the Operational Start Date.

       

      For
STAR+PLUS HMOs, HHSC will negotiate and implement Performance Improvement Goals
for the first full fiscal year following the STAR+PLUS Operational Start
Date.  One standard
STAR+PLUS goal will relate to Consumer-Directed Services. STAR+PLUS improvement
goals for SFY2008 will be included in Attachment B-4.1.

       

      For CHIP
Perinatal HMOs, HHSC will negotiate and implement Performance Improvement Goals
for the first full State Fiscal Year following the CHIP Perinatal Operational
Start Date.

       

      The HMO
must participate in semi-annual Contract Status Meetings (CSMs) with HHSC for
the primary purpose of reviewing progress toward the achievement of annual
Performance Improvement Goals and Contract requirements.  HHSC may
request additional CSMs, as it deems necessary to address areas of
noncompliance.  HHSC will provide the HMO with reasonable advance
notice of additional CSMs, generally at least five (5) business
days.

      


      The HMO
must provide to HHSC, no later than 14 business days prior to each semi-annual
CSM, one electronic copy of a written update, detailing and documenting the
HMO’s progress toward meeting the annual Performance Improvement Goals or other
areas of noncompliance.

       

      HHSC will
track HMO performance on Performance Improvement Goals.  It will also
track other key facets of HMO performance through the use of a Performance Indicator Dashboard (see
HHSC’s Uniform Managed Care Manual). HHSC will compile the Performance
Indicator Dashboard based on HMO submissions, data from the External Quality
Review Organization (EQRO), and other data available to HHSC.  HHSC
will share the Performance Indicator Dashboard with the HMO on a quarterly
basis.

      


      
        	
                8.1.1.2
       Additional HMO
      Readiness Reviews

              


      

      


      During
the Operations Phase, a HMO that chooses to make a change to any operational
system or undergo any major transition may be subject to an additional Readiness
Review(s).  HHSC will determine whether the proposed changes will
require a desk review and/or an onsite review.  The HMO is responsible
for all costs incurred by HHSC or its authorized agent to conduct an onsite
Readiness Review.

       

      Refer to
Attachment B-1, Section
7 and Attachment B-1,
Section 8.1.18 for additional information regarding HMO Readiness
Reviews. Refer to Attachment A,
Section 4.08(c) for information regarding Readiness Reviews of the HMO’s
Material Subcontractors.

       

      8.1.2  Covered
Services

      The HMO
is responsible for authorizing, arranging, coordinating, and providing Covered
Services in accordance with the requirements of the Contract. The HMO must
provide Medically Necessary Covered Services to all Members beginning on the
Member’s date of enrollment regardless of pre-existing conditions, prior
diagnosis and/or receipt of any prior health care services. STAR+PLUS HMOs must
also provide Functionally Necessary Community Long-term Care Services to all
Members beginning on the Member’s date of enrollment regardless of pre-existing
conditions, prior diagnosis and/or receipt of any prior health care services.
The HMO must not impose any pre-existing condition limitations or exclusions or
require Evidence of Insurability to provide coverage to any Member.

       

      The HMO
must provide full coverage for Medically Necessary Covered Services to all
Members and, for STAR+PLUS Members, Functionally Necessary Community Long-term
Care Services, without regard to the Member’s:

      


      
        	
                 
      

              	
                1. previous
      coverage, if any, or the reason for termination of such
      coverage;

              


      

      


      
        	
                 
      

              	
                2. health
      status;

              


      

      


      
        	
                 
      

              	
                3. confinement
      in a health care facility; or

              


      

      


      
        	
                 
      

              	
                4. for any
      other reason.

              


      

      


      Please Note:

      


      (STAR
HMOs):  A Member cannot change from one STAR HMO to another STAR HMO
during an inpatient hospital stay.  The STAR HMO responsible for the
hospital charges for STAR Members at the start of an Inpatient Stay remains
responsible for hospital charges until the time of discharge or until such time
that there is a loss of Medicaid eligibility.  STAR HMOs are
responsible for professional charges during every month for which the HMO
receives a full capitation for a Member.

       

      (STAR+PLUS
HMOs):  A Member cannot change from one STAR+PLUS HMO to another
STAR+PLUS HMO during an inpatient hospital stay.  The STAR+PLUS HMO is
responsible for authorization and management of the inpatient hospital stay
until the time of discharge, or until such time that there is a loss of Medicaid
eligibility.  STAR+PLUS HMOs are responsible for professional charges
during every month for which the HMO receives a full capitation for a
Member.

       

      A Member
cannot change from one STAR+PLUS HMO to another STAR+PLUS HMO during a nursing
facility stay.

       

      (CHIP
HMOs):  If a CHIP Member’s Effective Date of Coverage occurs while the
CHIP Member is confined in a hospital, HMO is responsible for the CHIP Member’s
costs of Covered Services beginning on the Effective Date of
Coverage.  If a CHIP Member is disenrolled while the CHIP Member is
confined in a hospital, HMO’s responsibility for the CHIP Member’s costs of
Covered Services terminates on the Date of Disenrollment.

       

      (CHIP
Perinatal HMOs):  If a CHIP Perinate’s Effective Date of Coverage
occurs while the CHIP Perinate is confined in a Hospital, HMO is responsible for
the CHIP Perinate’s costs of Covered Services beginning on the Effective Date of
Coverage. If a CHIP Perinate is disenrolled while the CHIP Perinate is confined
in a Hospital, HMO’s responsibility for the CHIP Perinate’s costs of Covered
Services terminates on the Date of Disenrollment.

       

      The HMO
must not practice discriminatory selection, or encourage segregation among the
total group of eligible Members by excluding, seeking to exclude, or otherwise
discriminating against any group or class of individuals.

       

      Covered
Services for all Medicaid HMO Members are listed in Attachments B-2 and B-2.1 of the
Contract (STAR and STAR+PLUS Covered Services). As noted in Attachments B-2 and B-2.1, all
Medicaid HMOs must provide Covered Services described in the most recent Texas Medicaid Provider Procedures
Manual (Provider Procedures Manual), the THSteps Manual (a supplement
to the Provider Procedures Manual), and in all Texas Medicaid Bulletins,
which update the Provider Procedures Manual except for those services identified
in Section 8.2.2.8 as
non-capitated services. A description of CHIP Covered Services and exclusions is
provided in Attachment B-2 of
the Contract. A description of CHIP Perinatal Program Covered Services
and exclusions is provided in Attachment B-2.2 of the
Contract. Covered Services are subject to change due to changes in
federal and state law, changes in Medicaid, CHIP or CHIP Perinatal Program
policy, and changes in medical practice, clinical protocols, or
technology.

      


      8.1.2.1  Value-added
Services

      HMOs may
propose additional services for coverage. These are referred to as “Value-added
Services.” Value-added Services may be actual Health Care Services, benefits, or
positive incentives that HHSC determines will promote healthy lifestyles and
improved health outcomes among Members.  Value-added Services that
promote healthy lifestyles should target specific weight loss, smoking
cessation, or other programs approved by HHSC. Temporary phones, cell phones,
additional transportation benefits, and extra home health services may be
Value-added Services, if approved by HHSC.  Best practice approaches
to delivering Covered Services are not considered Value-added
Services.

       

      If
offered, Value-added Services must be offered to all mandatory STAR, and CHIP
and CHIP Perinatal HMO Members within the applicable HMO Program and Service
Area. For STAR+PLUS Acute Care services, the HMO may distinguish between the
Dual Eligible and non-Dual Eligible populations. Value-added Services do not
need to be consistent across more than one HMO Program or across more than one
Service Area. Value-added Services that are approved by HHSC during the
contracting process will be included in the Contract’s scope of
services.

       

      The HMO
must provide Value-added Services at no additional cost to HHSC. The HMO must
not pass on the cost of the Value-added Services to Providers. The HMO must
specify the conditions and parameters regarding the delivery of the Value-added
Services in the HMO’s Marketing Materials and Member Handbook, and must clearly
describe any limitations or conditions specific to the Value-added
Services.

       

      Transition
Phase.  During the Transition Phase, HHSC will offer a one-time
opportunity for the HMO to propose two additional Value-added Services to its
list of current, approved Value-added Services. (See Attachment B-3, Value-Added
Services).  HHSC will establish the requirements and the
timeframes for submitting the two additional proposed Value-added
Services.

       

      During
this HHSC-designated opportunity, the HMO may propose either to add new
Value-added Services or to enhance its current, approved Value-added
Services.  The HMO may propose two additional Value-added Services per
HMO Program, and the services do not have to be the same for each HMO
Program.  HHSC will review the proposed additional services and, if
appropriate, will approve the additional Value-added Services, which will be
effective on the Operational Start Date.  The HMO’s Contract will be
amended to reflect the additional, approved Value-added Services.

       

      The HMO
does not have to add Value-added Services during the HHSC-designated
opportunity, but this will be the only time during the Transition Phase for the
HMO to add Value-added Services.  At no time during the Transition
Phase will the HMO be allowed to delete, limit or restrict any of its current,
approved Value-added Services.

       

      Operations
Phase.  During the Operations Phase,
Value-added Services can be added or removed only by written amendment of the
Contract one time per fiscal year to be effective September 1 of the fiscal
year, except when services are amended by HHSC during the fiscal
year.  This will allow HHSC to coordinate with annual revisions to
HHSC’s HMO Comparison Charts for Members. A HMO’s request to add or delete a
Value-added Service must be submitted to HHSC
by May 1 of each year to be effective September 1 for the following contract
period. (For STAR and CHIP, see Attachment
B-3, Value-Added Services.  For
STAR+PLUS, see Attachment
B-3.1, STAR+PLUS Value-Added Services.  For
CHIP Perinatal, see
Attachment
B-3.2, CHIP Perinatal Value-Added Services.)

      


      A HMO’s
request to add a Value-added Service must:

      


      
        	
                 
      

              	
                a. Define
      and describe the proposed Value-added
Service;

              


      

      


      
        	
                 
      

              	
                b. Specify
      the Service Areas and HMO Programs for the proposed Value-added
      Service;

              


      

      


      
        	
                 
      

              	
                c. Identify
      the category or group of mandatory Members eligible to receive the
      Value-added Service if it is a type of service that is not appropriate for
      all mandatory Members;

              


      

      


      
        	
                 
      

              	
                d. Note
      any limits or restrictions that apply to the Value-added
      Service;

              


      

      


      
        	
                 
      

              	
                e. Identify
      the Providers responsible for providing the Value-added
      Service;

              


      

      


      
        	
                 
      

              	
                f. Describe
      how the HMO will identify the Value-added Service in administrative
      (Encounter) data;

              


      

      


      
        	
                 
      

              	
                g. Propose
      how and when the HMO will notify Providers and mandatory Members about the
      availability of such Value-added
Service;

              


      

      


      
        	
                 
      

              	
                h. Describe
      how a Member may obtain or access the Value-added Service;
    and

              


      

      


      
        	
                 
      

              	
                i. Include
      a statement that the HMO will provide such Value-added Service for at
      least 12 months from the September 1 effective date.  

              


      

      


      A HMO
cannot include a Value-added Service in any material distributed to mandatory
Members or prospective mandatory Members until the Parties have amended the
Contract to include that Value-added Service. If a Value-added Service is
deleted by amendment, the HMO must notify each mandatory Member that the service
is no longer available through the HMO. The HMO must also revise all materials
distributed to prospective mandatory Members to reflect the change in
Value-added Services.

       

      8.1.2.2  Case-by-Case
Added Services

      Except as
provided below, the HMO may offer additional benefits that are outside the scope
of services to individual Members on a case-by-case basis, based on Medical
Necessity, cost-effectiveness, the wishes of the Member/Member’s family, the
potential for improved health status of the Member, and for STAR+PLUS Members
based on functional necessity.

       

      Section
8.1.2.2, Case-by-Case Added Services, does not apply to the CHIP Perinatal
Program.

       

      8.1.3  Access
to Care

      All
Covered Services must be available to Members on a timely basis in accordance
with medically appropriate guidelines, and consistent with generally accepted
practice parameters, requirements in this Contract. The HMO must comply with the
access requirements as established by the Texas Department of Insurance (TDI)
for all HMOs doing business in Texas, except as otherwise required by this
Contract. Medicaid HMOs must be responsive to the possibility of increased
Members due to the phase-out of the PCCM model in Service Areas where adequate
HMO coverage exists.

      


      The HMO
must provide coverage for Emergency Services to Members 24 hours a day and 7
days a week, without regard to prior authorization or the Emergency Service
provider’s contractual relationship with the HMO. The HMO’s policy and
procedures, Covered Services, claims adjudication methodology, and reimbursement
performance for Emergency Services must comply with all applicable state and
federal laws and regulations, whether the provider is in-network or
Out-of-Network. A HMO is not responsible for payment for unauthorized
non-emergency services provided to a Member by Out-of-Network
providers.

       

      The HMO
must also have an emergency and crisis Behavioral Health Services Hotline
available 24 hours a day, 7 days a week, toll-free throughout the Service Area.
The Behavioral Health Services Hotline must meet the requirements described in
Section 8.1.15. For
Medicaid Members, a HMO must provide coverage for Emergency Services in
compliance with 42 C.F.R. §438.114, and as described in more detail in Section 8.2.2.1. The HMO may
arrange Emergency Services and crisis Behavioral Health Services through mobile
crisis teams.

       

      For CHIP
Members, Emergency Services, including emergency Behavioral Health Services,
must be provided in accordance with the Texas Insurance Code and TDI
regulations.

       

      For the
CHIP Perinatal Program, refer to Attachment B-2.2 for description of emergency
services for CHIP Perinates and CHIP Perinate Newborns.

       

      For the
STAR, STAR+PLUS, and CHIP Programs, and for CHIP Perinate Newborns, HMO must
require, and make best efforts to ensure, that PCPs are accessible to Members 24
hours a day, 7 days a week and that its Network Primary Care Providers (PCPs)
have after-hours telephone availability that is consistent with, Section 8.1.4. CHIP Perinatal
HMOs are not required to establish PCP Networks for CHIP Perinates.

       

      The HMO
must provide that if Medically Necessary Covered Services are not available
through Network physicians or other Providers, the HMO must, upon the request of
a Network physician or other Provider, within the time appropriate to the
circumstances relating to the delivery of the services and the condition of the
patient, but in no event to exceed five business days after receipt of
reasonably requested documentation, allow a referral to a non-network physician
or provider. The HMO must fully reimburse the non-network provider in accordance
with the Out-of-Network methodology for Medicaid as defined by HHSC, and for
CHIP, at the usual and customary rate defined by TDI in 28 T.A.C. Section
11.506.

       

      The
Member will not be responsible for any payment for Medically Necessary Covered
Services, including Functionally Necessary Covered Services, other
than:

      


      
        	
                (1) HHSC-specified
      co-payments for CHIP Members, where applicable;
  and

              


      

      


      (2)
STAR+PLUS Members who qualify for 1915(c) Nursing Facility Waiver services and
enter a 24-hour setting will be required to pay the provider of care room and
board costs and any income in excess of the personal needs allowance, as
established by HHSC.  If the HMO provides Members who do not qualify
for the 1915(c) Nursing Facility Waiver

      services
in a 24-hour setting as an alternative to nursing facility or hospitalization,
the Member will be required to pay the provider of care room and board costs and
any income in excess of the personal needs allowance, as established by
HHSC.

       

      8.1.3.1  Waiting
Times for Appointments

      Through
its Provider Network composition and management, the HMO must ensure that
appointments for the following types of Covered Services are provided within the
time frames specified below. In all cases below, “day” is defined as a calendar
day.

      


      
        	
                 
      

              	
                1. Emergency
      Services must be provided upon Member presentation at the service delivery
      site, including at non-network and out-of-area
  facilities;

              


      

      


      
        	
                 
      

              	
                2. Urgent
      care, including urgent specialty care, must be provided within 24 hours of
      request.

              


      

      


      
        	
                 
      

              	
                3. Routine
      primary care must be provided within 14 days of
  request;

              


      

      


      
        	
                 
      

              	
                4. Initial
      outpatient behavioral health visits must be provided within 14 days of
      request;

              


      

      


      
        	
                 
      

              	
                5. Routine
      specialty care referrals must be provided within 30 days of
      request;

              


      

      


      
        	
                 
      

              	
                6. Pre-natal
      care must be provided within 14 days of request, except for high-risk
      pregnancies or new Members in the third trimester, for whom an appointment
      must be offered within five days, or immediately, if an emergency
      exists;

              


      

      


      
        	
                 
      

              	
                7. Preventive
      health services for adults must be offered to a Member within 90 days of
      request; and

              


      

      


      
        	
                 
      

              	
                8. Preventive
      health services for children, including well-child check-ups should be
      offered to Members in accordance with the American Academy of Pediatrics
      (AAP) periodicity schedule. Please note that for Medicaid Members, HMOs
      should use the THSteps Program modifications to the AAP periodicity
      schedule. For newly enrolled Members under age 21, overdue or upcoming
      well-child checkups, including THSteps medical checkups, should be offered
      as soon as practicable, but in no case later than 14 days of enrollment
      for newborns, and no later than 60 days of enrollment for all other
      eligible child Members.

              


      

      


      8.1.3.2  Access
to Network Providers

      The HMO’s
Network shall have within its Network, PCPs in sufficient numbers, and with
sufficient capacity, to provide timely access to regular and preventive
pediatric care and THSteps services to all child Members in accordance with the
waiting times for appointments in Section 8.1.3.1.

       

      PCP Access: At a minimum, the
HMO must ensure that all Members have access to an age-appropriate PCP in the
Provider Network with an Open Panel within 30 miles of the Member’s residence.
For the purposes of assessing compliance with this requirement, an internist who
provides primary care to adults only is not considered an age-appropriate PCP
choice for a Member under age 21, and a pediatrician is not considered an
age-appropriate choice for a Member age 21 and over.   Note: This
provision does not apply to CHIP Perinates, but it does apply to CHIP Perinate
Newborns.

       

      OB/GYN Access and CHIP Perinatal
Program Provider Access: STAR, STAR+PLUS and CHIP Program
Network:  at a minimum, STAR, STAR+PLUS and CHIP HMOs must ensure that
all female Members have access to an OB/GYN in the Provider Network within 75
miles of the Member’s residence. (If the OB/GYN is acting as the Member’s PCP,
the HMO must follow the access requirements for the PCP.) The HMO must allow
female Members to select an OB/GYN within its Provider Network. A female Member
who selects an OB/GYN must be allowed direct access to the OB/GYN’s health care
services without a referral from the Member’s PCP or a prior authorization. A
pregnant Member with 12 weeks or less remaining before the expected delivery
date must be allowed to remain under the Member’s current OB/GYN care though the
Member’s post-partum checkup, even if the OB/GYN provider is, or becomes,
Out-of-Network.

       

      CHIP
Perinatal Program Network:  At a minimum, CHIP Perinatal HMOs must
ensure that CHIP Perinates have access to a Provider of perinate services within
75 miles of the Member’s residence if the Member resides in an urban area and
within 125 miles of the Member’s residence if the Member resides in a rural
area.

       

      Outpatient Behavioral Health Service
Provider Access: At a minimum, the HMO must ensure that all Members
except CHIP Perinates have access to an outpatient Behavioral Health Service
Provider in the Network within 75 miles of the Member’s residence. Outpatient
Behavioral Health Service Providers must include Masters and Doctorate-level
trained practitioners practicing independently or at community mental health
centers, other clinics or at outpatient hospital departments. A Qualified Mental
Health Provider (QMHP), as defined and credentialed by the Texas Department of
State Health Services standards (T.A.C. Title 25, Part I, Chapter 412), is an
acceptable outpatient behavioral health provider as long as the QMHP is working
under the authority of an MHMR entity and is supervised by a licensed mental
health professional or physician.

       

      Other Specialist Physician
Access: At a minimum, the HMO must ensure that all Members except CHIP
Perinates have access to a Network specialist physician within 75 miles of the
Member’s residence for common medical specialties. For adult Members, common
medical specialties shall include general surgery, cardiology, orthopedics,
urology, and ophthalmology. For child Members, common medical specialties shall
include orthopedics and otolaryngology. In addition, all Members must be allowed
to: 1) select an in-network opthalmologist or therapeutic optometrist to provide
eye Health Care Services, other than surgery, and 2) have access without a PCP
referral to eye Health Care Services from a Network specialist who is an
ophthalmologist or therapeutic optometrist for non-surgical
services.

       

      Hospital Access: The HMO must
ensure that all Members have access to an Acute Care hospital in the Provider
Network within 30 miles of the Member’s residence.  For HMOs
participating in the CHIP Perinatal Program, exceptions to this access standard
may be requested on a case-by-case basis and must have HHSC
approval.

       

      All other Covered Services, except
for services provided in the Member’s residence: At a minimum, the HMO
must ensure that all Members have access to at least one Network Provider for
each of the remaining Covered Services described in Attachment B-2, within 75
miles of the Member’s residence. This access requirement includes, but is not
limited to, specialists, specialty hospitals, psychiatric hospitals, diagnostic
and therapeutic services, and single or limited service health care physicians
or Providers, as applicable to the HMO Program.

       

      The HMO
is not precluded from making arrangements with physicians or providers outside
the HMO’s Service Area for Members to receive a higher level of skill or
specialty than the level

      available
within the Service Area, including but not limited to, treatment of cancer,
burns, and cardiac diseases. HHSC may consider exceptions to the above
access-related requirements when an HMO has established, through utilization
data provided to HHSC, that a normal pattern for securing health care services
within an area does not meet these standards, or when an HMO is providing care
of a higher skill level or specialty than the level which is available within
the Service Area such as, but not limited to, treatment of cancer, burns, and
cardiac diseases.

      


      8.1.3.3   Monitoring
Access

      The HMO
is required to systematically and regularly verify that Covered Services
furnished by Network Providers are available and accessible to Members in
compliance with the standards described in Sections 8.1.3.1 and 8.1.3.2,
and for Covered Services furnished by PCPs, the standards described in Section 8.1.4.2.

       

      The HMO
must enforce access and other Network standards required by the Contract and
take appropriate action with Providers whose performance is determined by the
HMO to be out of compliance.

       

      8.1.4  Provider
Network

      
         

        The HMO
must enter into written contracts with properly credentialed Providers as
described in this Section. The Provider contracts must comply with the Uniform Managed Care Manual’s
requirements.

         

        The HMO
must maintain a Provider Network sufficient to provide all Members with access
to the full range of Covered Services required under the Contract. The HMO must
ensure its Providers and subcontractors meet all current and future state and
federal eligibility criteria, reporting requirements, and any other applicable
rules and/or regulations related to the Contract.

         

        The
Provider Network must be responsive to the linguistic, cultural, and other
unique needs of any minority, elderly, or disabled individuals, or other special
population in the Service Areas and HMO Programs served by the HMO, including
the capacity to communicate with Members in languages other than English, when
necessary, as well as with those who are deaf or hearing impaired.

         

        The HMO
must seek to obtain the participation in its Provider Network of qualified
providers currently serving the Medicaid and CHIP Members in the HMO’s proposed
Service Area(s).

         

        NOTE: The following Provider
descriptions do not require STAR+PLUS HMOs to contract with Hospital providers
for Inpatient Stay services. STAR+PLUS HMOs are required, however, to contract
with Hospitals for Outpatient Hospital Services , and with Hospital Providers
for Inpatient Behavioral Health Services resulting from a behavioral health
primary diagnosis.

         

        All Providers: All Providers
must be licensed in the State of Texas to provide the Covered Services for which
the HMO is contracting with the Provider, and not be under sanction
or

        exclusion
from the Medicaid program. All Acute Care Providers serving Medicaid Members
must be enrolled as Medicaid providers and have a Texas Provider Identification
Number (TPIN). Long-term Care Providers are not required to have a TPIN but must
have a LTC Provider number. Providers must also have a National Provider
Identifier (NPI) in accordance with the timelines established in 45 C.F.R. Part
162, Subpart D (for most Providers, the NPI must be in place by May 23,
2007.)

         

        Inpatient hospital and medical
services: The HMO must ensure that Acute Care hospitals and specialty
hospitals are available and accessible 24 hours per day, seven days per week,
within the HMO’s Network to provide Covered Services to Members throughout the
Service Area.

         

        Children’s Hospitals/hospitals with
specialized pediatric services: The HMO must ensure Members access to
hospitals designated as Children’s Hospitals by Medicare and hospitals with
specialized pediatric services, such as teaching hospitals and hospitals with
designated children’s wings, so that these services are available and accessible
24 hours per day, seven days per week, to provide Covered Services to Members
throughout the Service Area. The HMO must make Out-of-Network reimbursement
arrangements with a designated Children’s Hospital and/or hospital with
specialized pediatric services in proximity to the Member’s residence, and such
arrangements must be in writing, if the HMO does not include such hospitals in
its Provider Network. Provider Directories, Member materials, and Marketing
materials must clearly distinguish between hospitals designated as Children’s
Hospitals and hospitals that have designated children’s units.

         

        Trauma: The HMO must ensure
Members access to Texas Department of State Health Services (TDSHS) designated
Level I and Level II trauma centers within the State or hospitals meeting the
equivalent level of trauma care in the HMO’s Service Area, or in close proximity
to such Service Area. The HMO must make Out-of-Network reimbursement
arrangements with the DSHS-designated Level I and Level II trauma centers or
hospitals meeting equivalent levels of trauma care, and such arrangements must
be in writing, if the HMO does not include such a trauma center in its Provider
Network.

         

        Transplant centers: The HMO
must ensure Member access to HHSC-designated transplant centers or centers
meeting equivalent levels of care. A list of HHSC-designated transplant centers
can be found in the Procurement Library in Attachment H. The HMO must make
Out-of-Network reimbursement arrangements with a designated transplant center or
center meeting equivalent levels of care in proximity to the Member’s residence,
and such arrangements must be in writing, if the HMO does not include such a
center in its Provider Network.

         

        Hemophilia centers: The HMO
must ensure Member access to hemophilia centers supported by the Centers for
Disease Control (CDC). A list of these hemophilia centers can be found at
http://www.cdc.gov/ncbddd/hbd/htc_list.htm. The HMO must make Out-of-Network
reimbursement arrangements with a CDC-supported hemophilia center, and such
arrangements must be in writing, if the HMO does not include such a center in
its Provider Network.

         

        Physician services: The HMO
must ensure that Primary Care Providers are available and accessible 24 hours
per day, seven days per week, within the Provider Network. The HMO must contract
with a sufficient number of participating physicians and specialists within each
Service  Area to comply with the access requirements throughout Section 8.1.3 and meet the
needs of Members for all Covered Services.

        The HMO
must ensure that an adequate number of participating physicians have admitting
privileges at one or more participating Acute Care hospitals in the Provider
Network to ensure that necessary admissions are made. In no case may there be
less than one in-network PCP with admitting privileges available and accessible
24 hours per day, seven days per week for each Acute Care hospital in the
Provider Network.

        The HMO
must ensure that an adequate number of participating specialty physicians have
admitting privileges at one or more participating hospitals in the HMO’s
Provider Network to ensure necessary admissions are made. The HMO shall require
that all physicians who admit to hospitals maintain hospital access for their
patients through appropriate call coverage.

         

        Laboratory services: The HMO
must ensure that in-network reference laboratory services must be of sufficient
size and scope to meet the non-emergency and emergency needs of the enrolled
population and the access requirements in Section 8.1.3. Reference
laboratory specimen procurement services must facilitate the provision of
clinical diagnostic services for physicians, Providers and Members through the
use of convenient reference satellite labs in each Service Area,
strategically located specimen collection areas in each Service Area, and the
use of a courier system under the management of the reference lab. For Medicaid
Members, THSteps requires that laboratory specimens obtained as part of a
THSteps medical checkup visit must be sent to the TDSHS Laboratory.

         

        Diagnostic imaging: The HMO
must ensure that diagnostic imaging services are available and accessible to all
Members in each Service Area in accordance with the access standards in Section 8.1.3. The HMO must
ensure that diagnostic imaging procedures that require the injection or
ingestion of radiopaque chemicals are performed only under the direction of
physicians qualified to perform those procedures.

         

        Home health services: The HMO
must have a contract(s) with a home health Provider so that all Members living
within the HMO’s Service Area will have access to at least one such Provider for
home health Covered Services. (These services are provided as part of the Acute
Care Covered Services, not the Community Long-term Care Services.)

         

        Community Long-term Care services:
STAR+PLUS HMOs must have contracts with Community Long-term Care service
Providers, so that all Members living within the Contractor’s Service Area will
have access to Medically Necessary and Functionally Necessary Covered
Services.

      

       

      8.1.4.1  Provider
Contract Requirements

      The HMO
is prohibited from requiring a provider or provider group to enter into an
exclusive contracting arrangement with the HMO as a condition for participation
in its Provider Network.

       

      The HMO’s
contract with health care Providers must be in writing, must be in compliance
with applicable federal and state laws and regulations, and must include minimum
requirements specified in the Uniform Managed Care Contract Terms
and Conditions (Attachment A) and HHSC’s Uniform Managed Care
Manual.

       

      The HMO
must submit model Provider contracts to HHSC for review during Readiness
Review.  HHSC retains the right to reject or require changes to any
model Provider contract that does not comply with HMO Program requirements or
the HHSC-HMO Contract.

       

      8.1.4.2  Primary
Care Providers

      The HMO’s
PCP Network may include Providers from any of the following practice areas:
General Practice; Family Practice; Internal Medicine; Pediatrics;
Obstetrics/Gynecology (OB/GYN); Certified Nurse Midwives (CNM) and Physician
Assistants (PAs) practicing under the supervision of a physician; Federally
Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and similar
community clinics; and specialist physicians who are willing to provide a
Medical Home to selected Members with special needs and conditions. Section
533.005(a)(13), Government Code, requires the HMO to use Advanced Practice
Nurses practicing under the supervision of a physician as PCPs in its Provider
Network for STAR and STAR+PLUS.

       

      CHIP
Perinatal HMOs are not required to develop PCP Networks for CHIP Perinates. CHIP
Perinatal HMOs may use the same PCP Network for CHIP Members and CHIP Perinatal
Newborns.

       

      An
internist or other Provider who provides primary care to adults only is not
considered an age-appropriate PCP choice for a Member under age 21. An internist
or other Provider who provides primary care to adults and children may be a PCP
for children if:

      


      
        	
                 
      

              	
                1. the
      Provider assumes all HMO PCP responsibilities for such Members in a
      specific age group under age 21,

              


      

      


      
        	
                 
      

              	
                2. the
      Provider has a history of practicing as a PCP for the specified age group
      as evidenced by the Provider’s primary care practice including an
      established patient population under age 20 and within the specified age
      range, and

              


      

      


      
        	
                 
      

              	
                3. the
      Provider has admitting privileges to a local hospital that includes
      admissions to pediatric units.

              


      

      


      A
pediatrician is not considered an age-appropriate choice for a Member age 21 and
over.

       

      The PCP
for a Member with disabilities, Special Health Care Needs, or Chronic or Complex
Conditions may be a specialist physician who agrees to provide PCP services to
the Member. The specialty physician must agree to perform all PCP duties
required in the Contract and PCP duties must be within the scope of the
specialist’s license. Any interested person may initiate the request through the
HMO for a specialist to serve as a PCP for a Member with disabilities, Special
Health Care Needs, or Chronic or Complex Conditions. The HMO shall handle such
requests in accordance with 28 T.A.C. Part 1, Chapter 11, Subchapter
J.

       

      PCPs who
provide Covered Services for STAR, CHIP, and CHIP Perinatal Newborns must either
have admitting privileges at a Hospital that is part of the HMO’s Provider
Network or make referral arrangements with a Provider who has admitting
privileges to a Network Hospital. STAR+PLUS PCPs must either have admitting
privileges at a Medicaid Hospital or make referral arrangements with a Provider
who has admitting privileges to a Medicaid Hospital.

      


      The HMO
must require, through contract provisions, that PCPs are accessible to Members
24 hours a day, 7 days a week. The HMO is encouraged to include in its Network
sites that offer primary care services during evening and weekend hours. The
following are acceptable and unacceptable telephone arrangements for contacting
PCPs after their normal business hours.

       

      Acceptable
after-hours coverage:

      


      
        	
                 
      

              	
                1. The
      office telephone is answered after-hours by an answering service, which
      meets language requirements of the Major Population Groups and which can
      contact the PCP or another designated medical practitioner.  All
      calls answered by an answering service must be returned within 30
      minutes;

              


      

      


      
        	
                 
      

              	
                2. The
      office telephone is answered after normal business hours by a recording in
      the language of each of the Major Population Groups served, directing the
      patient to call another number to reach the PCP or another provider
      designated by the PCP. Someone must be available to answer the designated
      provider’s telephone. Another recording is not acceptable;
    and

              


      

      


      
        	
                 
      

              	
                3. The
      office telephone is transferred after office hours to another location
      where someone will answer the telephone and be able to contact the PCP or
      another designated medical practitioner, who can return the call within 30
      minutes.

              


      

      


      Unacceptable
after-hours coverage:

      


      
        	
                 
      

              	
                1. The
      office telephone is only answered during office
  hours;

              


      

      


      
        	
                 
      

              	
                2. The
      office telephone is answered after-hours by a recording that tells
      patients to leave a message;

              


      

      


      
        	
                 
      

              	
                3. The
      office telephone is answered after-hours by a recording that directs
      patients to go to an Emergency Room for any services needed;
      and

              


      

      


      
        	
                 
      

              	
                4. Returning
      after-hours calls outside of 30
minutes.

              


      

      


      The HMO
must require PCPs, through contract provisions or Provider Manual, to provide
children under the age of 21 with preventive services in accordance with the AAP
recommendations for CHIP Members and CHIP Perinate Newborns, and the THSteps
periodicity schedule published in the THSteps Manual for Medicaid Members. The
HMO must require PCPs, through contract provisions or Provider Manual, to
provide adults with preventive services in accordance with the U.S. Preventive
Services Task Force requirements. The HMO must make best efforts to ensure that
PCPs follow these periodicity requirements for children and adult Members. Best
efforts must include, but not be limited to, Provider education, Provider
profiling, monitoring, and feedback activities.

       

      The HMO
must require PCPs, through contract provisions or Provider Manual, to assess the
medical needs of Members for referral to specialty care providers and provide
referrals as needed. PCPs must coordinate Members’ care with specialty care
providers after referral. The HMO must make best efforts to ensure that PCPs
assess Member needs for referrals and make such referrals. Best efforts must
include, but not be limited to, Provider education activities and review of
Provider referral patterns.

       

      8.1.4.3  PCP
Notification

      The HMO
must furnish each PCP with a current list of enrolled Members enrolled or
assigned to that Provider no later than five (5) working days after the HMO
receives the Enrollment File from the HHSC Administrative Services Contractor
each month. The HMO may offer and provide such enrollment information in
alternative formats, such as through access to a secure Internet site, when such
format is acceptable to the PCP.

       

      8.1.4.4  Provider
Credentialing and Re-credentialing

      
        The HMO
must review, approve and periodically recertify the credentials of all
participating physician Providers and all other licensed Providers who
participate in the HMO’s Provider Network. The HMO may subcontract with another
entity to which it delegates such credentialing activities if such delegated
credentialing is maintained in accordance with the National Committee for
Quality Assurance (NCQA) delegated credentialing requirements and any comparable
requirements defined by HHSC.

         

        At a
minimum, the scope and structure of a HMO’s credentialing and re-credentialing
processes must be consistent with recognized HMO industry standards such as
those provided by NCQA and relevant state and federal regulations including 28
T.A.C. §11.1902, relating to credentialing of providers in HMOs, and as an
additional requirement for Medicaid HMOs, 42 C.F.R. §438.214(b). The initial
credentialing process, including application, verification of information, and a
site visit (if applicable), must be completed before the effective date of the
initial contract with the physician or Provider. The re-credentialing process
must occur at least every three years.

         

        The
re-credentialing process must take into consideration Provider performance data
including, but not be limited to, Member Complaints and Appeals, quality of
care, and utilization management.

         

        HMOs must
comply with the requirements of Texas Insurance Code Chapter 1452, Subchapter C,
regarding expedited credentialing and payment of physicians who have joined
medical groups that are already contracted with the HMO.

      

       

      8.1.4.5  Board
Certification Status

      The HMO
must maintain a policy with respect to Board Certification for PCPs and
specialty physicians that encourage participation of board certified PCPs and
specialty physicians in the Provider Network. The HMO must make information on
the percentage of Board-certified PCPs in the Provider Network and the
percentage of Board-certified specialty physicians, by specialty, available to
HHSC upon request.

       

      8.1.4.6  Provider
Manual, Materials and Training

      The HMO
must prepare and issue a Provider Manual(s), including any necessary specialty
manuals (e.g., behavioral health) to all existing Network
Providers.  For newly contracted Providers, the HMO must issue copies
of the Provider Manual(s) within five (5) working days from inclusion of the
Provider into the Network. The Provider Manual must contain sections relating to
special requirements of the HMO Program(s) and the enrolled populations in
compliance with the requirements of this Contract.

       

      HHSC or
its designee must approve the Provider Manual, and any substantive revisions to
the Provider Manual, prior to publication and distribution to
Providers.  The Provider Manual must contain the critical elements
defined in the Uniform Managed
Care Manual. HHSC’s initial review of the Provider Manual is part of the
Operational Readiness Review described in Attachment B-1, Section 7.

      The HMO
must provide training to all Providers and their staff regarding the
requirements of the Contract and special needs of Members. The HMO’s Medicaid,
CHIP and/or CHIP Perinatal Program training must be completed within 30 days of
placing a newly contracted Provider on active status. The HMO must provide
on-going training to new and existing Providers as required by the HMO or HHSC
to comply with the Contract. The HMO must maintain and make available upon
request enrollment or attendance rosters dated and signed by each attendee or
other written evidence of training of each Provider and their
staff.

       

      The HMO
must establish ongoing Provider training that includes, but is not limited to,
the following issues:

      


      
        	
                 
      

              	
                1. Covered
      Services and the Provider’s responsibilities for providing and/or
      coordinating such services. Special emphasis must be placed on areas that
      vary from commercial coverage rules (e.g., Early Intervention services,
      therapies and DME/Medical Supplies); and for Medicaid, making referrals
      and coordination with Non-capitated
Services;

              


      

      


      
        	
                 
      

              	
                2. Relevant
      requirements of the Contract;

              


      

      


      
        	
                 
      

              	
                3. The
      HMO’s quality assurance and performance improvement program and the
      Provider’s role in such a program;
and

              


      

      


      
        	
                 
      

              	
                4. The
      HMO’s policies and procedures, especially regarding in-network and
      Out-of-Network referrals.

              


      

      


      Provider
Materials produced by the HMO, relating to Medicaid Managed Care, the CHIP
Program, and/or the CHIP Perinatal Program must be in compliance with State and
Federal laws and requirements of the HHSC Uniform Managed Care Contract
Terms and Conditions.  HMO must make available any provider
materials to HHSC upon request.

       

      8.1.4.7  Provider
Hotline

      
        The HMO
must operate a toll-free telephone line for Provider inquiries from 8 a.m. to 5
p.m. local time for the Service Area, Monday through Friday, except for
State-approved holidays. The Provider Hotline must be staffed with personnel who
are knowledgeable about Covered Services and each applicable HMO Program, and
for Medicaid, about Non-capitated Services.

         

        The HMO
must ensure that after regular business hours the line is answered by an
automated system with the capability to provide callers with operating hours
information and instructions on how to verify enrollment for a Member with an
Urgent Condition or an Emergency Medical Condition. The HMO must have a process
in place to handle after-hours inquiries from Providers seeking to verify
enrollment for a Member with an Urgent Condition or an Emergency Medical
Condition,
provided, however, that the HMO and its Providers must not require such
verification prior to providing Emergency Services.

         

        The HMO
must ensure that the Provider Hotline meets the following minimum performance
requirements for all HMO Programs and Service Areas:

        


        
          	
                   
      

                	
                  1.
      99% of calls are answered by the fourth ring or an automated call pick-up
      system is used;

                


        

        


        
          	
                   
      

                	
                  2.
      no more than one percent of incoming calls receive a busy
      signal;

                


        

        


        
          	
                   
      

                	
                  3.
      the average hold time is 2 minutes or less;
and

                


        

        


        
          	
                   
      

                	
                  4.
      the call abandonment rate is 7% or
less.

                


        

        


        The HMO
must conduct ongoing call quality assurance to ensure these standards are met.
The Provider Hotline may serve multiple HMO Programs if Hotline staff is
knowledgeable about all of the HMO’s Programs. The Provider Hotline may serve
multiple Service Areas if the Hotline staff is knowledgeable about all such
Service Areas, including the Provider Network in such Service
Areas.

         

        The HMO
must monitor its performance regarding Provider Hotline standards and submit
performance reports summarizing call center performance for the Hotline as
indicated in Section
8.1.20. If the HMO subcontracts with a Behavioral Health Organization
(BHO) that is responsible for Provider Hotline functions related to Behavioral
Health Services, the BHO’s Provider Hotline must meet the requirements in Section 8.1.4.7.

         

        If HHSC
determines that it is necessary to conduct onsite monitoring of the HMO’s
Provider Hotline functions, the HMO is responsible for all reasonable costs
incurred by HHSC or its authorized agent(s) relating to such
monitoring.

      

       

      8.1.4.8  Provider
Reimbursement

      The HMO
must make payment for all Medically Necessary Covered Services provided to all
Members for whom the HMO is paid a capitation.  A STAR+PLUS HMO must
also make payment for all Functionally Necessary Covered Services provided to
all Members for whom the HMO is paid a capitation. The HMO must ensure that
claims payment is timely and accurate as described in Section 8.1.18.5. The HMO must require
tax identification numbers from all participating Providers. The HMO is required
to do back-up withholding from all payments to Providers who fail to give tax
identification numbers or who give incorrect numbers.

       

      8.1.4.9  Termination
of Provider Contracts

      Unless
prohibited or limited by applicable law, at least 15 days prior to the effective
date of the HMO’s termination of contract of any participating Provider the HMO
must notify the HHSC Administrative Services Contractor and notify affected
current Members in writing.  Affected Members include all Members in a
PCP’s panel and all Members who have been receiving ongoing care from the
terminated Provider, where ongoing care is defined as two or more visits for
home-based or office-based care in the past 12 months.

       

      For the
CHIP and CHIP Perinatal Programs, the HMO’s process for terminating Provider
contracts must comply with the Texas Insurance Code and TDI
regulations.

       

      8.1.5  Member
Services

      The HMO
must maintain a Member Services Department to assist Members and Members’ family
members or guardians in obtaining Covered Services for Members. The HMO must
maintain employment standards and requirements (e.g., education, training, and
experience) for Member
Services Department staff and provide a sufficient number of staff for the
Member Services Department to meet the requirements of this Section, including
Member Hotline response times, and Linguistic Access capabilities, see 8.1.5.6
Member Hotline Requirements.

       

      8.1.5.1  Member
Materials

      The HMO
must design, print and distribute Member identification (ID) cards and a Member
Handbook to Members.  Within five business days following the receipt
of an Enrollment File from the HHSC Administrative Services Contractor, the HMO
must mail a Member’s ID card and Member Handbook to the Case Head or Account
Name for each new Member. When the Case Head or Account Name is on behalf of two
or more new Members, the HMO is only required to send one Member Handbook. The
HMO is responsible for mailing materials only to those Members for whom valid
address data are contained in the Enrollment File.

       

      The HMO
must design, print and distribute a Provider Directory to the HHSC
Administrative Services Contractor as described in Section 8.1.5.4.

       

      Member
materials must be at or below a 6th grade reading level as measured by the
appropriate score on the Flesch reading ease test. Member materials must be
available in English, Spanish, and the languages of other Major Population
Groups making up 10% or more of the managed care eligible population in the
HMO’s Service Area, as specified by HHSC.  HHSC will provide the HMO
with reasonable notice when the enrolled population reaches 10% within the HMO’s
Service Area. All Member materials must be available in a format accessible to
the visually impaired, which may include large print, Braille, and
audiotapes.

       

      The HMO
must submit member materials to HHSC for approval prior to use or
mailing.  HHSC will identify any required changes to the Member
materials within 15 business days.  If HHSC has not responded to the
Contractor by the fifteenth day, the Contractor may proceed to use the submitted
materials.  HHSC reserves the right to require discontinuation of any
Member materials that violate the terms of the Uniform Managed Care Terms and
Conditions, including but not limited to “Marketing Policies and
Procedures” as described in the Uniform Managed Care
Manual.

       

      8.1.5.2  Member
Identification (ID) Card

       

      All
Member ID cards must, at a minimum, include the following
information:

      


      
        	
                 
      

              	
                1. the
      Member’s name;

              


      

       

      
        	
              	
                2.
      the Member’s Medicaid, CHIP or CHIP Perinatal Program
    number;

              


         

      

      
        	
                 
      

              	
                3. the
      effective date of the PCP assignment (excluding CHIP
      Perinates);

              


      

      


      
        	
                 
      

              	
                4. the
      PCP’s name, address (optional for all products), and telephone number
      (excluding CHIP Perinates);

              


      

      


      
        	
                 
      

              	
                5. the
      name of the HMO;

              


      

      


      
        	
                 
      

              	
                6. the
      24-hour, seven (7) day a week toll-free Member services telephone number
      and BH Hotline number operated by the HMO;
and

              


      

      


      
        	
                 
      

              	
                7. any
      other critical elements identified in the Uniform Managed Care
      Manual.

              


      

       

      The HMO
must reissue the Member ID card if a Member reports a lost card, there is a
Member name change, if the Member requests a new PCP, or for any other reason
that results in a change to the information disclosed on the ID
card.  CHIP Perinatal HMOs must issue Member ID cards to both CHIP
Perinates and CHIP Perinate Newborns.

       

      8.1.5.3  Member
Handbook

      HHSC must
approve the Member Handbook, and any substantive revisions, prior to publication
and distribution. As described in Attachment B-1, Section 7, the HMO must
develop and submit to HHSC the draft Member Handbook for approval during the
Readiness Review and must submit a final Member Handbook incorporating changes
required by HHSC prior to the Operational Start Date.

       

      The
Member Handbook for each applicable HMO Program must, at a minimum, meet the
Member materials requirements specified by Section 8.1.5.1 above and must
include critical elements in the Uniform Managed Care
Manual.  CHIP Perinatal HMOs must issue Member Handbooks to
both CHIP Perinates and CHIP Perinate Newborns.  The Member Handbook
for CHIP Perinate Newborns may be the same as that used for CHIP.

       

      The HMO
must produce a revised Member Handbook, or an insert informing Members of
changes to Covered Services upon HHSC notification and at least 30 days prior to
the effective date of such change in Covered Services. In addition to modifying
the Member materials for new Members, the HMO must notify all existing Members
of the Covered Services change during the time frame specified in this
subsection.

       

      8.1.5.4  Provider
Directory

      The
Provider Directory for each applicable HMO Program, and any substantive
revisions, must be approved by HHSC prior to publication and distribution. The
HMO is responsible for submitting draft Provider directory updates to HHSC for
prior review and approval if changes other than PCP information or clerical
corrections are incorporated into the Provider Directory.

       

      As
described in Attachment B-1,
Section 7, during the Readiness Review, the HMO must develop and submit
to HHSC the draft Provider Directory template for approval and must submit a
final Provider Directory incorporating changes required by HHSC prior to the
Operational Start Date. Such draft and final Provider Directories must be
submitted according to the deadlines established in Attachment B-1, Section
7.

       

      The
Provider Directory for each applicable HMO Program must, at a minimum, meet the
Member Materials requirements specified by Section 8.1.5.1 above and must
include critical elements in the Uniform Managed Care Manual.
The Provider Directory must include only Network Providers credentialed by the
HMO in accordance with Section
8.1.4.4. If the HMO contracts with limited Provider Networks, the
Provider Directory must comply with the requirements of 28 T.A.C.
§11.1600(b)(11), relating to the disclosure and notice of limited Provider
Networks.

       

      CHIP
Perinatal HMOs must develop Provider Directories for both CHIP Perinates and
CHIP Perinate Newborns.  The Provider Directory for CHIP Perinate
Newborns may be the same as that used for the CHIP Program.

      


      The HMO
must update the Provider Directory on a quarterly basis. The HMO must make such
update available to existing Members on request, and must provide such update to
the HHSC Administrative Services Contractor at the beginning of each state
fiscal quarter. HHSC will consult with the HMOs and the HHSC Administrative
Services Contractors to discuss methods for reducing the HMO’s administrative
costs of producing new Provider Directories, including considering submission of
new Provider Directories on a semi-annual rather than a quarterly basis if a HMO
has not made major changes in its Provider Network, as determined by HHSC. HHSC
will establish weight limits for the Provider Directories. Weight limits may
vary by Service Area. HHSC will require HMOs that exceed the weight limits to
compensate HHSC for postage fees in excess of the weight limits.

       

      The HMO
must send the most recent Provider Directory, including any updates, to Members
upon request. The HMO must, at least annually, include written and verbal offers
of such Provider Directory in its Member outreach and education
materials.

       

      8.1.5.5  Internet
Website

      The HMO
must develop and maintain, consistent with HHSC standards and Section 843.2015
of the Texas Insurance Code and other applicable state laws, a website to
provide general information about the HMO’s Program(s), its Provider Network,
its customer services, and its Complaints and Appeals process. The HMO may
develop a page within its existing website to meet the requirements of this
section. The HMO must maintain a Provider Directory for its HMO Program(s) on
the HMO’s website with designation of open versus closed panels. All HMOs must
list Home Health Ancillary providers on their websites, with an indicator for
Pediatric services if provided. The HMO’s website must comply with the Marketing
Policies and Procedures for each applicable HHSC HMO Program.

       

      The
website’s HMO Program content must be:

      


      
        	
                 
      

              	
                1. Written
      in Major Population Group languages (which under this contract include
      only English and Spanish);

              


      

      


      
        	
                 
      

              	
                2. Culturally
      appropriate;

              


      

      


      
        	
                 
      

              	
                3. Written
      for understanding at the 6th grade reading level;
  and

              


      

      


      
        	
                 
      

              	
                4. Be
      geared to the health needs of the enrolled HMO Program
      population.

              


      

      


      To
minimize download and “wait times,” the website must avoid tools or techniques
that require significant memory or disk resources or require special
intervention on the customer side to install plug-ins or additional software.
Use of proprietary items that would require a specific browser are not
allowed.  HHSC strongly encourages the use of tools that take
advantage of efficient data access methods and reduce the load on the server or
bandwidth.

       

      8.1.5.6  Member
Hotline

      
        
          The
HMO must operate a toll-free hotline that Members can call 24 hours a day, seven
(7) days a week. The Member Hotline must be staffed with personnel who are
knowledgeable about its HMO Program(s) and Covered Services, between the hours
of 8:00 a.m. to 5:00 p.m. local time for the Service Area, Monday through
Friday, excluding state-approved holidays.

           

          The
HMO must ensure that after hours, on weekends, and on holidays the Member
Services Hotline is answered by an automated system with the capability to
provide callers with operating hours and instructions on what to do in cases of
emergency. All recordings must be in English and in Spanish. A voice mailbox
must be available after hours for callers to leave messages. The HMO’s Member
Services representatives must return member calls received by the automated
system on the next working day.

           

          If
the Member Hotline does not have a voice-activated menu system, the HMO must
have a menu system that will accommodate Members who cannot access the system
through other physical means, such as pushing a button.

           

          The
HMO must ensure that its Member Service representatives treat all callers with
dignity and respect the callers’ need for privacy. At a minimum, the HMO’s
Member Service representatives must be:

          


          
            	
                     
      

                  	
                    1.
      Knowledgeable about Covered
Services;

                  


          

          


          
            	
                     
      

                  	
                    2.
      Able to answer non-technical questions pertaining to the role of the PCP,
      as applicable;

                  


          

          


          
            	
                     
      

                  	
                    3.
      Able to answer non-clinical questions pertaining to referrals or the
      process for receiving authorization for procedures or
      services;

                  


          

          


          
            	
                     
      

                  	
                    4.
      Able to give information about Providers in a particular
    area;

                  


          

          


          
            	
                     
      

                  	
                    5.
      Knowledgeable about Fraud, Abuse, and Waste and the requirements to report
      any conduct that, if substantiated, may constitute Fraud, Abuse, or Waste
      in the HMO Program;

                  


          

          


          
            	
                     
      

                  	
                    6.
      Trained regarding Cultural
Competency;

                  


          

          


          
            	
                     
      

                  	
                    7.
      Trained regarding the process used to confirm the status of persons with
      Special Health Care Needs;

                  


          

          


          
            	
                     
      

                  	
                    8.
      For Medicaid members, able to answer non-clinical questions
      pertaining to accessing Non-capitated
Services.

                  


          

          


          
            	
                     
      

                  	
                    9.
      For Medicaid Members, trained regarding: a) the emergency prescription
      process and what steps to take to immediately address problems when
      pharmacies do not provide a 72-hour supply of emergency medicines; and b)
      DME processes for obtaining services and how to address common
      problems.

                  


          

          


          
            	
                     
      

                  	
                    10.
      For CHIP Members, able to give correct cost-sharing information relating
      to premiums, co-pays or deductibles, as applicable. (Cost-sharing does not
      apply to CHIP Perinates or CHIP Perinate
  Newborns.)

                  


          

          


          Hotline
services must meet Cultural Competency requirements and must appropriately
handle calls from non-English speaking (and particularly, Spanish-speaking)
callers, as well as calls from

          individuals
who are deaf or hard-of-hearing. To meet these requirements, the HMO must employ
bilingual Spanish-speaking Member Services representatives and must secure the
services of other contractors as necessary to meet these
requirements.

           

          The
HMO must process all incoming Member correspondence and telephone inquiries in a
timely and responsive manner. The HMO cannot impose maximum call duration limits
but must allow calls to be of sufficient length to ensure adequate information
is provided to the Member. The HMO must ensure that the toll-free Member Hotline
meets the following minimum performance requirements for all HMO Programs and
Service Areas:

          


          
            	
                     
      

                  	
                    1.
      99% of calls are answered by the fourth ring or an automated call pick-up
      system;

                  


          

          


          
            	
                     
      

                  	
                    2.
      no more than one percent (1%) of incoming calls receive a busy
      signal;

                  


          

          


          
            	
                     
      

                  	
                    3.
      at least 80% of calls must be answered by toll-free line staff within 30
      seconds measured from the time the call is placed in queue after selecting
      an option; and

                  


          

          


          
            	
                     
      

                  	
                    4.
      the call abandonment rate is 7% or
less.

                  


          

          


          The
HMO must conduct ongoing quality assurance to ensure these standards are
met.

           

          The
Member Services Hotline may serve multiple HMO Programs if Hotline staff is
knowledgeable about all of the HMO’s Medicaid and/or CHIP Programs. The Member
Services Hotline may serve multiple Service Areas if the Hotline staff is
knowledgeable about all such Service Areas, including the Provider Network in
each Service Area.

           

          The HMO must monitor
its performance regarding HHSC Member Hotline standards and submit performance
reports summarizing call center performance for the Member Hotline as indicated
in Section 8.1.20 and the Uniform Managed Care Manual.

           

          If
HHSC determines that it is necessary to conduct onsite monitoring of the HMO’s
Member Hotline functions, the HMO is responsible for all reasonable costs
incurred by HHSC or its authorized agent(s) relating to such
monitoring.

        

         

      

      8.1.5.6.1
Nurseline

      HMO is
encouraged to train staff at its 24-hour nurse hotline about: a) emergency
prescription process and what steps to take to immediately address Medicaid
Members’ problems when pharmacies do not provide a 72-hour supply of emergency
medicines; and b) DME processes for obtaining services and how to address common
problems.  The 24-hour nurse hotline will attempt to respond
immediately to problems concerning emergency medicines by means at its disposal,
including explaining the rules to Medicaid Members so that they understand their
rights and, if need be, by offering to contact the pharmacy that is refusing to
fill the prescription to explain the 72-hour supply policy and DME
processes.

       

      8.1.5.7  Member
Education

      The HMO
must, at a minimum, develop and implement health education initiatives that
educate Members about:

      


      
        	
                 
      

              	
                1. How the
      HMO system operates, including the role of the
  PCP;

              


      

      


      
        	
                 
      

              	
                2. Covered
      Services, limitations and any Value-added Services offered by the
      HMO;

              


      

      


      
        	
                 
      

              	
                3. The
      value of screening and preventive care,
and

              


      

      


      
        	
                 
      

              	
                4. How to
      obtain Covered Services, including:

              


      

      


      
        	
                 
      

              	
                a. Emergency
      Services;

              


      

      
        	
                 
      

              	
                b. Accessing
      OB/GYN and specialty care;

              


      

      
        	
                 
      

              	
                c. Behavioral
      Health Services;

              


      

      
        	
                 
      

              	
                d. Disease
      Management programs;

              


      

      
        	
                 
      

              	
                e. Service
      Coordination, treatment for pregnant women, Members with Special Health
      Care Needs, including Children with Special Health Care Needs; and other
      special populations;

              


      

      
        	
                 
      

              	
                f. Early
      Childhood Intervention (ECI)
Services;

              


      

      
        	
                 
      

              	
                g. Screening
      and preventive services, including well-child care (THSteps medical
      checkups for Medicaid Members);

              


      

      
        	
                 
      

              	
                h. For
      CHIP Members, Member co-payments

              


      

      
        	
                 
      

              	
                i. Suicide
      prevention;

              


      

      
        	
                 
      

              	
                j. Identification
      and health education related to Obesity; and

              
	 	k. Obtaining
      72 hour supplies of emergency prescriptions from pharmacies enrolled with
      HHSC as Medicaid providers.


      

       

      


      The HMO
must provide a range of health promotion and wellness information and activities
for Members in formats that meet the needs of all Members. The HMO must propose,
implement, and assess innovative Member education strategies for wellness care
and immunization, as well as general health promotion and prevention. The HMO
must conduct wellness promotion programs to improve the health status of its
Members. The HMO may cooperatively conduct health education classes for all
enrolled Members with one or more HMOs also contracting with HHSC in the Service
Area. The HMO must work with its Providers to integrate health education,
wellness and prevention training into the care of each Member.

       

      The HMO
also must provide condition and disease-specific information and educational
materials to Members, including information on its Service Management and
Disease Management programs described in Section 8.1.13 and Section
8.1.  Condition- and disease-specific information must be
oriented to various groups within the managed care eligible population, such as
children, the elderly, persons with disabilities and non-English speaking
Members, as appropriate to the HMO’s Medicaid, CHIP and/or CHIP Perinatal
Program(s).

       

      8.1.5.8  Cultural
Competency Plan

      The HMO
must have a comprehensive written Cultural Competency Plan describing how the
HMO will ensure culturally competent services, and provide Linguistic Access and
Disability-related Access. The Cultural Competency Plan must describe how the
individuals and systems within the HMO will effectively provide services to
people of all cultures, races, ethnic backgrounds, and religions as well as
those with disabilities in a manner that recognizes, values, affirms, and
respects the worth of the individuals and protects and preserves the dignity of
each. The HMO must submit the Cultural Competency Plan to HHSC for Readiness
Review. Modifications and amendments to the plan must be submitted to HHSC no
later than 30 days prior to implementation. The Plan must also be made available
to the HMO’s Network of Providers.

       

      8.1.5.9  Member
Complaint and Appeal Process

      The HMO
must develop, implement and maintain a system for tracking, resolving, and
reporting Member Complaints regarding its services, processes, procedures, and
staff. The HMO must ensure that Member Complaints are resolved within 30
calendar days after receipt. The HMO is subject to remedies, including
liquidated damages, if at least 98 percent of Member Complaints are not resolved
within 30 days of receipt of the Complaint by the HMO. Please see the Uniform Managed Care Contract Terms
& Conditions and
Attachment B-5, Deliverables/Liquidated Damages Matrix.

       

      The HMO
must develop, implement and maintain a system for tracking, resolving, and
reporting Member Appeals regarding the denial or limited authorization of a
requested service, including the type or level of service and the denial, in
whole or in part, of payment for service. Within this

      process,
the HMO must respond fully and completely to each Appeal and establish a
tracking mechanism to document the status and final disposition of each
Appeal.

      


      The HMO
must ensure that Member Appeals are resolved within 30 calendar days, unless the
HMO can document that the Member requested an extension or the HMO shows there
is a need for additional information and the delay is in the Member's interest.
The HMO is subject to liquidated damages if at least 98 percent of Member
Appeals are not resolved within 30 days of receipt of the Appeal by the HMO.
Please see the Uniform Managed
Care Contract Terms & Conditions and Attachment B-5,
Deliverables/Liquidated Damages Matrix.

       

      Medicaid
HMOs must follow the Member Complaint and Appeal Process described in Section 8.2.6. CHIP and CHIP
Perinatal HMOs must comply with the CHIP Complaint and Appeal Process described
in Sections 8.4.2
and 8.5.2,
respectively.

       

      8.1.6  Marketing
and Prohibited Practices

      The HMO
and its Subcontractors must adhere to the Marketing Policies and Procedures as
set forth by HHSC in the Contract, and the HHSC Uniform Managed Care
Manual.

       

      8.1.7  Quality
Assessment and Performance Improvement

      The HMO
must provide for the delivery of quality care with the primary goal of improving
the health status of Members and, where the Member’s condition is not amenable
to improvement, maintain the Member’s current health status by implementing
measures to prevent any further decline in condition or deterioration of health
status. The HMO must work in collaboration with Providers to actively improve
the quality of care provided to Members, consistent with the Quality Improvement
Goals and all other requirements of the Contract. The HMO must provide
mechanisms for Members and Providers to offer input into the HMO’s quality
improvement activities.

       

      8.1.7.1  QAPI
Program Overview

      The HMO
must develop, maintain, and operate a quality assessment and performance
improvement (QAPI) Program consistent with the Contract, and TDI requirements,
including 28 T.A.C. §11.1901(a)(5) and §11.1902. Medicaid HMOs must also meet
the requirements of 42 C.F.R. §438.240.

       

      The HMO
must have on file with HHSC an approved plan describing its QAPI Program,
including how the HMO will accomplish the activities required by this section.
The HMO must submit a QAPI Program Annual Summary in a format and timeframe
specified by HHSC or its designee. The HMO must keep participating physicians
and other Network Providers informed about the QAPI Program and related
activities. The HMO must include in Provider contracts a requirement securing
cooperation with the QAPI.

       

      The HMO
must approach all clinical and non-clinical aspects of quality assessment and
performance improvement based on principles of Continuous Quality Improvement
(CQI)/Total Quality Management (TQM) and must:

      


      
        	
                 
      

              	
                1. Evaluate
      performance using objective quality
indicators;

              


      

      


      
        	
                 
      

              	
                2. Foster
      data-driven decision-making;

              


      

      


      
        	
                 
      

              	
                3. Recognize
      that opportunities for improvement are
  unlimited;

              


      

      


      
        	
                 
      

              	
                4. Solicit
      Member and Provider input on performance and QAPI
    activities;

              


      

      


      
        	
                 
      

              	
                5. Support
      continuous ongoing measurement of clinical and non-clinical effectiveness
      and Member satisfaction;

              


      

      


      
        	
                 
      

              	
                6. Support
      programmatic improvements of clinical and non-clinical processes based on
      findings from on-going measurements;
and

              


      

      


      
        	
                 
      

              	
                7. Support
      re-measurement of effectiveness and Member satisfaction, and continued
      development and implementation of improvement interventions as
      appropriate.

              


      

      


      8.1.7.2  QAPI
Program Structure

      The HMO
must maintain a well-defined QAPI structure that includes a planned systematic
approach to improving clinical and non-clinical processes and outcomes. The HMO
must designate a senior executive responsible for the QAPI Program and the
Medical Director must have substantial involvement in QAPI Program activities.
At a minimum, the HMO must ensure that the QAPI Program structure:

      


      
        	
                 
      

              	
                1. Is
      organization-wide, with clear lines of accountability within the
      organization;

              


      

      


      
        	
                 
      

              	
                2. Includes
      a set of functions, roles, and responsibilities for the oversight of QAPI
      activities that are clearly defined and assigned to appropriate
      individuals, including physicians, other clinicians, and
      non-clinicians;

              


      

      


      
        	
                 
      

              	
                3. Includes
      annual objectives and/or goals for planned projects or activities
      including clinical and non-clinical programs or initiatives and
      measurement activities; and

              


      

      


      
        	
                 
      

              	
                4. Evaluates
      the effectiveness of clinical and non-clinical
  initiatives.

              


      

      


      8.1.7.3  Clinical
Indicators

      The HMO
must engage in the collection of clinical indicator data. The HMO must use such
clinical indicator data in the development, assessment, and modification of its
QAPI Program.

       

      8.1.7.4  QAPI
Program Subcontracting

      If the
HMO subcontracts any of the essential functions or reporting requirements
contained within the QAPI Program to another entity, the HMO must maintain a
file of the subcontractors. The file must be available for review by HHSC or its
designee upon request.

       

      8.1.7.5  Behavioral
Health Integration into QAPI Program

      If the
HMO provides Behavioral Health Services within the Covered Services as defined
in Attachments
B-2, B-2.1, and B-2.2, it must
integrate behavioral health into its QAPI Program and include a systematic and
on-going process for monitoring, evaluating, and improving the quality
and appropriateness of Behavioral Health Services provided to Members. The HMO
must collect data, and monitor and evaluate for improvements to physical health
outcomes resulting from behavioral health integration into the Member’s overall
care.

      


      8.1.7.6  Clinical
Practice Guidelines

      The HMO
must adopt not less than two evidence-based clinical practice guidelines for
each applicable HMO Program. Such practice guidelines must be based on valid and
reliable clinical evidence, consider the needs of the HMO’s Members, be adopted
in consultation with contracting health care professionals, and be reviewed and
updated periodically, as appropriate. The HMO must develop practice guidelines
based on the health needs and opportunities for improvement identified as part
of the QAPI Program.

       

      The HMO
may coordinate the development of clinical practice guidelines with other HHSC
HMOs to avoid providers in a Service Area receiving conflicting practice
guidelines from different HMOs.

       

      The HMO
must disseminate the practice guidelines to all affected Providers and, upon
request, to Members and potential Members.

       

      The HMO
must take steps to encourage adoption of the guidelines, and to measure
compliance with the guidelines, until such point that 90% or more of the
Providers are consistently in compliance, based on HMO measurement findings. The
HMO must employ substantive Provider motivational incentive strategies, such as
financial and non-financial incentives, to improve Provider compliance with
clinical practice guidelines. The HMO’s decisions regarding utilization
management, Member education, coverage of services, and other areas included in
the practice guidelines must be consistent with the HMO’s clinical practice
guidelines.

       

      8.1.7.7  Provider
Profiling

      The HMO
must conduct PCP and other Provider profiling activities at least annually. As
part of its QAPI Program, the HMO must describe the methodology it uses to
identify which and how many Providers to profile and to identify measures to use
for profiling such Providers.

       

      Provider
profiling activities must include, but not be limited to:

       

      1. Developing
PCP and Provider-specific reports that include a multi-dimensional assessment of
a PCP or Provider’s performance using clinical, administrative, and Member
satisfaction indicators of care that are accurate, measurable, and relevant to
the enrolled population;

      


      
        	
                2. Establishing
      PCP, Provider, group, Service Area or regional Benchmarks for areas
      profiled, where applicable, including STAR, STAR+PLUS, CHIP and CHIP
      Perinatal Program-specific Benchmarks, where appropriate;
    and

              


      

      


      
        	
                3. Providing
      feedback to individual PCPs and Providers regarding the results of their
      performance and the overall performance of the Provider
      Network.

              


      

      


      8.1.7.8  Network
Management

      The HMO
must:

      


      
        	
                 
      

              	
                1. Use the
      results of its Provider profiling activities to identify areas of
      improvement for individual PCPs and Providers, and/or groups of
      Providers;

              


      

      


      
        	
                 
      

              	
                2. Establish
      Provider-specific quality improvement goals for priority areas in which a
      Provider or Providers do not meet established HMO standards or improvement
      goals;

              


      

      


      
        	
                 
      

              	
                3. Develop
      and implement incentives, which may include financial and non-financial
      incentives, to motivate Providers to improve performance on profiled
      measures; and

              


      

      


      
        	
                 
      

              	
                4. At
      least annually, measure and report to HHSC on the Provider Network and
      individual Providers’ progress, or lack of progress, towards such
      improvement goals.

              


      

      


      8.1.7.9  Collaboration
with the EQRO

      The HMO
will collaborate with HHSC’s external quality review organization (EQRO) to
develop studies, surveys, or other analytical approaches that will be carried
out by the EQRO.  The purpose of the studies, surveys, or other
analytical approaches is to assess the quality of care and service provided to
Members and to identify opportunities for HMO improvement. To facilitate this
process, the HMO will supply claims data to the EQRO in a format identified by
HHSC in consultation with HMOs, and will supply medical records for focused
clinical reviews conducted by the EQRO. The HMO must also work collaboratively
with HHSC and the EQRO to annually measure selected HEDIS measures that require
chart reviews. During the first year of operations, HHSC anticipates that the
selected measures will include, at a minimum, well-child visits and
immunizations, appropriate use of asthma medications, measures related to
Members with diabetes, and control of high blood pressure.

       

      8.1.8  Utilization
Management

      The HMO
must have a written utilization management (UM) program description, which
includes, at a minimum:

      


      
        	
                 
      

              	
                1. Procedures
      to evaluate the need for Medically Necessary Covered
    Services;

              


      

      


      
        	
                 
      

              	
                2. The
      clinical review criteria used, the information sources, the process used
      to review and approve the provision of Covered
  Services;

              


      

      


      
        	
                 
      

              	
                3. The
      method for periodically reviewing and amending the UM clinical review
      criteria; and

              


      

      


      
        	
                 
      

              	
                4. The
      staff position functionally responsible for the day-to-day management of
      the UM function.

              


      

      


      The HMO
must make best efforts to obtain all necessary information, including pertinent
clinical information, and consult with the treating physician as appropriate in
making UM determinations.

       

      The HMO
must issue coverage determinations, including adverse determinations, according
to the following timelines:

      


      


      
        	
                 
      

              	
                • Within
      three (3) business days after receipt of the request for authorization of
      services;

              


      

      


      
        	
                 
      

              	
                • Within
      one (1) business day for concurrent hospitalization decisions;
      and

              


      

      


      
        	
                 
      

              	
                • Within
      one (1) hour for post-stabilization or life-threatening conditions, except
      that for Emergency Medical Conditions and Emergency Behavioral Health
      Conditions, the HMO must not require prior
  authorization.

              


      

      


      The HMO’s
UM Program must include written policies and procedures to ensure:

      


      
        	
                 
      

              	
                1. Consistent
      application of review criteria that are compatible with Members’ needs and
      situations;

              


      

      


      
        	
                 
      

              	
                2. Determinations
      to deny or limit services are made by physicians under the direction of
      the Medical Director;

              


      

      


      
        	
                 
      

              	
                3. Appropriate
      personnel are available to respond to utilization review inquiries 8:00
      a.m. to 5:00 p.m., Monday through Friday, with a telephone system capable
      of accepting utilization review inquiries after normal business hours. The
      HMO must respond to calls within one business
  day;

              


      

      


      
        	
                 
      

              	
                4. Confidentiality
      of clinical information; and

              


      

      


      
        	
                 
      

              	
                5. Quality
      is not adversely impacted by financial and reimbursement-related processes
      and decisions.

              


      

      


      For HMOs
with preauthorization or concurrent review programs, qualified medical
professionals must supervise preauthorization and concurrent review
decisions.

       

      The HMO
UM Program must include polices and procedures to:

      


      
        	
                 
      

              	
                1. Routinely
      assess the effectiveness and the efficiency of the UM
    Program;

              


      

      


      
        	
                 
      

              	
                2. Evaluate
      the appropriate use of medical technologies, including medical procedures,
      drugs and devices;

              


      

      


      
        	
                 
      

              	
                3. target
      areas of suspected inappropriate service
  utilization;

              


      

      


      
        	
                 
      

              	
                4. Detect
      over- and under-utilization;

              


      

      


      
        	
                 
      

              	
                5. Routinely
      generate Provider profiles regarding utilization patterns and compliance
      with utilization review criteria and
policies;

              


      

      


      
        	
                 
      

              	
                6. Compare
      Member and Provider utilization with norms for comparable
      individuals;

              


      

      


      
        	
                 
      

              	
                7. Routinely
      monitor inpatient admissions, emergency room use, ancillary, and
      out-of-area services;

              


      

      


      
        	
                 
      

              	
                8. Ensure
      that when Members are receiving Behavioral Health Services from the local
      mental health authority that the HMO is using the same UM guidelines as
      those prescribed for use by Local Mental Health Authorities by MHMR which
      are published at: http://www.mhmr.state.tx.us/centraloffice/behavioralhealthservices/RDMClinGuide.html;
      and

              


      

      


      
        	
                 
      

              	
                9. Refer
      suspected cases of provider or Member Fraud, Abuse, or Waste to the Office
      of Inspector General (OIG) as required by Section
      8.1.19.

              


      

      


      8.1.9  Early
Childhood Intervention (ECI)

      The HMO
must ensure that Network Providers are educated regarding their responsibility
under federal laws (e.g., 20 U.S.C. §1435 (a)(5); 34 C.F.R. §303.321(d)) to
identify and refer any Member age three (3) or under suspected of having a
developmental disability or delay, or who is at risk of delay, to the designated
ECI program for screening and assessment within two (2) working days from the
day the Provider identifies the Member.  The HMO must use written
educational materials developed or approved by the Department of Assistive and
Rehabilitative Services – Division for Early Childhood Intervention Services for
these “child find” activities. Eligibility for ECI services will be determined
by the local ECI program using the criteria contained in 40 T.A.C.
§108.25.

       

      The HMO
must contract with qualified ECI Providers to provide ECI services to Members
under age three who have been determined eligible for ECI services. The HMO must
permit Members to self refer to local ECI Service Providers without requiring a
referral from the Member’s PCP. The HMO’s policies and procedures, including its
Provider Manual, must include written policies and procedures for allowing such
self-referral to ECI providers.

       

      The HMO
must coordinate and cooperate with local ECI programs in the development and
implementation of the Individual Family Service Plan (IFSP), including on-going
case management and other non-capitated services required by the Member’s IFSP.
The IFSP is an agreement developed by the interdisciplinary team that consists
of the ECI Case Manager/Service Coordinator, the Member/family, and other
professionals who participated in the Member’s evaluation or are providing
direct services to the Member, and may include the Member’s Primary Care
Physician (PCP) with parental consent. The IFSP identifies the Member’s present
level of development based on assessment, describes the services to be provided
to the child to meet the needs of the child and the family, and identifies the
person or persons responsible for each service required by the plan. The IFSP
shall be transmitted by the ECI Provider to the HMO and the PCP with parental
consent to enhance coordination of the plan of care. The IFSP may be included in
the Member’s medical record.

       

      Cooperation
with the ECI program includes covering medical diagnostic procedures and
providing medical records required to perform developmental assessments and
developing the IFSP within the 45-day timeline established in federal rule (34
C.F.R. §303.342(a)). The HMO must require compliance with these requirements
through Provider contract provisions. The HMO must not withhold authorization
for the provision of such medical diagnostic procedures. The HMO must promptly
provide to the ECI program, relevant medical records available to the
HMO.

       

      The
interdisciplinary team will determine Medical Necessity for health and
Behavioral Health Services as approved by the Member’s PCP. The HMO must
require, through contract provisions, that all Medically Necessary health and
Behavioral Health Services contained in the Member’s IFSP are provided to the
Member in the amount, duration, scope and service setting established by the
IFSP. The HMO must allow services to be provided by a non-network provider if a
Network Provider is not available to provide the services in the amount,
duration, scope and service setting as required by the IFSP. The HMO cannot
modify the plan of care or alter the amount, duration, scope, or service setting
required by the Member’s IFSP. The HMO cannot create unnecessary barriers for
the Member to obtain IFSP services, including requiring prior

      authorization
for the ECI assessment or establishing insufficient authorization periods for
prior authorized services.

       

      8.1.10  Special
Supplemental Nutrition Program for Women, Infants, and Children (WIC) - Specific
Requirements

      The HMO
must, by contract, require its Providers to coordinate with the Special
Supplemental Nutrition Program for Women, Infants, and Children (WIC) to provide
medical information necessary for WIC eligibility determinations, such as
height, weight, hematocrit or hemoglobin. The HMO must make referrals to WIC for
Members potentially eligible for WIC. The HMO may use the nutrition education
provided by WIC to satisfy certain health education requirements of the
Contract.

       

      8.1.11  Coordination
with Texas Department of Family and Protective Services

      The HMO
must cooperate and coordinate with the Texas Department of Family and Protective
Services (TDFPS) (formerly the Department of Protective and Regulatory Services)
for the care of a child who is receiving services from or has been placed in the
conservatorship of TDFPS.

       

      The HMO
must comply with all provisions related to Covered Services, including
Behavioral Health Services, in the following documents:

      


      
        	
                 
      

              	
                • A court
      order (Order) entered by a Court of Continuing Jurisdiction placing a
      child under the protective custody of
TDFPS.

              


      

      


      
        	
                 
      

              	
                • A TDFPS
      Service Plan entered by a Court of Continuing Jurisdiction placing a child
      under the protective custody of
TDFPS.

              


      

      


      
        	
                 
      

              	
                • A TDFPS
      Service Plan voluntarily entered into by the parents or person having
      legal custody of a Member and
TDFPS.

              


      

      


      The HMO
cannot deny, reduce, or controvert the Medical Necessity of any health or
Behavioral Health Services included in an Order. The HMO may participate in the
preparation of the medical and behavioral care plan prior to TDFPS submitting
the health care plan to the Court. Any modification or termination of
court-ordered services must be presented and approved by the court having
jurisdiction over the matter.

       

      A Member
or the parent or guardian whose rights are subject to an Order or Service Plan
cannot use the HMO’s Complaint or Appeal processes, or the HHSC Fair Hearing
process to Appeal the necessity of the Covered Services.

       

      The HMO
must include information in its Provider Manuals and training materials
regarding:

      


      
        	
                 
      

              	
                1. Providing
      medical records to TDFPS;

              


      

      


      
        	
                 
      

              	
                2. Scheduling
      medical and Behavioral Health Services appointments within 14 days unless
      requested earlier by TDFPS; and

              


      

      


      
        	
                 
      

              	
                3. Recognition
      of abuse and neglect, and appropriate referral to
  TDFPS.

              


      

      


      


      The HMO
must continue to provide all Covered Services to a Member receiving services
from, or in the protective custody of, TDFPS until the Member has been;(1)
disenrolled from the HMO due to loss of Medicaid managed care eligibility; or
(2) enrolled in HHSC’s managed care program for children in foster care, once
the program is implemented.

       

      8.1.12  Services
for People with Special Health Care Needs

      This
section applies to STAR, STAR+PLUS, CHIP HMOs. It applies to CHIP Perinatal HMOs
with respect to their Perinate Newborn Members only.

       

      8.1.12.1  Identification

      The HMO
must develop and maintain a system and procedures for identifying Members with
Special Health Care Needs (MSHCN), including people with disabilities or chronic
or complex medical and behavioral health conditions and Children with Special
Health Care Needs (CSHCN)1.

       

      The HMO
must contact Members pre-screened by the HHSC Administrative Services Contractor
as MSHCN to determine whether they meet the HMO’s MSHCN assessment criteria, and
to determine whether the Member requires special services described in this
section. The HMO must provide information to the HHSC Administrative Services
Contractor that identifies Members who the HMO has assessed to be MSHCN,
including any Members pre-screened by the HHSC Administrative Services
Contractor and confirmed by the HMO as a MSHCN. The information must be
provided, in a format and on a timeline to be specified by HHSC in the Uniform Managed Care Manual,
and updated with newly identified MSHCN by the 10th day of each month. In the
event that a MSHCN changes HMOs, the HMO must provide the receiving contractor
information concerning the results of the HMO’s identification and assessment of
that Member’s needs, to prevent duplication of those activities.

       

      8.1.12.2  Access to Care
and Service Management

      
        Once
identified, the HMO must have effective systems to ensure the provision of
Covered Services to meet the special preventive, primary Acute Care, and
specialty health care needs appropriate for treatment of the individual Member’s
condition(s).  All STAR+PLUS Members are considered to be
MSHCN.

         

        The HMO
must provide access to identified PCPs and specialty care Providers with
experience serving MSHCN. Such Providers must be board-qualified or
board-eligible in their specialty. The HMO may request exceptions from HHSC for
approval of traditional providers who are not board-qualified or board-eligible
but who otherwise meet the HMO’s credentialing requirements.

         

        For
services to CSHCN, the HMO must have Network PCPs and specialty care Providers
that have demonstrated experience with CSHCN in pediatric specialty centers such
as children’s hospitals, teaching hospitals, and tertiary care
centers.

         

        The HMO
is responsible for working with MSHCN, their families and legal guardians if
applicable, and their health care providers to develop a seamless package of
care in which primary, Acute Care, and specialty service needs are met through a
Service Plan that is understandable to the Member, or, when applicable, the
Member’s legal guardian.

         

        The HMO
is responsible for providing Service Management to develop a Service Plan and
ensure MSHCN, including CSHCN, have access to treatment by a multidisciplinary
team when the Member’s PCP determines the treatment is Medically Necessary, or
to avoid separate and fragmented evaluations and service plans. The team must
include both physician and non-physician providers determined to be necessary by
the Member’s PCP for the comprehensive treatment of the Member. The team
must:

        


        1.
Participate in hospital discharge planning;

        2.
Participate in pre-admission hospital planning for non-emergency
hospitalizations; this
program may also be served by Medicaid or CHIP, the reference to “CSHCN” in this
Contract does not refer to children served through this program.

        3. Develop
specialty care and support service recommendations to be incorporated into the
Service Plan; and

        4. Provide
information to the Member, or when applicable, the Member’s legal guardian
concerning the specialty care recommendations.

        


        MSHCN,
their families, or their health providers may request Service Management from
the HMO. The HMO must make an assessment of whether Service Management is needed
and furnish Service Management when appropriate. The HMO may also recommend to a
MSHCN, or to a CSHCN’s family, that Service Management be furnished if the HMO
determines that Service Management would benefit the Member.

         

        The HMO
must provide information and education in its Member Handbook and Provider
Manual about the care and treatment available in the HMO’s plan for Members with
Special Health Care Needs, including the availability of Service
Management.

         

        The HMO
must have a mechanism in place to allow Members with Special Health Care Needs
to have direct access to a specialist as appropriate for the Member’s condition
and identified needs, such as a standing referral to a specialty physician. The
HMO must also provide MSHCN with access to non-primary care physician
specialists as PCPs, as required by 28 T.A.C. §11.900 and Section 8.1.

         

        The HMO
must implement a systematic process to coordinate Non-capitated Services, and
enlist the involvement of community organizations that may not be providing
Covered Services but are otherwise important to the health and wellbeing of
Members. The HMO also must make a best effort to establish relationships with
State and local programs and community organizations, such as those listed
below, in order to make referrals for MSHCN and other Members who need community
services:

         

        • Community
Resource Coordination Groups (CRCGs);

        • Early
Childhood Intervention (ECI) Program;

        • Local
school districts (Special Education);

        • Health
and Human Services Commission’s Medical Transportation Program
(MTP);

        • Texas
Department of Assistive and Rehabilitative Services (DARS) Blind Children’s
Vocational Discovery and Development Program;

        • Texas
Department of State Health (DSHS) services, including community mental health
programs, the Title V Maternal and Child Health and Children with Special Health
Care Needs (CSHCN) Programs, and the Program for Amplification of Children of
Texas (PACT);

        • Other
state and local agencies and programs such as food stamps, and the Women,
Infants, and Children’s (WIC) Program;

        • Civic and
religious organizations and consumer and advocacy groups, such as United
Cerebral Palsy, which also work on behalf of the MSHCN population.

         

      

      8.1.13  Service
Management for Certain Populations

      The HMO
must have service management programs and procedures for the following
populations, as applicable to the HMO’s Medicaid and/or CHIP Program(s) (See
CHIP Perinatal Program Covered Services, Attachment B-2.2, for the
applicability of these services to the CHIP Perinatal Program):

      


      
        	
                 
      

              	
                1. High-cost
      catastrophic cases;

              


      

      


      
        	
                 
      

              	
                2. Women
      with high-risk pregnancies (STAR and STAR+PLUS Programs
    only);

              


      

      


      
        	
                 
      

              	
                3. Individuals
      with mental illness and co-occurring substance abuse;
  and

              


      

      


      
        	
                 
      

              	
                4. FWC
      (STAR and STAR+PLUS Programs only).

              


      

      


      8.1.14  Disease
Management (DM)

       

      
        The HMO
must provide, or arrange to have provided to Members, comprehensive disease
management services consistent with state statutes and regulations. Such DM
services must be part of person-based approach to DM and holistically address
the needs of persons with multiple chronic conditions. The HMO must develop and
implement DM services that relate to chronic conditions that are prevalent in
HMO Program Members. HMOs must have DM Programs that address chronic conditions
identified in HHSC’sUniform
Managed Care Manual. HHSC will not identify individual Members with
chronic conditions. The HMO must implement policies and procedures to ensure
that Members that require DM services are identified and enrolled in a program
to provide such DM services. The HMO must develop and maintain screening and
evaluation procedures for the early detection, prevention, treatment, or
referral of participants at risk for or diagnosed with the chronic conditions
identified in the Uniform
Managed Care Manual. The HMO must ensure that all Members identified for
DM are enrolled into a DM Program with the opportunity to opt out of these
services within 30 days while still maintaining access to all other Covered
Services.

        


        For all
new Members not previously enrolled in the HMO and who require DM services, the
HMO must evaluate and ensure continuity of care with any previous DM services in
accordance with the requirements in the Uniform Managed Care
Manual.

         

        The DM
Program(s) must include:

        


        
          	
                   
      

                	
                  1.
      Patient self-management education;

                


        

        


        
          	
                   
      

                	
                  2.
      Provider education;

                


        

        


        
          	
                   
      

                	
                  3.
      Evidence-based models and minimum standards of
  care;

                


        

        


        
          	
                   
      

                	
                  4.
      Standardized protocols and participation
  criteria;

                


        

        


        
          	
                   
      

                	
                  5.
      Physician-directed or physician-supervised
care;

                


        

        


        
          	
                   
      

                	
                  6.
      Implementation of interventions that address the continuum of
      care;

                


        

        


        
          	
                   
      

                	
                  7.
      Mechanisms to modify or change interventions that are not proven
      effective; and

                


        

        


        
          	
                   
      

                	
                  8.
      Mechanisms to monitor the impact of the DM Program over time, including
      both the clinical and the financial
impact.

                


        

        


        The HMO
must maintain a system to track and monitor all DM participants for clinical,
utilization, and cost measures.

         

        The HMO
must provide designated staff to implement and maintain DM Programs and to
assist participating Members in accessing DM services. The HMO must educate
Members and Providers about the HMO’s DM Programs and activities. Additional
requirements related to the HMO’s Disease Management Programs and activities are
found in the HHSC Uniform
Managed Care Manual.

      

       

      8.1.14.1  DM
Services and Participating Providers

      At a
minimum, the HMO must:

      


      
        	
                 
      

              	
                1. Implement
      a system for Providers to request specific DM
    interventions;

              


      

      


      
        	
                 
      

              	
                2. Give
      Providers information, including differences between recommended
      prevention and treatment and actual care received by Members enrolled in a
      DM Program, and information concerning such Members’ adherence to a
      service plan; and

              


      

      


      
        	
                 
      

              	
                3. For
      Members enrolled in a DM Program, provide reports on changes in a Member’s
      health status to their PCP.

              


      

      


      8.1.14.2  HMO
DM Evaluation

      HHSC or
its EQRO will evaluate the HMO’s DM Program.

       

      8.1.15  Behavioral
Health (BH) Network and Services

      The
requirements in this sub-section pertain to all HMOs except: (1) the STAR HMOs
in the Dallas CSA, whose Members receive Behavioral Health Services through the
NorthSTAR Program, and (2) the CHIP Perinatal Program HMOs with respect to their
Perinate Members.

       

      The HMO
must provide, or arrange to have provided, to Members all Medically Necessary
Behavioral Health (BH) Services as described in Attachments
B-2, B-2.1, and B-2.2. All BH
Services must be provided in conformance with the access standards included in
Section
8.1.3. For
Medicaid HMOs, BH Services are described in more detail in the Texas
Medicaid Provider Procedures Manual and the
Texas
Medicaid Bulletins. When
assessing Members for BH Services, the HMO and its Network Behavioral Health
Service Providers must use the DSM-IV multi-axial classification. HHSC may
require use of other assessment instrument/outcome measures
in addition to the DSM-IV. Providers must document DSM-IV and assessment/outcome
information in the Member’s medical record.

      


      8.1.15.1  BH
Provider Network

      The HMO
must maintain a Behavioral Health Services Provider Network that includes
psychiatrists, psychologists, and other Behavioral Health Service Providers. The
Provider Network must include Behavioral Health Service Providers with
experience serving special populations among the HMO Program(s)’ enrolled
population, including, as applicable, children and adolescents, persons with
disabilities, the elderly, and cultural or linguistic minorities, to ensure
accessibility and availability of qualified Providers to all Members in the
Service Area.

       

      8.1.15.2  Member
Education and Self-referral for Behavioral Health Services

      The HMO
must maintain a Member education process to help Members know where and how to
obtain Behavioral Health Services.

       

      The HMO
must permit Members to self refer to any in-network Behavioral Health Services
Provider without a referral from the Member’s PCP. The HMOs’ policies and
procedures, including its Provider Manual, must include written policies and
procedures for allowing such self- referral to BH services.

       

      The HMO
must permit Members to participate in the selection of the appropriate
behavioral health individual practitioner(s) who will serve them and must
provide the Member with information on accessible in-network Providers with
relevant experience.

       

      8.1.15.3  Behavioral
Health Services Hotline

      
        This
Section includes Hotline functions pertaining to Members. Requirements for
Provider Hotlines are found in Section 8.1.4.7. The HMO must
have an emergency and crisis Behavioral Health Services Hotline staffed by
trained personnel 24 hours a day, 7 days a week, toll-free throughout the
Service Area. Crisis hotline staff must include or have access to qualified
Behavioral Health Services professionals to assess behavioral health
emergencies. Emergency and crisis Behavioral Health Services may be arranged
through mobile crisis teams. It is not acceptable for an emergency intake line
to be answered by an answering machine.

      

       

      The HMO
must operate a toll-free hotline as described in Section 8.1.5.6 to handle
Behavioral Health-related calls. The HMO may operate one hotline to handle
emergency and crisis calls and routine Member calls. The HMO cannot impose
maximum call duration limits and must allow calls to be of sufficient length to
ensure adequate information is provided to the Member. Hotline services must
meet Cultural Competency requirements and provide linguistic access to all
Members, including the interpretive services required for effective
communication.

       

      The
Behavioral Health Services Hotline may serve multiple HMO Programs Hotline staff
is knowledgeable about all of the HMO Programs. The Behavioral Health Services
Hotline may serve multiple Service Areas if the Hotline staff is knowledgeable
about all such Service Areas, including the Behavioral Health Provider Network
in each Service Area. The HMO must ensure

      that the
toll-free Behavioral Health Services Hotline meets the following minimum
performance requirements for all HMO Programs and Service Areas:

       

      1. 99% of calls
are answered by the fourth ring or an automated call pick-up
system;

      


      
        	
                2. No
      incoming calls receive a busy
signal;

              


      

      


      
        	
                3. At
      least 80% of calls must be answered by toll-free line staff within 30
      seconds measured from the time the call is placed in queue after selecting
      an option; and

              


      

      


      
        	
                4. The
      call abandonment rate is 7% or
less.

              


      

      


      The HMO
must conduct on-going quality assurance to ensure these standards are
met.

       

      The HMO
must monitor the HMO’s performance against the Behavioral Health Services
Hotline standards and submit performance reports summarizing call center
performance as indicated in Section 8.1.20 and the Uniform Managed Care
Manual.

       

      8.1.15.4  Coordination
between the BH Provider and the PCP

      The HMO
must require, through contract provisions, that PCPs have screening and
evaluation procedures for the detection and treatment of, or referral for, any
known or suspected behavioral health problems and disorders. PCPs may provide
any clinically appropriate Behavioral Health Services within the scope of their
practice.

       

      The HMO
must provide training to network PCPs on how to screen for and identify
behavioral health disorders, the HMO’s referral process for Behavioral Health
Services and clinical coordination requirements for such services. The HMO must
include training on coordination and quality of care such as behavioral health
screening techniques for PCPs and new models of behavioral health
interventions.

       

      The HMO
shall develop and disseminate policies regarding clinical coordination between
Behavioral Health Service Providers and PCPs. The HMO must require that
Behavioral Health Service Providers refer Members with known or suspected and
untreated physical health problems or disorders to their PCP for examination and
treatment, with the Member’s or the Member’s legal guardian’s consent.
Behavioral Health Providers may only provide physical health care services if
they are licensed to do so. This requirement must be specified in all Provider
Manuals.

       

      The HMO
must require that behavioral health Providers send initial and quarterly (or
more frequently if clinically indicated) summary reports of a Members’
behavioral health status to the PCP, with the Member’s or the Member’s legal
guardian’s consent. This requirement must be specified in all Provider
Manuals.

       

      8.1.15.5  Follow-up
after Hospitalization for Behavioral Health Services

      The HMO
must require, through Provider contract provisions, that all Members receiving
inpatient psychiatric services are scheduled for outpatient follow-up and/or
continuing treatment prior to discharge. The outpatient treatment must occur
within seven (7) days from the date of discharge.
The HMO must ensure that Behavioral Health Service Providers contact Members who
have missed appointments within 24 hours to reschedule
appointments.

      


      8.1.15.6  Chemical
Dependency

      The HMO
must comply with 28 T.A.C. §3.8001 et seq., regarding
utilization review for Chemical Dependency Treatment. Chemical Dependency
Treatment must conform to the standards set forth in 28 T.A.C. Part 1, Chapter
3, Subchapter HH.

       

      8.1.15.7  Court-Ordered
Services

      “Court-Ordered
Commitment” means
a commitment of a Member to a psychiatric facility for treatment that is ordered
by a court of law pursuant to the Texas Health and Safety Code, Title VII,
Subtitle C.

       

      The HMO
must provide inpatient psychiatric services to Members under the age of 21, up
to the annual limit, who have been ordered to receive the services by a court of
competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas
Health and Safety Code, relating to Court-Ordered Commitments to psychiatric
facilities. The HMO is not obligated to cover placements as a condition of
probation, authorized by the Texas Family Code.

       

      The HMO
cannot deny, reduce or controvert the Medical Necessity of inpatient psychiatric
services provided pursuant to a Court-ordered Commitment for Members under age
21. Any modification or termination of services must be presented to the court
with jurisdiction over the matter for determination.

       

      A Member
who has been ordered to receive treatment under the provisions of Chapter 573 or
574 of the Texas Health and Safety Code can only Appeal the commitment through
the court system.

       

      8.1.15.8  Local
Mental Health Authority (LMHA)

      The HMO
must coordinate with the Local Mental Health Authority (LMHA) and state
psychiatric facility regarding admission and discharge planning, treatment
objectives and projected length of stay for Members committed by a court of law
to the state psychiatric facility.

       

      Medicaid
HMOs are required to comply with additional Behavioral Health Services
requirements relating to coordination with the LMHA and care for special
populations. These Medicaid HMO requirements are described in Section 8.2.8.

       

      8.1.16  Financial
Requirements for Covered Services

      The HMO
must pay for or reimburse Providers for all Medically Necessary Covered Services
provided to all Members. The HMO is not liable for cost incurred in connection
with health care rendered prior to the date of the Member’s Effective Date of
Coverage in that HMO.  A Member may receive collateral health benefits
under a different type of insurance such as workers compensation or personal
injury protection under an automobile policy. If a Member is entitled to
coverage for specific services payable under another insurance plan and the HMO
paid for such

      Covered
Services, the HMO may obtain reimbursement from the responsible insurance entity
not to exceed 100% of the value of Covered Services paid.

       

      8.1.17  Accounting
and Financial Reporting Requirements

      
        The HMO’s
accounting records and supporting information related to all aspects of the
Contract must be accumulated in accordance with Federal Acquisition Regulations
(“FAR”), Generally Accepted Accounting Principles (GAAP), and the cost
principles contained in the Cost Principles Document in the Uniform Managed Care Manual.
The State will not recognize or pay services that cannot be properly
substantiated by the HMO and verified by HHSC.

         

      

      The HMO
must:

      


      
        	
                 
      

              	
                1. Maintain
      accounting records for each applicable HMO Program separate and apart from
      other corporate accounting records;

              


      

      


      
        	
                 
      

              	
                2. Maintain
      records for all claims payments, refunds and adjustment payments to
      providers, capitation payments, interest income and payments for
      administrative services or functions and must maintain separate records
      for medical and administrative fees, charges, and
  payments;

              


      

      


      
        	
                 
      

              	
                3. Maintain
      an accounting system that provides an audit trail containing sufficient
      financial documentation to allow for the reconciliation of billings,
      reports, and financial statements with all general ledger accounts;
      and

              


      

      


      
        	
                 
      

              	
                4. Within
      60 days after Contract execution, submit an accounting policy manual that
      includes all proposed policies and procedures the HMO will follow during
      the duration of the Contract. Substantive modifications to the accounting
      policy manual must be approved by
HHSC.

              


      

      


      The HMO
agrees to pay for all reasonable costs incurred by HHSC to perform an
examination, review or audit of the HMO’s books pertaining to the
Contract.

       

      8.1.17.1  General
Access to Accounting Records

      The HMO
must provide authorized representatives of the Texas and federal government full
access to all financial and accounting records related to the performance of the
Contract.

       

      The HMO
must:

      


      
        	
                 
      

              	
                1. Cooperate
      with the State and federal governments in their evaluation, inspection,
      audit, and/or review of accounting records and any necessary supporting
      information;

              


      

      
        	
                 
      

              	
                2. Permit
      authorized representatives of the State and federal governments full
      access, during normal business hours, to the accounting records that the
      State and the Federal government determine are relevant to the Contract.
      Such access is guaranteed at all times during the performance and
      retention period of the Contract, and will include both announced and
      unannounced inspections, on-site audits, and the review, analysis, and
      reproduction of reports produced by the
HMO;

              


      

      
        	
                 
      

              	
                3. Make
      copies of any accounting records or supporting documentation relevant to
      the Contract, including Network Provider agreements, available to HHSC or
      its agents within seven (7) Business Days, or as otherwise specified by
      HHSC, of receiving a written request from HHSC for specified records or
      information.  If such documentation is not made available as
      requested, the HMO agrees to reimburse HHSC for all costs, including, but
      not limited to, transportation, lodging, and subsistence for all State and
      federal representatives, or their agents, to carry out their inspection,
      audit, review, analysis, and reproduction functions at the location(s) of
      such accounting records; and

              


      

      
        	
                 
      

              	
                4. Pay any
      and all additional costs incurred by the State and federal government that
      are the result of the HMO’s failure to provide the requested accounting
      records or financial information within ten (10) business days of
      receiving a written request from the State or federal
      government.

              


      

       

      8.1.17.2  Financial
Reporting Requirements

      HHSC will
require the HMO to provide financial reports by HMO Program and by Service Area
to support Contract monitoring as well as State and Federal reporting
requirements. HHSC will consult with HMOs regarding the format and frequency of
such reporting. All financial information and reports that are not
Member-specific are property of HHSC and will be public record.  Any
deliverable or report in Section 8.1.17.2 without a specified due date is due
quarterly on the last day of the month. Where the due date states 30 days,
the HMO is to provide the deliverable by the last day of the month following the
end of the reporting period.  Where the due date states 45 days, the
HMO is to provide the deliverable by the 15th day of the second month following
the end of the reporting period.

       

      CHIP
Perinatal Program data must be reported, and the data will be integrated into
existing CHIP Program financial reports.  Except for the Financial
Statistical Report, no separate CHIP Perinatal Program reports are
required.  For all other CHIP financial reports, where appropriate,
HHSC will designate specific attributes within the CHIP Program financial
reports that the CHIP Perinatal HMOs must complete to allow HHSC to extract
financial data particular to the CHIP Perinatal Program.

       

      HHSC’s
Uniform Managed Care
Manual will govern the timing, format and content for the following
reports.

       

      Audited Financial Statement
–The HMO must provide the annual audited financial statement, for each
year covered under the Contract, no later than June 30. The HMO must provide the
most recent annual financial statements, as required by the Texas Department of
Insurance for each year covered under the Contract, no later than March
1.

       

      Affiliate Report – The HMO
must submit an Affiliate Report to HHSC if this information has changed since
the last report submission. The report must contain the following: 

      


      
        	
                 
      

              	
                1. A list
      of all Affiliates, and

              


      

      


      
        	
                 
      

              	
                2. For
      HHSC’s prior review and approval, a schedule of all transactions with
      Affiliates that, under the provisions of the Contract, will be allowable
      as expenses in the FSR Report for services provided to the HMO by the
      Affiliate. Those should include financial terms, a detailed description of
      the services to be provided, and an estimated amount that will be incurred
      by the HMO for such services during the Contract
  Period.

              


      

       

      Employee Bonus and/or Incentive
Payment Plan – If a HMO intends to include Employee Bonus or Incentive
Payments as allowable administrative expenses, the HMO must furnish a written
Employee Bonus and/or Incentive Payments Plan to HHSC so it may determine
whether such payments are allowable administrative expenses in accordance with
Cost Principles Document in the Uniform Managed Care Manual.
The written plan must include a description of the HMO’s criteria for
establishing bonus and/or incentive payments, the methodology to calculate bonus
and/or incentive payments, and the timing of bonus and/or incentive payments.
The Bonus and/or Incentive Payment Plan and description must be submitted to
HHSC for approval no later than 30 days after the Effective Date of the Contract
and any Contract renewal. If the HMO substantively revises the Employee Bonus
and/or Incentive Payment Plan, the HMO must submit the revised plan to HHSC for
prior review and approval.

       

      Claims Lag Report - The HMO
must submit Claims Lag Report as a Contract year-to-date report. The report must
be submitted quarterly by the last day of the month following the reporting
period. The report must be submitted to HHSC in a format specified by HHSC. The
report format is contained in the Uniform Managed Care Manual
Chapter 5, Section 5.6.2.  The report must disclose the amount
of incurred claims each month and the amount paid each month. 

       

      DSP Report - The HMO must
submit a monthly Delivery Supplemental Payment (DSP) Report that includes the
data elements specified by HHSC in the format specified by HHSC. HHSC will
consult with contracted HMOs prior to revising the DSP Report data elements and
requirements. The DSP Report must include only unduplicated deliveries and only
deliveries for which the HMO has made a payment, to either a hospital or other
provider. 

       

      Form CMS-1513 - The HMO must
file an original Form CMS-1513 prior to beginning operations regarding the HMO’s
control, ownership, or affiliations. An updated Form CMS-1513 must also be filed
no later than 30 days after any change in control, ownership, or affiliations.


       

      FSR Reports – The HMO must
file quarterly and annual Financial-Statistical Reports (FSR) in the format and
timeframe specified by HHSC. HHSC will include FSR format and directions in the
Uniform Managed Care
Manual. The HMO must incorporate financial and statistical data of
delegated networks (e.g., IPAs, ANHCs, Limited Provider Networks), if any, in
its FSR Reports. Administrative expenses reported in the FSRs must be reported
in accordance with the Cost Principles Document in the Uniform Managed Care Manual.
Quarterly FSR reports are due no later than 30 days after the end of the quarter
and must provide information for the current quarter and year-to-date
information through the current quarter. The first annual FSR report must
reflect expenses incurred through the 90th day after the end of the fiscal
year.  The first annual report must be filed on or before the 120th
day after the end of each fiscal year. Subsequent annual reports must reflect
data completed through the 334th day after the end of each fiscal year and must
be filed on or before the 365th day following the end of each fiscal
year.

       

      HHSC will
post all FSRs on the HHSC website.

       

      CHIP
Perinatal HMOs are required to submit separate FSRs for the CHIP Perinatal
Program following the instructions outlined above and in the Uniform Managed Care
Manual.

       

      Out-of-Network
Utilization Reports– The HMO
must file quarterly Out-of
Network Utilization Reports in the format and timeframe specified by
HHSC.  HHSC will include the report format

      and
directions in the Uniform
Managed Care Manual.  Quarterly
reports are due 30 days after the end of each quarter.

      


      HUB Reports – Upon contract
award, the HMO must attend a post award meeting in Austin, Texas, at a time
specified by HHSC, to discuss the development and submission of a Client
Services HUB Subcontracting Plan for inclusion and the HMO’s good faith efforts
to notify HUBs of subcontracting opportunities.  The HMO must maintain
its HUB Subcontracting Plan and submit monthly reports documenting the HMO’s
Historically Underutilized Business (HUB) program efforts and accomplishments to
the HHSC HUB Office. The report must include a narrative description of the
HMO’s program efforts and a financial report reflecting payments made to HUBs.
HMOs must use the formats included in HHSC’s Uniform Managed Care Manual
for the HUB monthly reports. The HMO must comply with
HHSC’s standard Client Services HUB Subcontracting Plan requirements for all
subcontractors.

       

      IBNR Plan - The HMO must
furnish a written IBNR Plan to manage incurred-but-not-reported (IBNR) expenses,
and a description of the method of insuring against insolvency, including
information on all existing or proposed insurance policies. The Plan must
include the methodology for estimating IBNR. The plan and description must be
submitted to HHSC no later than 60 days after the Effective Date of the
Contract. Substantive changes to a HMO’s IBNR plan and description must be
submitted to HHSC no later than 30 days before the HMO implements changes to the
IBNR plan.

       

      Medicaid Disproportionate Share
Hospital (DSH) Reports – Medicaid HMOs must file preliminary and final
Medicaid DSH reports, required by HHSC to identify and reimburse hospitals that
qualify for Medicaid DSH funds. The preliminary and final DSH reports must
include the data elements and be submitted in the form and format specified by
HHSC in the Uniform Managed
Care Manual. The preliminary DSH reports are due on or before June 1 of
the year following the state fiscal reporting year. The final DSH reports are
due no later than July 15 of the year following the state fiscal reporting year.
This reporting requirement does not apply to CHIP or CHIP Perinatal Program
HMOs. For STAR+PLUS, HMOs will include only outpatient services in the DSH
report.

       

      TDI Examination Report - The
HMO must furnish a copy of any TDI Examination Report, including the financial,
market conduct, target exam, quality of care components, and corrective action
plans and responses, no later than 10 days after receipt of the final report
from TDI. 

       

      TDI Filings – The HMO must
submit annual figures for controlled risk-based capital, as well as its
quarterly financial statements, both as required by TDI.

       

      Registration Statement (also known as
the “Form B”) - If the HMO is a part of an insurance holding company
system, the HMO must submit to HHSC a complete registration statement, also
known as Form B, and all amendments to this form, and any other information
filed by such insurer with the insurance regulatory authority of its domiciliary
jurisdiction.

       

      Section 1318 Financial Disclosure
Report - The HMO must file an original CMS Public Health Service (PHS)
Section 1318 Financial Disclosure Report prior to the start of Operations and an
updated CMS PHS Section 1318 Financial Disclosure Report no later than 30 days
after the end of each Contract Year and no later than 30 days after entering
into, renewing, or terminating a relationship with an affiliated
party.

       

      Third Party Recovery (TPR) Reports -
The HMO must file TPR Reports in accordance with the format developed by
HHSC in the Uniform Managed
Care Manual.  HHSC will require the HMO to submit TPR reports
no more often than quarterly.  TPR reports must include total dollars
recovered from third party payers for each HMO Program for services to the HMO’s
Members, and the total dollars recovered through coordination of benefits,
subrogation, and worker’s compensation. For CHIP HMOs, the TPR Reports only
apply if the HMO chooses to engage in TPR activities.

       

      8.1.18  Management
Information System Requirements

      The HMO
must maintain a Management Information System (MIS) that supports all functions
of the HMO’s processes and procedures for the flow and use of HMO data. The HMO
must have hardware, software, and a network and communications system with the
capability and capacity to handle and operate all MIS subsystems for the
following operational and administrative areas:

      


      
        	
                 
      

              	
                1. Enrollment/Eligibility
      Subsystem;

              


      

      


      
        	
                 
      

              	
                2. Provider
      Subsystem;

              


      

      


      
        	
                 
      

              	
                3. Encounter/Claims
      Processing Subsystem;

              


      

      


      
        	
                 
      

              	
                4. Financial
      Subsystem;

              


      

      


      
        	
                 
      

              	
                5. Utilization/Quality
      Improvement Subsystem;

              


      

      


      
        	
                 
      

              	
                6. Reporting
      Subsystem;

              


      

      


      
        	
                 
      

              	
                7. Interface
      Subsystem; and

              


      

      


      
        	
                 
      

              	
                8. TPR
      Subsystem, as applicable to each HMO
Program.

              


      

      


      The MIS
must enable the HMO to meet the Contract requirements, including all applicable
state and federal laws, rules, and regulations. The MIS must have the capacity
and capability to capture and utilize various data elements required for HMO
administration.

       

      HHSC will
provide the HMO with pharmacy data on the HMO’s Members on a weekly basis
through the HHSC Vendor Drug Program, or should these services be outsourced,
through the Pharmacy Benefit Manager. HHSC will provide a sample format of
pharmacy data to contract awardees.

       

      The HMO
must have a system that can be adapted to changes in Business Practices/Policies
within the timeframes negotiated by the Parties. The HMO is expected to cover
the cost of such systems modifications over the life of the
Contract.

       

      The HMO
is required to participate in the HHSC Systems Work Group.

       

      The HMO
must provide HHSC prior written notice of major systems changes, generally
within 90 days, and implementations, including any changes relating to Material
Subcontractors, in accordance with the requirements of this Contract and the
Uniform Managed Care Terms and
Conditions.

       

      The HMO
must provide HHSC any updates to the HMO’s organizational chart relating to MIS
and the description of MIS responsibilities at least 30 days prior to the
effective date of the change. The HMO must provide HHSC official points of
contact for MIS issues on an on-going basis.

       

      HHSC, or
its agent, may conduct a Systems Readiness Review to validate the HMO’s ability
to meet the MIS requirements as described in Attachment B-1, Section 7. The System
Readiness Review may include a desk review and/or an onsite review and must be
conducted for the following events:

      


      
        	
                 
      

              	
                1. A new
      plan is brought into the HMO
Program;

              


      

      


      
        	
                 
      

              	
                2. An
      existing plan begins business in a new Service
  Area;

              


      

      


      
        	
                 
      

              	
                3. An
      existing plan changes location;

              


      

      


      
        	
                 
      

              	
                4. An
      existing plan changes its processing system, including changes in Material
      Subcontractors performing MIS or claims processing functions;
      and

              


      

      


      
        	
                 
      

              	
                5. An
      existing plan in one or two HHSC HMO Programs is initiating a Contract to
      participate in any additional HMO
Programs.

              


      

      


      If for
any reason, a HMO does not fully meet the MIS requirements, then the HMO must,
upon request by HHSC, either correct such deficiency or submit to HHSC a
Corrective Action Plan and Risk Mitigation Plan to address such deficiency as
requested by HHSC. Immediately upon identifying a deficiency, HHSC may impose
remedies and either actual or liquidated damages according to the severity of
the deficiency. HHSC may also freeze enrollment into the HMO’s plan for any of
its HMO Programs until such deficiency is corrected. Refer to Attachment A, Article 12 and
Attachment B-5 for
additional information regarding remedies and damages.  Refer to Attachment B-1, Section
7 and Attachment B-1,
Section 8.1.1.2 for additional information regarding HMO Readiness
Reviews. Refer to Attachment A,
Section 4.08(c) for information regarding Readiness Reviews of the HMO’s
Material Subcontractors.

       

      8.1.18.1  Encounter
Data

      
        The HMO
must provide complete Encounter Data for all Covered Services, including
Value-added Services. Encounter Data must follow the format, and data elements
as described in the HIPAA-compliant 837 format. HHSC will specify the method of
transmission, the submission schedule, and any other requirements in the Uniform Managed Care Manual.
The HMO must submit Encounter Data transmissions monthly, and include all
Encounter Data and Encounter Data adjustments processed by the HMO. Encounter
Data quality validation must incorporate assessment standards developed jointly
by the HMO and HHSC. The HMO must make original records available for inspection
by HHSC for validation purposes. Encounter Data that do not meet quality
standards must be corrected and returned within a time period specified by
HHSC.

         

        In
addition to providing Encounter Data in the 837 format described above, HMOs may
be requested to submit an Encounter Data file to HHSC's EQRO, in the format
provided in the Uniform Managed Care Manual.
This additional submission requirement is time-limited and may not be required
for the entire term of the Contract.

         

        For
reporting Encounters and fee-for-service claims to HHSC, the HMO must use the
procedure codes, diagnosis codes, and other codes as directed by HHSC. Any
exceptions will be considered on a code-by-code basis after HHSC receives
written notice from the HMO requesting an exception. The HMO must also use the
provider numbers as directed by HHSC for both Encounter and fee-for-service
claims submissions, as applicable.



      8.1.18.2  HMO
Deliverables related to MIS Requirements

      
        At the
beginning of each state fiscal year, the HMO must submit for HHSC’s review and
approval any modifications to the following documents:

        


        
          	
                   
      

                	
                  1.
      Joint Interface Plan;

                


        

        


        
          	
                   
      

                	
                  2.
      Disaster Recovery Plan;

                


        

        


        
          	
                   
      

                	
                  3.
      Business Continuity Plan;

                


        

        


        
          	
                   
      

                	
                  4.
      Risk Management Plan; and

                


        

        


        
          	
                   
      

                	
                  5.
      Systems Quality Assurance Plan.

                


        

        


        The HMO
must submit such modifications to HHSC according to the format and schedule
identified the HHSC Uniform
Managed Care Manual.

        The HMO
must follow all applicable Joint Interface Plans (JIPs) and all required file
submissions for HHSC’s Administrative Services Contractor, External Quality
Review Organization (EQRO) and HHSC Medicaid Claims Administrator. The JIPs can
be accessed through the Uniform
Managed Care Manual.

      

       

      8.1.18.3  System-wide
Functions

      The HMO’s
MIS system must include key business processing functions and/or features, which
must apply across all subsystems as follows:

      


      
        	
                 
      

              	
                1. Process
      electronic data transmission or media to add, delete or modify membership
      records with accurate begin and end
dates;

              


      

      


      
        	
                 
      

              	
                2. Track
      Covered Services received by Members through the system, and accurately
      and fully maintain those Covered Services as HIPAA-compliant Encounter
      transactions;

              


      

      


      
        	
                 
      

              	
                3. Transmit
      or transfer Encounter Data transactions on electronic media in the HIPAA
      format to the contractor designated by HHSC to receive the Encounter
      Data;

              


      

      


      
        	
                 
      

              	
                4. Maintain
      a history of changes and adjustments and audit trails for current and
      retroactive data;

              


      

      


      
        	
                 
      

              	
                5. Maintain
      procedures and processes for accumulating, archiving, and restoring data
      in the event of a system or subsystem
failure;

              


      

      


      
        	
                 
      

              	
                6. Employ
      industry standard medical billing taxonomies (procedure codes, diagnosis
      codes)  to describe services delivered and Encounter
      transactions produced;

              


      

      


      
        	
                 
      

              	
                7. Accommodate
      the coordination of benefits;

              


      

      


      
        	
                 
      

              	
                8. Produce
      standard Explanation of Benefits
(EOBs);

              


      

      


      
        	
                 
      

              	
                9. Pay
      financial transactions to Providers in compliance with federal and state
      laws, rules and regulations;

              


      

      


      
        	
                 
      

              	
                10. Ensure
      that all financial transactions are auditable according to GAAP
      guidelines.

              


      

      


      
        	
                 
      

              	
                11. Relate
      and extract data elements to produce report formats (provided within the
      Uniform Managed Care
      Manual) or otherwise required by
HHSC;

              


      

      


      
        	
                 
      

              	
                12. Ensure
      that written process and procedures manuals document and describe all
      manual and automated system procedures and processes for the
      MIS;

              


      

      


      
        	
                 
      

              	
                13. Maintain
      and cross-reference all Member-related information with the most current
      Medicaid, CHIP or CHIP Perinatal Program Provider number;
    and

              


      

      


      
        	
                 
      

              	
                14. Ensure
      that the MIS is able to integrate pharmacy data from HHSC’s Drug Vendor
      file (available through the Virtual Private Network (VPN)) into the HMO’s
      Member data.

              


      

      


      8.1.18.4  Health
Insurance Portability and Accountability Act (HIPAA) Compliance

      The HMO’s
MIS system must comply with applicable certificate of coverage and data
specification and reporting requirements promulgated pursuant to the Health
Insurance Portability and Accountability Act (HIPAA) of 1996, P.L. 104-191
(August 21, 1996), as amended or modified. The HMO must comply with HIPAA EDI
requirements. HMO’s enrollment files must be in the 834 HIPAA-compliant format.
Eligibility inquiries must be in the 270/271 format and all claims and
remittance transactions in the 837/835 format.

       

      The HMO
must provide its Members with a privacy notice as required by HIPAA. The HMO
must provide HHSC with a copy of its privacy notice for filing.

       

      8.1.18.5  Claims
Processing Requirements

      The HMO
must process and adjudicate all provider claims for Medically Necessary
Covered Services that are filed within the time frames specified in the Uniform Managed Care
Manual.   The HMO is subject to remedies, including
liquidated damages and interest, if the HMO does not process and adjudicate
claims within the timeframes listed in the Uniform Managed Care
Manual.

      


      The HMO must administer an effective,
accurate, and efficient claims payment process in compliance with federal laws
and regulations, applicable state laws and rules, the Contract, and the
Uniform
Managed Care Manual.  In addition, a Medicaid
HMO must be able to accept and process provider claims in compliance with the
Medicaid Provider Procedures Manual and The Texas Medicaid
Bulletin.

       

      The HMO
must maintain an automated claims processing system that registers the date a
claim is received by the MCO, the detail of each claim transaction (or action)
at the time the transaction occurs, and has the capability to report each claim
transaction by date and type to include interest payments.   The
claims system must maintain information at the claim and line detail
level.  The claims system must maintain adequate audit trails and
report accurate claims performance measures to HHSC.

       

      The HMO’s
claims system must maintain online and archived files. The HMO must keep online
automated claims payment history for the most current 18 months.  The
HMO must retain other financial information and records, including all original
claims forms, for the time period established in Attachment A, Section 9.01.
 All claims data must be easily sorted and produced in formats as requested
by HHSC.

      


      The HMO
must offer its Providers/Subcontractors the option of submitting and receiving
claims information through electronic data interchange (EDI) that allows for
automated processing and adjudication of claims. EDI processing must be offered
as an alternative to the filing of paper claims. Electronic claims must use
HIPAA-compliant electronic formats.

      


      The HMO
must make an electronic funds transfer (EFT) payment process (for direct
deposit) available to in-network providers when processing claims for Medically
Necessary covered STAR+PLUS services.

       

      The HMO may deny a claim submitted by a
provider for failure to file in a timely manner as provided for in the
Uniform
Managed Care Manual.  The HMO must not pay any
claim submitted by a provider excluded or suspended from the Medicare, Medicaid,
CHIP or CHIP Perinatal programs for Fraud, Abuse, or Waste.  The HMO
must not pay any claim submitted by a Provider that is on payment hold under the
authority of HHSC or its authorized agent(s), or who has pending accounts
receivable with HHSC.

      


      The HMO
is subject to the requirements related to coordination of benefits for secondary
payors in the Texas Insurance Code Section 843.349 (e) and (f).

      


      The HMO must notify HHSC of major claim
system changes in writing no later than 90 days prior to implementation. The HMO
must provide an implementation plan and schedule of proposed changes. HHSC
reserves the right to require a desk or on-site readiness review of the
changes.

      


      The HMO must inform all Network
Providers about the information required to submit a claim at least 30 days
prior to the Operational Start Date and as a provision within the HMO/Provider
contract.  The HMO must make available to Providers claims coding and
processing guidelines for the applicable provider type. Providers must receive
90 days notice prior to the HMO’s implementation of changes to claims
guidelines. 

      


      8.1.19  Fraud
and Abuse

      A HMO is
subject to all state and federal laws and regulations relating to Fraud, Abuse,
and Waste in health care and the Medicaid and CHIP programs. The HMO must
cooperate and assist HHSC and any state or federal agency charged with the duty
of identifying, investigating, sanctioning or prosecuting suspected Fraud, Abuse
or Waste. The HMO must provide originals and/or copies of all records and
information requested and allow access to premises and provide records to the
Inspector General for the Texas Health and Human Services System, HHSC or its
authorized agent(s), the Centers for Medicare and Medicaid Services (CMS), the
U.S. Department of Health and Human Services (DHHS), Federal Bureau of
Investigation, TDI, or other units of state government. The HMO must provide all
copies of records free of charge.

       

      The HMO
must submit a written Fraud and Abuse compliance plan to the Office of Inspector
General at HHSC for approval (See Attachment B-1, Section 7 for requirements
regarding timeframes for submitting the original plan.) The plan must ensure
that all officers, directors, managers and employees know and understand the
provisions of the HMO’s Fraud and Abuse compliance plan. The plan must include
the name, address, telephone number, electronic mail address, and fax number of
the individual(s) responsible for carrying out the plan.

       

      The
written Fraud and Abuse compliance plan must:

       

      
        	
                 
      

              	
                1. Contain
      procedures designed to prevent and detect potential or suspected Abuse,
      Fraud and Waste in the administration and delivery of services under the
      Contract;

              


      

      


      
        	
                 
      

              	
                2. Contain
      a description of the HMO’s procedures for educating and training personnel
      to prevent Fraud, Abuse, or Waste;

              


      

      


      
        	
                 
      

              	
                3. Include
      provisions for the confidential reporting of plan violations to the
      designated person within the HMO’s organization and ensure that the
      identity of an individual reporting violations is protected from
      retaliation;

              


      

      


      
        	
                 
      

              	
                4. Include
      provisions for maintaining the confidentiality of any patient information
      relevant to an investigation of Fraud, Abuse, or
  Waste;

              


      

      


      
        	
                 
      

              	
                5. Provide
      for the investigation and follow-up of any allegations of Fraud, Abuse, or
      Waste and contain specific and detailed internal procedures for officers,
      directors, managers and employees for detecting, reporting, and
      investigating Fraud and Abuse compliance plan
  violations;

              


      

      


      
        	
                 
      

              	
                6. Require
      that confirmed violations be reported to the Office of Inspector General
      (OIG); and

              


      

      


      
        	
                 
      

              	
                7. Require
      any confirmed violations or confirmed or suspected Fraud, Abuse, or Waste
      under state or federal law be reported to
OIG.

              


      

      


      If the
HMO contracts for the investigation of allegations of Fraud, Abuse, or Waste and
other types of program abuse by Members or Providers, the plan must include a
copy of the subcontract; the names, addresses, telephone numbers, electronic
mail addresses, and fax numbers of the principals of the subcontracted entity;
and a description of the qualifications of the subcontracted
entity.  Such subcontractors must be held to the requirements stated
in this Section.

       

      The HMO
must designate executive and essential personnel to attend mandatory training in
Fraud and Abuse detection, prevention and reporting. Designated executive and
essential personnel means the HMO staff persons who supervise staff in the
following areas: data collection, provider enrollment or disenrollment,
encounter data, claims processing, utilization review, appeals or grievances,
quality assurance and marketing, and who are directly involved in the
decision-making and administration of the Fraud and Abuse detection program
within the HMO. The training will be conducted by the OIG free of charge. The
HMO must schedule and complete training no later than 90 days after the
Effective Date of the Contract. If the HMO updates or modifies its written Fraud
and Abuse compliance plan, the HMO must train its executive and essential
personnel on these updates or modifications no later than 90 days after the
effective date of the updates or modifications.

       

      The HMO
must designate an officer or director in its organization with responsibility
and authority to carry out the provisions of the Fraud and Abuse compliance
plan. A HMO’s failure to report potential or suspected Fraud or Abuse may result
in sanctions, cancellation of the Contract, and/or exclusion from participation
in the Medicaid, CHIP or CHIP Perinatal HMO Programs. The HMO must allow the
OIG, HHSC, its agents, or other governmental units to conduct private interviews
of the HMO’s personnel, subcontractors and their personnel, witnesses, and
Members with regard to a confirmed violation. The HMO’s personnel and it
subcontractors must reasonably cooperate, to the satisfaction of HHSC, by being
available in person for interviews, consultation, grand jury proceedings,
pre-trial conferences, hearings, trials and in any other process, including
investigations, at the HMO’s and subcontractors’ own expense.

       

      Additional
Requirements for STAR and STAR+PLUS HMOs:

      In
accordance with Section 1902(a)(68) of the Social Security Act, STAR and
STAR+PLUS HMOs that receive or make annual Medicaid payments of at least $5
million must:

      


      
        	
                 
      

              	
                1. Establish
      written policies for all employees, managers, officers, contractors,
      subcontractors, and agents of the HMO, which provide detailed information
      about the False Claims Act, administrative remedies for false claims and
      statements, any state laws pertaining to civil or criminal penalties for
      false claims, and whistleblower protections under such laws, as described
      in Section 1902(a)(68)(A).

              


      

      


      
        	
                 
      

              	
                2. Include
      as part of such written policies, detailed provisions regarding the HMO’s
      policies and procedures for detecting and preventing fraud, waste, and
      abuse.

              


      

      


      
        	
                 
      

              	
                3. Include
      in any employee handbook a specific discussion of the laws described in
      Section 1902(a)(68)(A), the rights of employees to be protected as
      whistleblowers, and the HMO’s policies and procedures for detecting and
      preventing fraud, waste, and abuse.

              


      

      


      8.1.20  Reporting
Requirements

      The HMO
must provide and must require its subcontractors to provide:

      


      
        	
                 
      

              	
                1. All
      information required under the Contract, including but not limited to, the
      reporting requirements or other information related to the performance of
      its responsibilities hereunder as reasonably requested by the HHSC;
      and

              


      

      


      
        	
                 
      

              	
                2. Any
      information in its possession sufficient to permit HHSC to comply with the
      Federal Balanced Budget Act of 1997 or other Federal or state laws, rules,
      and regulations. All information must be provided in accordance with the
      timelines, definitions, formats and instructions as specified by HHSC.
      Where practicable, HHSC may consult with HMOs to establish time frames and
      formats reasonably acceptable to both
parties.

              


      

      


      Any
deliverable or report in Section 8.1.20 without a specified due date is due
quarterly on the last day of the month following the end of the reporting
period. Where the due date states 30 days, the HMO is to provide the
deliverable by the last day of the month following the end of the reporting
period.  Where the due date states 45 days, the HMO is to provide the
deliverable by the 15th day of the second month following the end of the
reporting period. 

       

      The HMO’s
Chief Executive and Chief Financial Officers, or persons in equivalent
positions, must certify that financial data, Encounter Data and other
measurement data has been reviewed by the HMO and is true and accurate to the
best of their knowledge after reasonable inquiry.

       

      8.1.20.1  HEDIS
and Other Statistical Performance Measures

      The HMO
must provide to HHSC or its designee all information necessary to analyze the
HMO’s provision of quality care to Members using measures to be determined by
HHSC in consultation with the HMO. Such measures must be consistent with HEDIS
or other externally based measures or measurement sets, and involve collection
of information beyond that present in Encounter Data. The Performance Indicator
Dashboard, found in the Uniform Managed Care Manual
provides additional information on the role of the HMO and the EQRO in the
collection and calculation of HEDIS, CAHPS, and other performance
measures.

       

      8.1.20.2  Reports

      
        The HMO
must provide the following reports, in addition to the Financial Reports
described in Section 8.1.17
and those reporting requirements listed elsewhere in the Contract. The
HHSC Uniform Managed Care
Manual will include a list of all required reports, and a description of
the format, content, file layout and submission deadlines for each
report.

         

        For the
following reports, CHIP Perinatal Program data will be integrated into existing
CHIP Program reports. Generally, no separate CHIP Perinatal Program reports are
required. Where appropriate, HHSC will designate specific attributes within the
CHIP Program reports that the CHIP Perinatal HMOs must complete to allow HHSC to
extract data particular to the CHIP Perinatal Program.

        


        
          	
                  (a)
      Claims Summary Report
      - The HMO must submit quarterly Claims Summary Reports to HHSC by
      HMO Program, Service Area and claim type by the 30th
      day following the end of the reporting period unless otherwise
      specified. Claim Types include facility and/or professional services for
      Acute Care, Behavioral Health, Vision, and Long Term Services and
      Supports. Within each claim type, claims data must be reported separately
      on the UB and CMS 1500 claim forms. The format for the Claims Summary
      Report is contained in Chapter 5, Section 5.6.1 of the Uniform Managed Care
      Manual.

                


        

        


        
          	
                  (b)
      QAPI Program Annual
      Summary Report - The HMO must submit a QAPI Program Annual Summary
      in a format and timeframe as specified in the Uniform Managed Care
      Manual.

                


        

        


        
          	
                  (c)
      Fraudulent Practices
      Report - Utilizing the HHSC-Office of Inspector General (OIG) fraud
      referral form, the HMO’s assigned officer or director must report and
      refer all possible acts of waste, abuse or fraud to the HHSC-OIG within 30
      working days of receiving the reports of possible acts of waste, abuse or
      fraud from the HMO’s Special Investigative Unit (SIU). The report and
      referral must include: an investigative report identifying the allegation,
      statutes/regulations violated or considered, and the results of the
      investigation; copies of program rules and regulations violated for the
      time period in question; the estimated overpayment identified; a summary
      of the interviews conducted; the encounter data submitted by the provider
      for the time period in question; and all supporting documentation obtained
      as the result of the investigation. This requirement applies to all
      reports of possible acts of waste, abuse and
  fraud.

                


        

         

        Additional
reports required by the Office of the Inspector General relating to waste, abuse
or fraud are listed in the HHSC
Uniform Managed Care Manual.

        


        
          	
                  (d)
      Provider Termination
      Report: (CHIP (including integrated CHIP Perinatal Program data), STAR,
      and STAR+PLUS) - MCO must submit a quarterly report that identifies
      any providers who cease to participate in MCO's provider network, either
      voluntarily or involuntarily. The report must be submitted to HHSC in the
      format specified by HHSC, no later than 30 days after the end of the
      reporting period.

                


        

        


        
          	
                  (e)
      PCP Network &
      Capacity Report: (CHIP only (including integrated CHIP Perinatal Program
      data)) - For the CHIP Program, MCO must submit a quarterly report
      listing all unduplicated PCPs in the MCO's Provider Network. For the CHIP
      Perinatal Program, the Perinatal Newborns are assigned PCPs that are part
      of the CHIP PCP Network. The report must be submitted to HHSC in the
      format specified by HHSC, no later than 30 days after the end of the
      reporting quarter.

                


        

        


        
          	
                  (f)
      Summary Report of Member
      Complaints and Appeals - The HMO must submit quarterly Member
      Complaints and Appeals reports. The HMO must include in its reports
      Complaints and Appeals submitted to its subcontracted risk groups (e.g.,
      IPAs) and any other subcontractor that provides Member services. The HMO
      must submit the Complaint and Appeals reports electronically on or before
      45 days following the end of the state fiscal quarter, using the format
      specified by HHSC in the HHSC Uniform Managed Care
      Manual, Chapter 5.4.2.

                


        

         

        HHSC may
direct the CHIP Perinatal HMOs to provide segregated Member Complaints and
Appeals reports on an as-needed basis.

        


        
          	
                  (g)
      Summary Report of
      Provider Complaints - The HMO must submit Provider complaints
      reports on a quarterly basis. The HMO must include in its reports
      complaints submitted by providers to its subcontracted risk groups (e.g.,
      IPAs) and any other subcontractor that provides Provider services. The
      complaint reports must be submitted electronically on or before 45 days
      following the end of the state fiscal quarter, using the format specified
      by HHSC in the HHSC
      Uniform Managed Care Manual, Chapter
  5.4.2.

                


        

         

        HHSC may
direct the CHIP Perinatal HMOs to provide segregated Provider Complaints and
Appeals reports on an as-needed basis.

        


        
          	
                  (h)
      Hotline Reports -
      The HMO must submit, on a quarterly basis, a status report for the
      Member Hotline, the Behavioral Health Services Hotline, and the Provider
      Hotline in comparison with the performance standards set out in Sections 8.1.5.6, 8.1.14.3, and
      8.1.4.7. The HMO shall submit such reports using a format to be
      prescribed by HHSC in consultation with the
  HMOs.

                


        

         

        If the
HMO is not meeting a hotline performance standard, HHSC may require the HMO to
submit monthly hotline performance reports and implement corrective actions
until the hotline performance standards are met. If a HMO has a single hotline
serving multiple Service Areas, multiple HMO Programs, or multiple hotline
functions, (i.e. Member, Provider, Behavioral Health Services hotlines), HHSC
may request on an annual basis that the HMO submit certain hotline response
information by HMO Program, by Service Area, and by hotline function, as
applicable to the HMO. HHSC may also request this type of hotline information if
a HMO is not meeting a hotline performance standard.

        


        
          	
                  (i)
      Audit Reports –
      The HMO must comply with the Uniform Managed Care Manual’s
      requirements regarding notification and/or submission of audit
      reports.

                


        

        


        
          	
                  (j)
      Medicaid Managed Care
      THSteps Medical Checkups Annual Report (90-Day FREW Report) –
      Medicaid HMOs must submit an annual report (based on SFY activity)
      that identifies:

                


        

        


        
          	
                   
      

                	
                  (1)
      the total number of New Members under the age of 21 who were enrolled
      continuously for 90 days or more with the
HMO;

                


        

        


        
          	
                   
      

                	
                  (2)
      the number of New Members under the age of 21 who were enrolled
      continuously for 90 days or more with the HMO who get medical check-ups
      within 90 days of enrollment into the
HMO;

                


        

        


        
          	
                   
      

                	
                  (3)
      the total number of Existing Members under the age of 21 who were enrolled
      at the beginning of the reporting year and continuously enrolled for 90
      days or more with the HMO into the reporting year (excludes New Members
      reported in the same reporting year);
and

                


        

        


        
          	
                   
      

                	
                  (4)
      the number of Existing Members under the age of 21 who were enrolled at
      the beginning of the reporting year and continuously enrolled for 90 days
      or more with the HMO into the reporting year (excludes New Members
      reported in the same reporting year) who got timely, age-appropriate
      medical check-ups during the reporting
year.

                


        

         

        Medicaid
HMOs must also document and report those Members refusing to obtain the medical
check-ups. The documentation must include the reason the Member refused the
check-up or the reason the check-up was not received. For purposes of the 90-Day
FREW Report, “New Members” are Members who have not previously been enrolled at
any time in the prior two years in the HMO that is preparing the
report.

         

        The
definitions, timeframe, format, and details of the report are contained and
described in the Uniform
Managed Care Manual.

        


        
          	
                  (k)
      Children of Migrant Farm
      Workers Annual Report (FWC Annual Report) Beginning in SFY 2008,
      Medicaid HMOs must submit an annual report, in the timeframe and format
      described in the Uniform Managed Care Manual, about the identification of
      and delivery of services to children of migrant farm workers (FWC). The
      report will include a description and results of the each of the
      following:

                


        

        


        
          	
                   
      

                	
                  (1)
      the HMO’s efforts to identify as many community and statewide groups that
      work with FWC as possible within each of its Service
  Areas;

                


        

        


        
          	
                   
      

                	
                  (2)
      the HMO’s efforts to coordinate and cooperate with as many of such groups
      as possible; and

                


        

        


        
          	
                   
      

                	
                  (3)
      the HMO’s efforts to encourage the community groups to assist in the
      identification of FWC.

                


        

         

        The HMO
will maintain accurate, current lists of all identified FWC
Members.

         

      

      8.2
Additional Medicaid HMO Scope of Work

      The
following provisions apply to any HMO participating in the STAR or STAR+PLUS HMO
Program.

       

      8.2.1  Continuity
of Care and Out-of-Network Providers

       

      
        The HMO
must ensure that the care of newly enrolled Members is not disrupted or
interrupted. The HMO must take special care to provide continuity in the care of
newly enrolled Members whose health or behavioral health condition has been
treated by specialty care providers or whose health could be placed in jeopardy
if Medically Necessary Covered Services are disrupted or interrupted. See
Section 8.1.14 Disease Management for specific requirements for new Members
transferring to the HMO’s DM Program.

         

        The HMO
must allow pregnant Members with 12 weeks or less remaining before the expected
delivery date to remain under the care of the Member’s current OB/GYN through
the Member’s postpartum checkup, even if the provider is Out-of-Network. If a
Member wants to change her OB/GYN to one who is in the Network, she must be
allowed to do so if the Provider to whom she wishes to transfer agrees to accept
her in the last trimester of pregnancy.

         

        The HMO
must pay a Member’s existing Out-of-Network providers for Medically Necessary
Covered Services until the Member’s records, clinical information and care can
be transferred to a Network Provider, or until such time as the Member is no
longer enrolled in that HMO, whichever is shorter. Payment to Out-of-Network
providers must be made within the time period required for Network Providers.
The HMO must comply with out-of-network provider reimbursement rules as adopted
by HHSC.

         

        This
Article does not extend the obligation of the HMO to reimburse the Member’s
existing Out-of-Network providers for on-going care for:

        


        
          	
                   
      

                	
                  1.
      More than 90 days after a Member enrolls in the HMO’s Program,
      or

                


        

        


        
          	
                   
      

                	
                  2.
      For more than nine (9) months in the case of a Member who, at the time of
      enrollment in the HMO, has been diagnosed with and receiving treatment for
      a terminal illness and remains enrolled in the
  HMO.

                


        

        


        The HMO’s
obligation to reimburse the Member’s existing Out-of-Network provider for
services provided to a pregnant Member with 12 weeks or less remaining before
the expected delivery date extends through delivery of the child, immediate
postpartum care, and the follow-up checkup within the first six weeks of
delivery.

         

        The HMO
must provide or pay Out-of-Network providers who provide Medically Necessary
Covered Services to Members who move out of the Service Area through the end of
the period for which capitation has been paid for the Member.

         

        The HMO
must provide Members with timely and adequate access to Out-of-Network services
for as long as those services are necessary and covered benefits not available
within the network,

        in
accordance with 42 C.F.R. §438.206(b)(4). The HMO will not be obligated to
provide a Member with access to Out-of-Network services if such services become
available from a Network Provider.

         

        The HMO
must ensure that each Member has access to a second opinion regarding the use of
any Medically Necessary Covered Service. A Member must be allowed access to a
second opinion from a Network Provider or Out-of-Network provider if a Network
Provider is not available, at no cost to the Member, in accordance with 42
C.F.R. §438.206(b)(3).

      

       

      8.2.2  Provisions
Related to Covered Services for Medicaid Members

      8.2.2.1  Emergency
Services

      HMO
policy and procedures, Covered Services, claims adjudication methodology, and
reimbursement performance for Emergency Services must comply with all applicable
state and federal laws, rules, and regulations including 42 C.F.R. §438.114,
whether the provider is in-network or Out-of-Network. HMO policies and
procedures must be consistent with the prudent layperson definition of an
Emergency Medical Condition and the claims adjudication processes required under
the Contract and 42 C.F.R. §438.114.

       

      The HMO
must pay for the professional, facility, and ancillary services that are
Medically Necessary to perform the medical screening examination and
stabilization of a Member presenting with an Emergency Medical
Condition or an Emergency Behavioral Health Condition to the hospital emergency
department, 24 hours a day, 7 days a week, rendered by either the HMO's Network
or Out-of-Network providers.

       

      The HMO
cannot require prior authorization as a condition for payment for an Emergency
Medical Condition, an Emergency Behavioral Health Condition, or labor and
delivery. The HMO cannot limit what constitutes an Emergency Medical Condition
on the basis of lists of diagnoses or symptoms. The HMO cannot refuse to cover
Emergency Services based on the emergency room provider, hospital, or fiscal
agent not notifying the Member’s PCP or the HMO of the Member’s screening and
treatment within 10 calendar days of presentation for Emergency Services. The
HMO may not hold the Member who has an Emergency Medical Condition liable for
payment of subsequent screening and treatment needed to diagnose the specific
condition or stabilize the patient. The HMO must accept the emergency physician
or provider’s determination of when the Member is sufficiently stabilized for
transfer or discharge.

       

      A medical
screening examination needed to diagnose an Emergency Medical Condition must be
provided in a hospital based emergency department that meets the requirements of
the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 C.F.R.
§§489.20, 489.24 and 438.114(b)&(c)). The HMO must pay for the emergency
medical screening examination, as required by 42 U.S.C. §1395dd. The HMO must
reimburse for both the physician's services and the hospital's Emergency
Services, including the emergency room and its ancillary services.

       

      When the
medical screening examination determines that an Emergency Medical Condition
exists, the HMO must pay for Emergency Services performed to stabilize the
Member. The emergency physician must document these services in the Member's
medical record. The HMO must reimburse for both the physician's and hospital's
emergency stabilization services including the emergency room and its ancillary
services.

       

      The HMO
must cover and pay for Post-Stabilization Care Services in the amount, duration,
and scope necessary to comply with 42 C.F.R. §438.114(b)&(e) and 42 C.F.R.
§422.113(c)(iii). The HMO is financially responsible for post-stabilization care
services obtained within or outside the Network that are not pre-approved by a
Provider or other HMO representative, but administered to maintain, improve, or
resolve the Member’s stabilized condition if:

       

      
        	
                 
      

              	
                1. The HMO
      does not respond to a request for pre-approval within 1
    hour;

              


      

      


      
        	
                 
      

              	
                2. The HMO
      cannot be contacted; or

              


      

      


      
        	
                 
      

              	
                3. The HMO
      representative and the treating physician cannot reach an agreement
      concerning the Member’s care and a Network physician is not available for
      consultation. In this situation, the HMO must give the treating physician
      the opportunity to consult with a Network physician and the treating
      physician may continue with care of the patient until an HMO physician is
      reached. The HMO’s financial responsibility ends as follows: the HMO
      physician with privileges at the treating hospital assumes responsibility
      for the Member’s care; the HMO physician assumes responsibility for the
      Member’s care through transfer; the HMO representative and the treating
      physician reach an agreement concerning the Member’s care; or the Member
      is discharged.

              


      

      


      8.2.2.2  Family
Planning - Specific Requirements

      The HMO
must require, through Provider contract provisions, that Members requesting
contraceptive services or family planning services are also provided counseling
and education about the family planning and family planning services available
to Members. The HMO must develop outreach programs to increase community support
for family planning and encourage Members to use available family planning
services.

       

      The HMO
must ensure that Members have the right to choose any Medicaid participating
family planning provider, whether the provider chosen by the Member is in or
outside the Provider Network. The HMO must provide Members access to information
about available providers of family planning services and the Member’s right to
choose any Medicaid family planning provider. The HMO must provide access to
confidential family planning services.

       

      The HMO
must provide, at minimum, the full scope of services available under the Texas
Medicaid program for family planning services. The HMO will reimburse family
planning agencies the Medicaid fee-for service amounts for family planning
services, including Medically Necessary medications, contraceptives, and
supplies not covered by the Vendor Drug Program and will reimburse
Out-of-Network family planning providers in accordance with HHSC’s
administrative rules.

       

      The HMO
must provide medically approved methods of contraception to Members, provided
that the methods of contraception are Covered Services. Contraceptive methods
must be accompanied by verbal and written instructions on their correct use. The
HMO must establish mechanisms to ensure all medically approved methods of
contraception are made available to the Member, either directly or by referral
to a subcontractor.

       

      The HMO
must develop, implement, monitor, and maintain standards, policies and
procedures for providing information regarding family planning to Providers and
Members, specifically regarding State and federal laws governing Member
confidentiality (including minors). Providers and family planning agencies
cannot require parental consent for minors to receive family planning services.
The HMO must require, through contractual provisions, that subcontractors have
mechanisms in place to ensure Member’s (including minor’s) confidentiality for
family planning services.

       

      8.2.2.3  Texas
Health Steps (EPSDT)

      The HMO
must develop effective methods to ensure that children under the age of 21
receive THSteps services when due and according to the recommendations
established by the AAP and the THSteps periodicity schedule for children. The
HMO must arrange for THSteps services for all eligible Members except when a
Member knowingly and voluntarily declines or refuses services after receiving
sufficient information to make an informed decision.

       

      HMO must
have mechanisms in place to ensure that all newly enrolled newborns receive an
appointment for a THSteps checkup within 14 days of enrollment and all other
eligible child Members receive a THSteps checkup within 60 days of enrollment,
if one is due according to the AAP periodicity schedule.

       

      The HMO
must ensure that Members are provided information and educational materials
about the services available through the THSteps Program, and how and when they
may obtain the services. The information should tell the Member how they can
obtain dental benefits, transportation services through the Texas Department of
Transportation’s Medical Transportation Program, and advocacy assistance from
the HMO.  The HMO will encourage Medicaid-enrolled pharmacies to also
become Medicaid-enrolled durable medical equipment (DME) providers.

       

      The HMO
must provide appropriate training to all Network Providers and Provider staff in
the Providers’ area of practice regarding the scope of benefits available and
the THSteps Program. Training must include:

      


      
        	
                 
      

              	
                1. THSteps
      benefits,

              


      

      


      
        	
                 
      

              	
                2. The
      periodicity schedule for THSteps medical checkups and
      immunizations,

              


      

      


      
        	
                 
      

              	
                3. The
      required elements of THSteps medical
checkups,

              


      

      


      
        	
                 
      

              	
                4. Providing
      or arranging for all required lab screening tests (including lead
      screening), and Comprehensive Care Program (CCP) services available under
      the THSteps program to Members under age 21
  years.

              


      

      


      HMO must
also educate and train Providers regarding the requirements imposed on HHSC and
contracting HMOs under the Consent Decree entered in Frew v. Hawkins, et.
al., Civil Action No. 3:93CV65, in the United States District Court for
the Eastern District of Texas, Paris Division. Providers should be educated and
trained to treat each THSteps visit as an opportunity for a comprehensive
assessment of the Member.

       

      The HMO
must provide outreach to Members to ensure they receive prompt services and are
effectively informed about available THSteps services. Each month, the HMO must
retrieve from the HHSC Administrative Services Contractor Bulletin Board System
a list of Members who are due and overdue THSteps services. Using these lists
and its own internally generated list, the HMO will contact such Members to
obtain the service as soon as possible. The HMO outreach staff must coordinate
with DSHS THSteps outreach staff to ensure that Members have access to the
Medical Transportation Program, and that any coordination with other agencies is
maintained.

       

      The HMO
must cooperate and coordinate with the State, outreach programs and THSteps
regional program staff and agents to ensure prompt delivery of services to
children of migrant

      farm
workers and other migrant populations who may transition into and out of the
HMO’s Program more rapidly and/or unpredictably than the general
population.

      


      The HMO
must have mechanisms in place to ensure that all newborn Members have an initial
newborn checkup before discharge from the hospital and again within two weeks
from the time of birth. The HMO must require Providers to send all THSteps
newborn screens to the DSHS Bureau of Laboratories or a DSHS certified
laboratory. Providers must include detailed identifying information for all
screened newborn Members and the Member’s mother to allow DSHS to link the
screens performed at the hospital with screens performed at the two-week
follow-up.

       

      All
laboratory specimens collected as a required component of a THSteps checkup (see
Medicaid Provider Procedures Manual for age-specific requirements) must be
submitted to the DSHS Laboratory for analysis. The HMO must educate Providers
about THSteps Program requirements for submitting laboratory tests to the DSHS
Bureau of Laboratories.

       

      The HMO
must make an effort to coordinate and cooperate with existing community and
school-based health and education programs that offer services to school-aged
children in a location that is both familiar and convenient to the Members. The
HMO must make a good faith effort to comply with Head Start’s requirement that
Members participating in Head Start receive their THSteps checkup no later than
45 days after enrolling into either program.

       

      The HMO
must educate Providers on the Immunization Standard Requirements set forth in
Chapter 161, Health and Safety Code; the standards in the ACIP Immunization
Schedule; the AAP Periodicity Schedule for CHIP Members; and the DSHS
Periodicity Schedule for Medicaid Members. The HMO shall educate Providers that
Medicaid Members under age 21 must be immunized during the THSteps checkup
according to the DSHS routine immunization schedule. The HMO shall also educate
Providers that the screening provider is responsible for administration of the
immunization and should not refer children to Local Health Departments to
receive immunizations.

       

      The HMO
must educate Providers about, and require Providers to comply with, the
requirements of Chapter 161, Health and Safety Code, relating to the Texas
Immunization Registry (ImmTrac), to include parental consent on the Vaccine
Information Statement.

       

      The HMO
must require all THSteps Providers to submit claims for services paid (either on
a capitated or fee-for service basis) on the HCFA 1500 claim form and use the
HIPAA compliant code set required by HHSC.

       

      Encounter
Data will be validated by chart review of a random sample of THSteps eligible
enrollees against monthly Encounter Data reported by the HMO. HHSC or its
designee will conduct chart reviews to validate that all screens are performed
when due and as reported, and that reported data is accurate and timely.
Substantial deviation between reported and charted Encounter Data could result
in the HMO and/or Network Providers being investigated for potential Fraud,
Abuse, or Waste without notice to the HMO or the Provider.

       

      
        8.2.2.3.1
Oral Evaluation and Fluoride Varnish

        The HMO
must educate Providers on the availability of the Oral Evaluation and Fluoride
Varnish (OEVS) Medicaid benefit that can be rendered and billed by certified
THSteps providers when performed on the same day as the THSteps medical check
up. The Provider education must include information about how to assist a Member
with referral to a dentist to establish a dental home.

      

       

      8.2.2.4
Perinatal Services

      The HMO’s
perinatal health care services must ensure appropriate care is provided to women
and infant Members of the HMO from the preconception period through the infant’s
first year of life. The HMO’s perinatal health care system must comply with the
requirements of the Texas Health and Safety Code, Chapter 32 (the Maternal and
Infant Health Improvement Act) and administrative rules codified at 25 T.A.C.
Chapter 37, Subchapter M.

       

      The HMO
must have a perinatal health care system in place that, at a minimum, provides
the following services:

      


      
        	
                 
      

              	
                1. Pregnancy
      planning and perinatal health promotion and education for reproductive-
      age women;

              


      

      


      
        	
                 
      

              	
                2. Perinatal
      risk assessment of non-pregnant women, pregnant and postpartum women, and
      infants up to one year of age;

              


      

      


      
        	
                 
      

              	
                3. Access
      to appropriate levels of care based on risk assessment, including
      emergency care;

              


      

      


      
        	
                 
      

              	
                4. Transfer
      and care of pregnant women, newborns, and infants to tertiary care
      facilities when necessary;

              


      

      


      
        	
                 
      

              	
                5. Availability
      and accessibility of OB/GYNs, anesthesiologists, and neonatologists
      capable of dealing with complicated perinatal problems;
  and

              


      

      


      
        	
                 
      

              	
                6. Availability
      and accessibility of appropriate outpatient and inpatient facilities
      capable of dealing with complicated perinatal
  problems.

              


      

      


      The HMO
must have a process to expedite scheduling a prenatal appointment for an
obstetrical exam for a TP40 Member no later than two weeks after receiving the
daily Enrollment File verifying the Member’s enrollment into the
HMO.

       

      The HMO
must have procedures in place to contact and assist a pregnant/delivering Member
in selecting a PCP for her baby either before the birth or as soon as the baby
is born.

       

      The HMO
must provide inpatient care and professional services relating to labor and
delivery for its pregnant/delivering Members, and neonatal care for its newborn
Members at the time of delivery and for up to 48 hours following an
uncomplicated vaginal delivery and 96 hours following an uncomplicated Caesarian
delivery.

       

      The HMO
must Adjudicate provider claims for services provided to a newborn Member in
accordance with HHSC’s claims processing requirements using the proxy ID number
or State-issued Medicaid ID number. The HMO cannot deny claims based on a
provider’s non-use of State-issued Medicaid ID number for a newborn Member. The
HMO must accept provider claims for newborn services based on mother’s name
and/or Medicaid ID number with accommodations for multiple births, as specified
by the HMO.

       

      The HMO
must notify providers involved in the care of pregnant/delivering women and
newborns (including Out-of-Network providers and hospitals) of the HMO’s prior
authorization requirements. The HMO cannot require a prior authorization for
services provided to a pregnant/delivering Member or newborn Member for a
medical condition that requires Emergency Services, regardless of when the
emergency condition arises.

       

      8.2.2.5
Sexually Transmitted Diseases (STDs) and Human Immunodeficiency Virus
(HIV)

      The HMO
must provide STD services that include STD/HIV prevention, screening,
counseling, diagnosis, and treatment. The HMO is responsible for implementing
procedures to ensure that Members have prompt access to appropriate services for
STDs, including HIV. The HMO must allow Members access to STD services and HIV
diagnosis services without prior authorization or referral by a
PCP.

       

      The HMO
must comply with Texas Family Code Section 32.003, relating to consent to
treatment by a child. The HMO must provide all Covered Services required to form
the basis for a diagnosis by the Provider as well as the STD/HIV treatment
plan.

       

      The HMO
must make education available to Providers and Members on the prevention,
detection and effective treatment of STDs, including HIV.

       

      The HMO
must require Providers to report all confirmed cases of STDs, including HIV, to
the local or regional health authority according to 25 T.A.C. §§97.131 - 97.134,
using the required forms and procedures for reporting STDs. 

      The HMO
must require the Providers to coordinate with the HHSC regional health authority
to ensure that Members with confirmed cases of syphilis, chancroid, gonorrhea,
chlamydia and HIV receive risk reduction and partner elicitation/notification
counseling.

       

      The HMO
must have established procedures to make Member records available to public
health agencies with authority to conduct disease investigation, receive
confidential Member information, and provide follow up activities.

       

      The HMO
must require that Providers have procedures in place to protect the
confidentiality of Members provided STD/HIV services. These procedures must
include, but are not limited to, the manner in which medical records are to be
safeguarded, how employees are to protect medical information, and under what
conditions information can be shared. The HMO must inform and require its
Providers who provide STD/HIV services to comply with all state laws relating to
communicable disease reporting requirements. The HMO must implement policies and
procedures to monitor Provider compliance with confidentiality
requirements.

       

      The HMO
must have policies and procedures in place regarding obtaining informed consent
and counseling Members provided STD/HIV services.

       

      8.2.2.6  Tuberculosis
(TB)

      The HMO
must provide Members and Providers with education on the prevention, detection
and effective treatment of tuberculosis (TB). The HMO must establish mechanisms
to ensure all procedures required to screen at-risk Members and to form the
basis for a diagnosis and proper prophylaxis and management of TB are available
to all Members, except services referenced in

      Section
8.2.2.8 as
Non-Capitated Services. The HMO must develop policies and procedures to ensure
that Members who may be or are at risk for exposure to TB are screened for TB.
An at-risk Member means a person who is susceptible to TB because of the
association with certain risk factors, behaviors, drug resistance, or
environmental conditions. The HMO must consult with the

      local TB
control program to ensure that all services and treatments are in compliance
with the guidelines recommended by the American Thoracic Society (ATS), the
Centers for Disease Control and Prevention (CDC), and DSHS policies and
standards.

      


      The HMO
must implement policies and procedures requiring Providers to report all
confirmed or suspected cases of TB to the local TB control program within one
working day of identification, using the most recent DSHS forms and procedures
for reporting TB. The HMO must provide access to Member medical records to DSHS
and the local TB control program for all confirmed and suspected TB cases upon
request.

       

      The HMO
must coordinate with the local TB control program to ensure that all Members
with confirmed or suspected TB have a contact investigation and receive Directly
Observed Therapy (DOT). The HMO must require, through contract provisions, that
Providers report to DSHS or the local TB control program any Member who is
non-compliant, drug resistant, or who is or may be posing a public health
threat. The HMO must cooperate with the local TB control program in enforcing
the control measures and quarantine procedures contained in Chapter 81 of the
Texas Health and Safety Code.

       

      The HMO
must have a mechanism for coordinating a post-discharge plan for follow-up DOT
with the local TB program. The HMO must coordinate with the DSHS South Texas
Hospital and Texas Center for Infectious Disease for voluntary and court-ordered
admission, discharge plans, treatment objectives and projected length of stay
for Members with multi-drug resistant TB.

       

      8.2.2.7  Objection
to Provide Certain Services

      In
accordance with 42 C.F.R. §438.102, the HMO may file an objection to providing,
reimbursing for, or providing coverage of, a counseling or referral service for
a Covered Service based on moral or religious grounds. The HMO must work with
HHSC to develop a work plan to complete the necessary tasks and determine an
appropriate date for implementation of the requested changes to the requirements
related to Covered Services. The work plan will include timeframes for
completing the necessary Contract and waiver amendments, adjustments to
Capitation Rates, identification of the HMO and enrollment materials needing
revision, and notifications to Members.

       

      In order
to meet the requirements of this section, the HMO must notify HHSC of grounds
for and provide detail concerning its moral or religious objections and the
specific services covered under the objection, no less than 120 days prior to
the proposed effective date of the policy change. 

       

      8.2.2.8
Medicaid Non-capitated Services

      The
following Texas Medicaid programs and services have been excluded from HMO
Covered Services.  Medicaid Members are eligible to receive these
Non-capitated Services on a Fee-for-Service basis from Texas Medicaid providers.
HMOs should refer to relevant chapters in the Provider Procedures Manual and
the Texas Medicaid
Bulletins for more information.

      


      
        	
                 
      

              	
                1. THSteps
      dental (including orthodontia);

              


      

      
        	
                 
      

              	
                2. Early
      Childhood Intervention (ECI) case management/service
      coordination;

              


      

      
        	
                 
      

              	
                3. DSHS
      targeted case management;

              


      

      
        	
                 
      

              	
                4. DSHS
      mental health rehabilitation;

              


      

      
        	
                 
      

              	
                5. DSHS
      case management for Children and Pregnant
Women;

              


      

      
        	
                 
      

              	
                6. Texas
      School Health and Related Services
(SHARS);

              


      

      
        	
                 
      

              	
                7. Department
      of Assistive and Rehabilitative Services Blind Children’s Vocational
      Discovery and Development Program;

              


      

      
        	
                 
      

              	
                8. Tuberculosis
      services provided by DSHS-approved providers (directly observed therapy
      and contact investigation);

              


      

      
        	
                 
      

              	
                9. Vendor
      Drug Program (out-of-office drugs);

              


      

      
        	
                 
      

              	
                10. Texas
      Department of Transportation Medical
  Transportation;

              


      

      
        	
                 
      

              	
                11. DADS
      hospice services (all Members are disenrolled from their health plan upon
      enrollment into hospice except STAR+PLUS members receiving 1915(c) Nursing
      Facility Waiver services that are not covered by the Hospice
      Program);

              


      

      
        	
                 
      

              	
                12. Audiology
      services and hearing aids for children (under age 21) (hearing screening
      services are provided through the THSteps Program and are capitated)
      through PACT (Program for Amplification for Children of
      Texas).

              


      

      
        	
                 
      

              	
                13. For
      STAR+PLUS, Inpatient Stays are Non-capitated
  Services.

              


      

      
        	
                 
      

              	
                14. For
      STAR, Personal Care Services for persons under age 21 are Non-capitated
      Services.

              


      

       

      8.2.2.9  Referrals
for Non-capitated Services

      Although
Medicaid HMOs are not responsible for paying or reimbursing for Non-capitated
Services, HMOs are responsible for educating Members about the availability of
Non-capitated Services, and for providing appropriate referrals for Members to
obtain or access these services. The HMO is responsible for informing Providers
that bills for all Non-capitated Services must be submitted to HHSC’s Claims
Administrator for reimbursement.

       

      8.2.2.10
Cooperation with Immunization Registry

      The HMO
must work with HHSC and health care providers to improve the immunization rate
of Medicaid clients and the reporting of immunization information for inclusion
in the Texas Immunization Registry, called “ImmTrac.”

       

      8.2.2.11
Case Management for Children and Pregnant Women

      The HMO
must educate Members and Providers on the services available through Case
Management for Children and Pregnant Women (CPW) as described on the program’s
website at http://www.dshs.state.tx.us/caseman/default.shtm.  An
HMO may provide information about CPW’s website and basic information about CPW
services in order to meet this requirement. CPW information and materials must
be included in the HMO’s Provider Manual, Member Handbook and Provider
orientations.  The information and materials must also inform
Providers that the disclosure of medical records or information between
Providers, HMO’s and CPW case managers does not require a medical release form
from the Member.

       

      The HMO
must coordinate services with CPW regarding a Member’s health care needs that
are identified by CPW and referred to the HMO.  Upon receipt of a
referral or assessment from a CPW case manager, the HMO’s designated staff are
required to review the assessment and determine, based on the HMO’s policies,
the appropriate level of health care and services.  The HMO’s staff
must also coordinate with the Member’s family, Member’s Primary Care Provider
(PCP), in
and Out-of-Network Providers, agencies, and the HMO’s utilization management
staff to ensure that the health care and services identified are properly
referred, authorized, scheduled and provided within a timely
manner.

      


      The HMO
must ensure that access to medically necessary health care needed by the Member
is available within the standards established by HHSC for respective
care.  HMOs are not required to arrange or provide for any covered or
non-covered services identified in the CPW assessment.  The decision
whether to authorize these services is made by the HMO.  Within five
(5) business days of identifying any non-covered health care services or other
services that the Member may need, the HMO’s staff must report to the CPW case
manager which items/services will not be performed by the
HMO.  Additionally, within ten (10) business days after all of the
authorized services have been provided, the HMO’s staff must follow-up with CPW
case manager to report the provision of services.  The HMO’s staff
must ensure that all services provided to a Member by an HMO Provider are
reported to the Member’s PCP.

       

      The CPW
program requires its contracted case managers to coordinate with the HMO and the
HMO’s PCPs.  The HMO should report problems regarding CPW referrals,
assessments or coordination activities to HHSC for follow-up with CPW program
staff.

       

      8.2.2.12
Children of Migrant Farmworkers (FWC)

      The HMO
must cooperate and coordinate with the State, outreach programs, and THSteps
regional program staff and agents to ensure prompt delivery of services, in
accordance with the timeframes in this Contract, to FWC Members and other
migrant populations who may transition into and out of the HMO more rapidly
and/or unpredictably than the general population.

       

      The HMO
must provide accelerated services to FWC Members.  For purposes of
this section, “accelerated services” are services that are provided to a child
of a migrant farm worker prior to their leaving Texas to work in other
states.   Accelerated services include the provision of
preventive Health Care Services that will be due during the time the FWC Member
is out of Texas.  The need for accelerated services must be determined
on a case-by-case and according to the FWC Member’s age, periodicity schedule
and health care needs.

       

      The HMO
must develop a plan annually for the process it will use to identify FWC and for
the methods that will be used to provide accelerated services and submit an
annual certification that the HMO will comply with the plan.  The plan
for FY2008 must be submitted for HHSC approval no later than December 1, 2007
and implemented by February 1, 2008.  The plan must include at a
minimum:

      


      
        	
                 
      

              	
                • Identification
      of community and statewide groups that work with FWC Members within the
      HMO’s Service Areas;

              


      

      
        	
                 
      

              	
                • Participation
      of the community groups in assisting with the identification of FWC
      Members;

              


      

      
        	
                 
      

              	
                • Appropriate
      aggressive efforts to reach each identified FWC to provide timely medical
      checkups and follow up care if
needed;

              


      

      
        	
                 
      

              	
                • Methods
      to maintain accurate, current lists of all identified FWC
      Members;

              


      

      
        	
                 
      

              	
                • Methods
      that the HMO and its Subcontractors will implement to maintain the
      confidentiality of information about the identity of FWC;
    and

              


      

      
        	
                 
      

              	
                • Methods
      to provide accelerated services to
FWC.

              


      

      


       8.2.3  Medicaid
Significant Traditional Providers

      In the
first three (3) years of a Medicaid HMO Program operating in a Service Area, the
HMO must seek participation in its Network from all Medicaid Significant
Traditional Providers (STPs) defined by HHSC in the applicable Service Area for
the applicable HMO Program.  For STAR HMOs, the Medicaid STP
requirements only apply in the Nueces Service Area.  For STAR+PLUS
HMOs, the Medicaid STP requirements apply to all Service Areas, except Harris
County within the Harris Service Area.

       

      Medicaid
STPs are defined as PCPs and, for STAR+PLUS, Community-based Long Term Care
providers in a county, that, when listed
by provider type by county in descending order by unduplicated number of
clients, served the top 80% of unduplicated clients. Hospitals receiving
Disproportionate Share Hospital (DSH) funds are also considered STPs in the
Service Area in which they are located.  Note that STAR+PLUS HMOs are
not required to contract with Hospitals for Inpatient Stays, but are required to
contract with Hospitals for Outpatient Hospital Services. The HHSC website
includes a list of Medicaid STPs by Service Area.

       

      Because
the STP lists were produced in FY2005, HHSC has developed an updated list for
Long Term Care Providers. The list will be provided to HMOs and posted on HHSC’s
website.

       

      The STP
requirement will be in place for three years after the program has been
implemented. During that time, providers who believe they meet the STP
requirements may contact HHSC request HHSC’s consideration for STP
status.  STAR+PLUS HMOs will be notified when Providers are added to
the list of STPs for a Service Area.

       

      The HMO
must give STPs the opportunity to participate in its Network for at least three
(3) years commencing on the implementation date of Medicaid managed care in the
Service Area. However, the STP provider must:

      


      
        	
                 
      

              	
                1. Agree
      to accept the HMO’s Provider reimbursement rate for the provider type;
      and

              


      

      


      
        	
                 
      

              	
                2. Meet
      the standard credentialing requirements of the HMO, provided that lack of
      board certification or accreditation by the Joint Commission on
      Accreditation of Health Care Organizations (JCAHO) is not the sole grounds
      for exclusion from the Provider
Network.

              


      

      


      8.2.4  Federally
Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

       

      
        The HMO
must make reasonable efforts to include FQHCs and RHCs (freestanding and
hospital-based) in its Provider Network. The HMO must reimburse FQHCs, RHCs, and
Municipal Health Department’s public clinics for Health Care Services provided
outside of regular business hours, as defined by HHSC in rules, including
weekend days or holidays, at a rate that is equal to the allowable rate for
those services as determined under Section 32.028, Human Resources Code, if the
Member does not have a referral from their PCP. Depending on the date of the
claim, FQHCs or RHCs may receive a cost settlement from HHSC and must agree to
accept initial payments from the HMO in an amount that is equal to or greater
than the HMO’s payment terms for other Providers providing the same or similar
services.

        


        
          	
                   
      

                	
                  1.
      Prior to September 1,
      2007: For claims accruing prior to September 1, 2007, cost
      settlements apply to all Service Areas except the Nueces Service Area and
      the STAR+PLUS Service Areas. The HMOs serving the Nueces Service Area and
      the STAR+PLUS Service Areas must pay the full encounter rates to the FQHCs
      and RHCs for claims accruing before September 1,
  2007.

                


        

        


        
          	
                   
      

                	
                  2.
      September 1, 2007 to
      September 1, 2008: For claims accruing on or after September 1,
      2007 but prior to September 1, 2008, HMOs are not required to pay full
      encounter rates to the FQHCs and RHCs. Therefore, HHSC cost settlements
      for FQHC’s will continue to apply to all STAR and STAR+PLUS Service Areas
      for this period of time.

                


        

        


        
          	
                   
      

                	
                  3.
      On or after September 1,
      2008: HMOs are required to pay the full encounter rates to RHCs for
      claims accruing on or after September 1, 2008; therefore, HHSC cost
      settlements will not apply to RHCs for this period of time. However, HMOs
      are not required to pay the full encounter rates to FQHCs for claims
      accruing on or after September 1, 2008; therefore, HHSC cost settlements
      will apply to FQHCs for this period of
time.

                


        

        


        The HMO
must submit monthly FQHC and RHC encounter and payment reports to all contracted
FQHCs and RHCs, and FQHCs and RHCs with which there have been encounters, not
later than 21 days from the end of the month for which the report is submitted.
The format will be developed by HHSC and provided in the Uniform Managed Care Manual.
The FQHC and RHC must validate the encounter and payment information contained
in the report(s). The HMO and the FQHC/RHC must both sign the report(s) after
each party agrees that it accurately reflects encounters and payments for the
month reported. The HMO must submit the signed FQHC and RHC encounter and
payment reports to HHSC not later than 45 days from the end of the reported
month. Encounter and payment reports will not be necessary for

        


        
          	
                   
      

                	
                  1.
      the Nueces Service Area and the STAR+PLUS Service Areas for claims
      accruing before September 1, 2007, since the HMOs in those Areas will pay
      the full encounter rates to the FQHCs and RHCs for this period of time;
      and

                


        

        


        
          	
                   
      

                	
                  2.
      for claims paid to RHCs on or after September 1, 2008, because the HMOs
      will pay full encounter rates to RHCs for this period of
    time.

                


        

      

       

      8.2.5  Provider
Complaints and Appeals

      8.2.5.1  Provider
Complaints

      Medicaid
HMOs must develop, implement, and maintain a system for tracking and resolving
all Medicaid Provider complaints. Within this process, the HMO must respond
fully and completely to each complaint and establish a tracking mechanism to
document the status and final disposition of each Provider
complaint.  The HMO must resolve Provider Complaints
within 30 days from the date the Complaint is received.

       

      8.2.5.2  Appeal
of Provider Claims

      Medicaid
HMOs must develop, implement, and maintain a system for tracking and resolving
all Medicaid Provider appeals related to claims payment. Within this process,
the Provider must respond fully and completely to each Medicaid Provider’s
claims payment appeal and establish a tracking mechanism to document the status
and final disposition of each Medicaid Provider’s claims payment
appeal.

       

      Medicaid
HMOs must contract with physicians who are not Network Providers to resolve
claims disputes related to denial on the basis of medical necessity that remain
unresolved subsequent to a Provider appeal. The determination of the physician
resolving the dispute must be binding on the HMO and the Provider. The physician
resolving the dispute must hold the same specialty or a related specialty as the
appealing Provider. HHSC reserves the right to amend this process to include an
independent review process established by HHSC for final determination on these
disputes.

       

      8.2.6  Member
Rights and Responsibilities

      In
accordance with 42 C.F.R. §438.100, all Medicaid HMOs must maintain written
policies and procedures for informing Members of their rights and
responsibilities, and must notify their Members of their right to request a copy
of these rights and responsibilities. The Member Handbook must include
notification of Member rights and responsibilities.

       

      8.2.7  Medicaid
Member Complaint and Appeal System

      The HMO
must develop, implement, and maintain a Member Complaint and Appeal system that
complies with the requirements in applicable federal and state laws and
regulations, including 42 C.F.R. §431.200, 42 C.F.R. Part 438, Subpart F,
“Grievance System,” and the provisions of 1 T.A.C. Chapter 357 relating to
Medicaid managed care organizations.

       

      The
Complaint and Appeal system must include a Complaint process, an Appeal process,
and access to HHSC’s Fair Hearing System. The procedures must be the same for
all Members and must be reviewed and approved in writing by HHSC or its
designee.  Modifications and amendments to the Member Complaint and
Appeal system must be submitted for HHSC’s approval at least 30 days prior to
the implementation.

       

      8.2.7.1  Member
Complaint Process

      The HMO
must have written policies and procedures for receiving, tracking, responding
to, reviewing, reporting and resolving Complaints by Members or their authorized
representatives. For purposes of this Section 8.2.7, an “authorized
representative” is any person or entity acting on behalf of the Member and with
the Member’s written consent. A Provider may be an authorized
representative.

       

      The HMO
must resolve Complaints within 30 days from the date the Complaint is received.
The HMO is subject to remedies, including liquidated damages, if at least 98
percent of Member Complaints are not resolved within 30 days of receipt of the
Complaint by the HMO. Please see the Uniform Managed Care Contract Terms
& Conditions and
Attachment B-5, Deliverables/Liquidated Damages Matrix. The Complaint
procedure must be the same for all Members under the Contract. The Member or
Member’s authorized representative may file a Complaint either orally or in
writing. The HMO must also inform Members how to file a Complaint directly with
HHSC, once the Member has exhausted the HMO’s complaint process.

       

      The HMO
must designate an officer of the HMO who has primary responsibility for ensuring
that Complaints are resolved in compliance with written policy and within the
required timeframe. For purposes of Section 8.2.7.2, an “officer”
of the HMO means a president, vice president, secretary, treasurer, or
chairperson of the board for a corporation, the sole proprietor, the managing
general partner of a partnership, or a person having similar executive authority
in the organization.

       

      The HMO
must have a routine process to detect patterns of Complaints. Management,
supervisory, and quality improvement staff must be involved in developing policy
and procedure improvements to address the Complaints.

       

      The HMO’s
Complaint procedures must be provided to Members in writing and through oral
interpretive services. A written description of the HMO’s Complaint procedures
must be available in prevalent non-English languages for Major Population Groups
identified by HHSC, at no more than a 6th grade reading level.

       

      The HMO
must include a written description of the Complaint process in the Member
Handbook. The HMO must maintain and publish in the Member Handbook, at least one
local and one toll-free telephone number with TeleTypewriter/Telecommunications
Device for the Deaf (TTY/TDD) and interpreter capabilities for making
Complaints.

       

      The HMO’s
process must require that every Complaint received in person, by telephone, or
in writing must be acknowledged and recorded in a written record and logged with
the following details:

      


      
        	
                 
      

              	
                1. Date;

              


      

      


      
        	
                 
      

              	
                2. Identification
      of the individual filing the
Complaint;

              


      

      


      
        	
                 
      

              	
                3. Identification
      of the individual recording the
Complaint;

              


      

      


      
        	
                 
      

              	
                4. Nature
      of the Complaint;

              


      

      


      
        	
                 
      

              	
                5. Disposition
      of the Complaint (i.e., how the HMO resolved the
    Complaint);

              


      

      


      
        	
                 
      

              	
                6. Corrective
      action required; and

              


      

      


      
        	
                 
      

              	
                7. Date
      resolved.

              


      

      


      The HMO
is prohibited from discriminating or taking punitive action against a Member or
his or her representative for making a Complaint.

       

      If the
Member makes a request for disenrollment, the HMO must give the Member
information on the disenrollment process and direct the Member to the HHSC
Administrative Services Contractor. If the request for disenrollment includes a
Complaint by the Member, the Complaint will be processed separately from the
disenrollment request, through the Complaint process.

       

      The HMO
will cooperate with the HHSC’s Administrative Services Contractor and HHSC or
its designee to resolve all Member Complaints. Such cooperation may include, but
is not limited to, providing information or assistance to internal Complaint
committees.

       

      The HMO
must provide designated Member Advocates to assist Members in understanding and
using the HMO’s Complaint system as described in Section 8.2.7.9. The HMO’s
Member Advocates must assist Members in writing or filing a Complaint and
monitoring the Complaint through the HMO’s Complaint process until the issue is
resolved.

       

      8.2.7.2
Medicaid Standard Member Appeal Process

       

      
        The HMO
must develop, implement and maintain an Appeal procedure that complies with
state and federal laws and regulations, including 42 C.F.R.§ 431.200 and 42
C.F.R. Part 438, Subpart F, “Grievance System.” An Appeal is a disagreement with
an HMO Action as defined in HHSC’s Uniform Contract Terms and
Conditions. The Appeal procedure must be the same for all Members. When a
Member or his or her authorized representative expresses orally or in writing
any dissatisfaction or disagreement with an Action, the HMO must regard the
expression of dissatisfaction as a request to Appeal an Action.

         

        A Member
must file a request for an Appeal with the HMO within 30 days from receipt of
the notice of the Action. The HMO is subject to remedies, including liquidated
damages, if at least 98 percent of Member Appeals are not resolved within 30
days of receipt of the Appeal by the HMO. Please see the Uniform Managed Care Contract Terms
& Conditions and Attachment B-5, Deliverables/Liquidated Damages Matrix.
To ensure continuation of currently authorized services, however, the
Member must file the Appeal on or before the later of 10 days following the
HMO’s mailing of the notice of the Action, or the intended effective date of the
proposed Action. The HMO must designate an officer who has primary
responsibility for ensuring that Appeals are resolved in compliance with written
policy and within the 30-day time limit.

         

        The
provisions of Chapter 4201, Texas Insurance Code, relating to a Member’s right
to Appeal an Adverse Determination made by the HMO or a utilization review agent
to an independent review organization, do not apply to a Medicaid recipient.
Chapter 4201 is pre-empted by federal Fair Hearings requirements.

         

        The HMO
must have policies and procedures in place outlining the Medical Director’s role
in an Appeal of an Action. The Medical Director must have a significant role in
monitoring, investigating and hearing Appeals. In accordance with 42 C.F.R.§
438.406, the HMO’s policies and procedures must require that individuals who
make decisions on Appeals are not involved in any previous level of review or
decision-making, and are health care professionals who have the appropriate
clinical expertise in treating the Member’s condition or disease.

        


        The HMO
must provide designated Member Advocates, as described in Section 8.2.7.9, to assist
Members in understanding and using the Appeal process. The HMO’s Member
Advocates must assist Members in writing or filing an Appeal and monitoring the
Appeal through the HMO’s Appeal process until the issue is
resolved.

         

        The HMO
must have a routine process to detect patterns of Appeals. Management,
supervisory, and quality improvement staff must be involved in developing policy
and procedure improvements to address the Appeals.

         

        The HMO’s
Appeal procedures must be provided to Members in writing and through oral
interpretive services. A written description of the Appeal procedures must be
available in prevalent non-English languages identified by HHSC, at no more than
a 6th grade reading level. The HMO must include a written description of the
Appeals process in the Member Handbook. The HMO must maintain and publish in the
Member Handbook at least one local and one toll-free telephone number with
TTY/TDD and interpreter capabilities for requesting an Appeal of an
Action.

         

        The HMO’s
process must require that every oral Appeal received must be confirmed by a
written, signed Appeal by the Member or his or her representative, unless the
Member or his or her representative requests an expedited resolution. All
Appeals must be recorded in a written record and logged with the following
details:

        


        
          	
                   
      

                	
                  1)
      Date notice is sent;

                


        

        


        
          	
                   
      

                	
                  2)
      Effective date of the Action;

                


        

        


        
          	
                   
      

                	
                  3)
      Date the Member or his or her representative requested the
      Appeal;

                


        

        


        
          	
                   
      

                	
                  4)
      Date the Appeal was followed up in
writing;

                


        

        


        
          	
                   
      

                	
                  5)
      Identification of the individual
filing;

                


        

        


        
          	
                   
      

                	
                  6)
      Nature of the Appeal; and

                


        

        


        
          	
                   
      

                	
                  7)
      Disposition of the Appeal, and notice of disposition to
      Member.

                


        

        


        The HMO
must send a letter to the Member within five (5) business days acknowledging
receipt of the Appeal request. Except for the resolution of an Expedited Appeal
as provided in Section
8.2.7.3, the HMO must complete the entire standard Appeal process within
30 calendar days after receipt of the initial written or oral request for
Appeal. The timeframe for a standard Appeal may be extended up to 14 calendar
days if the Member or his or her representative requests an extension; or the
HMO shows that there is a need for additional information and how the delay is
in the Member’s interest. If the timeframe is extended, the HMO must give the
Member written notice of the reason for delay if the Member had not requested
the delay. The HMO must designate an officer who has primary responsibility for
ensuring that Appeals are resolved within these timeframes and in accordance
with the HMO’s written policies.

         

        During
the Appeal process, the HMO must provide the Member a reasonable opportunity to
present evidence and any allegations of fact or law in person as well as in
writing. The HMO must inform the Member of the time available for providing this
information and that, in the case of an expedited resolution, limited time will
be available.

         

        The HMO
must provide the Member and his or her representative opportunity, before and
during the Appeal process, to examine the Member’s case file, including medical
records and any other documents
considered during the Appeal process. The HMO must include, as parties to the
Appeal, the Member and his or her representative or the legal representative of
a deceased Member’s estate.

         

        In
accordance with 42 C.F.R.§ 438.420, the HMO must continue the Member’s benefits
currently being received by the Member, including the benefit that is the
subject of the Appeal, if all of the following criteria are met:

        


        
          	
                   
      

                	
                  1.
      The Member or his or her representative files the Appeal timely as defined
      in this Contract:

                


        

        


        
          	
                   
      

                	
                  2.
      The Appeal involves the termination, suspension, or reduction of a
      previously authorized course of
treatment;

                


        

        


        
          	
                   
      

                	
                  3.
      The services were ordered by an authorized
  provider;

                


        

        


        
          	
                   
      

                	
                  4.
      The original period covered by the original authorization has not expired;
      and

                


        

        


        
          	
                   
      

                	
                  5.
      The Member requests an extension of the
  benefits.

                


        

        


        If, at
the Member’s request, the HMO continues or reinstates the Member’s benefits
while the Appeal is pending, the benefits must be continued until one of the
following occurs:

        1. The
Member withdraws the Appeal;

        2. Ten
(10) days pass after the HMO mails the notice resolving the Appeal against the
Member, unless the Member, within the 10-day timeframe, has requested a Fair
Hearing with continuation of benefits until a Fair Hearing decision can be
reached; or

        3. A
state Fair Hearing officer issues a hearing decision adverse to the Member or
the time period or service limits of a previously authorized service has been
met.

         

        In
accordance with 42 C.F.R.§ 438.420(d), if the final resolution of the Appeal is
adverse to the Member and upholds the HMO’s Action, then to the extent that the
services were furnished to comply with the Contract, the HMO may recover such
costs from the Member.

         

        If the
HMO or State Fair Hearing Officer reverses a decision to deny, limit, or delay
services that were not furnished while the Appeal was pending, the HMO must
authorize or provide the disputed services promptly and as expeditiously as the
Member’s health condition requires.

         

        If the
HMO or State Fair Hearing Officer reverses a decision to deny authorization of
services and the Member received the disputed services while the Appeal was
pending, the HMO is responsible for the payment of services.

         

        The HMO
is prohibited from discriminating or taking punitive action against a Member or
his or her representative for making an Appeal.

      

       

      8.2.7.3  Expedited
Medicaid HMO Appeals

      In
accordance with 42 C.F.R. §438.410, the HMO must establish and maintain an
expedited review process for Appeals, when the HMO determines (for a request
from a Member) or the provider indicates (in making the request on the Member’s
behalf or supporting the Member’s request) that taking the time for a standard
resolution could seriously jeopardize the Member’s life or health. The HMO must
follow all Appeal requirements for standard Member Appeals as set forth in Section 8.2.7.2), except where
differences are specifically noted. The HMO must accept oral or written requests
for Expedited Appeals.

       

      Members
must exhaust the HMO’s Expedited Appeal process before making a request for an
expedited Fair Hearing. After the HMO receives the request for an Expedited
Appeal, it must hear an approved request for a Member to have an Expedited
Appeal and notify the Member of the outcome of the Expedited Appeal within 3
business days, except that the HMO must complete investigation and resolution of
an Appeal relating to an ongoing emergency or denial of continued
hospitalization: (1) in accordance with the medical or dental immediacy of the
case; and (2) not later than one (1) business day after receiving the Member’s
request for Expedited Appeal is received.

       

      Except
for an Appeal relating to an ongoing emergency or denial of continued
hospitalization, the timeframe for notifying the Member of the outcome of the
Expedited Appeal may be extended up to 14 calendar days if the Member requests
an extension or the HMO shows (to the satisfaction of HHSC, upon HHSC’s request)
that there is a need for additional information and how the delay is in the
Member’s interest. If the timeframe is extended, the HMO must give the Member
written notice of the reason for delay if the Member had not requested the
delay.

       

      If the
decision is adverse to the Member, the HMO must follow the procedures relating
to the notice in

      Section
8.2.7.5. The HMO
is responsible for notifying the Member of his or her right to access an
expedited Fair Hearing from HHSC. The HMO will be responsible for
providing

      documentation
to the State and the Member, indicating how the decision was made, prior to
HHSC’s expedited Fair Hearing.

       

      The HMO
is prohibited from discriminating or taking punitive action against a Member or
his or her representative for requesting an Expedited Appeal.  The HMO
must ensure that punitive action is neither taken against a provider who
requests an expedited resolution or supports a Member’s request.

       

      If the
HMO denies a request for expedited resolution of an Appeal, it
must:

      


      
        	
                 
      

              	
                (1) Transfer
      the Appeal to the timeframe for standard resolution,
  and

              


      

      


      
        	
                 
      

              	
                (2) Make a
      reasonable effort to give the Member prompt oral notice of the denial, and
      follow up within two (2) calendar days with a written
    notice.

              


      

      


      8.2.7.4
Access to Fair Hearing for Medicaid Members

      The HMO
must inform Members that they have the right to access the Fair Hearing process
at any time during the Appeal system provided by the HMO. In the case of an
expedited Fair Hearing process, the HMO must inform the Member that he or she
must first exhaust the HMO’s internal Expedited Appeal process prior to filing
an Expedited Fair Hearing. The HMO must notify Members that they may be
represented by an authorized representative in the Fair Hearing
process.

       

      If a
Member requests a Fair Hearing, the HMO will complete the request for Fair
Hearing, and submit the form via facsimile to the appropriate Fair Hearings
office, within five (5) calendar days of the Member's request for a Fair
Hearing.

       

      Within
five (5) calendar days of notification that the Fair Hearing is set, the HMO
will prepare an evidence packet for submission to the HHSC Fair Hearings staff
and send a copy of the packet to the Member. The evidence packet must comply
with HHSC’s Fair Hearings requirements.

      


      8.2.7.5  Notices
of Action and Disposition of Appeals for Medicaid Members

      The HMO
must notify the Member, in accordance with 1 T.A.C. Chapter 357, whenever the
HMO takes an Action. The notice must, at a minimum, include any information
required by 1 T.A.C. Chapter 357 that relates to a managed care organization’s
notice of Action and any information required by 42 C.F.R. §438.404 as directed
by HHSC, including but not limited to:

       

      1. The dates,
types and amount of service requested;

      2. The
Action the HMO has taken or intends to take;

      3. The
reasons for the Action (If the Action taken is based upon a determination that
the requested service is not medically necessary, the HMO must provide an
explanation of the medical
basis for the decision, application of policy or accepted standards of medical
practice to the individuals medical circumstances, in it’s notice to the
member.);

      4. The
Member’s right to access the HMO’s Appeal process.

      5. The
procedures by which the Member may Appeal the HMO’s Action;

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

      7. The
circumstances under which a Member may continue to receive benefits pending
resolution of the Appeal, how to request that benefits be continued, and the
circumstances under which the Member may be required to pay the costs of these
services;

      8. The
date the Action will be taken;

      9. A
reference to the HMO policies and procedures supporting the HMO’s
Action;

      10. An
address where written requests may be sent and a toll-free number that the
Member can call to request the assistance of a Member representative, file an
Appeal, or request a Fair Hearing;

      11. An
explanation that Members may represent themselves, or be represented by a
provider, a friend, a relative, legal counsel or another
spokesperson;

      12. A
statement that if the Member wants a Fair Hearing on the Action, the Member must
make the request for a Fair Hearing within 90 days of the date on the notice or
the right to request a hearing is waived;

      13. A
statement explaining that the HMO must make its decision within 30 days from the
date the Appeal is received by the HMO, or 3 business days in the case of an
Expedited Appeal; and

      14. A
statement explaining that the hearing officer must make a final decision within
90 days from the date a Fair Hearing is requested.

       

      8.2.7.6  Timeframe
for Notice of Action

      In
accordance with 42 C.F.R.§ 438.404(c), the HMO must mail a notice of Action
within the following timeframes:

      


      
        	
                 
      

              	
                1. For
      termination, suspension, or reduction of previously authorized
      Medicaid-covered services, within the timeframes specified in 42 C.F.R.§§
      431.211, 431.213, and 431.214;

              


      

      
        	
                 
      

              	
                2. For
      denial of payment, at the time of any Action affecting the
      claim;

              


      

      
        	
                 
      

              	
                3. For
      standard service authorization decisions that deny or limit services,
      within the timeframe specified in 42 C.F.R.§
  438.210(d)(1);

              


      

      
        	
                 
      

              	
                4. If the
      HMO extends the timeframe in accordance with 42 C.F.R. §438.210(d)(1), it
      must:

              


      

      
        	
                 
      

              	
                5. give
      the Member written notice of the reason for the decision to extend the
      timeframe and inform the Member of the right to file an Appeal if he or
      she disagrees with that decision;
and

              


      

      
        	
                 
      

              	
                6. issue
      and carry out its determination as expeditiously as the Member’s health
      condition requires and no later than the date the extension
      expires;

              


      

      
        	
                 
      

              	
                7. For
      service authorization decisions not reached within the timeframes
      specified in 42 C.F.R.§ 438.210(d) (which constitutes a denial and is thus
      an adverse Action), on the date that the timeframes expire;
      and

              


      

      
        	
                 
      

              	
                8. For
      expedited service authorization decisions, within the timeframes specified
      in 42 C.F.R. 438.210(d).

              


      

       

      8.2.7.7
Notice of Disposition of Appeal

      In
accordance with 42 C.F.R.§ 438.408(e), the HMO must provide written notice of
disposition of all Appeals including Expedited Appeals. The written resolution
notice must include the results and date of the Appeal resolution. For decisions
not wholly in the Member’s favor, the notice must contain:

      


      
        	
                 
      

              	
                1. The
      right to request a Fair Hearing;

              


      

      


      
        	
                 
      

              	
                2. How to
      request a Fair Hearing;

              


      

      


      
        	
                 
      

              	
                3. The
      circumstances under which the Member may continue to receive benefits
      pending a Fair Hearing;

              


      

      


      
        	
                 
      

              	
                4. How to
      request the continuation of
benefits;

              


      

      


      
        	
                 
      

              	
                5. If the
      HMO’s Action is upheld in a Fair Hearing, the Member may be liable for the
      cost of any services furnished to the Member while the Appeal is pending;
      and

              


      

      


      
        	
                 
      

              	
                6. Any
      other information required by 1 T.A.C. Chapter 357 that relates to a
      managed care organization’s notice of disposition of an
      Appeal.

              


      

      


      8.2.7.8
Timeframe for Notice of Resolution of Appeals

      In
accordance with 42 C.F.R.§ 438.408, the HMO must provide written notice of
resolution of Appeals, including Expedited Appeals, as expeditiously as the
Member’s health condition requires, but the notice must not exceed the timelines
as provided in this Section for Standard or Expedited Appeals. For expedited
resolution of Appeals, the HMO must make reasonable efforts to give the Member
prompt oral notice of resolution of the Appeal, and follow up with a written
notice within the timeframes set forth in this Section for Expedited Appeals. If
the HMO denies a request for expedited resolution of an Appeal, the HMO must
transfer the Appeal to the timeframe for standard resolution as provided in this
Section, and make reasonable efforts to give the Member prompt oral notice of
the denial, and follow up within two calendar days with a written
notice.

       

      8.2.7.9
Medicaid Member Advocates

      The HMO
must provide Member Advocates to assist Members. Member Advocates must be
physically located within the Service Area unless an exception is approved by
HHSC. Member Advocates must inform Members of the following:

      


      
        	
                 
      

              	
                1. Their
      rights and responsibilities,

              


      

      
        	
                 
      

              	
                2. The
      Complaint process,

              


      

      
        	
                 
      

              	
                3. The
      Appeal process,

              


      

      
        	
                 
      

              	
                4. Covered
      Services available to them, including preventive services,
    and

              


      

      
        	
                 
      

              	
                5. Non-capitated
      Services available to them.

              


      

       

      Member
Advocates must assist Members in writing Complaints and are responsible for
monitoring the Complaint through the HMO’s Complaint process.

       

      Member
Advocates are responsible for making recommendations to management on any
changes needed to improve either the care provided or the way care is delivered.
Member Advocates are also responsible for helping or referring Members to
community resources available to meet Member needs that are not available from
the HMO as Medicaid Covered Services.

       

      8.2.8
Additional Medicaid Behavioral Health Provisions

      8.2.8.1  Local
Mental Health Authority (LMHA)

      Assessment
to determine eligibility for rehabilitative and targeted DSHS case management
services is a function of the LMHA. Covered Services must be provided to Members
with severe and persistent mental illness (SPMI) and severe emotional
disturbance (SED), when Medically Necessary, whether or not they are also
receiving targeted case management or rehabilitation services through the
LMHA.

       

      The HMO
must enter into written agreements with all LMHAs in the Service Area that
describe the process(es) that the HMO and LMHAs will use to coordinate services
for Medicaid Members with SPMI or SED. The agreements will:

      


      
        	
                 
      

              	
                1. Describe
      the Behavioral Health Services indicated in detail in the Provider Procedures
      Manual and in the Texas Medicaid Bulletin,
      include the amount, duration, and scope of basic and Value-added Services,
      and the HMO’s responsibility to provide these
  services;

              


      

      
        	
                 
      

              	
                2. Describe
      criteria, protocols, procedures and instrumentation for referral of
      Medicaid Members from and to the HMO and the
  LMHA;

              


      

      
        	
                 
      

              	
                3. Describe
      processes and procedures for referring Members with SPMI or SED to the
      LMHA for assessment and determination of eligibility for rehabilitation or
      targeted case management services;

              


      

      
        	
                 
      

              	
                4. Describe
      how the LMHA and the HMO will coordinate providing Behavioral Health
      Services to Members with SPMI or
SED;

              


      

      
        	
                 
      

              	
                5. Establish
      clinical consultation procedures between the HMO and LMHA including
      consultation to effect referrals and on-going consultation regarding the
      Member’s progress;

              


      

      
        	
                 
      

              	
                6. Establish
      procedures to authorize release and exchange of clinical treatment
      records;

              


      

      
        	
                 
      

              	
                7. Establish
      procedures for coordination of assessment, intake/triage, utilization
      review/utilization management and care for persons with SPMI or
      SED;

              


      

      
        	
                 
      

              	
                8. Establish
      procedures for coordination of inpatient psychiatric services (including
      Court- ordered Commitment of Members under 21) in state psychiatric
      facilities within the LMHA’s catchment
area;

              


      

      
        	
                 
      

              	
                9. Establish
      procedures for coordination of emergency and urgent services to
      Members;

              


      

      
        	
                 
      

              	
                10. Establish
      procedures for coordination of care and transition of care for new Members
      who are receiving treatment through the LMHA;
  and

              


      

      
        	
                 
      

              	
                11. Establish
      that when Members are receiving Behavioral Health Services from the Local
      Mental Health Authority that the HMO is using the same UM guidelines as
      those prescribed for use by local mental health authorities by DSHS which
      are published at: http://www.mhmr.state.tx.us/centraloffice/behavioralhealthservices/RDMClinGuide.html.

              


      

      


      The HMO
must offer licensed practitioners of the healing arts (defined in 25 T.A.C.,
Part 2, Chapter 419, Subchapter L), who are part of the Member’s treatment team
for rehabilitation services, the opportunity to participate in the HMO’s
Network. The practitioner must agree to accept the HMO’s Provider reimbursement
rate, meet the credentialing requirements, and comply with all the terms and
conditions of the HMO’s standard Provider contract.

       

      HMOs must
allow Members receiving rehabilitation services to choose the licensed
practitioners of the healing arts who are currently a part of the Member’s
treatment team for rehabilitation services to provide Covered Services. If the
Member chooses to receive these services from licensed practitioners of the
healing arts who are part of the Member’s rehabilitation services treatment team
but are not part of the HMO’s Network, the HMO must reimburse the Local Mental
Health Authority through Out-of-Network reimbursement arrangements.

       

      Nothing
in this section diminishes the potential for the Local Mental Health Authority
to seek best value for rehabilitative services by providing these services under
arrangement, where possible, as specified is 25 T.A.C. §419.455.

       

      8.2.9   Third
Party Liability and Recovery

      Medicaid
HMOs are responsible for establishing a plan and process for recovering costs
for services that should have been paid through a third party in accordance with
State and Federal law and regulations. To recognize this requirement, capitation
payments to the HMOs are reduced by the projected amount of TPR that the HMO is
expected to recover.

      


      The HMOs
must provide required reports as stated in Section 8.1.17.2, Financial
Reporting Requirements. 

       

      After
120-days from the date of service on any claim, encounter, or other Medicaid
related payment by the HMO subject to Third Party Recovery, HHSC may attempt
recovery independent of any HMO action.  HHSC will retain, in full,
all funds received as a result of the state initiated recovery or subrogation
action.

       

      HMOs
shall provide a Member quarterly file, which contains the following information
if available to the HMO:  the Member name, address, claim submission
address, group number, employer's mailing address, social security number, and
date of birth for each subscriber or policyholder and each dependent of the
subscriber or policyholder covered by the insurer.  The file shall be
used for the purpose of matching the Texas Medicaid eligibility file against the
HMO Member file to identify Medicaid clients enrolled in the HMO, which may not
be known the Medicaid Program.

       

      8.2.10  Coordination
With Public Health Entities

      8.2.10.1
Reimbursed Arrangements with Public Health Entities

      The HMO
must make a good faith effort to enter into a subcontract for Covered Services
with Public Health Entities. Possible Covered Services that could be provided by
Public Health Entities include, but are not limited to, the following
services:

      


      
        	
                 
      

              	
                1. Sexually
      Transmitted Diseases (STDs)
services;

              


      

      


      
        	
                 
      

              	
                2. Confidential
      HIV testing;

              


      

      


      
        	
                 
      

              	
                3. Immunizations;

              


      

      


      
        	
                 
      

              	
                4. Tuberculosis
      (TB) care;

              


      

      


      
        	
                 
      

              	
                5. Family
      Planning services;

              


      

      


      
        	
                 
      

              	
                6. THSteps
      medical checkups, and

              


      

      


      
        	
                 
      

              	
                7. Prenatal
      services.

              


      

      


      These
subcontracts must be available for review by HHSC or its designated agent(s) on
the same basis as all other subcontracts. If the HMO is unable to enter into a
contract with Public Health Entities, the HMO must document efforts to contract
with Public Health Entities, and make such documentation available to HHSC upon
request.

       

      HMO
Contracts with Public Health Entities must specify the scope of responsibilities
of both parties, the methodology and agreements regarding billing and
reimbursements, reporting responsibilities, Member and Provider educational
responsibilities, and the methodology and agreements regarding sharing of
confidential medical record information between the Public Health Entity and the
HMO or PCP.

       

      The HMO
must:

      


      
        	
                 
      

              	
                1. Identify
      care managers who will be available to assist public health providers and
      PCPs in efficiently referring Members to the public health providers,
      specialists, and health-related service providers either within or outside
      the HMO’s Network; and

              


      

      


      
        	
                 
      

              	
                2. Inform
      Members that confidential healthcare information will be provided to the
      PCP, and educate Members on how to better utilize their PCPs, public
      health providers, emergency departments, specialists, and health-related
      service providers.

              


      

      


      8.2.10.2  Non-Reimbursed
Arrangements with Local Public Health Entities

      The HMO
must coordinate with Public Health Entities in each Service Area regarding the
provision of essential public health care services. In addition to the
requirements listed above in Section 8.2.2, or otherwise required under state
law or this contract, the HMO must meet the following requirements:

      


      
        	
                 
      

              	
                1. Report
      to public health entities regarding communicable diseases and/or diseases
      that are preventable by immunization as defined by state
    law;

              


      

      
        	
                 
      

              	
                2. Notify
      the local Public Health Entity, as defined by state law, of communicable
      disease outbreaks involving
Members;

              


      

      
        	
                 
      

              	
                3. Educate
      Members and Providers regarding WIC services available to Members;
      and

              


      

      
        	
                 
      

              	
                4. Coordinate
      with local public health entities that have a child lead program, or with
      DSHS regional staff when the local public health entity does not have a
      child lead program, for follow-up of suspected or confirmed cases of
      childhood lead exposure.

              


      

      


      8.2.11  Coordination
with Other State Health and Human Services (HHS) Programs

      The HMO
must coordinate with other state HHS Programs in each Service Area regarding the
provision of essential public health care services.  In addition to
the requirements listed above in Section 8.2.2. or otherwise required under
state law or this contract, the HMO must meet the following
requirements:

      


      
        	
                 
      

              	
                1. Require
      Providers to use the DSHS Bureau of Laboratories for specimens obtained as
      part of a THSteps medical checkup, including THSteps newborn screens, lead
      testing, and hemoglobin/hematocrit
tests;

              


      

      


      
        	
                 
      

              	
                2. Notify
      Providers of the availability of vaccines through the Texas Vaccines for
      Children Program;

              


      

      


      
        	
                 
      

              	
                3. Work
      with HHSC and Providers to improve the reporting of immunizations to the
      statewide ImmTrac Registry;

              


      

      


      
        	
                 
      

              	
                4. Educate
      Providers and Members about the Department of State Health Services (DSHS)
      Case Management for Children and Pregnant Women (CPW) services
      available;

              


      

      


      
        	
                 
      

              	
                5. Coordinate
      services with CPW specifically in regard to an HMO Member’s health care
      needs that are identified by CPW and referred to the
  HMO;

              


      

      


      
        	
                 
      

              	
                6. Participate,
      to the extent practicable, in the community-based coalitions with the
      Medicaid-funded case management programs in the Department of Assistive
      and Rehabilitative Services (DARS), the Department of Aging and Disability
      Services (DADS), and DSHS;

              


      

      


      
        	
                 
      

              	
                7. Cooperate
      with activities required of state and local public health authorities
      necessary to conduct the annual population and community based needs
      assessment;

              


      

      


      
        	
                 
      

              	
                8. Report
      all blood lead results, coordinate and follow-up of suspected or confirmed
      cases of childhood lead exposure with the Childhood Lead Poisoning
      Prevention Program in DSHS; and

              


      

      


      
        	
                 
      

              	
                9. Coordinate
      with THSteps.

              


      

      


      8.2.12
Advance Directives

      Federal
and state law require HMOs and providers to maintain written policies and
procedures for informing all adult Members 18 years of age and older about their
rights to refuse, withhold or withdraw medical treatment and mental health
treatment through advance directives (see Social Security Act §1902(a)(57) and
§1903(m)(1)(A)). The HMO’s policies and procedures must include written
notification to Members and comply with provisions contained in 42 C.F.R. § 489,
Subpart I, relating to advance directives for all hospitals, critical access
hospitals, skilled nursing facilities, home health agencies, providers of home
health care, providers of personal care services and hospices, as well as the
following state laws and rules:

      


      
        	
                 
      

              	
                1. A
      Member’s right to self-determination in making health care
      decisions;

              


      

      
        	
                 
      

              	
                2. The
      Advance Directives Act, Chapter 166, Texas Health and Safety Code, which
      includes:

              


      

      
        	
                 
      

              	
                a. A
      Member’s right to execute an advance written directive to physicians and
      family or surrogates, or to make a non-written directive to administer,
      withhold or withdraw life-sustaining treatment in the event of a terminal
      or irreversible condition;

              


      

      


      
        	
                 
      

              	
                b. A
      Member’s right to make written and non-written out-of-hospital
      do-not-resuscitate (DNR) orders;

              


      

      


      
        	
                 
      

              	
                c. A
      Member’s right to execute a Medical Power of Attorney to appoint an agent
      to make health care decisions on the Member’s behalf if the Member becomes
      incompetent; and

              


      

      


      
        	
                 
      

              	
                3. The
      Declaration for Mental Health Treatment, Chapter 137, Texas Civil Practice
      and Remedies Code, which includes: a Member’s right to execute a
      Declaration for Mental Health Treatment in a document making a declaration
      of preferences or instructions regarding mental health
      treatment.

              


      

      


      The HMO
must maintain written policies for implementing a Member’s advance directive.
Those policies must include a clear and precise statement of limitation if the
HMO or a Provider cannot or will not implement a Member’s advance
directive.

       

      The HMO
cannot require a Member to execute or issue an advance directive as a condition
of receiving health care services. The HMO cannot discriminate against a Member
based on whether or not the Member has executed or issued an advance
directive.

       

      The HMO’s
policies and procedures must require the HMO and subcontractors to comply with
the requirements of state and federal law relating to advance directives. The
HMO must provide education and training to employees and Members on issues
concerning advance directives.

       

      All
materials provided to Members regarding advance directives must be written at a
7th
- 8th grade
reading comprehension level, except where a provision is required by state or
federal law and the provision cannot be reduced or modified to a 7th -
8th
grade reading level because it is a reference to the law or is required to be
included “as written” in the state or federal law.

       

      The HMO
must notify Members of any changes in state or federal laws relating to advance
directives within 90 days from the effective date of the change, unless the law
or regulation contains a specific time requirement for
notification.

       

      8.3
Additional STAR+PLUS Scope of Work

      8.3.1
Covered Community-Based Long-Term Care Services

      The HMO
must ensure that STAR+PLUS Members needing Community Long-term Care Services are
identified and that services are referred and authorized in a timely manner. The
HMO must ensure that Providers of Community Long-term Care Services are licensed
to deliver the service they provide. The inclusion of Community Long-term Care
Services in a managed care model presents challenges, opportunities and
responsibilities.

      


      Community
Long-term Care Services may be necessary as a preventative service to avoid more
expensive hospitalizations, emergency room visits, or institutionalization.
Community Long-term Care Services should also be made available to Members to
assure maintenance of the highest level of functioning possible in the least
restrictive setting. A Member’s need for Community Long-term Care Services to
assist with the activities of daily living must be considered as important as
needs related to a medical condition. HMOs must provide Functionally Necessary
Covered Services to Community Long-term Care Service Members.

      


      
        	
                8.3.1.1
      Community Based Long-Term Care Services Available to All
      Members

              


      

      


      The HMO
shall enter into written contracts with Providers of Personal Assistance
Services and Day Activity and Health Services (DAHS) to make them available to
all STAR+PLUS Members.  These Providers must at a minimum, meet all of
the following state licensure and certification requirements for providing the
services in Attachment B-2.1,
Covered Services.

       

      
        	
                Community Long-Term Care
      Services Available to All Members

              
	
                Service

              	
                Licensure
      and Certification Requirements

              	 
      
	
                Personal
      Attendant Services

              	
                The
      Provider must be licensed by the Texas Department of Human Services as a
      Home and Community Support Services Agency. The level of licensure
      required depends on the type of service delivered. NOTE: For primary home
      care and client managed attendant care, the agency may have only the
      Personal Assistance Services level of licensure.

              	 
      
	
                Day
      Activity and Health Services (DAHS)

              	
                The
      Provider must be licensed by the Texas Department of Human Services, Long
      Term Care Regulatory Division, as an adult day care provider. To provide
      DAHS, the Provider must provide the range of services required for
      DAHS.

              	 
      


      

      
      

      


      


      
        	
                8.3.1.2
      1915(c) Nursing Facility Waiver Services Available to Members Who Qualify
      for 1915 (c) Nursing Facility Waiver
Services

              


      

      


      The
1915(c) Nursing Facility Waiver provides Community Long-term Care Services to
Medicaid Eligibles who are elderly and to adults with disabilities as a
cost-effective alternative to living in a nursing facility. These Members must
be age 21 or older, be a Medicaid recipient or be otherwise financially eligible
for waiver services. To be eligible for 1915(c) Nursing Facility Waiver
Services, a Member must meet income and resource requirements for Medicaid
nursing facility care, and receive a determination from HHSC on the medical
necessity of the nursing facility care. The HMO must make available to STAR+PLUS
Members who meet the eligibility requirements the array of services allowable
through HHSC’s CMS-approved 1915(c) Nursing Facility Waiver (see Appendix B-2.1, STAR+PLUS Covered
Services).

       

      
        	
                Community Long-Term Care
      Services Under the 1915(c) Nursing Facility
  Waiver

              
	
                Service

              	
                Licensure
      and Certification Requirements

              
	
                Personal
      Attendant Services

              	
                The
      Provider must be licensed by the Texas Department of Human Services as a
      Home and Community Support Services Agency. The level of licensure
      required depends on the type of service delivered. For Primary Home Care
      and Client Managed Attendant Care, the agency may have only the Personal
      Assistance Services level of licensure.

              
	
                Assisted
      Living

              	
                The
      Provider must be licensed by the Texas Department of Aging and Disability
      Services, Long Term Care Regulatory Division. The type of licensure
      determines what services may be provided.

              
	
                Emergency
      Response Service Provider

              	
                Texas
      Department of Aging and Disability Services (DADS) Standards for Emergency
      Response Services at 40 T.A.C. §52.201(a), and be licensed by the Texas
      Board of Private Investigators and Private Security Agencies, unless
      exempt from licensure.

              
	
                Adult
      Foster Home

              	
                TDSHS
      Provider standards for Adult Foster Care and TDSHS Rules at 40 T.A.C.
      §48.6032. Four bed homes also licensed under TDSHS Rules at 40 T.A.C.
      §481.8906.

                DFPS
      licensure in accordance with 24-hour Care Licensing requirements found in
      T.A.C., Title 40, Part 19, Chapter 720.

              
	
                Home
      Delivered

                Meals

              	
                T.A.C.,
      Title 40, Part 1, Chapter 55.

              
	
                Physical

                Therapy

              	
                Licensed
      Physical Therapist through the Texas Board of Physical Therapy Examiners,
      Chapter 453.

              
	
                Occupational

                Therapy

              	
                Licensed
      Occupational Therapist through the Texas Board of Occupational Therapy
      Examiners, Chapter 454.

              
	
                Speech
      Therapy

              	
                Licensed
      Speech Therapist Through the Department of State Health
      Services.

              
	
                Consumer
      Directed Services

              	
                Home
      and Community Support Services Agency (HCSSA)

              
	
                Transition
      Assistance Services

              	
                No
      licensure or certification requirements.

              
	
                Minor
      Home Modification

              	
                No
      licensure or certification requirements.

              
	
                Adaptive
      Aids and Medicaid Equipment

              	
                No
      licensure or certification requirements.

              
	
                Medical
      supplies

              	
                No
      licensure or certification
requirements.

              


      

      
      

      


      8.3.2  Service
Coordination

      The HMO
must furnish a Service Coordinator to all STAR+PLUS Members who request one. The
HMO should also furnish a Service Coordinator to a STAR+PLUS Member when the HMO
determines one is required through an assessment of the Member’s health and
support needs. The HMO must ensure that each STAR+PLUS Member has a qualified
PCP who is responsible for overall clinical direction and, in conjunction with
the Service Coordinator, serves as a central point of integration and
coordination of Covered Services, including primary, Acute Care, long-term care
and Behavioral Health Services.

       

      The
Service Coordinator must work as a team with the PCP, and coordinate all
STAR+PLUS Covered Services and any applicable Non-capitated Services with the
PCP.  This requirement applies whether or not the PCP is in the HMO’s
Network, as some STAR+PLUS Members dually eligible for Medicare may have a PCP
that is not in the HMO’s Provider Network. In order to integrate the Member’s
Acute Care and primary care, and stay abreast of the Member’s needs and
condition, the Service Coordinator must also actively involve and coordinate
with the Member’s primary and specialty care providers, including Behavioral
Health Service providers, and providers of Non-capitated Services.

       

      STAR+PLUS
Members dually eligible for Medicare will receive most prescription drug
services through Medicare rather than Medicaid.  The Texas Vendor Drug
Program will pay for a limited number of medications not covered by
Medicare.

       

      The HMO
must identify and train Members or their families to coordinate their own care,
to the extent of the Member’s or the family’s capability and willingness to
coordinate care.

       

      8.3.2.1  Service
Coordinators

      The HMO
must employ as Service Coordinators persons experienced in meeting the needs of
vulnerable populations who have Chronic or Complex Conditions. Such Service
Coordinators are Key HMO Personnel as described in Attachment A, HHSC’s Uniform Managed Care Contract
Terms and Conditions, Section 4.02, and must meet the requirements set
forth in Section 4.04.1
of HHSC’s Uniform Managed Care
Contract Terms and Conditions.

       

      8.3.2.2
Referral to Community Organizations

      The HMO
must provide information about and referral to community organizations that may
not be providing STAR+PLUS Covered Services, but are otherwise important to the
health and well being of Members. These organizations include, but are not
limited to:

      


      
        	
                 
      

              	
                1. State/federal
      agencies (e.g., those agencies with jurisdiction over aging, public
      health, substance abuse, mental health/retardation, rehabilitation,
      developmental disabilities, income support, nutritional assistance, family
      support agencies, etc.);

              


      

      
        	
                 
      

              	
                2. social
      service agencies (e.g., Area Agencies on Aging, residential support
      agencies, independent living centers, supported employment agencies,
      etc.);

              


      

      
        	
                 
      

              	
                3. city
      and county agencies (e.g., welfare departments, housing programs,
      etc.);

              


      

      
        	
                 
      

              	
                4. civic
      and religious organizations; and

              


      

      
        	
                 
      

              	
                5. consumer
      groups, advocates, and councils (e.g., legal aid offices, consumer/family
      support groups, permanency planning,
etc.).

              


      

       

      8.3.2.3   Discharge
Planning

      The HMO
must have a protocol for quickly assessing the needs of Members discharged from
a Hospital or other care or treatment facility.

       

      The HMO’s
Service Coordinator must work with the Member’s PCP, the hospital discharge
planner(s), the attending physician, the Member, and the Member’s family to
assess and plan for the Member’s discharge. When long-term care is needed, the
HMO must ensure that the Member’s discharge plan includes arrangements for
receiving community-based care whenever possible. The HMO must ensure that the
Member, the Member’s family, and the Member’s PCP are all well informed of all
service options available to meet the Member’s needs in the
community.

       

      8.3.2.4
Transition Plan for New STAR+PLUS Members

      The HMO
must provide a transition plan for Members enrolled in the STAR+PLUS
Program.  HHSC, and/or the previous STAR+PLUS HMO contractor, will
provide the HMO with detailed Care Plans, names of current providers, etc., for
newly enrolled Members already receiving long-term care services at the time of
enrollment. The HMO must ensure that current providers are paid for Medically
Necessary Covered Services that are delivered in accordance with the Member’s
existing treatment/long-term care services plan after the Member has become
enrolled in the HMO and until the transition plan is developed.

       

      The
transition planning process must include, but is not limited to, the
following:

      


      
        	
                 
      

              	
                1. review
      of existing DADS long-term care services
plans;

              


      

      


      
        	
                 
      

              	
                2. preparation
      of a transition plan that ensures continuous care under the Member’s
      existing Care Plan during the transfer into the HMO’s Network while the
      HMO conducts an appropriate assessment and development of a new plan, if
      needed;

              


      

      


      
        	
                 
      

              	
                3. if
      durable medical equipment or supplies had been ordered prior to enrollment
      but have not been received by the time of enrollment, coordination and
      follow-through to ensure that the Member receives the necessary supportive
      equipment and supplies without undue delay;
and

              


      

      


      
        	
                 
      

              	
                4. payment
      to the existing provider of service under the existing authorization until
      the HMO has completed the assessment and service plans and issued new
      authorizations.

              


      

      


      The HMO
must review any existing care plan and develop a transition plan within 30 days
of receiving the Member’s enrollment. The transition plan will remain in place
until the HMO contacts the Member and coordinates modifications to the Member’s
current treatment/long-term care services plan. The HMO must ensure that the
existing services continue and that there are no breaks in services. For initial
implementation of the STAR+PLUS program in a Service Area, the HMO must complete
this process within 90-days of the Member’s enrollment.

      


      The HMO
must ensure that the Member is involved in the assessment process and fully
informed about options, is included in the development of the care plan, and is
in agreement with the plan when completed.

       

      8.3.2.5   Centralized
Medical Record and Confidentiality

      The
Service Coordinator shall be responsible for maintaining a centralized record
related to Member contacts, assessments and service authorizations. The HMO
shall ensure that the organization of and documentation included in the
centralized Member record meets all applicable professional standards ensuring
confidentiality of Member records, referrals, and documentation of
information.

       

      The HMO
must have a systematic process for generating or receiving referrals and sharing
confidential medical, treatment, and planning information across
providers.

       

      8.3.2.6
Nursing Facilities

      Nursing
facility care, although a part of the care continuum, presents a challenge for
managed care. Because of the process for becoming eligible for Medicaid
assistance in a nursing facility, there is frequently a significant time gap
between entry into the nursing home and determination of Medicaid
eligibility.  During this gap from entry to Medicaid eligibility, the
resident has “nested” in the facility and many of the community supports are no
longer available. To require participation of all nursing facility residents
would result in the HMO maintaining a Member in the nursing facility without
many options for managing their health. For this reason, persons who qualify for
Medicaid as a result of nursing facility residency are not enrolled in
STAR+PLUS.

       

      The
STAR+PLUS HMO must participate in the Promoting Independence initiative for such
individuals. Promoting Independence (PI) is a philosophy that aged and disabled
individuals remain in the most integrated setting to receive long-term care
services. PI is Texas' response to the U.S. Supreme Court ruling in Olmstead v. L.C. that
requires states to provide community-based services for persons with
disabilities who would otherwise be entitled to institutional services,
when:

      


      
        	
                 
      

              	
                • the
      state's treatment professionals determine that such placement is
      appropriate;

              


      

      


      
        	
                 
      

              	
                • the
      affected persons do not oppose such treatment;
  and

              


      

      


      
        	
                 
      

              	
                • the
      placement can be reasonably accommodated, taking into account the
      resources available to the state and the needs of others who are receiving
      state supported disability
services.

              


      

      


      In
accordance with legislative direction, the HMO must designate a point of contact
to receive referrals for nursing facility residents who may potentially be able
to return to the community through the use of 1915(c) Nursing Facility Waiver
services. To be eligible for this option, an individual must reside in a nursing
facility until a written plan of care for safely moving the resident back into a
community setting has been developed and approved.

       

      A
STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS Member
for a total of four months. The nursing facility will bill the state directly
for covered nursing facility services delivered while the Member is in the
nursing facility.  See Section 8.3.2.7 for further
information.

       

      The HMO
is responsible for the Member at the time of nursing facility entry and must
utilize the Service Coordinator staff to complete an assessment of the Member
within 30 days of entry in the nursing facility, and develop a plan of care to
transition the Member back into the community if possible.  If at this
initial review, return to the community is possible, the Service Coordinator
will work with the resident and family to return the Member to the community
using 1915(c) Waiver Services.

       

      If the
initial review does not support a return to the community, the Service
Coordinator will conduct a second assessment 90 days after the initial
assessment to determine any changes in the individual’s condition or
circumstances that would allow a return to the community. The Service
Coordinator will develop and implement the transition plan.

       

      The HMO
will provide these services as part of the Promoting Independence initiative.
The HMO must maintain the documentation of the assessments completed and make
them available for state review at any time.

       

      It is
possible that the STAR+PLUS HMO will be unaware of the Member’s entry into a
nursing facility. It is the responsibility of the nursing facility to review the
Member’s Medicaid card upon entry into the facility and notify the HMO. The
nursing facility is also required to notify HHSC of the entry of a new resident.


       

      8.3.2.7    HMO
Four-Month Liability for Nursing Facility Care

      A
STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS Member
for a total of four months.  The four months do not have to be
consecutive. Upon completion of four months of nursing facility care, the
individual will be disenrolled from the STAR+PLUS Program and the Medicaid
Fee-for-Service program will provide Medicaid benefits. A STAR+PLUS Member may
not change HMOs while in a nursing facility.

       

      Tracking
the four months of liability is done through a counter system. The four-month
counter starts with the Medicaid admission or on the 21st day of a Medicare
stay. A partial month counts as a full month. In other words, the month in which
the Medicaid admission occurs or the month on which the 21st day of the Medicare
stay occurs, is counted as one of the four months.

       

      An amount
will be included in the capitation rates to cover the cost of four months of
nursing facility services (based upon experience from STAR+PLUS in Harris
County) for the historical average number of admissions to nursing facilities.
Nursing facility costs for STAR+PLUS in Harris County have accounted for less
than one percent of premiums in recent years. HHSC believes that these costs
will not deviate substantially from this experience.

       

      The HMO
will be liable for the cost of care in a nursing facility care and, for
Medicaid-only Members, the cost of all other Covered Services. The HMO will not
maintain nursing facilities in its Network and will not reimburse the nursing
facilities directly. Nursing facilities will use the

      traditional
Fee-for-Service system of billing HHSC rather than billing the HMO. The HMO's
liability will be established based on the amount paid through the
Fee-for-Service billing system on behalf of the Member. HHSC will recoup those
costs from the HMO by an offset to the monthly Capitation Payment. The offset
will be recognized as a nursing facility expense.. The HMO will record the
nursing facility liability recoupment as nursing facility expense on its
Financial-Statistical Reports (FSR).   The HMO will be
responsible for direct payment of all non-nursing facility Medicaid expenses on
behalf of the Member.

       

      8.3.3    STAR+PLUS
Assessment Instruments

      
        
          The HMO
must have and use functional assessment instruments to identify Members with
significant health problems, Members requiring immediate attention, and Members
who need or are at risk of needing long-term care services. The HMO, a
subcontractor, or a Provider may complete assessment instruments, but the HMO
remains responsible for the data recorded.

           

          HMOs must
use the DADS Form 2060, as amended or modified, to assess a Member’s need for
Functionally Necessary Personal Attendant Services. The HMO may adapt the form
to reflect the HMO’s name or distribution instructions, but the elements must be
the same and instructions for completion must be followed without
amendment.

           

          The DADS
Form 2060 must be completed if a need for or a change in Personal Attendant
Services is warranted at the initial contact, at the annual reassessment, and
anytime a Member requests the services or requests a change in services. The
DADS Form 2060 must also be completed at any time the HMO determines the Member
requires the services or requires a change in the Personal Attendant Services
that are authorized.

           

          HMOs must
use the Texas Medicaid Children’s Comprehensive Assessment Form (CCAF Form) on
the LTC online portal in lieu of the DADS Form 2060 for children under the age
of 21 when assessing the Member’s need for Functional Necessary Personal
Attendant Services. HMOs may adapt the CCAF Form to reflect the HMO’s name or
distribution instructions, but the elements must be the same and instructions
for completion must be followed without amendment. Reassessments using the CCAF
Form must be completed every six months and as requested by the Member’s parent
or other legal guardian. The CCAF Form must also be completed at any time the
HMO determines the Member may require a change in the number of authorized
Personal Attendant Service hours.

           

          For
Members and applicants seeking or needing the 1915(c) Nursing Facility Waiver
services, the HMOs must use the Community Medical Necessity and Level of Care
Assessment Instrument, as amended or modified, to assess Members and to supply
current medical information for Medical Necessity determinations. The HMO must
also complete the Individual Service Plan (ISP), Form 3671 for each Member
receiving 1915(c) Nursing Facility Waiver Services. The ISP is established for a
one-year period. After the initial ISP is established, the ISP must be completed
on an annual basis and the end date or expiration date does not change. Both of
these forms (Community Medical Necessity and Level of Care Assessment Instrument
and Form 3671) must be completed annually at reassessment. The HMO is
responsible for tracking the end dates of the ISP to ensure all Member
reassessment activities have been completed and posted on the LTC online portal
no earlier than 90 days and no later than 30 days prior to the expiration date
of the ISP. Note that the Community Medical Necessity and Level of Care
Assessment Instrument cannot be submitted earlier than 90 days prior to the
expiration date of the ISP.

        

         

      

      8.3.4  1915(c)
Nursing Facility Waiver Service Eligibility

      Recipients
of 1915(c) Nursing Facility Waiver services must meet nursing facility criteria
for participation in the waiver and must have a plan of care at initial
determination of eligibility in which the plan’s annualized cost is equal to or
less than 200% of the annualized cost of care if the individual were to enter a
nursing facility.

       

      8.3.4.1   For
Members

      
        The HMO
must notify HHSC when it initiates 1915(c) Nursing Facility Waiver eligibility
testing on a STAR+PLUS Member. The HMO must apply risk criteria, complete the
Community Medical Necessity and Level of Care Assessment Instrument for Medical
Necessity determination, complete the assessment documentation, and prepare a
1915(c) Nursing Facility Waiver Individual Service Plan (ISP) for each Member
requesting 1915(c) Nursing Facility Waiver services and for Members the HMO has
identified as needing 1915(c) Nursing Facility Waiver services. The HMO must
provide HHSC the results of the assessment activities within 45 days of
initiating the assessment process.

         

        HHSC will
notify the Member and the HMO of the eligibility determination, which will be
based on the information provided by the HMO. If the STAR+PLUS Member is
eligible for 1915(c) Nursing Facility Waiver services, HHSC will notify the
Member of the effective date of eligibility. If the Member is not eligible for
1915(c) Nursing Facility Waiver services, HHSC will provide the Member
information on right to Appeal the Adverse Determination. Regardless of the
1915(c) Nursing Facility Waiver eligibility determination, HHSC will send a copy
of the Member notice to the HMO.

      

       

      8.3.4.2   For
Medical Assistance Only (MAO) Non-Member Applicants

      
        Non-Member
persons who are not eligible for Medicaid in the community may apply for
participation in the 1915(c) Nursing Facility Waiver program under the financial
and functional eligibility requirements for MAO. HHSC will inform the applicant
that services are provided through an HMO and allow the applicant to select the
HMO. HHSC will authorize the selected HMO to initiate pre-enrollment assessment
services required under the 1915(c) Nursing Facility Waiver for the non-member.
The HMO must complete Community Medical Necessity and Level of Care Assessment
Instrument for Medical Necessity determination, complete the assessment
documentation, and prepare a 1915(c) Nursing Facility Waiver service plan for
each applicant referred by HHSC. The initial home visit with the applicant must
occur within 14 days of the receipt of the referral. The HMO must provide HHSC
the results of the assessment activities within 45 days of the receipt of the
referral.

         

        HHSC will
notify the applicant and the HMO of the results of its eligibility
determination. If the applicant is eligible, HHSC will notify the applicant and
the HMO will be notified of the effective date of eligibility, which will be the
first day of the month following the determination of eligibility. The HMO must
initiate the Individual Service Plan (ISP) on the date of
enrollment.

         

        If the
applicant is not eligible, the HHSC notice will provide information on the
applicant’s right to Appeal the Adverse Determination. HHSC will also send
notice to the HMO if the applicant is not eligible for 1915(c) Nursing Facility
Waiver services.

      

       

      8.3.4.3   Annual
Reassessment

      
        Prior to
the end date of the annual ISP, the HMO must initiate an annual reassessment to
determine and validate continued eligibility for 1915(c) Nursing Facility Waiver
services for each Member receiving such services. The HMO will be expected to
complete the same activities for each annual reassessment as required for the
initial eligibility determination.

      

       

      8.3.5  Personal
Attendant Services

      There are
three options available to STAR+PLUS Members desiring the delivery of Personal
Attendant Services (PAS): 1) Self-Directed; 2) Agency Model, Self-Directed; and
3) Agency Model.  The HMO must provide information to all eligible
Members on the three options and must provide Member orientation in the option
selected by the Member. The HMO must provide the information to any STAR+PLUS
Member receiving PAS:

      


      
        	
                 
      

              	
                • at
      initial assessment;

              


      

      
        	
                 
      

              	
                • at
      annual reassessment or annual contact with the STAR+PLUS
      Member;

              


      

      
        	
                 
      

              	
                • at any
      time when a STAR+PLUS Member receiving PAS requests the information;
      and

              


      

      
        	
                 
      

              	
                • in the
      Member Handbook.

              


      

      


      The HMO
must contract with providers who are able to offer PAS and must also
educate/train the HMO Network Providers regarding the three PAS options. To
participate as a PAS Network Provider, the Provider must have a contract with
DADS for the delivery of PAS.  The HMO must assure compliance with the
Texas Administrative Code in Title 40, Part 1, Chapter 41, Sections 41.101,
41.103, and 41.105.  The HMO must include the requirements in the
Provider Manual and in the STAR+PLUS Provider training.

       

      8.3.5.1  Personal Attendant
Services Delivery Option – Self-Directed Model

      In the
Self-Directed Model, the Member or the Member’s legal guardian is the employer
of record and retains control over the hiring, management, and termination of an
individual providing Personal Attendant Services.  The Member is
responsible for assuring that the employee meets the requirements for Personal
Attendant Services, including the criminal history check.  The Member
uses a Home and Community Support Services (HCSS) agency to handle the
employer-related administrative functions such as payroll, substitute (back-up),
and filing tax-related reports of Personal Attendant Services.

       

      8.3.5.2 Personal Attendant Services
Delivery Option – Agency Model, Self-Directed 

      In the
Agency Model, Self-Directed, the Member or the Member’s legal guardian chooses a
Home and Community Support Services (HCSS) agency in the HMO Provider Network
who is the employer of record.  In this model, the Member selects the
personal attendant from the HCSS agency’s personal attendant
employees.  The personal attendant’s schedule is set up based on the
Member input, and the Member manages the Personal Attendant
Services.  The Member retains the right to supervise and train the
personal attendant.  The Member may request a different personal
attendant and the HCSS agency would be expected to honor the
request.  The HCSS agency establishes the payment rate, benefits, and
provides all administrative functions such as payroll, substitute (back-up), and
filing tax-related reports of personal attendant services.

       

      8.3.5.3
Personal Attendant Services Delivery Option – Agency Model

      In the
Agency Model, the Member chooses a Home and Community Support Services (HCSS)
agency to hire, manage, and terminate the individual providing Personal
Attendant Services.  The HCSS agency is selected by the Member from
the HCSS agencies in the HMO Provider Network.  The Service
Coordinator and Member develop the schedule and send it to the HCSS
agency.  The Member retains the right to supervise and train the
personal attendant.  The Member may request a different personal
attendant and the HCSS agency would be expected to honor the
request.  The HCSS agency establishes the payment rate, benefits, and
provides all administrative functions such as payroll, substitute (back-up), and
filing tax-related reports of personal attendant services.

       

      8.3.6
Community Based Long-term Care Service Providers

       

      8.3.6.1
Training

      The HMO
must comply with Section 8.1.4.6 regarding Provider Manual and Provider training
specific to the STAR+PLUS Program. The HMO must train all Community Long-term
Care Service Providers regarding the requirements of the Contract and special
needs of STAR+PLUS Members. The HMO must establish ongoing STAR+PLUS Provider
training addressing the following issues at a minimum:

      


      
        	
                 
      

              	
                1. Covered
      Services and the Provider’s responsibilities for providing such services
      to STAR+PLUS Members and billing the HMO for such services. The HMO must
      place special emphasis on Community Long-term Care Services and STAR+PLUS
      requirements, policies, and procedures that vary from Medicaid
      Fee-for-Service and commercial coverage rules, including payment policies
      and procedures.

              


      

      


      
        	
                 
      

              	
                2. Inpatient
      Stay hospital services and the authorization and billing of such services
      for STAR+PLUS Members.

              


      

      


      
        	
                 
      

              	
                3. Relevant
      requirements of the STAR+PLUS Contract, including the role of the Service
      Coordinator;

              


      

      


      
        	
                 
      

              	
                4. Processes
      for making referrals and coordinating Non-capitated
    Services;

              


      

      


      
        	
                 
      

              	
                5. The
      HMO’s quality assurance and performance improvement program and the
      Provider’s role in such programs;
and

              


      

      


      
        	
                 
      

              	
                6. The
      HMO’s STAR+PLUS policies and procedures, including those relating to
      Network and Out-of-Network
referrals.

              


      

      


      8.3.6.2    LTC
Provider Billing

      Long-term
care providers are not required to utilize the billing systems that most medical
facilities use on a regular basis. For this reason, the HMO must make
accommodations to the claims processing system for such providers to allow for a
smooth transition from traditional Medicaid to Managed Care
Medicaid.

       

      HHSC will
meet with HMOs to develop a standardized method long-term care
billing.  All STAR+PLUS HMOs will be required to utilize the
standardized method, which will be incorporated into the HHSC Uniform Managed Care
Manual.

       

      8.3.6.3   Rate
Enhancement Payments for Agencies Providing Attendant Care

      All HMOs
participating in the STAR+PLUS program must allow their Long-term Support
Services (LTSS) Providers to participate in the STAR+PLUS Attendant Care
Enhancement Program if the providers are currently participating in the enhanced
payment program with the Department of Aging and Disability Services
(DADS).  HMOs may choose not to offer participation to DADS-contracted
providers who do not currently participate in the enhancement
program.  Additionally, HMOs may choose to include Providers in the
network who do not participate in the enhanced payment program.

      


      Attachment B-7, STAR+PLUS
Attendant Care Enhanced Payment Methodology explains the methodology that the
STAR+PLUS HMO will use to implement and pay the enhanced payments, including a
description of the timing of the payments, in accordance with the requirements
in the Uniform Managed Care
Manual and the intent of the 2000-01 General Appropriations Act (Rider
27, House Bill 1, 76th
Legislature, Regular Session, 1999) and T.A.C. Title 1, Part 15, Chapter
355.

       

      8.3.6.4
Payment for 1915(c) Nursing Facility Waiver Services for
Non-Members

       

      Disenrolled Members:
Occasionally, the Social Security Administration will place SSI recipients on
hold for a short period of time, usually due failure to provide timely updates
required for the continuation of SSI benefits. During this period, the
recipients will not appear to be eligible for Medicaid or 1915(c) Nursing
Facility Waiver services. Often the Social Security Administration reinstates
these Medicaid Eligibles retroactively without a break in Medicaid coverage. To
deal with this situation, for at least thirty (30) days after disenrollment, the
HMO will continue to authorize and pay for 1915(c) Nursing Facility Waiver
services for disenrolled STAR+PLUS Members who appear to lose eligibility due to
an administrative problem related to SSI. If at the end of the thirty (30) days,
the Medicaid Eligible’s 1915(c) Nursing Facility Waiver eligibility is
reinstated, the Medicaid Eligible will be manually enrolled into the STAR+PLUS
HMO back to the date of disenrollment and the retroactive adjustment system will
properly reimburse the HMO. If after thirty (30) days, the former STAR+PLUS
Member continues to be ineligible for Medicaid, the individual will not be
retroactively enrolled, and the HMO will bill HHSC for 1915(c) Nursing Facility
Waiver services rendered during this time.

      


      
        	
                8.4
      Additional CHIP Scope of Work

              


      

      


      The
following provisions only apply to HMOs participating in CHIP.

       

      8.4.1  CHIP
Provider Network

      In each
Service Area, the HMO must seek to obtain the participation in its Provider
Network of CHIP Significant Traditional Providers (STPs), defined by HHSC as PCP
Providers currently serving the CHIP population and DSH hospitals. The
Procurement Library includes CHIP STPs by Service Area.

       

      The HMO
must give STPs the opportunity to participate in its Network if the
STPs:

      


      
        	
                 
      

              	
                1. Agree
      to accept the HMO’s Provider reimbursement rate for the provider type;
      and

              


      

      


      
        	
                 
      

              	
                2. Meet
      the standard credentialing requirements of the HMO, provided that lack of
      board certification or accreditation by the Joint Commission on
      Accreditation of Health Care Organizations (JCAHO) is not the sole grounds
      for exclusion from the Provider
Network.

              


      

      


      8.4.2  CHIP
Provider Complaint and Appeals

      CHIP
Provider Complaints and Appeals are subject to disposition consistent with the
Texas Insurance Code and any applicable TDI regulations.  The HMO must
resolve Provider Complaints within 30 days from the date the Complaint is
received.

       

      8.4.3  CHIP
Member Complaint and Appeal Process

      CHIP
Member Complaints and Appeals are subject to disposition consistent with the
Texas Insurance Code and any applicable TDI regulations.  HHSC will
require the HMO to resolve Complaints and Appeals (that are not elevated to TDI)
within 30 days from the date the Complaint or Appeal is received. The HMO is
subject to remedies, including liquidated damages, if at least 98 percent of
Member Complaints or Member Appeals are not resolved within 30 days of receipt
of the Complaint or Appeal by the HMO. Please see the Uniform Managed Care Contract Terms
& Conditions and
Attachment B-5, Deliverables/Liquidated Damages Matrix.  Any
person, including those dissatisfied with a HMO’s resolution of a Complaint or
Appeal, may report an alleged violation to TDI.

       

      8.4.4  Dental
Coverage for CHIP Members

      The HMO
is not responsible for reimbursing dental providers for preventive and
therapeutic dental services obtained by CHIP Members. However, medical and/or
hospital charges, such as anesthesia, that are necessary in order for CHIP
Members to access standard therapeutic dental services, are Covered Services for
CHIP Members. The HMO must provide access to facilities and physician services
that are necessary to support the dentist who is providing dental services to a
CHIP Member under general anesthesia or intravenous (IV) sedation.

      The HMO
must inform Network facilities, anesthesiologists, and PCPs what authorization
procedures are required, and how Providers are to be reimbursed for the
preoperative evaluations by the PCP and/or anesthesiologist and for the facility
services. For dental-related medical Emergency Services, the HMO must reimburse
in-network and Out-of-Network providers in accordance with federal and state
laws, rules, and regulations.

       

      8.5
Additional CHIP Perinatal Scope of Work

      The
following provisions only apply to HMOs participating in CHIP Perinatal
Program.

       

      8.5.1  CHIP
Perinatal Provider Network

      In each
Service Area, the CHIP Perinatal HMO must seek to obtain the participation of
Providers for CHIP Perinate Members.  CHIP Perinatal HMOs are
encouraged to obtain the participation of Obstetricians/Gynecologists (OB/GYNs),
Family Practice Physicians with experience in prenatal care, or other qualified
health care Providers as CHIP Perinate Providers.

      


      See
Sections 8.1.3.2, Access to Network Providers, and 8.1.4.2, Primary Care
Providers, regarding distinctions in the provider networks for CHIP Perinates
and CHIP Perinate Newborns.

       

      8.5.2  CHIP
Perinatal Program Provider Complaint and Appeals

      CHIP
Perinatal Program Provider Complaints and Appeals are subject to disposition
consistent with the Texas Insurance Code and any applicable TDI
regulations.  The HMO must resolve Provider Complaints within 30 days
from the date the Complaint is received.

       

      8.5.3  CHIP
Perinatal Program Member Complaint and Appeal Process

      CHIP
Perinatal Program Member Complaints and Appeals are subject to disposition
consistent with the Texas Insurance Code and any applicable TDI
regulations.  HHSC will require the HMO to resolve Complaints and
Appeals (that are not elevated to TDI) within 30 days from the date the
Complaint or Appeal is received. Any person, including those dissatisfied with a
HMO’s resolution of a Complaint or Appeal, may report an alleged violation to
TDI.

       

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
Subject: Attachment B-1 - HHSC
Joint Medicia/CHIP HMO RFP, Section 9

       

      
        
          	
                  DOCUMENT
      HISTORY LOG

                
	
                  STATUS1

                	
                  DOCUMENT

                  REVISION2

                	
                  EFFECTIVE

                  DATE

                	
                  DESCRIPTION3

                	 
      
	
                   

                  Baseline

                   

                	
                   

                  n/a

                   

                	 
      	
                   

                  Initial
      version Attachment B-1, Section 7

                   

                	 
      
	
                  Revision

                	
                  1.1

                	
                  June
      30, 2006

                	
                  Contract
      amendment to include STAR+PLUS program. No change to this
      Section.

                   

                	 
      
	
                  Revision

                	
                  1.2

                	
                  September
      1, 2006

                	
                  Contract
      amendment did not revise Attachment B-1 Section 9 – Turnover
      Requirements

                   

                	 
      
	
                  Revision

                	
                  1.3

                	
                  September
      1, 2006

                	
                  Contract
      amendment did not revise Attachment B-1 Section 9 – Turnover
      Requirements

                   

                	 
      
	
                  Revision

                	
                  1.4

                	
                  September
      1, 2006

                	
                  Contract
      amendment did not revise Attachment B-1 Section 9 – Turnover
      Requirements

                   

                	 
      
	
                  Revision

                	
                  1.5

                	
                  January
      1, 2007

                	
                  Contract
      amendment did not revise Attachment B-1 Section 9 – Turnover
      Requirements

                   

                	 
      
	
                  Revision

                	
                  1.6

                	
                  February
      1, 2007

                	
                  Contract
      amendment did not revise Attachment B-1 Section 9 – Turnover
      Requirements

                   

                	 
      
	
                  Revision

                	
                  1.7

                	
                  July
      1, 2007

                	
                  Contract
      amendment did not revise Attachment B-1 Section 9 – Turnover
      Requirements

                   

                	 
      
	
                  Revision

                	
                  1.8

                	
                  September
      1, 2007

                	
                  Contract
      amendment did not revise Attachment B-1 Section 9 – Turnover
      Requirements

                   

                	 
      
	
                  Revision

                	
                  1.9

                	
                  December
      1, 2007

                	
                  Contract
      amendment did not revise Attachment B-1 Section 9 – Turnover
      Requirements

                   

                	 
      
	Revision 	1.10 	March
      1, 2008 	
                  Contract
      amendment did not revise Attachment B-1 Section 9 – Turnover
      Requirements

                   

                	 
	Revision 	1.11	September
      1, 2008	
                  Contract
      amendment did not revise Attachment B-1 Section 9 – Turnover
      Requirements

                   

                	 
	
                   

                   1  Status
      should be represented as “Baseline” for initial issuances, “Revision” for
      changes to the Baseline version, and “Cancellation” for withdrawn
      versions

                  2
      Revisions should be numbered in accordance according to the version
      of the issuance and sequential numbering of the revision—e.g., “1.2”
      refers to the first version of the document and the second
      revision.

                  3  Brief
      description of the changes to the document made in the
      revision.

                


        

        
        

         

        9. Turnover
Requirements  

        9.1 Introduction 

        This
section presents the Turnover Requirements to which the HMO must agree. Turnover
is defined as those activities that are required for the HMO to perform upon
termination of the Contract in situations in which the HMO must transition
Contract operations to HHSC or a subsequent Contractor.

         

        9.2 Transfer of Data


        The HMO
must transfer all data regarding the provision of Covered Services to Members to
HHSC or a new HMO, at the sole discretion of HHSC and as directed by HHSC. All
transferred data must be compliant with HIPAA.

         

        All
relevant data must be received and verified by HHSC or the subsequent
Contractor. If HHSC determines that not all of the data regarding the provision
of Covered Services to Members was transferred to HHSC or the subsequent
Contractor, as required, or the data is not HIPAA compliant, HHSC reserves the
right to hire an independent contractor to assist HHSC in obtaining and
transferring all the required data and to ensure that all the data are HIPAA
compliant. The reasonable cost of providing these services will be the
responsibility of the HMO.

         

        9.3 Turnover Services


        Six
months prior to the end of the Contract Period, including any extensions to such
Period, the HMO must propose a Turnover Plan covering the possible turnover of
the records and information maintained to either the State or a successor HMO.
The Turnover Plan must be a comprehensive document detailing the proposed
schedule, activities, and resource requirements associated with the turnover
tasks. The Turnover Plan must be approved by HHSC.

         

        As part
of the Turnover Plan, the HMO must provide HHSC with copies of all relevant
Member and service data, documentation, or other pertinent information
necessary, as determined by the HHSC, for HHSC or a subsequent Contractor to
assume the operational activities successfully. This includes correspondence,
documentation of ongoing outstanding issues, and other operations support
documentation. The plan will describe the HMO’s approach and schedule for
transfer of all data and operational support information, as applicable. The
information must be supplied in media and format specified by the State and
according to the schedule approved by the State.

         

        HHSC is
not limited or restricted in the ability to require additional information from
the HMO or modify the turnover schedule as necessary.

         

        9.4 Post-Turnover Services


        Thirty
(30) days following turnover of operations, the HMO must provide HHSC with a
Turnover Results report documenting the completion and results of each step of
the Turnover Plan. Turnover will not be considered complete until this document
is approved by HHSC.

         

        If the
HMO does not provide the required relevant data and reference tables,
documentation, or other pertinent information necessary for HHSC or the
subsequent Contractor to assume the operational activities successfully, the HMO
agrees to reimburse the State for all reasonable costs, including, but
not

        limited
to, transportation, lodging, and subsistence for all state and federal
representatives, or their agents, to carry out their inspection, audit, review,
analysis, reproduction and transfer functions at the location(s) of such
records.

         

        The HMO
also agrees to pay any and all additional costs incurred by the State that are
the result of the HMO’s failure to provide the requested records, data or
documentation within the time frames agreed to in the Turnover
Plan.

         

        The HMO
must maintain all files and records related to Members and Providers for five
years after the date of final payment under the Contract or until the resolution
of all litigation, claims, financial management review or audit pertaining to
the Contract, whichever is longer. The HMO agrees to repay any valid, undisputed
audit exceptions taken by HHSC in any audit of the Contract.

        


        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

    

     

    Subject: Attachment B-2 - Covered Services

     

    
      
        	
                DOCUMENT
      HISTORY LOG

              
	
                STATUS1

              	
                DOCUMENT

                REVISION2

              	
                EFFECTIVE

                DATE

              	
                DESCRIPTION3

              
	
                 

                Baseline

                 

              	
                 

                n/a

                 

              	 
      	
                 

                Initial
      version Attachment B-2, Covered Services

                 

              
	
                Revision

              	
                1.1

              	
                June
      30, 2006

              	
                Revised
      Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS
      Covered Services.

                 

              
	
                Revision

              	
                1.2

              	
                September
      1. 2006

              	
                Revised
      Attachment B-2 to include provisions applicable to MCOs participating in
      the STAR and CHIP Programs.

                 

                STAR
      Covered Services, Services Included under the HMO Capitation Payment, is
      modified to clarify the STAR covered services related to “optometry” and
      “vision.”

                 

                CHIP
      Covered Services is modified to correct services related to artificial
      aids including surgical implants.

                 

              
	
                Revision

              	
                1.3

              	
                September
      1, 2006

              	
                Contract
      amendment did not revise Attachment B-2, Covered
  Services.

              
	
                Revision

              	
                1.4

              	
                September
      1, 2006

              	
                Contract
      amendment did not revise Attachment B-2, Covered
  Services.

              
	
                Revision

              	
                1.5

              	
                January
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-2, Covered
  Services.

              
	
                Revision

              	
                1.6

              	
                February
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-2, Covered
  Services.

              
	
                Revision

              	
                1.7

              	
                July
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-2, Covered
  Services.

              
	
                Revision

              	
                1.8

              	
                September
      1, 2007

              	
                CHIP
      Covered Services are modified to comply with legislative changes required
      by HB 109 to eliminate the 6 month enrollment period effective
      9/1/07.

              
	
                Revision

              	
                1.9

              	
                December
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-2, Covered
  Services.

              
	Revision 	1.10	March
      1, 2008 	
                Contract
      amendment did not revise Attachment B-2, Covered
      Services. 

              
	Revision	1.11	September
      1, 2008	Attachment
      B-2, Covered Services is modified to include additional covered services
      resulting from the Frew Settlement.
	
                 

                 1  Status
      should be represented as “Baseline” for initial issuances, “Revision” for
      changes to the Baseline version, and “Cancellation” for withdrawn
      versions

                2
      Revisions should be numbered in accordance according to the version
      of the issuance and sequential numbering of the revision—e.g., “1.2”
      refers to the first version of the document and the second
      revision.

                3  Brief
      description of the changes to the document made in the
      revision.

              


      

      
      

      


      


      STAR
Covered Services

      


      The
following is a non-exhaustive, high-level listing of Acute Care Covered Services
included under the STAR Medicaid managed care program.

      


      Medicaid
HMO Contractors are responsible for providing a benefit package to Members that
includes all medically necessary services covered under the traditional,
fee-for-service Medicaid programs except for Non-capitated Services provided to
STAR Members outside of the HMO capitation and listed in Attachment B-1, Section
8.2.2.8.  Medicaid HMO Contractors must coordinate care for
Members for these Non-capitated Services so that Members have access to a full
range of medically necessary Medicaid services, both capitated and
non-capitated. A Contractor may elect to offer additional acute care Value-added
Services.

      


      The STAR
Members are provided with three enhanced benefits compared to the traditional,
fee-for-service Medicaid coverage:

      


      
        	
                 
      

              	
                1) waiver
      of the three-prescription per month
limit;

              


      

      


      
        	
                 
      

              	
                2) waiver
      of the 30-day spell-of-illness limitation under fee-for-services;
      and

              


      

      


      
        	
                 
      

              	
                3) inclusion
      of an annual adult well check for patients 21 years of age and
      over.

              


      

      


      


      Medicaid
HMO Contractors are responsible for providing a benefit package to Members that
includes the waiver of the 30-day spell-of-illness limitation under
fee-for-service and the inclusion of an annual adult well check for patients 21
years of age and over.  Prescription drug benefits to Medicaid HMO
Members are provided outside of the HMO capitation.

      


      Bidders
and Contractors should refer to the current Texas Medicaid
Provider Procedures Manual and the bi-monthly Texas Medicaid
Bulletin for a more inclusive listing of limitations and exclusions that
apply to each Medicaid benefit category. (These documents can be accessed online
at: http://www.tmhp.com.)

      


      The
services listed in this Attachment are subject to modification based on Federal
and State laws and regulations and Programs policy updates.

      


      Services included under the
HMO capitation payment

      
        
          	
                   
      

                	
                  •
      Ambulance services

                


        

        


        
          	
                   
      

                	
                  •
      Audiology services, including hearing aids for adults (hearing aids for
      children are provided through the PACT program and are a non-capitated
      service)

                


        

        


        
          	
                   
      

                	
                  •
      Behavioral Health Services,
including:

                


        

        


        
          	
                  ·  

                	
                  Inpatient
      and outpatient mental health services for children (under age
      21)

                


        

        


        
          	
                  ·  

                	
                  Outpatient
      chemical dependency services for children (under age
  21)

                


        

        


        
          	
                  ·  

                	
                  Detoxification
      services

                


        

        


        
          	
                  ·  

                	
                  Psychiatry
      services

                


        

        


        
          	
                  ·  

                	
                  Counseling
      services for adults (21 years of age and
over)

                


        

        


        
          	
                   
      

                	
                  •
      Birthing center services

                


        

        


        
          	
                   
      

                	
                  •
      Chiropractic services

                


        

        


        
          	
                   
      

                	
                  •
      Dialysis

                


        

        


        
          	
                   
      

                	
                  •
      Durable medical equipment and
supplies

                


        

        


        
          	
                   
      

                	
                  •
      Emergency Services

                


        

        


        
          	
                   
      

                	
                  •
      Family planning services

                


        

        


        
          	
                   
      

                	
                  •
      Home health care services

                


        

        


        
          	
                   
      

                	
                  •
      Hospital services, including inpatient and
  outpatient

                


        

        


        
          	
                   
      

                	
                  •
      Laboratory

                


        

         

        
          	
                	
                  •
      Medical check-ups and Comprehensive Care Program (CCP) Services for
      children (under age 21) through the Texas Health Steps
    Program

                


        

         

        
          	
                   
      

                	
                  •
      Oral evaluation and fluoride varnish in the Medical Home in conjunction
      with Texas Health Steps medical check up for children 6 through 35 months
      of age.

                


        

        


        
          	
                   
      

                	
                  •
      Podiatry

                


        

        


        
          	
                   
      

                	
                  •
      Prenatal care

                


        

        


        
          	
                   
      

                	
                  •
      Primary care services

                


        

        


        
          	
                   
      

                	
                  •
      Radiology, imaging, and X-rays

                


        

        


        
          	
                   
      

                	
                  •
      Specialty physician services

                


        

        


        
          	
                   
      

                	
                  •
      Therapies – physical, occupational and
speech

                


        

        


        
          	
                   
      

                	
                  •
      Transplantation of organs and
tissues

                


        

        


        
          	
                   
      

                	
                  •
      Vision (Includes optometry and glasses. Contact lenses are only covered if
      they are medically necessary for vision correction, which can not be
      accomplished by glasses.)

                


        

      

       

      CHIP
Covered Services

      


      Covered
CHIP services must meet the CHIP definition of Medically Necessary Covered
Services as defined in this
Contract.  There is no lifetime maximum on benefits; however,
12-month period or lifetime limitations do apply to certain services, as
specified in the following chart.  Co-pays apply until a family
reaches its specific cost-sharing maximum.

       

      
        	
                Covered
      Benefit

              	
                Description

              
	
                Inpatient
      General Acute and Inpatient Rehabilitation Hospital Services

                 

                 

              	
                Services
      include, but are not limited to, the following:

                 

                 Hospital-provided
      Physician or Provider services

                 

                 Semi-private
      room and board (or private if medically necessary as certified by
      attending)

                 

                 General
      nursing care

                 

                 Special
      duty nursing when medically necessary

                 

                 ICU and
      services

                 

                 Patient
      meals and special diets

                 

                 Operating,
      recovery and other treatment rooms

                 

                 Anesthesia
      and administration (facility technical component)

                 

                 Surgical
      dressings, trays, casts, splints

                 

                 Drugs,
      medications and biologicals

                 

                 Blood
      or blood products that are not provided free-of-charge to the patient and
      their administration

                 

                 X-rays,
      imaging and other radiological tests (facility technical
      component)

                 

                 Laboratory
      and pathology services (facility technical component)

                 

                 Machine
      diagnostic tests (EEGs, EKGs, etc.)

                 

                 Oxygen
      services and inhalation therapy

                 

                 Radiation
      and chemotherapy

                 

                 Access
      to DSHS-designated Level III perinatal centers or Hospitals meeting
      equivalent levels of care

                 

                 In-network
      or out-of-network facility and Physician services for a mother and her
      newborn(s) for a minimum of 48 hours following an uncomplicated vaginal
      delivery and 96 hours following an uncomplicated delivery by caesarian
      section.

                 

                 Hospital,
      physician and related medical services, such as anesthesia, associated
      with dental care

                 

                 Surgical
      implants

                 

                 Other
      artificial aids including surgical implants

                 

                 Implantable
      devices are covered under Inpatient and Outpatient services and do not
      count towards the DME 12-month period limit

                 

              
	
                Skilled
      Nursing

                Facilities

                (Includes
      Rehabilitation

                Hospitals)

                 

                 

              	
                Services
      include, but are not limited to, the following:

                 

                 Semi-private
      room and board

                 

                 Regular
      nursing services

                 

                 Rehabilitation
      services

                 

                 Medical
      supplies and use of appliances and equipment furnished by the
      facility

                 

              
	
                Outpatient
      Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic
      (Including Health Center) and Ambulatory Health Care Center

                 

              	
                Services
      include, but are not limited to, the following services provided in a
      hospital clinic or emergency room, a clinic or health center,
      hospital-based emergency department or an ambulatory health care
      setting:

                 X-ray,
      imaging, and radiological tests (technical component)

                 Laboratory
      and pathology services (technical component)

                 Machine
      diagnostic tests

                 Ambulatory
      surgical facility services

                 Drugs,
      medications and biologicals

                 Casts,
      splints, dressings

                 Preventive
      health services

                 Physical,
      occupational and speech therapy

                 Renal
      dialysis

                 Respiratory
      services

                 Radiation
      and chemotherapy

                 Blood
      or blood products that are not provided free-of-charge to the patient and
      the administration of these products

                 Facility
      and related medical services, such as anesthesia, associated with dental
      care, when provided in a licensed ambulatory surgical
      facility.

                 Surgical
      implants

                 Other
      artificial aids including surgical implants

                 Implantable
      devices are covered under Inpatient and Outpatient services and do not
      count towards the DME 12-month period limit

              
	
                Physician/Physician

                Extender
      Professional Services

                 

              	
                Services
      include, but are not limited to, the following:

                 

                 American
      Academy of Pediatrics recommended well-child exams and preventive health
      services (including, but not limited to, vision and hearing screening and
      immunizations)

                 

                 Physician
      office visits, in-patient and out-patient services

                 

                 Laboratory,
      x-rays, imaging and pathology services, including technical component
      and/or professional interpretation

                 

                 Medications,
      biologicals and materials administered in Physician’s office

                 

                 Allergy
      testing, serum and injections

                 

                 Professional
      component (in/outpatient) of surgical services, including:

                 

                - Surgeons
      and assistant surgeons for surgical procedures including appropriate
      follow-up care

                 

                - Administration
      of anesthesia by Physician (other than surgeon) or CRNA

                 

                - Second
      surgical opinions

                 

                - Same-day
      surgery performed in a Hospital without an over-night stay

                 

                - Invasive
      diagnostic procedures such as endoscopic examinations

                 

                 Hospital-based
      Physician services (including Physician-performed technical and
      interpretive components)

                 

                 In-network
      and out-of-network Physician services for a mother and her newborn(s) for
      a minimum of 48 hours following an uncomplicated vaginal delivery and 96
      hours following an uncomplicated delivery by caesarian
      section.

                 

                 Physician
      services medically necessary to support a dentist providing dental
      services to a CHIP member such as general anesthesia or intravenous (IV)
      sedation.

                 

              
	
                Durable
      Medical Equipment (DME), Prosthetic Devices and

                Disposable
      Medical Supplies

                 

                 

              	
                $20,000
      12-month period limit for DME, prosthetics, devices and disposable medical
      supplies (diabetic supplies and equipment are not counted against this
      ccap).   Services include DME (equipment which can
      withstand repeated use and is primarily and customarily used to serve a
      medical purpose, generally is not useful to a person in the absence of
      Illness, Injury, or Disability, and is appropriate for use in the home),
      including devices and supplies that are medically necessary and necessary
      for one or more activities of daily living and appropriate to assist in
      the treatment of a medical condition, including:

                 

                 Orthotic
      braces and orthotics

                 

                 Prosthetic
      devices such as artificial eyes, limbs, and braces

                 

                 Prosthetic
      eyeglasses and contact lenses for the management of severe ophthalmologic
      disease

                 

                 Hearing
      aids

                 

                 Diagnosis-specific
      disposable medical supplies, including diagnosis-specific prescribed
      specialty formula and dietary supplements.  (See Attachment
      A)

              
	
                Home
      and Community Health Services

                 

                 

                 

              	
                Services
      that are provided in the home and community, including, but not limited
      to:

                 

                 Home
      infusion

                 

                 Respiratory
      therapy

                 

                 Visits
      for private duty nursing (R.N., L.V.N.)

                 

                 Skilled
      nursing visits as defined for home health purposes (may include R.N. or
      L.V.N.).

                 

                 Home
      health aide when included as part of a plan of care during a period that
      skilled visits have been approved.

                 

                 Speech,
      physical and occupational therapies.

                 

                 Services
      are not intended to replace the CHILD'S caretaker or to provide relief for
      the caretaker

                 

                 Skilled
      nursing visits are provided on intermittent level and not intended to
      provide 24-hour skilled nursing services

                 

                 Services
      are not intended to replace 24-hour inpatient or skilled nursing facility
      services

                 

              
	
                Inpatient
      Mental Health Services

                 

              	
                Mental
      health services, including for serious mental illness, furnished in a
      free-standing psychiatric hospital, psychiatric units of general acute
      care hospitals and state-operated facilities, including, but not limited
      to:

                 

                 Neuropsychological
      and psychological testing.

                 

                 Inpatient
      mental health services are limited to:

                 

                 45 days
      12-month inpatient limit

                 

                 Includes
      inpatient psychiatric services, up to 12-month period limit, ordered by a
      court of competent jurisdiction under the provisions of Chapters 573 and
      574 of the Texas Health and Safety Code, relating to court ordered
      commitments to psychiatric facilities. Court order serves as binding
      determination of medical necessity. Any modification or termination of
      services must be presented to the court with jurisdiction over the matter
      for determination

                 

                 25 days
      of the inpatient benefit can be converted to residential treatment,
      therapeutic foster care or other 24-hour therapeutically planned and
      structured services or sub-acute outpatient (partial hospitalization or
      rehabilitative day treatment) mental health services on the basis of
      financial equivalence against the inpatient per diem cost

                 

                 20 of
      the inpatient days must be held in reserve for inpatient use
      only

                 

                 Does
      not require PCP referral

                 

              
	
                Outpatient
      Mental Health Services

                 

              	
                Mental
      health services, including for serious mental illness, provided on an
      outpatient basis, including, but not limited to:

                 Medication
      management visits do not count against the outpatient visit
      limit.

                 The
      visits can be furnished in a variety of community-based settings
      (including school and home-based) or in a state-operated
      facility

                 Up to
      60 days 12-month period limit for rehabilitative day
treatment

                 60
      outpatient visits 12-month period limit

                 60
      rehabilitative day treatment days can be converted to outpatient visits on
      the basis of financial equivalence against the day treatment per diem
      cost

                 60
      outpatient visits can be converted to skills training (psycho educational
      skills development) or rehabilitative day treatment on the basis of
      financial equivalence against the outpatient visit cost

                 Includes
      outpatient psychiatric services, up to 12-month period limit, ordered by a
      court of competent jurisdiction under the provisions of Chapters 573 and
      574 of the Texas Health and Safety Code, relating to court ordered
      commitments to psychiatric facilities. Court order serves as binding
      determination of medical necessity. Any modification or termination of
      services must be presented to the court with jurisdiction over the matter
      for determination

                 Inpatient
      days converted to sub-acute outpatient services are in addition to the
      outpatient limits and do not count towards those limits

                 A
      Qualified Mental Health Professional (QMHP), as defined by and
      credentialed through Texas Department of State Health Services (DSHS)
      standards (TAC Title 25, Part II, Chapter 412), is a Local Mental Health
      Authorities provider. A QMHP must be working under the authority of an
      DSHS entity and be supervised by a licensed mental health professional or
      physician. QMHPs are acceptable providers as long as the services would be
      within the scope of the services that are typically provided by QMHPs.
      Those services include individual and group skills training (which can be
      components of interventions such as day treatment and in-home services),
      patient and family education, and crisis services

                 Does
      not require PCP referral

              
	
                Inpatient
      Substance Abuse Treatment Services

                 

              	
                Services
      include, but are not limited to:

                 

                 Inpatient
      and residential substance abuse treatment services including
      detoxification and crisis stabilization, and 24-hour residential
      rehabilitation programs

                 

                 

                 Does
      not require PCP referral

                 

                 Medically
      necessary   detoxification/stabilization services, limited
      to 14 days per 12-month period.

                 

                 24-hour
      residential rehabilitation programs, or the equivalent, up to 60 days per
      12-month period

                 

                 30 days
      may be converted to partial hospitalization or intensive outpatient
      rehabilitation, on the basis of financial equivalence against the
      inpatient per diem cost

                 

                 30 days
      must be held in reserve for inpatient use only.

                 

              
	
                Outpatient
      Substance Abuse Treatment Services

                 

              	
                 

                 

                 Services
      include, but are not limited to, the following:

                 

                 Prevention
      and intervention services that are provided by physician and non-physician
      providers, such as screening, assessment and referral for chemical
      dependency disorders.

                 

                 Intensive
      outpatient services is defined as an organized non-residential service
      providing structured group and individual therapy, educational services,
      and life skills training which consists of at least 10 hours per week for
      four to 12 weeks, but less than 24 hours per day

                 

                 Outpatient
      treatment service is defined as consisting of at least one to two hours
      per week providing structured group and individual therapy, educational
      services, and life skills training

                 

                 Outpatient
      treatment services up to a maximum of:

                 

                 Intensive
      outpatient program (up to 12 weeks per 12-month period)

                 

                 Outpatient
      services (up to six-months per 12-month period)

                 

                 Does
      not require PCP referral

                 

              
	
                Rehabilitation
      Services

                 

                 

              	
                Services
      include, but are not limited to, the following:

                 

                 Habilitation
      (the process of supplying a child with the means to reach age-appropriate
      developmental milestones through therapy or treatment) and rehabilitation
      services include, but are not limited to the following:

                 

                 Physical,
      occupational and speech therapy

                 

                 Developmental
      assessment

                 

              
	
                Hospice
      Care Services

                 

              	
                Services
      include, but are not limited to:

                 

                 Palliative
      care, including medical and support services, for those children who have
      six months or less to live, to keep patients comfortable during the last
      weeks and months before death

                 

                 Treatment
      for unrelated conditions is unaffected

                 

                 Up to a
      maximum of 120 days with a 6 month life expectancy

                 

                 Patients
      electing hospice services waive their rights to treatment related to their
      terminal illnesses; however, they may cancel this election at
      anytime

                 

                 Services
      apply to the hospice diagnosis

                 

              
	
                Emergency
      Services, including Emergency Hospitals, Physicians, and Ambulance
      Services

                 

              	
                HMO
      cannot require authorization as a condition for payment for emergency
      conditions or labor and delivery.

                Covered
      services include, but are not limited to, the following:

                 

                 Emergency
      services based on prudent lay person definition of emergency health
      condition

                 

                 Hospital
      emergency department room and ancillary services and physician services 24
      hours a day, 7 days a week, both by in-network and out-of-network
      providers

                 

                 Medical
      screening examination 

                 

                 Stabilization
      services

                 

                 Access
      to DSHS designated Level 1 and Level II trauma centers or hospitals
      meeting equivalent levels of care for emergency services

                 

                 Emergency
      ground, air and water transportation

                 

                 Emergency
      dental services, limited to fractured or dislocated jaw, traumatic damage
      to teeth, and removal of cysts.

                 

              
	
                Transplants

                 

              	
                Services
      include, but are not limited to, the following:

                 

                 Using
      up-to-date FDA guidelines, all non-experimental human organ and tissue
      transplants and all forms of non-experimental corneal, bone marrow and
      peripheral stem cell transplants, including donor medical
      expenses.

                 

              
	
                Vision
      Benefit

                 

                 

                 

                 

              	
                The
      health plan may reasonably limit the cost of the
      frames/lenses.

                Services
      include:

                 

                 One
      examination of the eyes to determine the need for and prescription for
      corrective lenses per 12-month period, without authorization

                 

                 One
      pair of non-prosthetic eyewear per 12-month period

                 

              
	
                Chiropractic
      Services

                 

              	
                Services
      do not require physician prescription and are limited to spinal
      subluxation

              
	
                Tobacco
      Cessation

                Program

                 

              	
                Covered
      up to $100 for a 12- month period limit for a plan- approved
      program

                 

                 Health
      Plan defines plan-approved program.

                 

                 May be
      subject to formulary requirements.

                 

              
	
                [Value-added
      services]

              	
                See
      Attachment B-3

              


      

      
      

       

       CHIP
EXCLUSIONS FROM COVERED SERVICES

      


      


      
        	
                 
      

              	
                 Inpatient
      and outpatient infertility treatments or reproductive services other than
      prenatal care, labor and delivery, and care related to disease, illnesses,
      or abnormalities related to the reproductive
  system

              


      

      
        	
                 
      

              	
                 Personal
      comfort items including but not limited to personal care kits provided on
      inpatient admission, telephone, television, newborn infant photographs,
      meals for guests of patient, and other articles which are not required for
      the specific treatment of sickness or
injury

              


      

      
        	
                 
      

              	
                 Experimental
      and/or investigational medical, surgical or other health care procedures
      or services which are not generally employed or recognized within the
      medical community

              


      

      
        	
                 
      

              	
                 Treatment
      or evaluations required by third parties including, but not limited to,
      those for schools, employment, flight clearance, camps, insurance or
      court

              


      

      
        	
                 
      

              	
                 Private
      duty nursing services when performed on an inpatient basis or in a skilled
      nursing facility.

              


      

      
        	
                 
      

              	
                 Mechanical
      organ replacement devices including, but not limited to artificial
      heart

              


      

      
        	
                 
      

              	
                 Hospital
      services and supplies when confinement is solely for diagnostic testing
      purposes, unless otherwise pre-authorized by Health
  Plan

              


      

      
        	
                 
      

              	
                 Prostate
      and mammography screening

              


      

      
        	
                 
      

              	
                 Elective
      surgery to correct vision

              


      

      
        	
                 
      

              	
                 Gastric
      procedures for weight loss

              


      

      
        	
                 
      

              	
                 Cosmetic
      surgery/services solely for cosmetic
purposes

              


      

      
        	
                 
      

              	
                 Out-of-network
      services not authorized by the Health Plan except for emergency care and
      physician services for a mother and her newborn(s) for a minimum of 48
      hours following an uncomplicated vaginal delivery and 96 hours following
      an uncomplicated delivery by caesarian
section

              


      

      
        	
                 
      

              	
                 Services,
      supplies, meal replacements or supplements provided for weight control or
      the treatment of obesity, except for the services associated with the
      treatment for morbid obesity as part of a treatment plan approved by the
      Health Plan

              


      

      
        	
                 
      

              	
                 Acupuncture
      services, naturopathy and
hypnotherapy

              


      

      
        	
                 
      

              	
                 Immunizations
      solely for foreign travel

              


      

      
        	
                 
      

              	
                 Routine
      foot care such as hygienic care

              


      

      
        	
                 
      

              	
                 Diagnosis
      and treatment of weak, strained, or flat feet and the cutting or removal
      of corns, calluses and toenails (this does not apply to the removal of
      nail roots or surgical treatment of conditions underlying corns, calluses
      or ingrown toenails)

              


      

      
        	
                 
      

              	
                 Replacement
      or repair of prosthetic devices and durable medical equipment due to
      misuse, abuse or loss when confirmed by the Member or the vendor
      

              


      

      
        	
                 
      

              	
                 Corrective
      orthopedic shoes

              


      

      
        	
                 
      

              	
                 Convenience
      items

              


      

      
        	
                 
      

              	
                 Orthotics
      primarily used for athletic or recreational
  purposes

              


      

      
        	
                 
      

              	
                 Custodial
      care (care that assists a child with the activities of daily living, such
      as assistance in walking, getting in and out of bed, bathing, dressing,
      feeding, toileting, special diet preparation, and medication supervision
      that is usually self-administered or provided by a parent. This care does
      not require the continuing attention of trained medical or paramedical
      personnel.)  This exclusion does not apply to hospice
      services.

              


      

      
        	
                 
      

              	
                 Housekeeping

              


      

      
        	
                 
      

              	
                 Public
      facility services and care for conditions that federal, state, or local
      law requires be provided in a public facility or care provided while in
      the custody of legal authorities

              


      

      
        	
                 
      

              	
                 Services
      or supplies received from a nurse, which do not require the skill and
      training of a nurse

              


      

      
        	
                 
      

              	
                 Vision
      training and vision therapy

              


      

      
        	
                 
      

              	
                 Reimbursement
      for school-based physical therapy, occupational therapy, or speech therapy
      services are not covered except when ordered by a
      Physician/PCP

              


      

      
        	
                 
      

              	
                 Donor
      non-medical expenses

              


      

      
        	
                 
      

              	
                 Charges
      incurred as a donor of an organ when the recipient is not covered under
      this health plan

              


      

       

      CHIP
DME/SUPPLIES

       

      
        	
                SUPPLIES

              	
                COVERED

              	
                EXCLUDED

              	
                COMMENTS/MEMBER

                CONTRACT
      PROVISIONS

              
	
                Ace
      Bandages

              	 
      	
                X

              	
                Exception:
      If provided by and billed through the clinic or home care agency it is
      covered as an incidental supply.

              
	
                Alcohol,
      rubbing

              	 
      	
                X

              	
                Over-the-counter
      supply.

              
	
                Alcohol,
      swabs (diabetic)

              	
                X

              	 
      	
                Over-the-counter
      supply not covered, unless RX provided at time of
    dispensing.

              
	
                Alcohol,
      swabs

              	
                X

              	 
      	
                Covered
      only when received with IV therapy or central line
      kits/supplies.

              
	
                Ana
      Kit Epinephrine

              	
                X

              	 
      	
                A
      self-injection kit used by patients highly allergic to bee
      stings.

              
	
                Arm
      Sling

              	
                X

              	 
      	
                Dispensed
      as part of office visit.

              
	
                Attends
      (Diapers)

              	
                X

              	 
      	
                Coverage
      limited to children age 4 or over only when prescribed by a physician and
      used to provide care for a covered diagnosis as outlined in a treatment
      care plan

              
	
                Bandages

              	 
      	
                X

              	 
      
	
                Basal
      Thermometer

              	 
      	
                X

              	
                Over-the-counter
      supply.

              
	
                Batteries
      – initial

              	
                X

              	
                .

              	
                For
      covered DME items

              
	
                Batteries
      – replacement

              	
                X

              	 
      	
                For
      covered DME when replacement is necessary due to normal
    use.

              
	
                Betadine

              	 
      	
                X

              	
                See
      IV therapy supplies.

              
	
                Books

              	 
      	
                X

              	 
      
	
                Clinitest

              	
                X

              	 
      	
                For
      monitoring of diabetes.

              
	
                Colostomy
      Bags

              	 
      	 
      	
                See
      Ostomy Supplies.

              
	
                Communication
      Devices

              	 
      	
                X

              	 
      
	
                Contraceptive
      Jelly

              	 
      	
                X

              	
                Over-the-counter
      supply. Contraceptives are not covered under the plan.

              
	
                Cranial
      Head Mold

              	 
      	
                X

              	 
      
	
                Diabetic
      Supplies

              	
                X

              	 
      	
                Monitor
      calibrating solution, insulin syringes, needles, lancets, lancet device,
      and glucose strips.

              
	
                Diapers/Incontinent
      Briefs/Chux

              	
                X

              	 
      	
                Coverage
      limited to children age 4 or over only when prescribed by a physician and
      used to provide care for a covered diagnosis as outlined in a treatment
      care plan

              
	
                Diaphragm

              	 
      	
                X

              	
                Contraceptives
      are not covered under the plan.

              
	
                Diastix

              	
                X

              	 
      	
                For
      monitoring diabetes.

              
	
                Diet,
      Special

              	 
      	
                X

              	 
      
	
                Distilled
      Water

              	 
      	
                X

              	 
      
	
                Dressing
      Supplies/Central Line

              	
                X

              	 
      	
                Syringes,
      needles, Tegaderm, alcohol swabs, Betadine swabs or ointment,
      tape.  Many times these items are dispensed in a kit when
      includes all necessary items for one dressing site
  change.

              
	
                Dressing
      Supplies/Decubitus

              	
                X

              	 
      	
                Eligible
      for coverage only if receiving covered home care for wound
      care.

              
	
                Dressing
      Supplies/Peripheral IV Therapy

              	
                X

              	 
      	
                Eligible
      for coverage only if receiving home IV therapy.

              
	
                Dressing
      Supplies/Other

              	 
      	
                X

              	 
      
	
                Dust
      Mask

              	 
      	
                X

              	 
      
	
                Ear
      Molds

              	
                X

              	 
      	
                Custom
      made, post inner or middle ear surgery

              
	
                Electrodes

              	
                X

              	 
      	
                Eligible
      for coverage when used with a covered DME.

              
	
                Enema
      Supplies

              	 
      	
                X

              	
                Over-the-counter
      supply.

              
	
                Enteral
      Nutrition

                Supplies

              	
                X

              	 
      	
                Necessary
      supplies (e.g., bags, tubing, connectors, catheters, etc.)
are

                eligible
      for coverage.  Enteral nutrition products are not covered except
      for those prescribed for hereditary metabolic disorders, a non-function or
      disease of the structures that normally permit food to reach the small
      bowel, or malabsorption due to disease

              
	
                Eye
      Patches

              	
                X

              	 
      	
                Covered
      for patients with amblyopia.

              
	
                Formula

              	 
      	
                X

              	
                Exception:
      Eligible for coverage only for chronic hereditary metabolic disorders a
      non-function or disease of the structures that normally permit food to
      reach the small bowel; or malabsorption due to disease (expected to last
      longer than 60 days when prescribed by the physician and authorized by
      plan.)  Physician documentation to justify prescription of
      formula must include:

                 

                • Identification
      of a metabolic disorder, dysphagia that results in a medical need for a
      liquid diet, presence of a gastrostomy, or disease resulting in
      malabsorption that requires a medically necessary nutritional
      product

                 

                Does
      not include formula:

                 

                • For
      members who could be sustained on an age-appropriate diet.

                 

                • Traditionally
      used for infant feeding

                 

                • In
      pudding form (except for clients with documented oropharyngeal motor
      dysfunction who receive greater than 50 percent of their daily caloric
      intake from this product)

                 

                • For the
      primary diagnosis of failure to thrive, failure to gain weight, or lack of
      growth or for infants less than twelve months of age unless medical
      necessity is documented and other criteria, listed above, are
      met.

                 

                 

                Food
      thickeners, baby food, or other regular grocery products that can be
      blenderized and used with an enteral system that are not medically
      necessary, are not covered, regardless of whether these regular food
      products are taken orally or parenterally.

              
	
                Gloves

              	 
      	
                X

              	
                Exception:  Central
      line dressings or wound care provided by home care
  agency.

              
	
                Hydrogen
      Peroxide

              	 
      	
                X

              	
                Over-the-counter
      supply.

              
	
                Hygiene
      Items

              	 
      	
                X

              	 
      
	
                Incontinent
      Pads

              	
                X

              	 
      	
                Coverage
      limited to children age 4 or over only when prescribed by a physician and
      used to provide care for a covered diagnosis as outlined in a treatment
      care plan

              
	
                Insulin
      Pump (External) Supplies

              	
                X

              	 
      	
                Supplies
      (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible
      for coverage if the pump is a covered item.

              
	
                Irrigation
      Sets, Wound Care

              	
                X

              	 
      	
                Eligible
      for coverage when used during covered home care for wound
      care.

              
	
                Irrigation
      Sets, Urinary

              	
                X

              	 
      	
                Eligible
      for coverage for individual with an indwelling urinary
      catheter.

              
	
                IV
      Therapy Supplies

              	
                X

              	 
      	
                Tubing,
      filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other
      related supplies necessary for home IV therapy.

              
	
                K-Y
      Jelly

              	 
      	
                X

              	
                Over-the-counter
      supply.

              
	
                Lancet
      Device

              	
                X

              	 
      	
                Limited
      to one device only.

              
	
                Lancets

              	
                X

              	 
      	
                Eligible
      for individuals with diabetes.

              
	
                Med
      Ejector

              	
                X

              	 
      	 
      
	
                Needles
      and

                Syringes/Diabetic

              	 
      	 
      	
                See
      Diabetic Supplies

              
	
                Needles
      and Syringes/IV and Central Line

              	 
      	 
      	
                See
      IV Therapy and Dressing Supplies/Central Line.

              
	
                Needles
      and Syringes/Other

              	
                X

              	 
      	
                Eligible
      for coverage if a covered IM or SubQ medication is being administered at
      home.

              
	
                Normal
      Saline

              	 
      	 
      	
                See
      Saline, Normal

              
	
                Novopen

              	
                X

              	 
      	 
      
	
                Ostomy
      Supplies

              	
                X

              	 
      	
                Items
      eligible for coverage include: belt, pouch, bags, wafer, face plate,
      insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape, skin
      prep, adhesives, drain sets, adhesive remover, and pouch
      deodorant.

                Items
      not eligible for coverage include:  scissors, room deodorants,
      cleaners, rubber gloves, gauze, pouch covers, soaps, and
      lotions.

              
	
                Parenteral
      Nutrition/Supplies

              	
                X

              	 
      	
                Necessary
      supplies (e.g., tubing, filters, connectors, etc.) are eligible for
      coverage when the Health Plan has authorized the parenteral
      nutrition.

              
	
                Saline,
      Normal

              	
                X

              	 
      	
                Eligible
      for coverage:

                a)
      when used to dilute medications for nebulizer treatments;

                b)
      as part of covered home care for wound care;

                c)
      for indwelling urinary catheter irrigation.

              
	
                Stump
      Sleeve

              	
                X

              	 
      	 
      
	
                Stump
      Socks

              	
                X

              	 
      	 
      
	
                Suction
      Catheters

              	
                X

              	 
      	 
      
	
                Syringes

              	 
      	 
      	
                See
      Needles/Syringes.

              
	
                Tape

              	 
      	 
      	
                See
      Dressing Supplies, Ostomy Supplies, IV Therapy
Supplies.

              
	
                Tracheostomy
      Supplies

              	
                X

              	 
      	
                Cannulas,
      Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for
      coverage.

              
	
                Under
      Pads

              	 
      	 
      	
                See
      Diapers/Incontinent Briefs/Chux.

              
	
                Unna
      Boot

              	
                X

              	 
      	
                Eligible
      for coverage when part of wound care in the home
      setting.  Incidental charge when applied during office
      visit.

              
	
                Urinary,
      External Catheter & Supplies

              	 
      	
                X

              	
                Exception:  Covered
      when used by incontinent male where injury to the urethra prohibits use of
      an indwelling catheter ordered by the PCP and approved by the
      plan

              
	
                Urinary,
      Indwelling Catheter & Supplies

              	
                X

              	 
      	
                Cover
      catheter, drainage bag with tubing, insertion tray, irrigation set and
      normal saline if needed.

              
	
                Urinary,
      Intermittent

              	
                X

              	 
      	
                Cover
      supplies needed for intermittent or straight
  catherization.

              
	
                Urine
      Test Kit

              	
                X

              	 
      	
                When
      determined to be medically necessary.

              
	
                Urostomy
      supplies

              	 
      	 
      	
                See
      Ostomy Supplies.

              


      

      
      

      


      


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      


      Subject: Attachment B-2.1 - STAR +
PLUS Covered Services

       

      
        
          	
                  DOCUMENT
      HISTORY LOG

                
	
                  STATUS1

                	
                  DOCUMENT

                  REVISION2

                	
                  EFFECTIVE

                  DATE

                	
                  DESCRIPTION3

                	 
      
	
                  Baseline

                	
                  n/a

                	 
      	
                  Initial
      version of Attachment B-2, Covered Services.

                	 
      
	
                  Revision

                	
                  1.1

                	
                  June
      30, 2006

                	
                  Revised
      Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS
      Covered Services. This is the initial version of Attachment B-2.1,
      STAR+PLUS Covered Services, which lists the Acute Care Services and the
      Community Based Long Term Care Services.

                	 
      
	
                  Revision

                	
                  1.2

                	
                  September
      1, 2006

                	
                  Contract
      Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
      Services.

                	 
      
	
                  Revision

                	
                  1.3

                	
                  September
      1, 2006

                	
                  Contract
      Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
      Services.

                	 
      
	
                  Revision

                	
                  1.4

                	
                  September
      1, 2006

                	
                  Contract
      Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
      Services.

                	 
      
	
                  Revision

                	
                  1.5

                	
                  January
      1, 2007

                	
                  Revised
      Attachment B-2.1, STAR+PLUS Covered Services, to include inpatient and
      outpatient mental health services for adults.

                	 
      
	
                  Revision

                	
                  1.6

                	
                  February
      1, 2007

                	
                  Revised
      Attachment B-2.1, STAR+PLUS Covered Services, to exclude inpatient mental
      health services for adults and children, and to establish monetary limits
      on Transition Assistance Services.

                  Personal
      Attendant Services is clarified to include the three service delivery
      options described in Attachment B-1, Section 8.3.5.  Consumer
      Directed Personal Attendant Services is deleted from the list since it is
      one of the three service delivery options under Personal Attendant
      Services.

                	 
      
	
                  Revision

                	
                  1.7

                	
                  June
      1, 2007

                	
                  Revised
      Attachment B-2.1, STAR+PLUS Covered Services, to include inpatient mental
      health services for adults and children and to include effective dates by
      service area.

                	 
      
	
                  Revision

                	
                  1.8

                	
                  September
      1, 2007

                	
                  Contract
      Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
      Services.

                	 
      
	
                  Revision

                	
                  1.9

                	
                  December
      1, 2007

                	
                  Contract
      Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
      Services.

                	 
      
	Revision 	1.10 	March 1,
      2008 	
                  Contract
      Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
      Services. 

                	 
	Revision	1.11	September
      1, 2008	Attachment
      B-2.1 - STAR+PLUS Covered Services is modified to include additional
      covered services resulting from the Frew Settlement.	 
	
                   

                   1  Status
      should be represented as “Baseline” for initial issuances, “Revision” for
      changes to the Baseline version, and “Cancellation” for withdrawn
      versions

                  2
      Revisions should be numbered in accordance according to the version
      of the issuance and sequential numbering of the revision—e.g., “1.2”
      refers to the first version of the document and the second
      revision.

                  3  Brief
      description of the changes to the document made in the
      revision.

                


        

        
        

        STAR+PLUS
Covered Services

        


        Acute
Care Services

        


        The
following is a non-exhaustive, high-level listing of Acute Care Covered Services
included under the STAR+PLUS Medicaid managed care program.

        


        Medicaid
HMO Contractors are responsible for providing a benefit package to Members that
includes all medically necessary services covered under the traditional,
fee-for-service Medicaid programs except for Non-capitated Services provided to
Medicaid Members outside of the HMO capitation and listed in Attachment B-1,
Section 8.2.2.8. In addition to the non-capitated services listed in Attachment
B-1, Section 8.2.2.8, Hospital Inpatient Stays are excluded from the capitation
payment to STAR+PLUS HMOs and are paid through HHSC’s Administrative Contractor
responsible for payment of Traditional Medicaid fee-for-service claims. Medicaid
HMO Contractors must coordinate care for Members for these Non-capitated
Services so that Members have access to a full range of medically necessary
Medicaid services, both capitated and non-capitated. A Contractor may elect to
offer additional acute care Value-added Services.

        


        The
STAR+PLUS Members are provided with two enhanced benefits compared to the
traditional, fee-for-service Medicaid coverage:

        


        
          	
                   
      

                	
                  1) waiver
      of the three-prescription per month limit, for members not covered by
      Medicare;

                


        

        


        
          	
                   
      

                	
                  2) inclusion
      of an annual adult well check for patients 21 years of age and
      over.

                


        

        


        


        Medicaid
HMO Contractors are responsible for providing a benefit package to Members that
includes an annual adult well check for patients 21 years of age and
over.  Prescription drug benefits to HMO Members are provided outside
of the HMO capitation.

        


        STAR+PLUS
HMO Contractors should refer to the current Texas Medicaid
Provider Procedures Manual and the bi-monthly Texas Medicaid
Bulletin for a more inclusive listing of limitations and exclusions that
apply to each Medicaid benefit category. (These documents can be accessed online
at: http://www.tmhp.com.)

        


        The
services listed in this Attachment are subject to modification based on Federal
and State laws and regulations and Programs policy updates.

        


        Services included under the
HMO capitation payment

        


        
          	
                   
      

                	
                  • Ambulance
      services

                


        

        


        
          	
                   
      

                	
                  • Audiology
      services, including hearing aids for adults (hearing aids for children are
      provided through the PACT program and are a non-capitated
      service)

                


        

        


        
          	
                   
      

                	
                  • Behavioral
      Health Services, including:

                


        

        


        
          	
                   
      

                	
                  o Inpatient
      mental health services for Adults and Children (Effective 6/01/07 in the
      Harris Service Area; and effective 9/01/07 in the Bexar, Nueces and Travis
      Service Areas.)

                


        

        


        
          	
                   
      

                	
                  o Outpatient
      mental health services for Adults and
Children

                


        

        


        
          	
                   
      

                	
                  o Outpatient
      chemical dependency services for children (under age
  21)

                


        

        


        
          	
                   
      

                	
                  o Detoxification
      services

                


        

        


        
          	
                   
      

                	
                  o Psychiatry
      services

                


        

        


        
          	
                   
      

                	
                  o Counseling
      services for adults (21 years of age and
over)

                


        

        


        
          	
                   
      

                	
                  • Birthing
      center services

                


        

        
          	
                   
      

                	
                  • Chiropractic
      services

                


        

        
          	
                   
      

                	
                  • Dialysis

                


        

        
          	
                   
      

                	
                  • Durable
      medical equipment and supplies

                


        

        
          	
                   
      

                	
                  • Emergency
      Services

                


        

        
          	
                   
      

                	
                  • Family
      planning services

                


        

        
          	
                   
      

                	
                  • Home
      health care services

                


        

        
          	
                   
      

                	
                  • Hospital
      services, outpatient

                


        

        
          	
                   
      

                	
                  • Laboratory

                


        

        
          	
                   
      

                	
                  • Medical
      check-ups and Comprehensive Care Program (CCP) Services for children
      (under age 21) through the Texas Health Steps Program

                
	 	
                  • Oral
      evaluation and fluoride varnish in the Medical Home in conjunction with
      Texas Health Steps medical check up for children 6 through 35 months of
      age.

                


        

        
          	
                   
      

                	
                  • Optometry,
      glasses, and contact lenses, if medically
  necessary

                


        

        
          	
                   
      

                	
                  • Podiatry

                


        

        
          	
                   
      

                	
                  • Prenatal
      care

                


        

        
          	
                   
      

                	
                  • Primary
      care services

                


        

        
          	
                   
      

                	
                  • Radiology,
      imaging, and X-rays

                


        

        
          	
                   
      

                	
                  • Specialty
      physician services

                


        

        
          	
                   
      

                	
                  • Therapies
      – physical, occupational and speech

                


        

        
          	
                   
      

                	
                  • Transplantation
      of organs and tissues

                


        

        
          	
                   
      

                	
                  • Vision

                


        

         

        Community
Based Long Term Care Services

        


        The
following is a non-exhaustive, high-level listing of Community Based Long Term
Care Covered Services included under the STAR+PLUS Medicaid managed care
program.

        


        • Community Based Long Term
Care Services for all Members

        


        
          	
                   
      

                	
                  o Personal
      Attendant Services – All Members of a STAR+PLUS HMO may receive medically
      and functionally necessary Personal Attendant Services
    (PAS).

                


        

        


        
          	
                   
      

                	
                  o Day
      Activity and Health Services – All Members of a STAR+PLUS HMO may receive
      medically and functionally necessary Day Activity and Health Care Services
      (DAHS).

                


        

        


        


        
          	
                  • 1915 (c) Nursing
      Facility Waiver Services for those Members who qualify for such
      services

                


        

        The state
provides an enriched array of services to clients who would otherwise qualify
for nursing facility care through a Home and Community Based Medicaid
Waiver.  In traditional Medicaid, this is known as the Community Based
Alternatives (CBA) waiver.  The STAR+PLUS HMO must also provide the
services that are available to clients through the CBA waiver in traditional
Medicaid to those clients that meet the functional and financial eligibility for
the 1915 (c) Nursing Facility Waiver Services.

        


        
          	
                   
      

                	
                  o Personal
      Attendant Services (including the three service delivery options:
      Self-Directed; Agency Model, Self-Directed; and Agency
    Model)

                


        

        
          	
                   
      

                	
                  o Nursing
      Services (in home)

                


        

        
          	
                   
      

                	
                  o Emergency
      Response Services (Emergency call
button)

                


        

        
          	
                   
      

                	
                  o Home
      Delivered Meals

                


        

        
          	
                   
      

                	
                  o Minor
      Home Modifications

                


        

        
          	
                   
      

                	
                  o Adaptive
      Aids and Medical Equipment

                


        

        
          	
                   
      

                	
                  o Medical
      Supplies

                


        

        
          	
                   
      

                	
                  o Physical
      Therapy, Occupational Therapy, Speech
Therapy

                


        

        
          	
                   
      

                	
                  o Adult
      Foster Care

                


        

        
          	
                   
      

                	
                  o Assisted
      Living

                
	 	o Transition
      Assistance Services (These services are limited to a maximum of
      $2,500.00.  If the HMO determines that no other resources are
      available to pay for the basic services/items needed to assist a Member,
      who is leaving a nursing facility, with setting up a household, the HMO
      may authorize up to $2,500.00 for Transition Assistance Services
      (TAS).  The $2,500.00 TAS benefit is part of the expense ceiling
      when determining the Total Annual Individual Service Plan (ISP)
      Cost.)


        

         

         

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      


      Subject: Attachment B-2.2 - CHIP
Perinatal Covered Services

       

      
         

        
          	
                  DOCUMENT
      HISTORY LOG

                
	
                  STATUS1

                	
                  DOCUMENT

                  REVISION2

                	
                  EFFECTIVE

                  DATE

                	
                  DESCRIPTION3

                
	
                   

                  Baseline

                   

                	
                   

                  n/a

                   

                	 
      	
                   

                  Initial
      version of Attachment B-2, Covered Services

                   

                
	
                  Revision

                	
                  1.1

                	
                  June
      30, 2006

                	
                  Revised
      Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS
      Covered Services.

                   

                
	
                  Revision

                	
                  1.2

                	
                  September
      1, 2006

                	
                  Revised
      Attachment B-2, Covered Services, by updating provisions applicable to
      MCOs participating in the STAR and CHIP Programs.

                   

                
	
                  Revision

                	
                  1.3

                	
                  September
      1, 2006

                	
                  Revised
      Attachment B-2, Covered Services, by adding Attachment B-2.2, CHIP
      Perinatal Covered Services.  This is the initial version of
      Attachment B-2.2, which lists the CHIP Perinatal Covered Services,
      exclusions and DME/Supplies.

                   

                
	
                  Revision

                	
                  1.4

                	
                  September
      1, 2006

                	
                  Contract
      Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
      Services.

                   

                
	
                  Revision

                	
                  1.5

                	
                  January
      1, 2007

                	
                  Contract
      Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
      Services.

                   

                
	
                  Revision

                	
                  1.6

                	
                  February
      1, 2007

                	
                  Contract
      Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
      Services.

                   

                
	
                  Revision

                	
                  1.7

                	
                  July
      1, 2007

                	
                  Contract
      Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
      Services.

                   

                
	
                  Revision

                	
                  1.8

                	
                  September
      1, 2007

                	
                  Contract
      Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
      Services.

                   

                
	
                  Revision

                	
                  1.9

                	
                  December
      1, 2007

                	
                  Contract
      Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
      Services.

                   

                
	Revision 	1.10 	March
      1, 2008 	
                  Contract
      Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
      Services.

                   

                
	Revision	1.11	September
      1, 2008	
                  Contract
      Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
      Services.

                   

                
	
                   

                   1  Status
      should be represented as “Baseline” for initial issuances, “Revision” for
      changes to the Baseline version, and “Cancellation” for withdrawn
      versions

                  2
      Revisions should be numbered in accordance according to the version
      of the issuance and sequential numbering of the revision—e.g., “1.2”
      refers to the first version of the document and the second
      revision.

                  3  Brief
      description of the changes to the document made in the
      revision.

                


        

        
        

        


        


         

        


        CHIP Perinatal Program Covered Services


        Covered
CHIP Perinatal Program services must meet the definition of Medically Necessary
Covered Services as defined in this Contract.  There is
no lifetime maximum on benefits; however, 12-month enrollment period or lifetime
limitations do apply to certain services, as specified in the following
chart.   Co-pays do not apply to CHIP Perinatal Program
Members.  CHIP Perinatal Program Members are eligible for 12-months
continuous coverage following enrollment in the program.

         

        
          	
                  Covered

                   Benefit

                	
                  CHIP
      Perinate Newborn

                	
                  CHIP
      Perinate

                
	
                  Inpatient
      General Acute and Inpatient Rehabilitation Hospital Services

                   

                	
                  For
      CHIP Perinate Newborns in families with incomes at or below 185% of the
      Federal Poverty Level, the facility charges are not a covered benefit for
      the initial Perinate Newborn admission; however, facility charges are a
      covered benefit after the initial Perinate Newborn admission. "Initial
      Perinate Newborn admission" means the hospitalization associated with the
      birth. 

                   

                  For
      CHIP Perinate Newborns in families with incomes at or below 185% of the
      Federal Poverty Level, professional service charges are a covered benefit
      for the initial Perinate Newborn admission and subsequent admissions.
      "Initial Perinate Newborn admission" means the hospitalization associated
      with the birth. 

                   

                  Services
      include, but are not limited to, the following:

                   

                   Hospital-provided
      Physician or Provider services

                   

                   Semi-private
      room and board (or private if medically necessary as certified by
      attending)

                   

                   General
      nursing care

                   

                   Special
      duty nursing when medically necessary

                   

                   ICU and
      services

                   

                   Patient
      meals and special diets

                   

                   Operating,
      recovery and other treatment rooms

                   

                   Anesthesia
      and administration (facility technical component)

                   Surgical
      dressings, trays, casts, splints

                   Drugs,
      medications and biologicals

                   Blood
      or blood products that are not provided free-of-charge to the patient and
      their administration

                   X-rays,
      imaging and other radiological tests (facility technical
      component)

                   Laboratory
      and pathology services (facility technical component)

                   Machine
      diagnostic tests (EEGs, EKGs, etc.)

                   Oxygen
      services and inhalation therapy

                   Radiation
      and chemotherapy

                   Access
      to DSHS-designated Level III perinatal centers or Hospitals meeting
      equivalentlevels of care

                   In-network
      or out-of-network facility and Physician services for a mother and her
      newborn(s) for a minimum of 48 hours following an uncomplicated vaginal
      delivery and 96 hours following an uncomplicated delivery by caesarian
      section.

                   Hospital,
      physician and related medical services, such as anesthesia, associated
      with dental care

                   Surgical
      implants

                   Other
      artificial aids including surgical implants

                   Implantable
      devices are covered under Inpatient and Outpatient services and do not
      count towards the DME 12-month period limit

                   

                   

                	
                  For
      CHIP Perinates in families with incomes at or below 185% of the Federal
      Poverty Level, the facility charges are not a covered benefit; however,
      professional services charges associated with labor with delivery are a
      covered benefit.

                   

                  For
      CHIP Perinates in families with incomes between 186% and 200% of the
      Federal Poverty Level, benefits are limited to professional service
      charges and facility charges associated with labor with
      delivery.

                   

                  Covered
      medically necessary Hospital-provided services are limited to labor with
      delivery until birth.

                   

                  Services
      include:

                   

                   Operating,
      recovery and other treatment rooms

                   

                   Anesthesia
      and administration (facility technical component

                   

                   Medically
      necessary surgical services are limited to services that directly relate
      to the delivery of the unborn child.

                   

                
	
                  Skilled
      Nursing

                  Facilities

                  (Includes
      Rehabilitation

                  Hospitals)

                   

                   

                	
                  Services
      include, but are not limited to, the following:

                   Semi-private
      room and board

                   Regular
      nursing services

                   Rehabilitation
      services

                   Medical
      supplies and use of appliances and equipment furnished by the
      facility

                   

                	
                  Not
      a covered benefit.

                
	
                  Outpatient
      Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic
      (Including Health Center) and Ambulatory Health Care Center

                   

                	
                  Services
      include, but are not limited to, the following services provided in a
      hospital clinic or emergency room, a clinic or health center,
      hospital-based emergency department or an ambulatory health care
      setting:

                   

                   X-ray,
      imaging, and radiological tests (technical component)

                   

                   Laboratory
      and pathology services (technical component)

                   

                   Machine
      diagnostic tests

                   

                   Ambulatory
      surgical facility services

                   

                   Drugs,
      medications and biologicals

                   

                   Casts,
      splints, dressings

                   

                   Preventive
      health services

                   

                   Physical,
      occupational and speech therapy

                   

                   Renal
      dialysis

                   

                   Respiratory
      services

                   

                   Radiation
      and chemotherapy

                   

                   Blood
      or blood products that are not provided free-of-charge to the patient and
      the administration of these products

                   

                   Facility
      and related medical services, such as anesthesia, associated with dental
      care, when provided in a licensed ambulatory surgical
      facility.

                   

                   Surgical
      implants

                   

                   Other
      artificial aids including surgical implants

                   

                   Implantable
      devices are covered under Inpatient and Outpatient services and do not
      count towards the DME 12-month period limit.

                   

                   

                   

                	
                  Services
      include, the following services provided in a hospital clinic or emergency
      room, a clinic or health center, hospital-based emergency department or an
      ambulatory health care setting:

                   

                   X-ray,
      imaging, and radiological tests (technical component)

                   

                   Laboratory
      and pathology services (technical component)

                   

                   Machine
      diagnostic tests

                   

                   Drugs,
      medications and biologicals that are medically necessary prescription and
      injection drugs.

                   

                   

                  (1)
      Laboratory and radiological services are limited to services that directly
      relate to ante partum care and/or the delivery of the covered CHIP
      Perinate until birth.

                   

                  (2)
      Ultrasound of the pregnant uterus is a covered benefit when medically
      indicated.  Ultrasound may be indicated for suspected genetic
      defects, high-risk pregnancy, fetal growth retardation, or gestational age
      confirmation.

                   

                  (3)
      Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion (FIUT) and
      Ultrasonic Guidance for Cordocentesis, FIUT are covered benefits with an
      appropriate diagnosis.

                   (4)
      Laboratory tests are limited to:  nonstress testing,
      contraction, stress testing, hemoglobin or hematocrit repeated once a
      trimester and at 32-36 weeks of pregnancy; or complete blood count (CBC),
      urinanalysis for protein and glucose every visit, blood type and RH
      antibody screen; repeat antibody screen for Rh negative women at 28 weeks
      followed by RHO immune globulin

                  administration
      if indicated; rubella antibody titer, serology for syphilis, hepatitis B
      surface antigen, cervical cytology, pregnancy test, gonorrhea test, urine
      culture, sickle cell test, tuberculosis (TB) test, human immunodeficiency
      virus (HIV) antibody screen, Chlamydia test, other laboratory tests not
      specified but deemed medically necessary, and multiple marker screens for
      neural tube defects (if the client initiates care between 16 and 20
      weeks); screen for gestational diabetes at 24-28 weeks of pregnancy; other
      lab tests as indicated by medical condition of client.

                
	
                  Physician/

                  Physician

                  Extender
      Professional Services

                   

                	
                  Services
      include, but are not limited to, the following:

                   

                   American
      Academy of Pediatrics recommended well-child exams and preventive health
      services (including, but not limited to, vision and hearing screening and
      immunizations)

                   

                   Physician
      office visits, in-patient and out-patient services

                   

                   Laboratory,
      x-rays, imaging and pathology services, including technical component
      and/or professional interpretation

                   

                   Medications,
      biologicals and materials administered in Physician’s office

                   

                   Allergy
      testing, serum and injections

                   

                   Professional
      component (in/outpatient) of surgical services, including:

                  - Surgeons
      and assistant surgeons for surgical procedures including appropriate
      follow-up care

                  - Administration
      of anesthesia by Physician (other than surgeon) or CRNA

                  - Second
      surgical opinions

                  - Same-day
      surgery performed in a Hospital without an over-night stay

                  - Invasive
      diagnostic procedures such as endoscopic examinations

                   Hospital-based
      Physician services (including Physician-performed technical and
      interpretive components)

                   

                   In-network
      and out-of-network Physician services for a mother and her newborn(s) for
      a minimum of 48 hours following an uncomplicated vaginal delivery and 96
      hours following an uncomplicated delivery by caesarian
      section.

                   

                   Physician
      services medically necessary to support a dentist providing dental
      services to a CHIP member such as general anesthesia or intravenous (IV)
      sedation.

                   

                   

                   

                	
                  Services
      include, but are not limited to the following:

                   

                   Medically
      necessary physician services are limited to prenatal and postpartum care
      and/or the delivery of the covered unborn child until birth

                   

                   Physician
      office visits, in-patient and out-patient services

                   

                   Laboratory,
      x-rays, imaging and pathology services including technical component and
      /or professional interpretation

                   

                   Medically
      necessary medications, biologicals and materials administered in
      Physician’s office

                   

                   Professional
      component (in/outpatient) of surgical services, including:

                   

                  o Surgeons
      and assistant surgeons for surgical procedures directly related to the
      labor with delivery of the covered unborn child until birth.

                   

                  o Administration
      of anesthesia by Physician (other than surgeon) or CRNA

                   

                  o Invasive
      diagnostic procedures directly related to the labor with
      delivery of the unborn child.

                   

                   Hospital-based
      Physician services (including Physician performed technical and
      interpretive components)

                   

                   Professional
      component of the ultrasound of the pregnant uterus when medically
      indicated for suspected genetic defects, high-risk pregnancy, fetal growth
      retardation, or gestational age confirmation.

                   

                   Professional
      component of Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion
      (FIUT) and Ultrasonic Guidance for Amniocentesis, Cordocentrsis, and
      FIUT.

                   

                
	
                  Prenatal
      Care and Pre-Pregnancy Family Services and Supplies

                   

                   

                	
                  Not
      a covered benefit.

                	
                  Services
      are limited to an initial visit and subsequent prenatal (ante partum) care
      visits that include:

                   

                  (1)
      One visit every four weeks for the first 28 weeks or
      pregnancy;

                  (2)
      one visit every two to three weeks from 28 to 36 weeks of pregnancy;
      and

                  (3)
      one visit per week from 36 weeks to delivery.

                   

                  More
      frequent visits are allowed as Medically Necessary. Benefits are limited
      to:

                   

                  Limit
      of 20 prenatal visits and 2 postpartum visits (maximum within 60 days)
      without documentation of a complication of pregnancy.  More
      frequent visits may be necessary for high-risk
      pregnancies.  High-risk prenatal visits are not limited to 20
      visits per pregnancy.  Documentation supporting medical
      necessity must be maintained in the physician’s files and is subject to
      retrospective review.

                   

                  Visits
      after the initial visit must include:

                   

                   interim
      history (problems, marital status, fetal status);

                   

                   physical
      examination (weight, blood pressure, fundalheight, fetal position and
      size, fetal heart rate, extremities) and

                   

                   laboratory
      tests (urinanalysis for protein and glucose every visit; hematocrit or
      hemoglobin repeated once a trimester and at 32-36 weeks of pregnancy;
      multiple marker screen for fetal abnormalities offered at 16-20 weeks of
      pregnancy; repeat antibody screen for Rh negative women at 28 weeks
      followed by Rho immune globulin administration if indicated; screen for
      gestational diabetes at 24-28 weeks of pregnancy; and other lab tests as
      indicated by medical condition of client).

                   

                
	
                  Durable
      Medical Equipment (DME), Prosthetic Devices and

                  Disposable
      Medical Supplies

                   

                   

                	
                  $20,000
      12-month period limit for DME, prosthetics, devices and disposable medical
      supplies (diabetic supplies and equipment are not counted against this
      cap).   Services include DME (equipment which can withstand
      repeated use and is primarily and customarily used to serve a medical
      purpose, generally is not useful to a person in the absence of Illness,
      Injury, or Disability, and is appropriate for use in the home), including
      devices and supplies that are medically necessary and necessary for one or
      more activities of daily living and appropriate to assist in the treatment
      of a medical condition, including:

                   Orthotic
      braces and orthotics

                   Prosthetic
      devices such as artificial eyes, limbs, and braces

                   Prosthetic
      eyeglasses and contact lenses for the management of severe ophthalmologic
      disease

                   Hearing
      aids

                   Diagnosis-specific
      disposable medical supplies, including diagnosis-specific prescribed
      specialty formula and dietary supplements.  (See Attachment
      A)

                   

                	
                  Not
      a covered benefit.

                
	
                  Home
      and Community Health Services

                   

                   

                   

                	
                  Services
      that are provided in the home and community, including, but not limited
      to:

                   

                   Home
      infusion

                   

                   Respiratory
      therapy

                   

                   Visits
      for private duty nursing (R.N., L.V.N.)

                   

                   Skilled
      nursing visits as defined for home health purposes (may include R.N. or
      L.V.N.).

                   

                   Home
      health aide when included as part of a plan of care during a period that
      skilled visits have been approved.

                   

                   Speech,
      physical and occupational therapies.

                   

                   Services
      are not intended to replace the CHILD'S caretaker or to provide relief for
      the caretaker

                   

                   Skilled
      nursing visits are provided on intermittent level and not intended to
      provide 24-hour skilled nursing services

                   

                   Services
      are not intended to replace 24-hour inpatient or skilled nursing facility
      services

                   

                   

                   

                	
                  Not
      a covered benefit.

                
	
                  Inpatient
      Mental Health Services

                   

                	
                  Mental
      health services, including for serious mental illness, furnished in a
      free-standing psychiatric hospital, psychiatric units of general acute
      care hospitals and state-operated facilities, including, but not limited
      to:

                   Neuropsychological
      and psychological testing.

                   Inpatient
      mental health services are limited to:

                   45 days
      12-month inpatient limit

                   Includes
      inpatient psychiatric services, up to 12-month period limit, ordered by a
      court of competent jurisdiction under the provisions of Chapters 573 and
      574 of the Texas Health and Safety Code, relating to court ordered
      commitments to psychiatric facilities. Court order serves as binding
      determination of medical necessity. Any modification or termination of
      services must be presented to the court with jurisdiction over the matter
      for determination

                   25 days
      of the inpatient benefit can be converted to residential treatment,
      therapeutic foster care or other 24-hour therapeutically planned and
      structured services or sub-acute outpatient (partial hospitalization or
      rehabilitative day treatment) mental health services on the basis of
      financial equivalence against the inpatient per diem cost

                   20 of
      the inpatient days must be held in reserve for inpatient use
      only

                   Does
      not require PCP referral

                   

                	
                  Not
      a covered benefit.

                
	
                  Outpatient
      Mental Health Services

                   

                	
                  Mental
      health services, including for serious mental illness, provided on an
      outpatient basis, including, but not limited to:

                   Medication
      management visits do not count against the outpatient visit
      limit.

                   The
      visits can be furnished in a variety of community-based settings
      (including school and home-based) or in a state-operated
      facility

                   Up to
      60 days 12-month period limit for rehabilitative day
treatment

                   60
      outpatient visits 12-month period limit

                   60
      rehabilitative day treatment days can be converted to outpatient visits on
      the basis of financial equivalence against the day treatment per diem
      cost

                   60
      outpatient visits can be converted to skills training (psycho educational
      skills development) or rehabilitative day treatment on the basis of
      financial equivalence against the outpatient visit cost

                   Includes
      outpatient psychiatric services, up to 12-month period limit, ordered by a
      court of competent jurisdiction under the provisions of Chapters 573 and
      574 of the Texas Health and Safety Code, relating to court ordered
      commitments to psychiatric facilities. Court order serves as binding
      determination of medical necessity. Any modification or termination of
      services must be presented to the court with jurisdiction over the matter
      for determination

                   Inpatient
      days converted to sub-acute outpatient services are in addition to the
      outpatient limits and do not count towards those limits

                   A
      Qualified Mental Health Professional (QMHP), as defined by and
      credentialed through Texas Department of State Health Services (DSHS)
      standards (TAC Title 25, Part II, Chapter 412), is a Local Mental Health
      Authorities provider. A QMHP must be working under the authority of an
      DSHS entity and be supervised by a licensed mental health professional or
      physician. QMHPs are acceptable providers as long as the services would be
      within the scope of the services that are typically provided by QMHPs.
      Those services include individual and group skills training (which can be
      components of interventions such as day treatment and in-home services),
      patient and family education, and crisis services

                   Does
      not require PCP referral

                   

                	
                  Not
      a covered benefit.

                
	
                  Inpatient
      Substance Abuse Treatment Services

                   

                	
                  Services
      include, but are not limited to:

                   

                   Inpatient
      and residential substance abuse treatment services including
      detoxification and crisis stabilization, and 24-hour residential
      rehabilitation programs

                   

                   

                   Does
      not require PCP referral

                   

                   Medically
      necessary   detoxification/stabilization services, limited
      to 14 days per 12-month period.

                   

                   24-hour
      residential rehabilitation programs, or the equivalent, up to 60 days per
      12-month period

                   

                   30 days
      may be converted to partial hospitalization or intensive outpatient
      rehabilitation, on the basis of financial equivalence against the
      inpatient per diem cost

                   

                   30 days
      must be held in reserve for inpatient use only.

                   

                   

                   

                	
                  Not
      a covered benefit.

                
	
                  Outpatient
      Substance Abuse Treatment Services

                   

                	
                   

                   Services
      include, but are not limited to, the following:

                   Prevention
      and intervention services that are provided by physician and non-physician
      providers, such as screening, assessment and referral for chemical
      dependency disorders.

                   Intensive
      outpatient services is defined as an organized non-residential service
      providing structured group and individual therapy, educational services,
      and life skills training which consists of at least 10 hours per week for
      four to 12 weeks, but less than 24 hours per day

                   Outpatient
      treatment service is defined as consisting of at least one to two hours
      per week providing structured group and individual therapy, educational
      services, and life skills training

                   Outpatient
      treatment services up to a maximum of:

                   Intensive
      outpatient program (up to 12 weeks per 12-month period)

                   Outpatient
      services (up to six-months per 12-month period)

                   Does
      not require PCP referral

                   

                	
                  Not
      a covered benefit.

                
	
                  Rehabilitation
      Services

                   

                   

                	
                  Services
      include, but are not limited to, the following:

                   

                   Habilitation
      (the process of supplying a child with the means to reach age-appropriate
      developmental milestones through therapy or treatment) and rehabilitation
      services include, but are not limited to the following:

                   

                   Physical,
      occupational and speech therapy

                   

                   Developmental
      assessment

                   

                   

                   

                	
                  Not
      a covered benefit.

                
	
                  Hospice
      Care Services

                   

                	
                  Services
      include, but are not limited to:

                   

                   Palliative
      care, including medical and support services, for those children who have
      six months or less to live, to keep patients comfortable during the last
      weeks and months before death

                   

                   Treatment
      for unrelated conditions is unaffected

                   

                   Up to a
      maximum of 120 days with a 6 month life expectancy

                   

                   Patients
      electing hospice services waive their rights to treatment related to their
      terminal illnesses; however, they may cancel this election at
      anytime

                   

                   Services
      apply to the hospice diagnosis

                   

                   

                   

                	
                  Not
      a covered benefit.

                
	
                  Emergency
      Services, including Emergency Hospitals, Physicians, and Ambulance
      Services

                   

                	
                  HMO
      cannot require authorization as a condition for payment for emergency
      conditions labor and

                  delivery.

                   

                  Covered
      services include, but are not limited to, the following:

                   

                   Emergency
      services based on prudent lay person definition of emergency health
      condition

                   

                   Hospital
      emergency department room and ancillary services and physician services 24
      hours a day, 7 days a week, both by in-network and out-of-network
      providers

                   

                   Medical
      screening examination 

                   

                   Stabilization
      services

                   

                   Access
      to DSHS designated Level 1 and Level II trauma centers or hospitals
      meeting equivalent levels of care for emergency services

                   

                   Emergency
      ground, air and water transportation

                   

                   Emergency
      dental services, limited to fractured or dislocated jaw, traumatic damage
      to teeth, and removal of cysts.

                   

                   

                   

                	
                  HMO
      cannot require authorization as a condition for payment for emergency
      conditions related to labor with delivery.

                   

                  Covered
      services are limited to those emergency services that are directly related
      to the delivery of the unborn child until birth.

                   

                   

                   Emergency
      services based on prudent lay person definition of emergency health
      condition

                   

                   Medical
      screening examination to determine emergency when directly related to the
      delivery of the covered unborn child.

                   

                   Stabilization
      services related to the labor with delivery of the covered unborn
      child.

                   

                   Emergency
      ground, air and water transportation for labor and threatened labor is a
      covered benefit

                   

                   

                  Benefit
      limits:  Post-delivery services or complications resulting in
      the need for emergency services for the mother of the CHIP Perinate are
      not a covered benefit.

                
	
                  Transplants

                   

                	
                  Services
      include, but are not limited to, the following:

                   

                   Using
      up-to-date FDA guidelines, all non-experimental human organ and tissue
      transplants and all forms of non-experimental corneal, bone marrow and
      peripheral stem cell transplants, including donor medical
      expenses.

                   

                   

                   

                	
                  Not
      a covered benefit.

                
	
                  Vision
      Benefit

                   

                   

                   

                   

                	
                  The
      health plan may reasonably limit the cost of the
      frames/lenses.

                  Services
      include:

                   

                   One
      examination of the eyes to determine the need for and prescription for
      corrective lenses per 12-month period, without authorization

                   

                   One
      pair of non-prosthetic eyewear per 12-month period

                   

                   

                   

                	
                  Not
      a covered benefit.

                
	
                  Chiropractic
      Services

                   

                	
                   

                   

                   Services
      do not require physician prescription and are limited to spinal
      subluxation.

                   

                   

                   

                	
                  Not
      a covered benefit.

                
	
                  Tobacco
      Cessation

                  Program

                   

                	
                  Covered
      up to $100 for a 12- month period limit for a plan- approved
      program

                   

                   Health
      Plan defines plan-approved program.

                   

                   May be
      subject to formulary requirements.

                   

                   

                   

                	
                  Not
      a covered benefit.

                
	
                  Case
      Management and Care Coordination Services

                   

                   

                	
                  These
      services include outreach informing, case management, care coordination
      and community referral.

                	
                  Covered
      benefit.

                   

                   

                
	
                  Value-added
      services

                	
                  See Attachment
      B-3.2

                	 
      


        

        
        

        


        


        CHIP
PERINATAL PROGRAM EXCLUSIONS FROM COVERED SERVICES FOR CHIP
PERINATES

        


        


        
          	
                   
      

                	
                  • For
      CHIP Perinates in families with incomes at or below 185% of the Federal
      Poverty Level, inpatient facility charges are not a covered benefit for
      the initial Perinatal Newborn admission. "Initial Perinatal Newborn
      admission" means the hospitalization associated with the birth. 

                


        

        
          	
                   
      

                	
                   Inpatient
      and outpatient treatments other than prenatal care, labor with delivery,
      and postpartum care related to the covered unborn child until
      birth.

                


        

        
          	
                   
      

                	
                   Inpatient
      mental health services.

                


        

        
          	
                   
      

                	
                   Outpatient
      mental health services.

                


        

        
          	
                   
      

                	
                   Durable
      medical equipment or other medically related remedial
    devices.

                


        

        
          	
                   
      

                	
                   Disposable
      medical supplies.

                


        

        
          	
                   
      

                	
                   Home
      and community-based health care
services.

                


        

        
          	
                   
      

                	
                   Nursing
      care services.

                


        

        
          	
                   
      

                	
                   Dental
      services.

                


        

        
          	
                   
      

                	
                   Inpatient
      substance abuse treatment services and residential substance abuse
      treatment services.

                


        

        
          	
                   
      

                	
                   Outpatient
      substance abuse treatment services.

                


        

        
          	
                   
      

                	
                   Physical
      therapy, occupational therapy, and services for individuals with speech,
      hearing, and language disorders.

                


        

        
          	
                   
      

                	
                   Hospice
      care.

                


        

        
          	
                   
      

                	
                   Skilled
      nursing facility and rehabilitation hospital
  services.

                


        

        
          	
                   
      

                	
                   Emergency
      services other than those directly related to the labor with delivery of
      the covered unborn child.

                


        

        
          	
                   
      

                	
                   Transplant
      services.

                


        

        
          	
                   
      

                	
                   Tobacco
      Cessation Programs.

                


        

        
          	
                   
      

                	
                   Chiropractic
      Services.

                


        

        
          	
                   
      

                	
                   Medical
      transportation not directly related to the labor or threatened labor
      and/or delivery of the covered unborn
child.

                


        

        
          	
                   
      

                	
                   Personal
      comfort items including but not limited to personal care kits provided on
      inpatient admission, telephone, television, newborn infant photographs,
      meals for guests of patient, and other articles which are not required for
      the specific treatment related to labor with delivery or post partum
      care.

                


        

        
          	
                   
      

                	
                   Experimental
      and/or investigational medical, surgical or other health care procedures
      or services which are not generally employed or recognized within the
      medical community

                


        

        
          	
                   
      

                	
                   Treatment
      or evaluations required by third parties including, but not limited to,
      those for schools, employment, flight clearance, camps, insurance or
      court

                


        

        
          	
                   
      

                	
                   Private
      duty nursing services when performed on an inpatient basis or in a skilled
      nursing facility.

                


        

        
          	
                   
      

                	
                   Mechanical
      organ replacement devices including, but not limited to artificial
      heart

                


        

        
          	
                   
      

                	
                   Hospital
      services and supplies when confinement is solely for diagnostic testing
      purposes and not a part of labor with
delivery

                


        

        
          	
                   
      

                	
                   Prostate
      and mammography screening

                


        

        
          	
                   
      

                	
                   Elective
      surgery to correct vision

                


        

        
          	
                   
      

                	
                   Gastric
      procedures for weight loss

                


        

        
          	
                   
      

                	
                   Cosmetic
      surgery/services solely for cosmetic
purposes

                


        

        
          	
                   
      

                	
                   Out-of-network
      services not authorized by the Health Plan except for emergency care
      related to the labor with delivery of the covered unborn
      child.

                


        

        
          	
                   
      

                	
                   Services,
      supplies, meal replacements or supplements provided for weight control or
      the treatment of obesity

                


        

        
          	
                   
      

                	
                   Acupuncture
      services, naturopathy and
hypnotherapy

                


        

        
          	
                   
      

                	
                   Immunizations
      solely for foreign travel

                


        

        
          	
                   
      

                	
                   Routine
      foot care such as hygienic care

                


        

        
          	
                   
      

                	
                   Diagnosis
      and treatment of weak, strained, or flat feet and the cutting or removal
      of corns, calluses and toenails (this does not apply to the removal of
      nail roots or surgical treatment of conditions underlying corns, calluses
      or ingrown toenails) 

                


        

        
          	
                   
      

                	
                   Corrective
      orthopedic shoes

                


        

        
          	
                   
      

                	
                   Convenience
      items

                


        

        
          	
                   
      

                	
                   Orthotics
      primarily used for athletic or recreational
  purposes

                


        

        
          	
                   
      

                	
                   Custodial
      care (care that assists with the activities of daily living, such as
      assistance in walking, getting in and out of bed, bathing, dressing,
      feeding, toileting, special diet preparation, and medication supervision
      that is usually self-administered or provided by a caregiver. This care
      does not require the continuing attention of trained medical or
      paramedical personnel.)

                


        

        
          	
                   
      

                	
                   Housekeeping

                


        

        
          	
                   
      

                	
                   Public
      facility services and care for conditions that federal, state, or local
      law requires be provided in a public facility or care provided while in
      the custody of legal authorities

                


        

        
          	
                   
      

                	
                   Services
      or supplies received from a nurse, which do not require the skill and
      training of a nurse

                


        

        
          	
                   
      

                	
                   Vision
      training, vision therapy, or vision
services

                


        

        
          	
                   
      

                	
                   Reimbursement
      for school-based physical therapy, occupational therapy, or speech therapy
      services are not covered

                


        

        
          	
                   
      

                	
                   Donor
      non-medical expenses

                


        

        
          	
                   
      

                	
                   Charges
      incurred as a donor of an organ

                


        

         

        CHIP PERINATAL PROGRAM EXCLUSIONS FROM
COVERED SERVICES FOR CHIP PERINATE NEWBORNS

        


        With the
exception of the first bullet, all the following exclusions match those found in
the CHIP Program.

        


        
          	
                   
      

                	
                  • For
      CHIP Perinate Newborns in families with incomes at or below 185% of the
      Federal Poverty Level, inpatient facility charges are not a covered
      benefit for the initial Perinate Newborn admission.  "Initial
      Perinate Newborn admission" means the hospitalization associated with the
      birth.

                


        

        
          	
                   
      

                	
                   Inpatient
      and outpatient infertility treatments or reproductive services other than
      prenatal care, labor and delivery, and care related to disease, illnesses,
      or abnormalities related to the reproductive
  system

                


        

        
          	
                   
      

                	
                   Personal
      comfort items including but not limited to personal care kits provided on
      inpatient admission, telephone, television, newborn infant photographs,
      meals for guests of patient, and other articles which are not required for
      the specific treatment of sickness or
injury

                


        

        
          	
                   
      

                	
                   Experimental
      and/or investigational medical, surgical or other health care procedures
      or services which are not generally employed or recognized within the
      medical community

                


        

        
          	
                   
      

                	
                   Treatment
      or evaluations required by third parties including, but not limited to,
      those for schools, employment, flight clearance, camps, insurance or
      court

                


        

        
          	
                   
      

                	
                   Private
      duty nursing services when performed on an inpatient basis or in a skilled
      nursing facility.

                


        

        
          	
                   
      

                	
                   Mechanical
      organ replacement devices including, but not limited to artificial
      heart

                


        

        
          	
                   
      

                	
                   Hospital
      services and supplies when confinement is solely for diagnostic testing
      purposes, unless otherwise pre-authorized by Health
  Plan

                


        

        
          	
                   
      

                	
                   Prostate
      and mammography screening

                


        

        
          	
                   
      

                	
                   Elective
      surgery to correct vision

                


        

        
          	
                   
      

                	
                   Gastric
      procedures for weight loss

                


        

        
          	
                   
      

                	
                   Cosmetic
      surgery/services solely for cosmetic
purposes

                


        

        
          	
                   
      

                	
                   Out-of-network
      services not authorized by the Health Plan except for emergency care and
      physician services for a mother and her newborn(s) for a minimum of 48
      hours following an uncomplicated vaginal delivery and 96 hours following
      an uncomplicated delivery by caesarian
section

                


        

        
          	
                   
      

                	
                   Services,
      supplies, meal replacements or supplements provided for weight control or
      the treatment of obesity, except for the services associated with the
      treatment for morbid obesity as part of a treatment plan approved by the
      Health Plan

                


        

        
          	
                   
      

                	
                   Acupuncture
      services, naturopathy and
hypnotherapy

                


        

        
          	
                   
      

                	
                   Immunizations
      solely for foreign travel

                


        

        
          	
                   
      

                	
                   Routine
      foot care such as hygienic care

                


        

        
          	
                   
      

                	
                   Diagnosis
      and treatment of weak, strained, or flat feet and the cutting or removal
      of corns, calluses and toenails (this does not apply to the removal of
      nail roots or surgical treatment of conditions underlying corns, calluses
      or ingrown toenails)

                


        

        
          	
                   
      

                	
                   Replacement
      or repair of prosthetic devices and durable medical equipment due to
      misuse, abuse or loss when confirmed by the Member or the vendor
      

                


        

        
          	
                   
      

                	
                   Corrective
      orthopedic shoes

                


        

        
          	
                   
      

                	
                   Convenience
      items

                


        

        
          	
                   
      

                	
                   Orthotics
      primarily used for athletic or recreational
  purposes

                


        

        
          	
                   
      

                	
                   Custodial
      care (care that assists a child with the activities of daily living, such
      as assistance in walking, getting in and out of bed, bathing, dressing,
      feeding, toileting, special diet preparation, and medication supervision
      that is usually self-administered or provided by a parent. This care does
      not require the continuing attention of trained medical or paramedical
      personnel.)  This exclusion does not apply to hospice
      services.

                


        

        
          	
                   
      

                	
                   Housekeeping

                


        

        
          	
                   
      

                	
                   Public
      facility services and care for conditions that federal, state, or local
      law requires be provided in a public facility or care provided while in
      the custody of legal authorities

                


        

        
          	
                   
      

                	
                   Services
      or supplies received from a nurse, which do not require the skill and
      training of a nurse

                


        

        
          	
                   
      

                	
                   Vision
      training and vision therapy

                


        

        
          	
                   
      

                	
                   Reimbursement
      for school-based physical therapy, occupational therapy, or speech therapy
      services are not covered except when ordered by a
      Physician/PCP

                


        

        
          	
                   
      

                	
                   Donor
      non-medical expenses

                


        

        
          	
                   
      

                	
                   Charges
      incurred as a donor of an organ when the recipient is not covered under
      this health plan

                


        

         

        CHIP & CHIP PERINATAL PROGRAM
DME/SUPPLIES

        Note:  DME/SUPPLIES
are not a covered benefit for CHIP Perinate Members but are a benefit for CHIP
Perinate Newborns.

        
          	
                  SUPPLIES

                	
                  COVERED

                	
                  EXCLUDED

                	
                  COMMENTS/MEMBER

                  CONTRACT
      PROVISIONS

                
	
                  Ace
      Bandages

                	 
      	
                  X

                	
                  Exception:
      If provided by and billed through the clinic or home care agency it is
      covered as an incidental supply.

                
	
                  Alcohol,
      rubbing

                	 
      	
                  X

                	
                  Over-the-counter
      supply.

                
	
                  Alcohol,
      swabs (diabetic)

                	
                  X

                	 
      	
                  Over-the-counter
      supply not covered, unless RX provided at time of
    dispensing.

                
	
                  Alcohol,
      swabs

                	
                  X

                	 
      	
                  Covered
      only when received with IV therapy or central line
      kits/supplies.

                
	
                  Ana
      Kit Epinephrine

                	
                  X

                	 
      	
                  A
      self-injection kit used by patients highly allergic to bee
      stings.

                
	
                  Arm
      Sling

                	
                  X

                	 
      	
                  Dispensed
      as part of office visit.

                
	
                  Attends
      (Diapers)

                	
                  X

                	 
      	
                  Coverage
      limited to children age 4 or over only when prescribed by a physician and
      used to provide care for a covered diagnosis as outlined in a treatment
      care plan.

                
	
                  Bandages

                	 
      	
                  X

                	 
      
	
                  Basal
      Thermometer

                	 
      	
                  X

                	
                  Over-the-counter
      supply.

                
	
                  Batteries
      – initial

                	
                  X

                	
                  .

                	
                  For
      covered DME items

                
	
                  Batteries
      – replacement

                	
                  X

                	 
      	
                  For
      covered DME when replacement is necessary due to normal
    use.

                
	
                  Betadine

                	 
      	
                  X

                	
                  See
      IV therapy supplies.

                
	
                  Books

                	 
      	
                  X

                	 
      
	
                  Clinitest

                	
                  X

                	 
      	
                  For
      monitoring of diabetes.

                
	
                  Colostomy
      Bags

                	 
      	 
      	
                  See
      Ostomy Supplies.

                
	
                  Communication
      Devices

                	 
      	
                  X

                	 
      
	
                  Contraceptive
      Jelly

                	 
      	
                  X

                	
                  Over-the-counter
      supply. Contraceptives are not covered under the plan.

                
	
                  Cranial
      Head Mold

                	 
      	
                  X

                	 
      
	
                  Diabetic
      Supplies

                	
                  X

                	 
      	
                  Monitor
      calibrating solution, insulin syringes, needles, lancets, lancet device,
      and glucose strips.

                
	
                  Diapers/Incontinent
      Briefs/Chux

                	
                  X

                	 
      	
                  Coverage
      limited to children age 4 or over only when prescribed by a physician and
      used to provide care for a covered diagnosis as outlined in a treatment
      care plan

                
	
                  Diaphragm

                	 
      	
                  X

                	
                  Contraceptives
      are not covered under the plan.

                
	
                  Diastix

                	
                  X

                	 
      	
                  For
      monitoring diabetes.

                
	
                  Diet,
      Special

                	 
      	
                  X

                	 
      
	
                  Distilled
      Water

                	 
      	
                  X

                	 
      
	
                  Dressing
      Supplies/Central Line

                	
                  X

                	 
      	
                  Syringes,
      needles, Tegaderm, alcohol swabs, Betadine swabs or ointment,
      tape.  Many times these items are dispensed in a kit when
      includes all necessary items for one dressing site
  change.

                
	
                  Dressing
      Supplies/Decubitus

                	
                  X

                	 
      	
                  Eligible
      for coverage only if receiving covered home care for wound
      care.

                
	
                  Dressing
      Supplies/Peripheral IV Therapy

                	
                  X

                	 
      	
                  Eligible
      for coverage only if receiving home IV therapy.

                
	
                  Dressing
      Supplies/Other

                	 
      	
                  X

                	 
      
	
                  Dust
      Mask

                	 
      	
                  X

                	 
      
	
                  Ear
      Molds

                	
                  X

                	 
      	
                  Custom
      made, post inner or middle ear surgery

                
	
                  Electrodes

                	
                  X

                	 
      	
                  Eligible
      for coverage when used with a covered DME.

                
	
                  Enema
      Supplies

                	 
      	
                  X

                	
                  Over-the-counter
      supply.

                
	
                  Enteral
      Nutrition Supplies

                	
                  X

                	 
      	
                  Necessary
      supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible
      for coverage.  Enteral nutrition products are not covered except
      for those prescribed for hereditary metabolic disorders, a non-function or
      disease of the structures that normally permit food to reach the small
      bowel, or malabsorption due to disease

                
	
                  Eye
      Patches

                	
                  X

                	 
      	
                  Covered
      for patients with amblyopia.

                
	
                  Formula

                	 
      	
                  X

                	
                  Exception:
      Eligible for coverage only for chronic hereditary metabolic disorders a
      non-function or disease of the structures that normally permit food to
      reach the small bowel; or malabsorption due to disease (expected to last
      longer than 60 days when prescribed by the physician and authorized by
      plan.)  Physician documentation to justify prescription of
      formula must include:

                   

                  • Identification
      of a metabolic disorder, dysphagia that results in a medical need for a
      liquid diet, presence of a gastrostomy, or disease resulting in
      malabsorption that requires a medically necessary nutritional
      product

                   

                  Does
      not include formula:

                   

                  • For
      members who could be sustained on an age-appropriate diet.

                   

                  • Traditionally
      used for infant feeding

                   

                  • In
      pudding form (except for clients with documented oropharyngeal motor
      dysfunction who receive greater than 50 percent of their daily caloric
      intake from this product)

                   

                  • For the
      primary diagnosis of failure to thrive, failure to gain weight, or lack of
      growth or for infants less than twelve months of age unless medical
      necessity is documented and other criteria, listed above, are
      met.

                   

                   

                  Food
      thickeners, baby food, or other regular grocery products that can be
      blenderized and used with an enteral system that are not medically
      necessary, are not covered, regardless of whether these regular food
      products are taken orally or parenterally.

                
	
                  Gloves

                	 
      	
                  X

                	
                  Exception:  Central
      line dressings or wound care provided by home care
  agency.

                
	
                  Hydrogen
      Peroxide

                	 
      	
                  X

                	
                  Over-the-counter
      supply.

                
	
                  Hygiene
      Items

                	 
      	
                  X

                	 
      
	
                  Incontinent
      Pads

                	
                  X

                	 
      	
                  Coverage
      limited to children age 4 or over only when prescribed by a physician and
      used to provide care for a covered diagnosis as outlined in a treatment
      care plan

                
	
                  Insulin
      Pump (External) Supplies

                	
                  X

                	 
      	
                  Supplies
      (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible
      for coverage if the pump is a covered item.

                
	
                  Irrigation
      Sets, Wound Care

                	
                  X

                	 
      	
                  Eligible
      for coverage when used during covered home care for wound
      care.

                
	
                  Irrigation
      Sets, Urinary

                	
                  X

                	 
      	
                  Eligible
      for coverage for individual with an indwelling urinary
      catheter.

                
	
                  IV
      Therapy Supplies

                	
                  X

                	 
      	
                  Tubing,
      filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other
      related supplies necessary for home IV therapy.

                
	
                  K-Y
      Jelly

                	 
      	
                  X

                	
                  Over-the-counter
      supply.

                
	
                  Lancet
      Device

                	
                  X

                	 
      	
                  Limited
      to one device only.

                
	
                  Lancets

                	
                  X

                	 
      	
                  Eligible
      for individuals with diabetes.

                
	
                  Med
      Ejector

                	
                  X

                	 
      	 
      
	
                  Needles
      and Syringes/Diabetic

                	 
      	 
      	
                  See
      Diabetic Supplies

                
	
                  Needles
      and Syringes/IV and Central Line

                	 
      	 
      	
                  See
      IV Therapy and Dressing Supplies/Central Line.

                
	
                  Needles
      and Syringes/Other

                	
                  X

                	 
      	
                  Eligible
      for coverage if a covered IM or SubQ medication is being administered at
      home.

                
	
                  Normal
      Saline

                	 
      	 
      	
                  See
      Saline, Normal

                
	
                  Novopen

                	
                  X

                	 
      	 
      
	
                  Ostomy
      Supplies

                	
                  X

                	 
      	
                  Items
      eligible for coverage include: belt, pouch, bags, wafer, face plate,
      insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape, skin
      prep, adhesives, drain sets, adhesive remover, and pouch
      deodorant.

                  Items
      not eligible for coverage include:  scissors, room deodorants,
      cleaners, rubber gloves, gauze, pouch covers, soaps, and
      lotions.

                
	
                  Parenteral
      Nutrition/Supplies

                	
                  X

                	 
      	
                  Necessary
      supplies (e.g., tubing, filters, connectors, etc.) are eligible for
      coverage when the Health Plan has authorized the parenteral
      nutrition.

                
	
                  Saline,
      Normal

                	
                  X

                	 
      	
                  Eligible
      for coverage:

                  a)
      when used to dilute medications for nebulizer treatments;

                  b)
      as part of covered home care for wound care;

                  c)
      for indwelling urinary catheter irrigation.

                
	
                  Stump
      Sleeve

                	
                  X

                	 
      	 
      
	
                  Stump
      Socks

                	
                  X

                	 
      	 
      
	
                  Suction
      Catheters

                	
                  X

                	 
      	 
      
	
                  Syringes

                	 
      	 
      	
                  See
      Needles/Syringes.

                
	
                  Tape

                	 
      	 
      	
                  See
      Dressing Supplies, Ostomy Supplies, IV Therapy
Supplies.

                
	
                  Tracheostomy
      Supplies

                	
                  X

                	 
      	
                  Cannulas,
      Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for
      coverage.

                
	
                  Under
      Pads

                	 
      	 
      	
                  See
      Diapers/Incontinent Briefs/Chux.

                
	
                  Unna
      Boot

                	
                  X

                	 
      	
                  Eligible
      for coverage when part of wound care in the home
      setting.  Incidental charge when applied during office
      visit.

                
	
                  Urinary,
      External Catheter & Supplies

                	 
      	
                  X

                	
                  Exception:  Covered
      when used by incontinent male where injury to the urethra prohibits use of
      an indwelling catheter ordered by the PCP and approved by the
      plan

                
	
                  Urinary,
      Indwelling Catheter & Supplies

                	
                  X

                	 
      	
                  Cover
      catheter, drainage bag with tubing, insertion tray, irrigation set and
      normal saline if needed.

                
	
                  Urinary,
      Intermittent

                	
                  X

                	 
      	
                  Cover
      supplies needed for intermittent or straight
  catherization.

                
	
                  Urine
      Test Kit

                	
                  X

                	 
      	
                  When
      determined to be medically necessary.

                
	
                  Urostomy
      supplies

                	 
      	 
      	
                  See
      Ostomy Supplies.

                


        

        
        

        


         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        


        Subject: Attachment B-3 -
Value-added Services


        
          
            	
                    DOCUMENT
      HISTORY LOG

                  
	
                    STATUS1

                  	
                    DOCUMENT

                    REVISION2

                  	
                    EFFECTIVE

                    DATE

                  	
                    DESCRIPTION3

                  
	
                    Baseline

                  	
                    n/a

                  	 
      	
                    Initial
      version of Attachment B-3, Value-added Services.

                  
	
                    Revision

                  	
                    1.1

                  	
                    June
      30, 2006

                  	
                    Contract
      amendment did not revise Attachment B-3, Value-added
    Services.

                  
	
                    Revision

                  	
                    1.2

                  	
                    September
      1, 2006

                  	
                    Revised
      the Physical Health Value-added Services to include Home Visits to New
      Mothers.  Revised the certification provision by changing the
      start date for the 12-month provision of services.

                  
	
                    Revision

                  	
                    1.3

                  	
                    September
      1, 2006

                  	
                    Contract
      amendment did not revise Attachment B-3, Value-added
    Services.

                  
	
                    Revision

                  	
                    1.4

                  	
                    September
      1, 2006

                  	
                    Contract
      amendment removed the separate signature requirement for Attachment B-3,
      Value-added Services.  By signing the Contract and/or Contract
      Amendment, the HMO certifies that it will provide the Value-added Services
      from September 1, 2006 through August 31, 2007.

                  
	
                    Revision

                  	
                    1.5

                  	
                    January
      1, 2007

                  	
                    Contract
      amendment did not revise Attachment B-3, Value-added
    Services.

                  
	
                    Revision

                  	
                    1.6

                  	
                    February
      1, 2007

                  	
                    Contract
      amendment did not revise Attachment B-3, Value-added
    Services.

                  
	
                    Revision

                  	
                    1.7

                  	
                    July
      1, 2007

                  	
                    Contract
      amendment did not revise Attachment B-3, Value-added
    Services.

                  
	
                    Revision

                  	
                    1.8

                  	
                    September
      1, 2007

                  	
                    Revised
      Attachment B-3, Value-added Services, to reflect newly negotiated
      Value-added Services for FY 2008.

                  
	
                    Revision

                  	
                    1.9

                  	
                    December
      1, 2007

                  	
                    Contract
      amendment did not revise Attachment B-3, Value-added
    Services.

                  
	Revision 	1.10 	March 1,
      2008 	
                    Contract
      amendment did not revise Attachment B-3, Value-added
      Services. 

                  
	Revision	1.11	September
      1, 2008	Revised
      Attachment B-3, Value-added Services, to reflect newly negotiated
      Value-added Services for FY 2009.
	
                     

                     1  Status
      should be represented as “Baseline” for initial issuances, “Revision” for
      changes to the Baseline version, and “Cancellation” for withdrawn
      versions

                    2
      Revisions should be numbered in accordance according to the version
      of the issuance and sequential numbering of the revision—e.g., “1.2”
      refers to the first version of the document and the second
      revision.

                    3  Brief
      description of the changes to the document made in the
      revision.

                  


          

          
          

          ATTACHMENT
B-3:  VALUE-ADDED SERVICES

          September
1, 2008 – August 31, 2009

          


          


          HMO:   Superior
HealthPlan, Inc.

          


          HMO
PROGRAM:    Medicaid

          


          SERVICE
AREA(S):Bexar, El Paso, Lubbock, Nueces, and Travis 

           

          
            	
                    Physical
      Health Value-added Services

                  	 
      	 
      	 
      	 
      
	
                    Value-added
      Service

                  	
                    Description
      of Value-added Services and Members Eligible to Receive the
      Services

                  	
                    Limitations
      or Restrictions

                  	
                    Provider(s)
      responsible for providing this service

                  	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      
	NurseWise	Twenty-four
      hour nurse advice line	Available
      to all members by calling the Member Services toll-free number	NurseWIse,
      an affiliate of Centene Corporation	 	 	 	 	 
	Transportation	
                    HMO
      will offer tokens or vouchers for bus services to HMO members that have
      trouble accessing the State's Medical Transportation Program in a timely
      manner to ensure access to their provider appointments. In addition, HMO
      will provide transportation to non-medical services such as health
      education programs, nutrition classes, and birth preparation classes.
      HMO's member service staff will approve and coordinate the transportation
      service".

                  	
                    Members
      in the Nueces Service Area. The Transportation Authority in this area will
      not agree to allow the plan to purchase bus vouchers or
      tokens.

                    The
      bus tokens must be requested in advance of a provider visit and authorized
      by Superior’s Member Services Department.

                  	 Transit
      Authorities in applicable Service Area.	 	 	 	 	 
	
                    Vision

                  	
                    Members
      are allowed to purchase any prescription eyewear and apply a $100
      allowance toward the purchase of that eyewear.

                  	
                    Members
      are responsible for any charges that exceed the $100
      allowance.  Disposable contact lenses are excluded from this
      $100 allowance.  This Value-Added benefit is only allowed one
      time per benefit period (i.e. 24-months).

                  	
                    TVHP
      contracted providers.

                  	 
      	 
      	 
      	 
      	 
      
	
                    Pharmacy

                  	
                    Provides
      members with a $15.00 per household per quarter credit toward over the
      counter medications and supplies.

                  	
                    Services
      must be sought from contracted pharmacies only.  Items eligible
      for purchase under this benefit are over-the-counter, health related items
      only.

                     

                  	
                    Pharmacy
      Data Management contracted providers.

                  	 
      	 
      	 
      	 
      	 
      
	
                    Home
      visits to New Mothers

                  	
                    Superior
      Social Work and/or CONNECTIONS staff will make home visits to any Member
      with a new baby.  This visit provides for resource and education
      coordination as identified in the visit, and ensures Members and the new
      babies are keeping all post natal and newborn doctor
      visits.  This benefit is available to all Superior Members who
      have delivered a baby.

                     

                  	
                    Only
      that a member consent to the home visit.

                  	
                    Superior’s
      CONNECTIONS and Social Work staff  provide this
      service.

                     

                  	 
      	 
      	 
      	 
      	 
      


          

          
          

          


          
            
 

          

          
            	
                    Behavioral
      Health Value-added Services for Members Under 21

                  	 
      	 
      	 
      	 
      
	
                    Value-added
      Service

                  	
                    Description
      of Value-added Services and Members Eligible to Receive the
      Services

                  	
                    Limitations
      or Restrictions

                  	
                    Provider(s)
      responsible for providing this service

                  	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      
	
                    Behavioral
      Health

                  	
                    Rehabilitation/skills
      training.  These are services provided to pregnant and
      parenting substance abusers at MHMR centers or in other treatment
      settings, focusing both on substance abuse and parenting issues. An
      augmentation of standard substance abuse treatment to focus on the special
      needs of this population. Authorized in increments of 15 minutes, with
      amount, duration, and scope based on medical necessity.  This
      benefit is available to all Members.  It is geared to pregnant
      women and parenting Members.

                  	
                     These
      services must be authorized by Superior’s Behavioral
      Health  Subcontractor.  In addition, the service will
      be authorized for15-minute increments.  The amount, duration,
      and scope are based on medical necessity.

                     

                  	
                    It
      is anticipated that Superior’s contracted MHMR providers specializing in
      Rehabilitation/Skills training in each Service Area will render this
      service.

                  	 
      	 
      	 
      	 
      
	
                    Behavioral
      Health

                  	
                    Superior’s
      Behavioral Health Subcontractor will authorize Behavioral Health
      practitioners in medical settings to provide health psychology
      interventions focused on the effective management of chronic medical
      conditions.   These might include psycho-educational groups
      for chronic conditions, individual coaching for patients with chronic
      disease states, or skills training activities.

                     

                  	
                    These
      services must be authorized by Superior’s Behavioral Health Subcontractor.
      The authorization will be tied to medical necessity.

                     

                  	
                    It
      is anticipated that these services will be rendered by Superior’s
      behavioral health practitioners located in Superior’s contracted Federally
      Qualified Health Centers.

                  	 
      	 
      	 
      	 
      
	
                    Behavioral
      Health

                  	
                    Partial
      Hospitalization/Extended Day Treatment- An alternative to, or a step down
      from, inpatient care.

                  	
                    These
      services must be authorized by Superior’s Behavioral Health Subcontractor.
      Services are authorized for a minimum of five hours, but for less than
      24-hours per day. The amount, duration, and scope will be based on medical
      necessity.

                  	
                    It
      is anticipated that Superior’s contracted Behavioral Health Providers such
      as its’ MHMR facilities and other contracted facilities in each Service
      Area will render this service.

                  	 
      	 
      	 
      	 
      
	
                    Behavioral
      Health

                  	
                    Intensive
      Outpatient Treatment/Day Treatment (IOP)- Used as an alternative to or
      step down from more restrictive levels of care.

                     

                  	
                    These
      services must be authorized by  Superior’s Behavioral Health
      Material Subcontractor.  In addition, the service will be
      authorized for greater than one and one half hours, but less than five
      hours per day.  Amount, duration, and scope are based on medical
      necessity.

                     

                  	
                    It
      is anticipated that Superior’s contracted Behavioral Health Providers such
      as the MHMR or other facilities in each Service Area will render this
      service.

                  	 
      	 
      	 
      	 
      


          

          
          

          


           

          
            	
                    Behavioral
      Health Value-added Services for Members 21
      and Over

                  	 
      	 
      	 
      	 
      
	
                    Value-added
      Service

                  	
                    Description
      of Value-added Services and Members Eligible to Receive the
      Services

                  	
                    Limitations
      or Restrictions

                  	
                    Provider(s)
      responsible for providing this service

                  	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      
	
                    Behavioral
      Health

                  	
                    Rehabilitation/skills
      training.  These are services provided to pregnant and
      parenting substance abusers at MHMR centers or in other treatment
      settings, focusing both on substance abuse and parenting issues. An
      augmentation of standard substance abuse treatment to focus on the special
      needs of this population. This benefit is available to all
      Members.  It is geared to pregnant women and parenting
      Members.

                     

                     

                  	
                    These
      services must be authorized by Superior’s Behavioral Health
      Subcontractor.  In addition, the service will be authorized
      for15-minute increments.  The amount, duration, and scope are
      based on medical necessity.

                     

                  	
                    It
      is anticipated that Superior’s contracted MHMR providers specializing in
      Rehabilitation/Skills training in each Service Area will render this
      service.

                  	 
      	 
      	 
      	 
      	 
      
	
                    Behavioral
      Health

                  	
                    Partial
      Hospitalization/Extended Day Treatment- An alternative to, or a step down
      from, inpatient care.

                  	
                    These
      services must be authorized by  Superior’s Behavioral Health
      Subcontractor.  Services are authorized for a minimum of five
      hours, but for less than 24-hours per day. The amount, duration, and scope
      will be based on medical necessity.

                     

                  	
                    It
      is anticipated that Superior’s contracted Behavioral Health Providers such
      as its’ MHMR facilities and other contracted facilities in each Service
      Area will render this service.

                  	 
      	 
      	 
      	 
      	 
      
	
                    Behavioral
      Health

                  	
                    Superior’s
      Behavioral Health Subcontractor, will authorize Behavioral Health
      practitioners in medical settings to provide health psychology
      interventions focused on the effective management of chronic medical
      conditions.   These might include psycho-educational groups
      for chronic conditions, individual coaching for patients with chronic
      disease states, or skills training activities.

                     

                  	
                    These
      services must be authorized by Superior’s Behavioral Health
      Subcontractor.  The authorization will be tied to medical
      necessity.

                     

                  	
                    It
      is anticipated that these services will be rendered by Superior’s
      behavioral health practitioners located in Superior’s contracted Federally
      Qualified Health Centers.

                  	 
      	 
      	 
      	 
      	 
      
	
                    Behavioral
      Health

                  	
                    Intensive
      Outpatient Treatment/Day Treatment (IOP)- Used as an alternative to or
      step down from more restrictive levels of care.

                     

                  	
                    These
      services must be authorized by  Superior’s Behavioral Health
      Subcontractor.  In addition, the service will be authorized for
      greater than one and one half hours, but less than five hours per
      day.  Amount, duration, and scope are based on medical
      necessity.

                     

                  	
                    It
      is anticipated that Superior’s contracted Behavioral Health Providers such
      as the MHMR or other facilities in each Service Area will render this
      service.

                  	 
      	 
      	 
      	 
      	 
      
	
                    Behavioral
      Health

                  	
                    Off-site
      Services such as home-based services, , mobile crisis, intensive case
      management. It should be noted that staff must go off-site to provide such
      services.  These services are provided to Members to help reduce
      or avoid inpatient admissions by a community based, mobile,
      multi-disciplinary team of licensed clinicians and trained, unlicensed
      workers working under the direction of a licensed
      professional.

                     

                  	
                    These
      services must be authorized by Superior’s Behavioral Health
      Subcontractor.  The amount, duration and scope are based on
      medical necessity.

                     

                  	
                    It
      is anticipated that Superior’s contracted Behavioral Health Providers such
      as the MHMR in each Service Area will render this service.

                  	 
      	 
      	 
      	 
      	 
      


          

          
          

          


          


          ADDITIONAL INFORMATION:


          


          


          
            	
                    1.
      Explain how and when Providers and Members will be notified about the
      availability of the value-added services to be
  provided.

                  


          

          


           

          
            	
                    Value
      Added Services information will be included in the Superior Provider
      Manual and also during training sessions. Members will receive this
      information via the Plan Comparison Chart, in the Member Handbook, with
      New Member Packets and during orientations.  Periodically,
      Superior will also highlight Value Added Services in the Provider and
      Member Newsletters.

                     

                  


          

          
          

          


          


          


          
            	
                    2.
      Describe how a Member may obtain or access the value-added services to be
      provided.

                  


          

          


           

          
            	
                    See
      explanations provided above for accessing services.

                     

                    
                      A Member may access the Home
      Visits to New Mothers service by accepting a home visit appointment from a
      Superior Social Work or CONNECTIONS staff
      member.  

                    

                  


          

          
          

           

          
            3. Describe how the HMO will
identify the Value-added Service in administrative (encounter) data.

          

          
             

          

          
            	
                    
                      Superior
      will track the value added services through our claims system for those
      value-adds that HIPAA-compliant procedural codes are available (vision,
      behavioral health).  Superior will create a specific benefit
      category to track and report the value added services 'separately' from
      our 'capitated' service data.  In addition, Superior will have
      the ability to pass this information to the State utilizing the encounter
      submission process, as long as the State is able to segregate the value
      adds data from the capitated services data.

                      For
      pharmacy services, Superior will receive a data file from the pharmacy
      vendor to capture all utilization of the pharmacy value-add
      benefit.

                      


                      For
      transportation services, Superior will maintain an electronic file of
      transportation services provided for Superior’s membership.

                      


                      Home
      visits to new mothers are tracked through Superior’s case management
      system.  Each staff member logs each member visit and the
      outcome/findings of the visit in Superior’s computer
      system.  Superior will work with HHSC to establish the most
      efficient transmission of the
data.

                    

                  


          

          
          

           

          4.  By
signing the Contract and/or Contract Amendment HMO certifies that it will
provide the approved Value-added Services described herein from September 1,
2008 through August 31, 2009.

        

         

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      Subject: Attachment B-3 -
Value-added Services


       

      
        	
                DOCUMENT
      HISTORY LOG

              
	
                STATUS1

              	
                DOCUMENT

                REVISION2

              	
                EFFECTIVE

                DATE

              	
                DESCRIPTION3

              
	
                Baseline

              	
                n/a

              	 
      	
                Initial
      version of Attachment B-3, Value-added Services.

              
	
                Revision

              	
                1.1

              	
                June
      30, 2006

              	
                Contract
      amendment did not revise Attachment B-3, Value-added
    Services.

              
	
                Revision

              	
                1.2

              	
                September
      1. 2006

              	
                Revised
      Physical Health Value-added Services to include Home Visits to New
      Mothers.  Revised the certification provision by changing the
      start date for the 12-month provision of services.

              
	
                Revision

              	
                1.3

              	
                September
      1, 2006

              	
                Contract
      amendment did not revise Attachment B-3, Value-added
    Services.

              
	
                Revision

              	
                1.4

              	
                September
      1, 2006

              	
                Contract
      amendment removed the separate signature requirement for Attachment B-3,
      Value-added Services.  By signing the Contract and/or Contract
      Amendment, the HMO certifies that it will provide the Value-added Services
      from September 1, 2006 through August 31, 2007.

              
	
                Revision

              	
                1.5

              	
                January
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-3, Value-added
    Services.

              
	
                Revision

              	
                1.6

              	
                February
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-3, Value-added
    Services.

              
	
                Revision

              	
                1.7

              	
                July
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-3, Value-added
    Services.

              
	
                Revision

              	
                1.8

              	
                September
      1, 2007

              	
                Revised
      Attachment B-3, Value-added Services, to reflect newly negotiated
      Value-added Services for FY 2008.

              
	
                Revision

              	
                1.9

              	
                December
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-3, Value-added
    Services.

              
	Revision 	1.10	March
      1, 2008	
                Contract
      amendment did not revise Attachment B-3, Value-added
      Services. 

              
	Revision	1.11	September
      1, 2008	
                Revised
      Attachment B-3, Value-added Services, to reflect newly negotiated
      Value-added Services for FY 2009.

              
	
                 

                 1  Status
      should be represented as “Baseline” for initial issuances, “Revision” for
      changes to the Baseline version, and “Cancellation” for withdrawn
      versions

                2
      Revisions should be numbered in accordance according to the version
      of the issuance and sequential numbering of the revision—e.g., “1.2”
      refers to the first version of the document and the second
      revision.

                3  Brief
      description of the changes to the document made in the
      revision.

              


      

      
      

       

      ATTACHMENT
B-3:  VALUE-ADDED SERVICES

      September
1, 2008 – August 31, 2009

      


      


      HMO: Superior HealthPlan,
Inc.

      


      HMO
PROGRAM:  CHIP

      


      SERVICE
AREA(S):Bexar, El Paso, Lubbock, Nueces, and Travis

      


       

      
        	
                Physical Health Value-added
      Services

              	 
      	 
      	 
      	 
      
	
                 

                Value-added
      Service

              	
                 

                Description
      of Value-added Services and Members Eligible to Receive the
      Services

              	
                 

                 

                Limitations
      or Restrictions

              	
                Provider(s)
      responsible for providing this service

              	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      


      

      
        	
                NurseWise

              	
                Twenty-four
      hour nurse advice line

              	
                Available
      to all members by calling the Member Services toll-free
    number

              	
                NurseWise,
      an affiliate of Centene Corporation

              	 
      	 
      	 
      	 
      


      

      
        	
                Transportation

              	
                For
      Members in need of transportation that cannot access transportation in a
      timely manner, Superior will provide bus tokens to ensure that Members
      have a means of accessing their provider appointment.

              	
                Members
      in the Nueces Service Area.  The Transportation Authority in
      this area will not agree to allow the plan to purchase bus vouchers or
      tokens.

                The
      bus tokens must be requested in advance of a provider visit and authorized
      by Superior’s Member Services Department.  

                 

              	
                Transit
      Authorities in applicable Service Area.

              	 
      	 
      	 
      	 
      


      

      
      

      
      

      
        	
                Vision

              	
                20%
      discount off of Upgraded Hardware- The Member will receive a 20% discount
      on upgraded hardware.

              	
                There
      is no limitation on the number of times the discount can be
      utilized.  

                 

              	
                TVHP
      contracted providers.

              	 
      	 
      	 
      	 
      
	
                Pharmacy

              	
                Provides
      members with a $15.00 per household per quarter credit toward over the
      counter medications and supplies.

              	
                Services
      must be sought from contracted pharmacies only.  Items eligible
      for purchase under this benefit are over-the-counter, health related items
      only.

                 

              	
                Pharmacy
      Data Management contracted providers.

              	 
      	 
      	 
      	 
      
	
                Transportation

              	
                For
      Members in need of transportation that cannot access transportation in a
      timely manner, Superior will provide bus tokens to ensure that Members
      have a means of accessing their provider appointment.

              	
                Members
      in the Nueces Service Area.  The Transportation Authority in
      this area will not agree to allow the plan to purchase bus vouchers or
      tokens.

                The
      bus tokens must be requested in advance of a provider visit and authorized
      by Superior’s Member Services Department.  

                 

              	
                Transit
      Authorities in applicable Service Area.

              	 
      	 
      	 
      	 
      
	
                NurseWise

              	
                Twenty-four
      hour nurse advice line

              	
                Available
      to all members by calling the Member Services toll-free
    number

              	
                NurseWise,
      an affiliate of Centene Corporation

              	 
      	 
      	 
      	 
      
	
                Home
      Visits to New Mothers

              	
                Superior
      Social Work and/or CONNECTIONS staff will make home visits to any Member
      with a new baby.  This visit provides for resource and education
      coordination as identified in the visit,[what does this mean?] and ensures
      Members and the new babies are keeping all post natal and newborn doctor
      visits.  This benefit is available to all Superior Members who
      have delivered a baby.

                 

              	
                Only
      that a member consent to the home visit.

              	
                Superior’s
      CONNECTIONS and Social Work staff provide this service.

                 

              	 
      	 
      	 
      	 
      


      

    

    
      
      

      


      
         

      

      
        	
                 

                 

                Behavioral
      Health Value-added Services for Members Under 21

              
	
                 

                Value-added
      Service

              	
                 

                Description
      of Value-added Services and Members Eligible to Receive the
      Services

              	
                 

                 

                Limitations
      or Restrictions

              	
                Provider(s)
      responsible for providing this service

              
	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      


      

      
      

      


      


       

      
        	
                 

                Behavioral
      Health Value-added Services for Members 21
      and Over

              
	
                 

                Value-added
      Service

              	
                 

                Description
      of Value-added Services and Members Eligible to Receive the
      Services

              	
                 

                 

                Limitations
      or Restrictions

              	
                Provider(s)
      responsible for providing this service

              
	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      


      

      
      

      


      


      


      ADDITIONAL INFORMATION:


      


      


      
        	
                1.
      Explain how and when Providers and Members will be notified about the
      availability of the value-added services to be
  provided.

              


      

      


       

      
        	
                Value
      Added Services information will be included in the Superior Provider
      Manual and also during training sessions. Members will receive this
      information via the Plan Comparison Chart, in the Member Handbook, with
      New Member Packets and during orientations.  Periodically,
      Superior will also highlight Value Added Services in the Provider and
      Member Newsletters.

                 

              


      

      
      

      


      


      


      
        	
                2.
      Describe how a Member may obtain or access the value-added services to be
      provided.

              


      

      


       

      
        	
                See
      explanations provided above for accessing services.

                 

                
                  A
      Member may access the Home Visits to New Mothers service by accepting a
      home visit appointment from a Superior Social Work or CONNECTIONS staff
      member.

                

              


      

      
      

      


      
3. Describe how the HMO will identify the Value-added Service in
administrative (encounter) data.

       

      
        	
                Superior
      will track the value added services through our claims system for those
      value-adds that HIPAA-compliant procedural codes are available (vision,
      behavioral health, flu shots).  Superior will create a specific
      benefit category to track and report the value added services 'separately'
      from our 'capitated' service data.  In addition, Superior will
      have the ability to pass this information to the State utilizing the
      encounter submission process, as long as the State is able to segregate
      the value adds data from the capitated services data.

                 

                For
      pharmacy services, Superior will receive a data file from the pharmacy
      vendor to capture all utilization of the pharmacy value-add
      benefit.

                 

                
                  For
      transportation services, Superior will maintain an electronic file of
      transportation services provided for Superior’s membership.

                  


                  Home
      visits to new mothers are tracked through Superior’s case management
      system.  Each staff member logs each member visit and the
      outcome/findings of the visit in Superior’s computer
      system.  Superior will work with HHSC to establish the most
      efficient transmission of the
data.

                

              


      

      
      

      


      4.  By
signing the Contract and/or Contract Amendment HMO certifies that it will
provide the approved Value-added Services described herein from September 1,
2008 through August 31, 2009.

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      


      Subject: Attachment B-3.1 -
STAR+PLUS Value-added services

      
        
          	
                   

                   

                  DOCUMENT
      HISTORY LOG

                
	
                  STATUS1

                	
                  DOCUMENT

                  REVISION2

                	
                  EFFECTIVE

                  DATE

                	
                  DESCRIPTION3

                
	
                  Baseline

                	
                  1.0

                	 
      	
                  Initial
      version of Attachment B-3, Value-added Services

                
	
                  Revision

                	
                  1.1

                	
                  June
      30, 2006

                	
                  Revised
      Attachment B-3, Value Added Services, by adding Attachment B-3.1,
      STAR+PLUS Value Added Services. This is the initial version of Attachment
      B-3.1, STAR+PLUS VAS.

                
	
                  Revision

                	
                  1.2

                	
                  September
      1, 2006

                	
                  Contract
      amendment did not revise Attachment B-3.1, STAR+PLUS Value Added
      Services

                
	
                  Revision

                	
                  1.3

                	
                  September
      1, 2006

                	
                  Contract
      amendment did not revise Attachment B-3.1, STAR+PLUS Value Added
      Services

                
	
                  Revision

                	
                  1.4

                	
                  September
      1, 2006

                	
                  Contract
      amendment removed the separate signature requirement for Attachment B-3.1,
      STAR+PLUS Value-added Services.  By signing the Contract and/or
      Contract Amendment, the HMO certifies that it will provide the Value-added
      Services from January 1, 2007 through August 31, 2007.

                
	
                  Revision

                	
                  1.5

                	
                  January
      1, 2007

                	
                  Revised
      Attachment B-3.1, STAR+PLUS Value Added Services to state that only
      non-dual members are eligible for dental benefits and to clarify
      description of Out-of-Home Respite.

                
	
                  Revision

                	
                  1.6

                	
                  February
      1, 2007

                	
                  Revised
      Attachment B-3.1, STAR+PLUS Value Added Services, to clarify the coverage
      period for the VAS.

                
	
                  Revision

                	
                  1.7

                	
                  July
      1, 2007

                	
                  Revised
      Attachment B-3.1, STAR+PLUS Value Added Services, to clarify the coverage
      period for the VAS.

                
	
                  Revision

                	
                  1.8

                	
                  September
      1, 2007

                	
                  Revised
      Attachment B-3-1, STAR+PLUS Value-added Services, to reflect newly
      negotiated Value-added Services for FY 2008.

                
	
                  Revision

                	
                  1.9

                	
                  December
      1, 2007

                	
                  Contract
      amendment did not revise Attachment B-3.1, STAR+PLUS Value Added
      Services

                
	Revision 	1.10 	March
      1, 2008	Revised
      Attachment B-3-1, STAR+PLUS Value-added Services, to reflect mid year
      negotiated Value-added Services for FY 2008. 
	Revision	1.11	September
      1, 2008	
                  Revised
      Attachment B-3-1, STAR+PLUS Value-added Services, to reflect newly
      negotiated Value-added Services for FY 2009.

                
	
                   

                   1  Status
      should be represented as “Baseline” for initial issuances, “Revision” for
      changes to the Baseline version, and “Cancellation” for withdrawn
      versions

                  2
      Revisions should be numbered in accordance according to the version
      of the issuance and sequential numbering of the revision—e.g., “1.2”
      refers to the first version of the document and the second
      revision.

                  3  Brief
      description of the changes to the document made in the
      revision.

                


        

        
        

         

         

        ATTACHMENT
B-3.1:  STAR+PLUS VALUE-ADDED SERVICES

        September
1, 2008 – August 31, 2009

        


        HMO:  Superior HealthPlan,
Inc.

        


        SERVICE AREA(S):
Bexar & Nueces

         

        
          	
                   

                  Physical
      Health Value-added Services

                
	
                  Value-added
      Service

                	
                  Description
      of Value-added Services and Members Eligible to Receive the
      Services

                	
                  Limitations
      or Restrictions

                	
                  Provider(s)
      responsible for providing this
service

                


        

        
          	
                  NurseWise

                   

                	
                  Twenty-four
      hour nurse advice line

                	
                  Available
      to all members by calling the Member Services toll-free
    number

                	
                  NurseWise,
      an affiliate of Centene Corporation

                


        

        
          	
                  Pharmacy

                   

                   

                	
                  Provides
      members with a $15.00 per household quarter credit toward over the counter
      medications and supplies.

                	
                  Services
      must be sought from contracted pharmacies only.  Items eligible
      for purchase under this benefit are over-the-counter health related items
      only.

                	
                  Pharmacy
      Data Management contracted providers.

                
	
                  Dental

                   

                   

                   

                	
                  Basic
      dental coverage, which includes the following CPT codes:  0140-
      Emergency Evaluation; 0120- Periodic Oral Evaluation; 0220- Intra-oral
      Periapaical First Film; 0230- Intraoral Periapical- Each Additional; 0240-
      Intra-oral Occlusal Film; 0270- Bitewings- single film; 0272- Bitewings-
      two films; 07110- Extraction- Single Tooth/Routine to Difficult; and 07120
      Extraction- Each Additional.

                	
                  If
      a Member receives services that are outside of the scope of the CPT Codes
      listed, the Member will be subject to a co-payment of 75% of the dentists’
      usual and customary charges for those services.

                  Only
      non-dual members are eligible for dental benefits.

                	
                  STARDent
      Dental Network

                
	
                  Transportation

                   

                   

                	
                  
                    HMO
      will offer tokens or vouchers for bus services to HMO members that have
      trouble accessing the State's Medical Transportation Program in a timely
      manner to ensure access to their provider appointments. HMO's member
      service staff will approve and coordinate the transportation
      service.

                  

                	
                  
                    The
      bus tokens must be requested in advance of a provider visit and authorized
      by Superior’s Member Services Department.

                    Excludes
      the Nueces Service Area.

                  

                	
                  
                    Transit
      Authorities in applicable Service
Area

                  

                


        

        
        

        


         

         

        
          	
                   

                  Behavioral
      Health Value-added Services for Members 21
      and Over

                
	
                  Value-added
      Service

                	
                  Description
      of Value-added Services and Members Eligible to Receive the
      Services

                	
                  Limitations
      or Restrictions

                	
                  Provider(s)
      responsible for providing this service

                	 
      
	
                  Behavioral
      Health

                   

                   

                	
                  Health
      Psychology Interventions provided by a behavioral health practitioner in a
      medical setting that focuses on the effective management of chronic
      medical conditions.  This might include psycho-educational
      groups for chronic conditions, individual coaching for patients with
      chronic disease states, or skills training activities.

                	
                  Limited
      to non-dual Members only.  Services must be authorized and is
      based on medical necessity.

                	
                  Network
      Federally Qualified Health Centers (FQHCs)

                	 
      
	
                  Behavioral
      Health

                   

                   

                	
                  Intensive
      Outpatient Treatment/Day Treatment (IOP)- Used as an alternative to step
      down from more restrictive levels of care.

                	
                  Limited
      to non-dual Members only.  Services must be authorized and is
      based on medical necessity.  Services will be authorized for
      greater than one and one half hours, but less than five hours per
      day.

                	
                  It
      is anticipated that behavioral health providers such as the MHMR or other
      facilities within the Service Area will render this
    service.

                	 
      
	
                  Behavioral
      Health

                   

                   

                	
                  Partial
      Hospitalization/Extended Day Treatment- An alternative to, or a step down
      from, inpatient care.

                   

                	
                  Limited
      to non-dual Members only.  Services must be authorized and is
      based on medical necessity.  Services will be authorized for a
      minimum of five hours, but for less than 24-hours per day.

                	
                  It
      is anticipated that behavioral health providers such as the MHMR or other
      facilities within the Service Area will render this
    service.

                	 
      
	
                  Behavioral
      Health

                   

                   

                	
                  Off-site
      services such as intensive case management.  It should be noted
      that staff must go off-site to provide such services.  These
      services are provided to Members to help reduce or avoid inpatient
      admissions by a community based, mobile, multi-disciplinary team of
      licensed clinicians and trained, unlicensed workers working under the
      direction of a licensed professional.

                	
                  Limited
      to non-dual Members only.  Services must be authorized and is
      based on medical necessity.

                	
                  It
      is anticipated that behavioral health providers such as the MHMR or other
      facilities within the Service Area will render this
    service.

                	 
      


        

        
        

        


        
          ADDITIONAL INFORMATION:


        

        


        


        
          	
                  1.
      Explain how and when Providers and Members will be notified about the
      availability of the value-added services to be
  provided.

                


        

        


         

        
          	
                  Value
      added services information will be included in the Superior Provider
      Manual and also during training sessions.  Members will receive
      this information via the Plan Comparison Chart, in the Member Handbook,
      with New Member Packets and during orientations.  Periodically,
      Superior will also highlight Value Added Services in the Provider and
      member Newsletters.

                   

                


        

        
        

        
 

        
          	
                  2.
      Describe how a Member may obtain or access the value-added services to be
      provided.

                


        

        
 

        
          	
                   

                  See
      explanations provided above for accessing
  services.

                


        

        
        

        


         

        
          	
                  3.
      Describe how the HMO will identify the Value-added Service in
      administrative (encounter) data.

                


        

        


         

        
          	
                  
                    Superior
      will track value added services through our claims system for those value
      –adds that are IIPAA-compliant procedural codes are available (podiatry,
      etc.). Superior will create specific benefit categories to track and
      report the value added services “separately” from our “capitated” service
      data. In addition, Superior will have the ability to pass this information
      to the State utilizing the encounter submission process, as long as the
      Sate is able to segregate the value adds data from the capitated services
      data.

                  

                   

                  
                    For
      pharmacy services, Superior will receive a data file from the pharmacy
      vendor to capture all utilization of pharmacy value added benefits. The
      same is true for dental services. For transportation services, Superior
      will maintain an electronic file of transportation services provided for
      Superior’s membership.

                  

                   

                


        

        
        

        


         

        4. By
signing the Contract and/or Contract Amendment HMO certifies that it will
provide the approved Value-added Services described herein from September
1, 2008 – August 31, 2009.

        


         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      Subject: Attachment B-3.2 CHIP
Perinatal Program Value-added Services

       

      
         

        
          	 
      	 
      	 
      	 
      
	
                  DOCUMENT
      HISTORY LOG

                
	
                  STATUS1

                	
                  DOCUMENT

                  REVISION2

                	
                  EFFECTIVE

                  DATE

                	
                  DESCRIPTION3

                
	
                  Baseline

                	
                  1.0

                	 
      	
                  Initial
      version of Attachment B-3, Value-added Services

                
	
                  Revision

                	
                  1.1

                	
                  June
      30, 2006

                	
                  Revised
      Attachment B-3, Value Added Services, by adding Attachment B-3.1,
      STAR+PLUS Value Added Services. 

                
	
                  Revision

                	
                  1.2

                	
                  September
      1, 2006

                	
                  Contract
      amendment did not revise Attachment B-3, Value Added
    Services

                
	
                  Revision

                	
                  1.3

                	
                  September
      1, 2006

                	
                  Revised
      Attachment B-3, Value Added Services, by adding Attachment B-3.2, CHIP
      Perinatal Program Value Added Services. This is the initial version of
      Attachment B-3.2, CHIP Perinatal Program Value Added
    Services.

                
	
                  Revision

                	
                  1.4

                	
                  September
      1, 2006

                	
                  Contract
      amendment removed the separate signature requirement for Attachment B-3.2,
      CHIP Perinatal Program Value-added Services.  By signing the
      Contract and/or Contract Amendment, the HMO certifies that it will provide
      the Value-added Services from January 1, 2007 through August 31,
      2007.

                
	
                  Revision

                	
                  1.5

                	
                  January
      1, 2007

                	
                  Contract
      amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value
      Added Services.

                
	
                  Revision

                	
                  1.6

                	
                  February
      1, 2007

                	
                  Contract
      amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value
      Added Services.

                
	
                  Revision

                	
                  1.7

                	
                  July
      1, 2007

                	
                  Contract
      amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value
      Added Services.

                
	
                  Revision

                	
                  1.8

                	
                  September
      1, 2007

                	
                  Revised
      Attachment B-3.2, CHIP Perinatal Program Value-added Services, to reflect
      newly negotiated Value-added Services for FY 2008.

                
	
                  Revision

                	
                  1.9

                	
                  December
      1, 2007

                	
                  Contract
      amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value
      Added Services.

                
	Revision    	1.10 	March
      1, 2008 	Contract
      amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value
      Added Services 
	Revision	1.11	September
      1, 2008	
                  Contract
      amendment did not revise Attachment B-3.2, CHIP Perinatal Program Value
      Added Services.

                
	
                   

                   1  Status
      should be represented as “Baseline” for initial issuances, “Revision” for
      changes to the Baseline version, and “Cancellation” for withdrawn
      versions

                  2
      Revisions should be numbered in accordance according to the version
      of the issuance and sequential numbering of the revision—e.g., “1.2”
      refers to the first version of the document and the second
      revision.

                  3  Brief
      description of the changes to the document made in the
      revision.

                


        

        
        

        ATTACHMENT
B-3.2:  CHIP PERINATAL PROGRAM VALUE-ADDED SERVICES

        September
1, 2008 – August 31, 2009

        


        HMO:   _________________________________________________________________________________

        


        SERVICE
AREA(S):  ______________________________________________________________________

         

        
          	
                  Physical
      Health Value-added Services

                
	
                   

                  Value-added
      Service

                	
                   

                  Description
      of Value-added Services and Members Eligible to Receive the
      Services

                	
                   

                   

                  Limitations
      or Restrictions

                	
                  Provider(s)
      responsible for providing this service

                
	 
      
	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      


        

        
        

        


        


         

        
          	
                   

                   

                  Behavioral
      Health Value-added Services for Members Under 21

                
	
                   

                  Value-added
      Service

                	
                   

                  Description
      of Value-added Services and Members Eligible to Receive the
      Services

                	
                   

                   

                  Limitations
      or Restrictions

                	
                  Provider(s)
      responsible for providing this service

                
	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      


        

        
        

        


        


         

        
          	
                   

                  Behavioral
      Health Value-added Services for Members 21
      and Over

                
	
                   

                  Value-added
      Service

                	
                   

                  Description
      of Value-added Services and Members Eligible to Receive the
      Services

                	
                   

                   

                  Limitations
      or Restrictions

                	
                  Provider(s)
      responsible for providing this service

                
	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      


        

        
        

        


        


        ADDITIONAL INFORMATION:


        


        


        
          	
                  1.
      Explain how and when Providers and Members will be notified about the
      availability of the value-added services to be
  provided.

                


        

        


         

        
          	 
      


        

        
        

        
 

        
          	
                  2.
      Describe how a Member may obtain or access the value-added services to be
      provided.

                


        

        


         

        
          	 
      


        

        
        

        


         

        
          	
                  3.
      Describe how the HMO will identify the Value-added Service in
      administrative (encounter) data.

                


        

        


         

        
          	 
      


        

        
        

        


        4.  By
signing the Contract and/or Contract Amendment HMO certifies that it will
provide the approved Value-added Services described herein from September 1,
2008 through August 31, 2009.

        


        


        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      Subject: Attachment B-4 -
Performance Improvement Goals

       

      
         

        
          	
                  DOCUMENT
      HISTORY LOG

                
	
                  STATUS1

                	
                  DOCUMENT

                  REVISION2

                	
                  EFFECTIVE

                  DATE

                	
                  DESCRIPTION3

                	 
      
	
                  Baseline

                	
                  n/a

                	 
      	
                  Initial
      version Attachment B-4, Performance Improvement Goals.

                	 
      
	
                  Revision

                	
                  1.1

                	
                  June
      30, 2006

                	
                  Contract
      amendment to include STAR+PLUS Program. Revised Attachment B-4,
      Performance Improvement Goals Template, by adding Attachment B-4.1, FY2008
      Performance Improvement Goals Template. No change to this
      Section.

                	 
      
	
                  Revision

                	
                  1.2

                	
                  September
      1, 2006

                	
                  Revised
      version of Attachment B-4 that includes provisions applicable to MCOs
      participating in the STAR and CHIP Programs.

                  Updates
      the attachment to reflect the changes made in Attachment B-1, Section
      8.1.1.1.

                	 
      
	
                  Revision

                	
                  1.3

                	
                  September
      1, 2006

                	
                  Contract
      amendment did not revise Attachment B-4, Performance Improvement
      Goals.

                	 
      
	
                  Revision

                	
                  1.4

                	
                  September
      1, 2006

                	
                  Contract
      amended to include Attachment B-4 Performance Improvement Goals for
      SFY2007 and format change

                	 
      
	
                  Revision

                	
                  1.5

                	
                  January
      1, 2007

                	
                  Contract
      amendment did not revise Attachment B-4, Performance Improvement
      Goals.

                	 
      
	
                  Revision

                	
                  1.6

                	
                  February
      1, 2007

                	
                  Contract
      amendment did not revise Attachment B-4, Performance Improvement
      Goals.

                	 
      
	
                  Revision

                	
                  1.7

                	
                  July
      1, 2007

                	
                  Contract
      amendment did not revise Attachment B-4, Performance Improvement
      Goals.

                	 
      
	
                  Revision

                	
                  1.8

                	
                  September
      1, 2007

                	
                  Revised
      Attachment B-4, to replace FY2007 Performance Improvement Goals with newly
      negotiated FY2008 Performance Improvement Goals by Program and by Service
      Area.  Attachment B-4.1, FY2008 Performance Improvement Goals
      Template, is deleted as duplicative.

                	 
      
	
                  Revision

                	
                  1.9

                	
                  December
      1, 2007

                	
                  Contract
      amendment did not revise Attachment B-4, Performance Improvement
      Goals.

                	 
      
	Revision 	1.10 	March
      1, 2008	
                  Contract
      amendment did not revise Attachment B-4, Performance Improvement
      Goals. 

                	 
	Revision	1.11	September
      1, 2008	Revised
      Attachment B-4, to replace FY2008 Performance Improvement Goals with newly
      negotiated FY2009 Performance Improvement Goals by Program and by Service
      Area.  	 
	
                   

                   1  Status
      should be represented as “Baseline” for initial issuances, “Revision” for
      changes to the Baseline version, and “Cancellation” for withdrawn
      versions

                  2
      Revisions should be numbered in accordance according to the version
      of the issuance and sequential numbering of the revision—e.g., “1.2”
      refers to the first version of the document and the second
      revision.

                  3  Brief
      description of the changes to the document made in the
      revision.

                


        

        
        

         

        Additional information related to the Performance
Improvement Goals can be found in Attachment B-1, Section 8.1.1.1, to the Contract

         

         

         Texas
Health and Human Services Commission

        HMO
Performance Improvement Goal Template

        for
State Fiscal Year 2009

        (September 1, 2008 – August 31,
2009)

        


         

        
          	
                  A.  Health
      Plan Information

                   

                  Plan
      Name:      Superior
      HealthPlan

                  HMO
      Program:   CHIP

                  HMO
      Service Delivery Area:  Bexar SDA

                   

                
	
                  B.  Overarching
      Goal

                	
                  C.  Sub
      Goals:

                	 
      
	
                  Goal
      1:

                  Improve
      Access to Primary Care Services for Members

                   

                	
                  90%
      of initial credentialing of PCPs will be finalized within 70 calendar days
      of receipt of application.

                   

                  The
      percentage of Family Practitioners with open panels will increase
      by 5 percentage points over baseline.

                   

                	 
      
	
                  Goal
      2:

                  Improve
      Access to Behavioral Health Services for Members

                   

                	
                  Increase
      Behavioral Health Urgent Care Appointment Availability by 5 percentage
      points over baseline.

                   

                  Increase
      Behavioral Health Routine Care Appointment Availability by 5 percentage
      points over baseline.

                	 
      
	
                  Goal
      3:

                  Increase
      Utilization of New Member Medical Check-Ups within 90 days of
      Enrollment

                   

                	
                  100%
      of new members with valid phone numbers will receive three call attempts
      within 30 days of enrollment to encourage a medical check-up within 90
      days of enrollment.

                   

                  100%
      of new members that did not select a valid PCP from the plan's network
      will be defaulated to a local, appropriate network PCP by the 15th of each
      month. 

                	 
      


        

        
        

        


        


         Texas
Health and Human Services Commission

        HMO
Performance Improvement Goal Template

        for
State Fiscal Year 2009

        (September 1, 2008 – August 31,
2009)

         

        
          	
                  A.  Health
      Plan Information

                   

                  Plan
      Name:      Superior HealthPlan

                  HMO
      Program:   CHIP

                  HMO
      Service Delivery Area:  El Paso SDA

                   

                
	
                  B.  Overarching
      Goal

                	
                  C.  Sub
      Goals:

                	 
      
	
                  Goal
      1:

                  Improve
      Access to Primary Care Services for Members

                   

                	
                  90%
      of initial credentialing of PCPs will be finalized within 70 calendar days
      of receipt of application.

                  
                     

                    The
      percentage of Family Practitioners with open panels will increase
      by 5 percentage points over baseline.

                  

                   

                	 
      
	
                  Goal
      2:

                  Improve
      Access to Behavioral Health Services for Members

                   

                	
                  
                    Increase
      Behavioral Health Urgent Care Appointment Availability by 5 percentage
      points over baseline.

                     

                    Increase
      Behavioral Health Routine Care Appointment Availability by 5 percentage
      points over baseline.

                  

                   

                	 
      
	
                  Goal
      3:

                  Increase
      Utilization of New Member Medical Check-Ups within 90 days of
      Enrollment

                   

                	
                  
                    100%
      of new members with valid phone numbers will receive three call attempts
      within 30 days of enrollment to encourage a medical check-up within 90
      days of enrollment.

                     

                    100%
      of new members that did not select a valid PCP from the plan's network
      will be defaulated to a local, appropriate network PCP by the 15th of each
      month. 

                  

                	 
      


        

        
        

        


         Texas
Health and Human Services Commission

        HMO
Performance Improvement Goal Template

        for
State Fiscal Year 2009

         (September 1, 2008 – August 31,
2009)

         

        
          	
                  A.  Health
      Plan Information

                   

                  Plan
      Name:      Superior HealthPlan

                  HMO
      Program:   CHIP

                  HMO
      Service Delivery Area:  Lubbock SDA

                   

                
	
                  B.  Overarching
      Goal

                	
                  C.  Sub
      Goals:

                	 
      
	
                  Goal
      1:

                  Improve
      Access to Primary Care Services for Members

                   

                	
                  
                    90%
      of initial credentialing of PCPs will be finalized within 70 calendar days
      of receipt of application.

                    
                       

                      The
      percentage of Family Practitioners with open panels will increase
      by 5 percentage points over baseline.

                    

                  

                   

                	 
      
	
                  Goal
      2:

                  Improve
      Access to Behavioral Health Services for Members

                   

                	
                  
                    
                      Increase
      Behavioral Health Urgent Care Appointment Availability by 5 percentage
      points over baseline.

                       

                      Increase
      Behavioral Health Routine Care Appointment Availability by 5 percentage
      points over baseline.

                    

                  

                   

                	 
      
	
                  Goal
      3:

                  Increase
      Utilization of New Member Medical Check-Ups within 90 days of
      Enrollment

                   

                	
                  
                    
                      100%
      of new members with valid phone numbers will receive three call attempts
      within 30 days of enrollment to encourage a medical check-up within 90
      days of enrollment.

                       

                      100%
      of new members that did not select a valid PCP from the plan's network
      will be defaulated to a local, appropriate network PCP by the 15th of each
      month. 

                    

                  

                   

                	 
      


        

        
        

        


         Texas
Health and Human Services Commission

        HMO
Performance Improvement Goal Template

        for
State Fiscal Year 2009

        (September 1, 2008 – August 31,
2009)

         

        
          	
                  A.  Health
      Plan Information

                   

                  Plan
      Name:      Superior HealthPlan

                  HMO
      Program:   CHIP

                  HMO
      Service Delivery Area:  Nueces SDA

                   

                
	
                  B.  Overarching
      Goal

                	
                  C.  Sub
      Goals:

                	 
      
	
                  Goal
      1:

                  Improve
      Access to Primary Care Services for Members

                   

                	
                  90%
      of initial credentialing of PCPs will be finalized within 70 calendar days
      of receipt of application.

                  
                    
                       

                      The
      percentage of Family Practitioners with open panels will increase
      by 5 percentage points over baseline.

                    

                  

                   

                	 
      
	
                  Goal
      2:

                  Improve
      Access to Behavioral Health Services for Members

                   

                	
                  Increase
      Behavioral Health Urgent Care Appointment Availability by 5 percentage
      points over baseline.

                  
                    
                       

                      Increase
      Behavioral Health Routine Care Appointment Availability by 5 percentage
      points over baseline.

                    

                  

                   

                	 
      
	
                  Goal
      3:

                  Increase
      Utilization of New Member Medical Check-Ups within 90 days of
      Enrollment

                   

                	
                  
                    100%
      of new members with valid phone numbers will receive three call attempts
      within 30 days of enrollment to encourage a medical check-up within 90
      days of enrollment.

                     

                    100%
      of new members that did not select a valid PCP from the plan's network
      will be defaulated to a local, appropriate network PCP by the 15th of each
      month. 

                  

                   

                	 
      


        

        
        

        


         Texas
Health and Human Services Commission

        HMO
Performance Improvement Goal Template

        for
State Fiscal Year 2009

        (September 1, 2008 – August 31,
2009)

         

        
          	
                  A.  Health
      Plan Information

                   

                  Plan
      Name:      Superior HealthPlan

                  HMO
      Program:   CHIP

                  HMO
      Service Delivery Area:  Travis SDA

                   

                
	
                  B.  Overarching
      Goal

                	
                  C.  Sub
      Goals:

                	 
      
	
                  Goal
      1:

                  Improve
      Access to Primary Care Services for Members

                   

                	
                  90%
      of initial credentialing of PCPs will be finalized within 70 calendar days
      of receipt of application.

                  
                    
                      
                         

                        The
      percentage of Family Practitioners with open panels will increase
      by 5 percentage points over baseline.

                      

                    

                  

                   

                	 
      
	
                  Goal
      2:

                  Improve
      Access to Behavioral Health Services for Members

                   

                	
                  
                    Increase
      Behavioral Health Urgent Care Appointment Availability by 5 percentage
      points over baseline.

                    
                      
                         

                        Increase
      Behavioral Health Routine Care Appointment Availability by 5 percentage
      points over baseline.

                      

                    

                  

                   

                	 
      
	
                  Goal
      3:

                  Increase
      Utilization of New Member Medical Check-Ups within 90 days of
      Enrollment

                   

                	
                  100%
      of new members with valid phone numbers will receive three call attempts
      within 30 days of enrollment to encourage a medical check-up within 90
      days of enrollment.

                  
                    
                       

                      100%
      of new members that did not select a valid PCP from the plan's network
      will be defaulated to a local, appropriate network PCP by the 15th of each
      month. 

                    

                  

                	 
      


        

        
        

        


         Texas
Health and Human Services Commission

        HMO
Performance Improvement Goal Template

        for
State Fiscal Year 2009

        (September 1, 2008 – August 31,
2009)

         

        
          	
                  A.  Health
      Plan Information

                   

                  Plan
      Name:      Superior HealthPlan

                  HMO
      Program:   STAR

                  HMO
      Service Delivery Area:  Bexar SDA

                   

                
	
                  B.  Overarching
      Goal

                	
                  C.  Sub
      Goals:

                	 
      
	
                  Goal
      1:

                  Improve
      Access to Primary Care Services for Members

                   

                	
                  90%
      of initial credentialing of PCPs will be finalized within 70 calendar days
      of receipt of application.

                  
                    
                      
                        
                           

                          The
      percentage of Family Practitioners with open panels will increase
      by 5 percentage points over
      baseline.

                        

                      

                    

                  

                   

                	 
      
	
                  Goal
      2:

                  Improve
      Access to Behavioral Health Services for Members

                   

                	
                  
                    
                      Increase
      Behavioral Health Urgent Care Appointment Availability by 5 percentage
      points over baseline.

                      
                        
                           

                          Increase
      Behavioral Health Routine Care Appointment Availability by 5 percentage
      points over baseline.

                        

                      

                    

                  

                   

                	 
      
	
                  Goal
      3:

                  Increase
      Utilization of New Member Medical Check-Ups within 90 days of
      Enrollment

                   

                	
                  
                    100%
      of new members with valid phone numbers will receive three call attempts
      within 30 days of enrollment to encourage a medical check-up within 90
      days of enrollment.

                    
                      
                         

                        100%
      of new members that did not select a valid PCP from the plan's network
      will be defaulated to a local, appropriate network PCP by the 15th of each
      month. 

                      

                    

                  

                   

                	 
      


        

        
        

        


        Texas
Health and Human Services Commission 

          HMO
Performance Improvement Goal Template

          for
State Fiscal Year 2009

          (September 1, 2008 – August 31,
2009)

           

          
            	
                    A.  Health
      Plan Information

                     

                    Plan
      Name:      Superior HealthPlan

                    HMO
      Program:   STAR

                    HMO
      Service Delivery Area:  El Paso SDA

                     

                  
	
                    B.  Overarching
      Goal

                  	
                    C.  Sub
      Goals:

                  	 
      
	
                    Goal
      1:

                    Improve
      Access to Primary Care Services for Members

                     

                  	
                    90%
      of initial credentialing of PCPs will be finalized within 70 calendar days
      of receipt of application.

                    
                      
                        
                          
                             

                            The
      percentage of Family Practitioners with open panels will increase
      by 5 percentage points over
      baseline.

                          

                        

                      

                    

                     

                  	 
      
	
                    Goal
      2:

                    Improve
      Access to Behavioral Health Services for Members

                     

                  	
                    
                      
                        Increase
      Behavioral Health Urgent Care Appointment Availability by 5 percentage
      points over baseline.

                        
                          
                             

                            Increase
      Behavioral Health Routine Care Appointment Availability by 5 percentage
      points over baseline.

                          

                        

                      

                    

                     

                  	 
      
	
                    Goal
      3:

                    Increase
      Utilization of New Member Medical Check-Ups within 90 days of
      Enrollment

                     

                  	
                    
                      100%
      of new members with valid phone numbers will receive three call attempts
      within 30 days of enrollment to encourage a medical check-up within 90
      days of enrollment.

                      
                        
                           

                          100%
      of new members that did not select a valid PCP from the plan's network
      will be defaulated to a local, appropriate network PCP by the 15th of each
      month. 

                        

                      

                    

                     

                  	 
      


          

          
          

          


           

        

         

        Texas
Health and Human Services Commission 

          HMO
Performance Improvement Goal Template

          for
State Fiscal Year 2009

          (September 1, 2008 – August 31,
2009)

           

          
            	
                    A.  Health
      Plan Information

                     

                    Plan
      Name:      Superior HealthPlan

                    HMO
      Program:   STAR

                    HMO
      Service Delivery Area:  Lubbock SDA

                     

                  
	
                    B.  Overarching
      Goal

                  	
                    C.  Sub
      Goals:

                  	 
      
	
                    Goal
      1:

                    Improve
      Access to Primary Care Services for Members

                     

                  	
                    90%
      of initial credentialing of PCPs will be finalized within 70 calendar days
      of receipt of application.

                    
                      
                        
                          
                             

                            The
      percentage of Family Practitioners with open panels will increase
      by 5 percentage points over
      baseline.

                          

                        

                      

                    

                     

                  	 
      
	
                    Goal
      2:

                    Improve
      Access to Behavioral Health Services for Members

                     

                  	
                    
                      
                        Increase
      Behavioral Health Urgent Care Appointment Availability by 5 percentage
      points over baseline.

                        
                          
                             

                            Increase
      Behavioral Health Routine Care Appointment Availability by 5 percentage
      points over baseline.

                          

                        

                      

                    

                     

                  	 
      
	
                    Goal
      3:

                    Increase
      Utilization of New Member Medical Check-Ups within 90 days of
      Enrollment

                     

                  	
                    
                      100%
      of new members with valid phone numbers will receive three call attempts
      within 30 days of enrollment to encourage a medical check-up within 90
      days of enrollment.

                      
                        
                           

                          100%
      of new members that did not select a valid PCP from the plan's network
      will be defaulated to a local, appropriate network PCP by the 15th of each
      month. 

                        

                      

                    

                     

                  	 
      


          

          
          

          


           

        

         

        Texas
Health and Human Services Commission 

          HMO
Performance Improvement Goal Template

          for
State Fiscal Year 2009

          (September 1, 2008 – August 31,
2009)

           

          
            	
                    A.  Health
      Plan Information

                     

                    Plan
      Name:      Superior HealthPlan

                    HMO
      Program:   STAR

                    HMO
      Service Delivery Area:  Nueces SDA

                     

                  
	
                    B.  Overarching
      Goal

                  	
                    C.  Sub
      Goals:

                  	 
      
	
                    Goal
      1:

                    Improve
      Access to Primary Care Services for Members

                     

                  	
                    90%
      of initial credentialing of PCPs will be finalized within 70 calendar days
      of receipt of application.

                    
                      
                        
                          
                             

                            The
      percentage of Family Practitioners with open panels will increase
      by 5 percentage points over
      baseline.

                          

                        

                      

                    

                     

                  	 
      
	
                    Goal
      2:

                    Improve
      Access to Behavioral Health Services for Members

                     

                  	
                    
                      
                        Increase
      Behavioral Health Urgent Care Appointment Availability by 5 percentage
      points over baseline.

                        
                          
                             

                            Increase
      Behavioral Health Routine Care Appointment Availability by 5 percentage
      points over baseline.

                          

                        

                      

                    

                     

                  	 
      
	
                    Goal
      3:

                    Increase
      Utilization of New Member Medical Check-Ups within 90 days of
      Enrollment

                     

                  	
                    
                      100%
      of new members with valid phone numbers will receive three call attempts
      within 30 days of enrollment to encourage a medical check-up within 90
      days of enrollment.

                      
                        
                           

                          100%
      of new members that did not select a valid PCP from the plan's network
      will be defaulated to a local, appropriate network PCP by the 15th of each
      month. 

                        

                      

                    

                     

                  	 
      


          

          
          

          


           

        

        Texas
Health and Human Services Commission 

          HMO
Performance Improvement Goal Template

          for
State Fiscal Year 2009

          (September 1, 2008 – August 31,
2009)

           

          
            	
                    A.  Health
      Plan Information

                     

                    Plan
      Name:      Superior HealthPlan

                    HMO
      Program:   STAR

                    HMO
      Service Delivery Area:  Travis SDA

                     

                  
	
                    B.  Overarching
      Goal

                  	
                    C.  Sub
      Goals:

                  	 
      
	
                    Goal
      1:

                    Improve
      Access to Primary Care Services for Members

                     

                  	
                    90%
      of initial credentialing of PCPs will be finalized within 70 calendar days
      of receipt of application.

                    
                      
                        
                          
                             

                            The
      percentage of Family Practitioners with open panels will increase
      by 5 percentage points over
      baseline.

                          

                        

                      

                    

                     

                  	 
      
	
                    Goal
      2:

                    Improve
      Access to Behavioral Health Services for Members

                     

                  	
                    
                      
                        Increase
      Behavioral Health Urgent Care Appointment Availability by 5 percentage
      points over baseline.

                        
                          
                             

                            Increase
      Behavioral Health Routine Care Appointment Availability by 5 percentage
      points over baseline.

                          

                        

                      

                    

                     

                  	 
      
	
                    Goal
      3:

                    Increase
      Utilization of New Member Medical Check-Ups within 90 days of
      Enrollment

                     

                  	
                    
                      100%
      of new members with valid phone numbers will receive three call attempts
      within 30 days of enrollment to encourage a medical check-up within 90
      days of enrollment.

                      
                        
                           

                          100%
      of new members that did not select a valid PCP from the plan's network
      will be defaulated to a local, appropriate network PCP by the 15th of each
      month. 

                        

                      

                    

                     

                  	 
      


          

          
          

          


           

        

         

        Texas Health and Human Services
Commission

          HMO
Performance Improvement Goal Template

          for
State Fiscal Year 2009

          (September 1, 2008 – August 31,
2009)

           

          
            	
                    A.  Health
      Plan Information

                     

                    Plan
      Name:      Superior HealthPlan

                    HMO
      Program:   STAR+PLUS

                    HMO
      Service Delivery Area:  Bexar SDA

                     

                  
	
                    B.  Overarching
      Goal

                  	
                    C.  Sub
      Goals:

                  	 
      
	
                    Goal
      1:

                    Improve
      Access to Primary Care Services for Members

                     

                  	
                    90%
      of initial credentialing of PCPs will be finalized within 70 calendar days
      of receipt of application.

                    
                      
                        
                          
                             

                            The
      percentage of Family Practitioners with open panels will increase
      by 5 percentage points over
      baseline.

                          

                        

                      

                    

                     

                  	 
      
	
                    Goal
      2:

                    Improve
      Access to Behavioral Health Services for Members

                     

                  	
                    
                      
                        Increase
      Behavioral Health Urgent Care Appointment Availability by 5 percentage
      points over baseline.

                        
                          
                             

                            Increase
      Behavioral Health Routine Care Appointment Availability by 5 percentage
      points over baseline.

                          

                        

                      

                    

                     

                  	 
      
	
                    Goal
      3:

                    Increase
      Utilization of New Member Medical Check-Ups within 90 days of
      Enrollment

                     

                  	
                    
                      100%
      of new members with valid phone numbers will receive three call attempts
      within 30 days of enrollment to encourage a medical check-up within 90
      days of enrollment.

                      
                        
                           

                          100%
      of new members that did not select a valid PCP from the plan's network
      will be defaulated to a local, appropriate network PCP by the 15th of each
      month. 

                        

                      

                    

                     

                  	 
      


          

          
          

          


           

        

        


        

           

          Texas Health and
Human Services Commission

            HMO
Performance Improvement Goal Template

            for
State Fiscal Year 2009

            (September 1, 2008 – August 31,
2009)

             

            
              	
                      A.  Health
      Plan Information

                       

                      Plan
      Name:      Superior HealthPlan

                      HMO
      Program:   STAR+PLUS

                      HMO
      Service Delivery Area:  Nueces SDA

                       

                    
	
                      B.  Overarching
      Goal

                    	
                      C.  Sub
      Goals:

                    	 
      
	
                      Goal
      1:

                      Improve
      Access to Primary Care Services for Members

                       

                    	
                      90%
      of initial credentialing of PCPs will be finalized within 70 calendar days
      of receipt of application.

                      
                        
                          
                            
                               

                              The
      percentage of Family Practitioners with open panels will increase
      by 5 percentage points over
      baseline.

                            

                          

                        

                      

                       

                    	 
      
	
                      Goal
      2:

                      Improve
      Access to Behavioral Health Services for Members

                       

                    	
                      
                        
                          Increase
      Behavioral Health Urgent Care Appointment Availability by 5 percentage
      points over baseline.

                          
                            
                               

                              Increase
      Behavioral Health Routine Care Appointment Availability by 5 percentage
      points over baseline.

                            

                          

                        

                      

                       

                    	 
      
	
                      Goal
      3:

                      Increase
      Utilization of New Member Medical Check-Ups within 90 days of
      Enrollment

                       

                    	
                      
                        100%
      of new members with valid phone numbers will receive three call attempts
      within 30 days of enrollment to encourage a medical check-up within 90
      days of enrollment.

                        
                          
                             

                            100%
      of new members that did not select a valid PCP from the plan's network
      will be defaulated to a local, appropriate network PCP by the 15th of each
      month. 

                          

                        

                      

                       

                    	 
      


            

            
            

            


             

          

           

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        


        Subject: Attachment B-5 -
Deliverables/Liquidated Damages Matrix

        

           

          
            	
                    DOCUMENT
      HISTORY LOG

                  
	
                    STATUS1

                  	
                    DOCUMENT

                    REVISION2

                  	
                    EFFECTIVE

                    DATE

                  	
                    DESCRIPTION3

                  	 
      
	
                    Baseline

                  	
                    n/a

                  	 
      	
                    Initial
      version of Attachment B-5, Deliverables/Liquidated Damage
      Matrix.

                  	 
      
	
                    Revision

                  	
                    1.1

                  	
                    June
      30, 2006

                  	
                    Contract
      amendment did not revise Attachment B-5, Deliverables/Liquidated Damage
      Matrix.

                  	 
      
	
                    Revision

                  	
                    1.2

                  	
                    September
      1, 2006

                  	
                    Amended
      Attachment B-5, Deliverables/Liquidated Damages Matrix, to add a footnote
      clarifying the deliverable due dates.  Also amended the
      provisions regarding Claims Processing Requirements and the Reporting
      Requirements for the Claims Summary Report.

                  	 
      
	
                    Revision

                  	
                    1.3

                  	
                    September
      1, 2006

                  	
                    Amended
      Attachment B-5, Deliverables/Liquidated Damages Matrix, performance
      standard for Provider Directories for the CHIP Perinatal
      Program.

                  	 
      
	
                    Revision

                  	
                    1.4

                  	
                    September
      1, 2006

                  	
                    Contract
      amendment did not revise Attachment B-5, Deliverables/Liquidated Damage
      Matrix.

                  	 
      
	
                    Revision

                  	
                    1.5

                  	
                    January
      1, 2007

                  	
                    Contract
      amendment did not revise Attachment B-5, Deliverables/Liquidated Damage
      Matrix.

                  	 
      
	
                    Revision

                  	
                    1.6

                  	
                    February
      1, 2007

                  	
                    Contract
      amendment did not revise Attachment B-5, Deliverables/Liquidated Damage
      Matrix.

                  	 
      
	
                    Revision

                  	
                    1.7

                  	
                    July
      1, 2007

                  	
                    Amended
      Attachment B-5, Deliverables/Liquidated Damages Matrix, to add
      clarifications to the provisions addressing Claims Processing Requirements
      and the Reporting Requirements for the Claims Summary
    Report.

                  	 
      
	
                    Revision

                  	
                    1.8

                  	
                    September
      1, 2007

                  	
                    Contract
      amendment did not revise Attachment B-5, Deliverables/Liquidated Damage
      Matrix.

                  	 
      
	
                    Revision

                  	
                    1.9

                  	
                    December
      1, 2007

                  	
                    Contract
      amendment did not revise Attachment B-5, Deliverables/Liquidated Damage
      Matrix.

                  	 
      
	Revision    	1.10	March
      1, 2008 	
                    Amended
      Attachment B-5 to add or revise performance standards and liquidated
      damages
      regarding: Failure to Perform an Administrative Service; Failure to
      Provide a
      Covered Service; Behavioral Health Services Hotline; Member Services
      Hotline; and
      Provider Hotline.

                  	 
	Revision    	1.11	September
      1, 2008	
                    Amended
      Attachment B-5 to revise performance standards regarding: Line 1 – Failure
      to Perform an Administrative Service and Line 2 – Failure to Provide a
      Covered Service; and to replace the MDS-HC instrument with the Community
      Medical Necessity and Level of Care Assessment Instrument in the
      Performance Standard for Line 21 – Contract Amendment B-1 RFP §8.3.3 –
      STAR+PLUS Assessment Instruments

                  	 
	
                     

                     1  Status
      should be represented as “Baseline” for initial issuances, “Revision” for
      changes to the Baseline version, and “Cancellation” for withdrawn
      versions

                    2
      Revisions should be numbered in accordance according to the version
      of the issuance and sequential numbering of the revision—e.g., “1.2”
      refers to the first version of the document and the second
      revision.

                    3  Brief
      description of the changes to the document made in the
      revision.

                  


          

          
          

           

          
            
              
                
                  
                    
                      
                        
                          
                            
                              
                                
                                  
                                     

                                  

                                

                              

                            

                          

                        

                      

                    

                  

                

              

            

          

          
            
               

            

          

          Deliverables/Liquidated
Damages Matrix

           

          
            	
                    Service/

                    Component1

                  	
                    Performance
      Standard2

                  	
                    Measurement
      Period3

                  	
                    Measurement
      Assessment4

                  	
                    Liquidated
      Damages

                  
	
                    
                      General
      Requirement:

                      Failure
      to Perform
      an Administrative
      Service
      

                      Contract
      Attachment
      A HHSC
      Uniform Managed
      Care Contract
      Terms and
      Conditions,

                      Contract
      Attachment
      B-1 RFP
      §§ 6, 7, 8 and
      9

                    

                  	
                    
                      The
      HMO fails to timely perform an HMO Administrative Service that is not
      otherwise associated with a performance standard in this matrix and, in
      the determination of HHSC, such failure either: (1) results in actual harm
      to a Member or places a Member at risk of imminent harm, or (2) materially
      affects HHSC’s ability to administer the Program(s).

                    

                  	
                    Ongoing

                  	
                    Each
      incident of non-compliance per HMO Program and SA.

                  	
                    HHSC
      may assess up to $5,000 per calendar day for each incident of
      non-compliance per HMO Program and SA.

                  
	
                    General
      Requirement:

                    Failure to Profide a Covered Service

                    
                      Contract
      Attachment
      A HHSC
      Uniform Managed
      Care Contract
      Terms and
      Conditions,

                      Contract
      Attachment
      B-1 RFP
      §§ 6, 7, 8 and
      9

                    

                  	
                    The
      HMO fails to timely provide a HMO Covered Service that is not otherwise
      associated with a performance standard in this matrix and, in the
      determination of HHSC, such failure results in actual harm to a Member or
      places a Member at risk of imminent harm.

                  	Ongoing	Each
      calendar day of non-compliance.   	
                    HHSC
      may assess up to $7,500.00 per day for each incident of
      non-compliance.

                  
	 Contract
      Attachment
      A HHSC
      Uniform Managed
      Care Contract
      Terms and
      Conditions, Section 4.08 Subcontractors	
                    The
      HMO must notify HHSC in writing
      immediately upon making a decision
      to terminate a subcontract with
      a Material Subcontractor or upon
      receiving notification from the Material
      Subcontractor of its intent to
      terminate such subcontract.

                  	Transition,
      Measured Quarterly during the Operations Period 	 Each
      calendar day of non-compliance, per HMO Program, per
      SA..   	 HHSC
      may assess up to $5,000 per calendar day of non-compliance
  


          

          
            	
                     

                    Contract
      Attachment B-1 RFP §§ 6, 7, 8 and 9 

                     

                    Uniform Managed Care Manual

                  	All
      reports and deliverables as specified in Sections 6, 7, 8 and 9 of
      Attachment B-1 must be submitted according to the timeframes and
      requirements stated in the Contract (including all attachments) and HHSC’s
      Uniform Managed Care Manual.  (Specific Reports or deliverables
      listed separately in this matrix are subject to the specified liquidated
      damages.)  	
                    Transition
      Period, Quarterly during Operations Period

                  	
                    Each calendar day of
      non-compliance, per HMO Program, per SA.

                  	
                    HHSC
      may assess up to $250 per calendar day if the report/deliverable is late,
      inaccurate, or incomplete. 

                  
	
                    Contract
      Attachment B-1, RFP
      §7.3 --Transition
      Phase Schedule
      

                     

                    Contract
      Attachment
      B-1, RFP
      §7.3.1 -- Transition
      Phase Tasks

                     

                    Contract
      Attachment
      B-1, RFP
      §8.1 -- General
      Scope

                  	 The
      HMO must be operational no later than the agreed upon Operations
      Start Date. HHSC, or its
      agent, will determine when the HMO
      is considered to be operational
      based on the requirements
      in Section 7 and 8 of Attachment
      B-1.	Operations
      Start Date	Each calendar da of
      non-compliance, per HMO Program, per Service Area (SA).	HHSC
      may asses up to $10,000 per calendar day for each day beyond the
      Operations Start date that the HMO is not operational until the day that
      the HMO is operational, including all
systems.


          

          
            	
                    Contract
      Attachment B-1 RFP §7.3.1.5 -- Systems Readiness Review

                  	
                    The
      HMO must submit to HHSC or to the designated Readiness Review Contractor
      the following plans for review, by December 14, 2005 for STAR and CHIP,
      and by July 31, 2006 for STAR+PLUS:

                    •
      Joint Interface Plan;

                    •
      Disaster Recovery Plan;

                    •
      Business Continuity Plan;

                    •
      Risk Management Plan; and

                    - Systems Quality Assurance Plan.

                  	
                    Transition
      Period

                  	
                    Each
      calendar day of non-compliance, per report, per HMO Program, and per
      SA.

                  	
                    HHSC
      may asses up to $1,000 per calendar day for each day a deliverable is
      late, inaccurate or incomplete.

                  


          

          
            	
                    Contract
      Attachment B-1 RFP 7.3.1.7 - Operations
      Readiness

                  	
                    
                      
                        Final
      versions of the Provider Directory must be submitted to the Administrative
      Services Contractor no later than 95 days prior to the Operational Start
      Date for the CHIP, STAR, and STAR+PLUS HMOs, and no later than 30 days
      prior to the Operational Start Date for the CHIP Perinatal
      HMOs.

                      

                       

                    

                  	 Transition
      Peroid	
                    Each
      calendar day of non-compliance, per directory, per HMO Program and per
      SA.

                  	
                    HHSC
      may assess up to $1,000 per calendar day for each day the directory is
      late, inaccurate or incomplete.

                  
	
                    Contract
      Attachment B-1 RFP §8.1.4.7 -- Provider Hotline

                     

                     

                  	
                     A.
      The HMO must operate a toll-free Provider telephone hotline that Provider
      inquiries from 8 AM - 5 PM, local time for the Service Area, Monday
      through Friday, excluding State-approved holidays.

                     

                    B. Performance Standards.

                     1. Call pickup rate - At least 99% of calls are
      answered on or before the fourth ring or an automated call pick up system
      is used.

                     2. Call hold rate - The average hold time is
      two minutes or less.

                     3. Call abandonment rate - Call abandonment rate
      is 7% or less.

                  	Operations
      and Turnover	
                    A.
      Each incident of non-compliance per. HMO Program and SA.

                     

                    B. Each percentage point below the standard for 1 and 2
      and each percentage point above the standard for 3 per HMO Program and
      SA.

                  	
                    HHSC
      may assess:

                    A. Per HMO Program and SA, up to $100.00 for each hour
      or portion thereof that appropriately staffed toll-free lines are not
      operational.  If the MCO's failure to meet the performance standard
      is caused by a Force Majeure Event, HHSC will not assess liquidated
      damages unless the MCO fails to implement its Disaster Recovery
      Plan.

                     

                    B.Up to $100.00 per HMO Program and SA for each
      percentage point for each standard that the HMO fails to meet the
      requirements for a monthly reporting period for any HMO operated toll-free
      lines.

                  
	 Contract
      Attachment B-1 RFP §8.1.5.6 -- Member Services Hotline	A.
      The HMO must operate a toll-free hotline that Members can call 24 hours a
      day, seven (7) days a week. 

                     

                    B. Performance Standards.

                     1. Call pickup rate - At least 99% of calls are
      answered on or before the fourth ring or an automated call pick up system
      is used.

                     2. Call hold rate - At least 80% of calls must be
      answered by toll-free line staff within 30 seconds.

                     3. Call abandonment rate - Call abandonment rate
      is 7% or less.

                  	 Ongoing
      during Operations Turnover	 
      

                    A.
      Each incident of non-compliance per. HMO Program and SA.

                     

                    B. Each percentage point below the standard for 1 and 2
      and each percentage point above the standard for 3 per HMO Program and
      SA.

                  	 
      

                    HHSC
      may assess:

                    A. Per HMO Program and SA, up to $100.00 for each hour
      or portion thereof that toll-free lines are not operational.  If the
      MCO's failure to meet the performance standard is caused by a Force
      Majeure Event, HHSC will not assess liquidated damages unless the MCO
      fails to implement its Disaster Recovery Plan.

                     

                    B. Per HMO Program and SA, up to $100.00 for each
      percentage point for each standard that the HMO fails to meet the
      requirements for a monthly reporting period for any HMO operated toll-free
      lines.

                  


          

          
            	
                    Contract
      Attachment B-1 RFP §8.1.5.9 -- Member Complaint and Appeal
      Process

                     

                    Contract Attachment B-1 RFP §8.2.7.1 -- Member Complaint
      Process

                     

                    Contract
      Attachment B-1 RFP §8.4.3 – CHIP Member Complaint and Appeal
      Process

                  	
                    The
      HMO must resolve at least 98% of Member Complaints within 30 calendar days
      from the date the Complaint is received by the HMO.
 	Measured
      Quarterly during the Operations Period 	 Per
      reporting period, per HMO Program, per SA.	 HHSC
      may assess up to $250 per reporting period if the HMO fails to meet the
      performance standard.


          

          
            	
                    Contract
      Attachment B-1 RFP §8.1.5.9 -- Member Complaint and Appeal
      Process

                     

                    Contract Attachment B-1 RFP §8.2.7.2 -- Mediciad
      Standard Member Appeal Process

                     

                    Contract
      Attachment B-1 RFP §8.4.3 – CHIP Member Complaint and Appeal Process

                  	The HMO must
      resolve at least 98% of Member Appeals within 30 calendar days from
      the date the Appeal is filed with the HMO. 	Measured
      Quarterly during the Operations Period 	Per
      reporting peorid, per HMO Program, per SA. 	HHSC
      may assess up to $500 per reporting period if the HMO fails to meet
      the performance standard. 


          

          	
                  Contract
      Attachment B-1 RFP §8.1.6 -- Marketing & Prohibited
      Practices

                   

                  Uniform Managed Care Manual

                	The
      HMO may not engage in prohobited marketing practices.	
                  Transition,
      Measured Quarterly during the Operations Period

                	
                  Per
      incident of non-compliance.

                	
                  HHSC
      may assess up to $1,000 per incident of non-compliance.

                
	 Contract
      Attachment B-1 RFP §8.1.15.3 -- Behavioral Health services
    Hotline	
                   A.
      The HMO must have an emergency and crisis Behavioral Health services
      Hotline available 24 hours a day, seven (7) days a week, toll-free
      throught the Service Area(s).
      

                   

                  B. Crisis hotline staff must
      include

                  or have access to qualified Behavioral
      Health Service professionals to assess behavioral health
      emergencies.

                   

                  C.  The HMO must ensure that the toll-free
      Behavioral Health Services Hotline meets the following minimum
      requiremetns for the HMO Program:

                   1. Call pickup rate - At least 99% of calls are
      answered on or before the fourth ring or an automated call pick up
      system.

                   2. Call hold rate - At least 80% of calls must be
      answered by toll-free line staff within 30 seconds.

                   3. Call abandonment rate - Call abandonment rate
      is 7% or less.

                	 Operations
      and Turnover	
                  A.
      Each incident of non-compliance per HMO Program and SA.

                   

                  B. Each incident of non-compliance per HMO Program and
      SA.

                   

                  C. Per HMO Program and SA, per month, each percentage
      point below the standard for 1 and 2 and each percentage point above the
      standard for 3.

                	 
      

                  HHSC
      may assess:

                   

                  A. Up to $100.00 for each hour or portion thereof that
      appropriately staffed toll-free lines are not operational.  If the
      MCO's failure to meet the performance standard is caused by a Force
      Majeure Event, HHSC will not assess liquidated damages unless the MCO
      fails to implement its Disaster Recovery Plan.

                   

                  B. Up to $100.00 per incident for each occurence that HHSC identifies
      through its recurring monitoring process that toll-free line staff were
      not qualified or did not have access to qualified professionals to assess
      behavioral health emergencies.  

                   

                  C.Up to $100.00 for each percentage point for each
      standard that the HMO fails to meet the requirements for a monthly
      reporting period for any HMO operated toll-free
  lines.

                


           

          
            	
                    Contract
      Attachment B-1 RFP §8.1.17.2 --Financial Reporting
      Requirements

                     

                    Uniform Managed Care Manual - Chapter
      5

                     

                     

                  	
                    
                      Financial
      Statistical Reports (FSR):

                       

                      For
      each HMO Program and SA, the HMO must file quarterly and annual
      FSRs.  Quarterly reports are due no later than 30 days after the
      conclusion of each State Fiscal Quarter (SFQ).  The first annual
      report is due no later than 120 days after the end of each Contract Year
      and the second annual report is due no later than 365 days after the end
      of each Contract Year.

                    

                     

                  	
                    Quarterly
      during the Operations Period

                  	
                    Per
      calendar day of non-compliance, per HMO Program, per SA.

                  	
                    
                      HHSC
      may assess up to $1,000 per calendar day, a quarterly or
      annual report is late, inaccurate or
      incomplete.

                    

                  


          

          
            	
                    Contract
      Attachment B-1 RFP §8.1.17.2 -- Financial Reporting
      Requirements:

                     

                    Uniform Managed Care Manual - Chapter
      5

                  	
                    Medicaid
      Disproportionate Share Hospital (DSH) Reports:  The
      Medicaid HMO must submit, on an annual basis, preliminary and final DSH
      Reports.  The Preliminary report is due no later than June
      1st  after
      each reporting year, and the final
      report is due no later than July 15th after
      each reporting year.

                     

                    This
      standard does not apply to CHIP HMOs.
  	
                    Measured
      during 4th Quarter of the Operations Period (6/1 - 8/31)

                  	
                    
                      Per
      calendar day of non-compliance per HMO Program, per
    SA.

                    

                  	
                    HHSC
      may assess up to $1,000 per calendar day, per program, per service area,
      for each day the report is late, incorrect, inaccurate or
      incomplete

                  


          

          
            	
                    Contract
      Attachment B-1 RFP §8.1.18 – Management Information System (MIS)
      Requirements

                     

                  	The
      HMO’s MIS must be able to resume operations within 72 hours of employing
      its Disaster Recovery Plan.  	
                    Measured
      Quarterly during the Operations Period    

                  	
                    Per
      calendar day of non-compliance per HMO Program, per SA.

                  	
                    HHSC
      may assess up to $5,000 per calendar day of
  non-compliance

                  


          

          
            	
                    
                      Contract
      Attachment B-1 RFP §8.1.18.3 – Management Information System (MIS)
      Requirements: System-Wide Functions

                    

                  	
                    The
      HMO’s MIS system must meet all requirements in Section 8.1.18.3 of
      Attachment B-1.

                  	Measured
      Quarterly during the Operations Period	
                    
                      Per
      calendar day of non-compliance per HMO Program, per
    SA.

                    

                  	
                    HHSC
      may assess up to $5,000 per calendar day of
  non-compliance.

                  


          

          
            	
                    Contract
      Attachment B-1 RFP §8.1.18.5 -- Claims Processing
Requirements

                     

                    Unifrom Managed Care Manual Chapter
      2

                     

                  	
                    
                      The
      HMO must adjudicate all provider Clean Claims within 30 days of receipt by
      the HMO.  The HMO must pay providers interest at an 18% per
      annum, calculated daily for the full period in which the
Clean

                      Claim
      remains unadjudicated beyond the 30-day claims processing
      deadline.   Interest owed the provider must be paid on the
      same date that the claim is adjudicated.

                    

                     

                  	 Measured
      Quarterly during the Operations Period	
                    
                      Per
      incident of non-compliance.

                    

                  	
                    HHSC
      may assess up to $1,000 per claim if the HMO fails to timely pay
      interest.

                  
	
                    
                      Contract
      Attachment B-1 RFP §8.1.18.5 -- Claims Processing
Requirements

                       

                      Unifrom Managed Care Manual - Chapter 2

                    

                  	
                    
                      The
      HMO must comply with the claims processing requirements and standards as
      described in Section 8.1.18.5 of Attachment B-1 and in Chapter 2 of the
      Uniform Managed Care Manual.

                    

                  	Measured
      Quarterly during the Operations Period  	
                    Per
      quarterly reporting period, per HMO Program, per Service Area, per claim
      type.

                  	
                    HHSC
      may assess liquidated damages of up to $5,000 for the first quarter that
      an HMO’s Claims Performance percentages by claim type, by Program, and by
      service area, fall below the performance standards.  HHSC may
      assess up to $25,000 per quarter for each additional quarter that the
      Claims Performance percentages by claim type, by Program, and by service
      area, fall below the performance standards.

                  
	
                    Contract
      Attachment B-1 RFP §8.1.20.2-- Reporting Requirements

                     

                    Uniform Managed Care Manual Chapters 2 and
    5

                  	
                    Claims
      Summary Report:

                    The
      HMO must submit quarterly, Claims Summary Reports to HHSC by HMO Program,
      by Service Area, and by claim type, by the 30th
      day following the reporting period unless otherwise
    specified.

                  	Measured
      Quarterly during the Operations Period 	Per
      calendar day of non-compliance, per HMO Program, Service Area, per claim
      type.	
                    HHSC
      may assess up to $1,000 per calendar day the report is late, inaccurate,
      or incomplete.

                  


          

          
            	
                    Contract
      Attachment B-1 RFP §8.3.3 – STAR+PLUS Assessment
      Instruments  

                     

                    Uniform
      Managed
      Care Manual

                  	
                    
                      The
      Community Medical Necessity and Level of Care Assessment Instrument must
      be completed and electronically submitted to HHSC in the specified format
      within 30 days of enrollment for every Member receiving Community-based
      Long-term Care Services, and then each year by the anniversary of the
      Member’s date of enrollment.

                    

                  	Operations,
      Turnover	 Per
      calendar day of non-compliance, per Service Area.	
                    HHSC
      may assess up to $500 per calendar day per Service Area, for each day a
      report is late, inaccurate or
incomplete. 

                  


          

          
            	Contract
      Attachment B-1 RFP §9.2 -- Transfer of Data	The
      HMO must transfer all data regarding the provision of Covered Services to
      Members to HHSC or a new HMO, at the sole discrection of HHSC and as
      directed by HHSC.  All transferred data must comply with the Contract
      requirements, including HIPAA. 	Measured
      at Time of Transfer of Data and ongoing after the Transfer of Data until
      satisfactorily completed	Per
      incident of non-compliance (failure to provide data and/or failure to
      provide data in required format), per HMO Program, per SA.	HHSC may assess up to $10,000 per calendar day the data is late,
      inaccurate or incomplete.
	Contract
      Attachment B-1 RFP §9.3 -- Turnover Services	 Six
      months prior to the end of the contract period or any extension thereof,
      the HMO must propose a Turnover Plan covering the possible turnover of the
      records and information maintained to either the State (HHSC) or a
      successor HMO.	 Measured
      at Six Months prior to the end of the contract period or any extension
      thereof and ongoing until satisfactorily completed	 Each
      calendar day of non-compliance per HMO Program, per SA.	
                    HHSC
      may assess up to $1,000 per calendar day the Plan is late, inaccurate, or
      incomplete.
 
	Contract
      Attachment B-1 RFP §9.4-- Post-Turnover Services	 The
      HMO must provide the State (HHSC) with a Turnover Results report
      documenting the completion and results of each step of the Turnover Plan
      30 days after the Turnover of Operations.	Measured
      30 days after the Turnover of Operations 	 Each
      calendar day of non-compliance per HMO Program, per SA.	HHSC
      may assess up to $250 per calendar day the report is late, inaccurate or
      incomplete. 


          

           

           

           

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        


        


        

        
 

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        
 

        
 

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        


         

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

    

    


    Subject: Attachment B-7 -
STAR+PLUS Attendant Care Enhanced Payments Methodology


    
      
        	
                DOCUMENT
      HISTORY LOG

              
	
                STATUS1

              	
                DOCUMENT

                REVISION2

              	
                EFFECTIVE

                DATE

              	
                DESCRIPTION3

              
	
                Baseline

              	
                n/a

              	
                January
      1, 2007

              	
                Initial
      version of Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments
      Methodology, was incorporated into Version 1.5 of the
      Contract.

              
	
                Revision

              	
                1.6

              	
                February
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced
      Payments Methodology.

              
	
                Revision

              	
                1.7

              	
                July
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced
      Payments Methodology.

              
	
                Revision

              	
                1.8

              	
                September
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced
      Payments Methodology.

              
	
                Revision

              	
                1.9

              	
                December
      1, 2007

              	
                Contract
      amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced
      Payments Methodology.

              
	Revision    	1.10	March
      1, 2008	
                Contract
      amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced
      Payments Methodology.

              
	Revision	1.11	September
      , 2008	
                Contract
      amendment did not revise Attachment B-7, STAR+PLUS Attendant Care Enhanced
      Payments Methodology.

              
	
                1
      Status should be represented as “Baseline” for initial issuances,
      “Revision” for changes to the Baseline version, and “Cancellation” for
      withdrawn versions

                2
      Revisions should be numbered in accordance according to the version
      of the issuance and sequential numbering of the revision—e.g., “1.2”
      refers to the first version of the document and the second
      revision.

                3
      Brief description of the changes to the document made in the
      revision.

              


      

       

      ATTACHMENT
B-7: STAR+PLUS ATTENDANT CARE ENHANCED PAYMENTS METHODOLOGY

       

       

      HMO: Superior Health Plan

       

       

      SERVICE
AREA(S): Bexar & Nueces

       

      
        	
                I.
      Provider Contracting

              	
                (a)
      Description of criteria the HMO will use to allow participation in the
      STAR+PLUS Attendant Care Enhanced Payments. Will the HMO have a enrollment
      period that corresponds to the DADS enrollment period to allow new
      providers to participate in the HMO's Attendant Care Enhanced Payments, or
      will the HMO have it's own enrollment period that is separate and not tied
      to the DADS enrollment?

                (b)
      Description of any limitations or restrictions.

              	 
      	 
      
	 
      	 
      
	 
      	
                Superior
      HealthPlan will only allow those providers that are currently
      participating in the DADS Attendant Compensation Rate Enhancements to
      participate in the STAR+PLUS Attendant Care Enhanced Payments. SHP will
      have an enrollment period corresponding to the DADS enrollment period to
      allow new providers to participate in the SHP Attendant Care Enhanced
      Payments.

              	 
      	 
      
	
                II.
      Payment for STAR+PLUS Attendant Care Enhanced Payments

              	
                Description
      of methodology the HMO will use to pay for the Attendant Care Enhanced
      Payments. Provide sufficient detail to fully explain the planned
      methodology.

              	 
      	 
      
	 
      	
                Superior
      will not use the DADS rates. SHP will establish an additional amount to be
      added on to the unit rate by type of service.

              	 
      	 
      
	
                III.
      Timing of the Attendant Care Enhanced Payments

              	
                Description
      of when the payments will be made to the Providers and the frequency of
      payments. Also include timeframes for Providers complaints and appeals
      regarding enhanced payments.

              	 
      	 
      
	 
      	
                The
      enhanced rate payment amount will be paid at the time of claims payment so
      the frequency will depend on the frequency with which providers file their
      claims. Provider complaints and appeals will be handled through the normal
      complaint and appeal process and finalized within 30 days from
      receipt.

              	 
      	 
      
	
                IV.
      Assurances from Participating Providers

              	
                Description of how the HMO will
      ensure that the participating Providers are using the enhancement funds to
      compensate direct care workers as intended by the 2000-01 General
      Appropriations Act (Rider 27, House Bill 1, 76th
      Legislature, Regular Session, 1999) and by T.A.C. Title 1, Part 15,
      Chapter 355.

              	 
      	 
      
	 
      	
                Participating
      Providers will be required by contract to complete and submit an affidavit
      annually stating they applied the enhancement funds to the compensation
      for direct care staff. Compensation may include increased hourly rates,
      bonuses, paid holidays or additional benefits such as employer paid
      insurance.

              	 
      	 
      
	
                V.
      Monitoring of Attendant Care Enhanced Payments

              	
                Explanation
      of the Monitoring Process that the HMO will use to monitor whether the
      Attendant Care Enhanced Payments are used for the purposes intended by the
      Texas Legislature.

              	 
      	 
      
	 
      	
                Each
      Provider’s compliance with the attendant compensation spending requirement
      for the reporting period will be monitored on an annual basis via the
      submission of the affidavit stating they applied the enhancement funds to
      the compensation for direct care staff. Compensation may include increased
      hourly rates, bonuses, paid holidays or additional benefits such as
      employer paid insurance. In addition, providers may be audited on as
      as-needed basis to ensure financial records support the pass through of
      the enhanced funds. Enhanced payments could potentially be recouped for
      those Providers who fail to pass the funds to their direct care
      staff.

              	 
      	 
      


      

      


       

      By
signing the Contract and/or Contract Amendment, HMO certifies that the approved
STAR+PLUS Attendant Care Enhanced Payments Methodology described herein is the
methodology the HMO will use to make the legislatively mandated payments to its
Long Term Services and Support (LTSS) Providers participating in the Attendant
Care Enhanced Payments.

       

       

      Additional
information related to the Attendant Care Enhanced Payments can be found in
Attachment B-1, Section 8.3.7.3 of the Contract.