##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 
 Texas Health & Human Service Commission
 Version 1.4




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms & Conditions
    
    Version 1.4
 DOCUMENT HISTORY LOG
 DOCUMENT
    
    EFFECTIVESTATUS'
    
    REVISION
    
    DATE
    
    DESCRIPTION3Baseline
    
    n/a
    
    
    
    Initial version of the Uniform Managed Care Contract
Terms & ConditionsRevision
    
    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 MembersArticle 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




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 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
Perintal 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
 
 Status should be represented as Baseline for initial issuances, Revision for changes to the Baseline version, and
Cancellation for withdrawn versions2
    
    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.
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 1.4
 TABLE OF CONTENTS
 Article 1. Introduction
    
    
    2Section 1.01 Purpose
    
    
    2Section 1.02 Risk-based contract
    
    
    2Section 1.03 Inducements
    
    
    2Section 1.04 Construction of the Contract
    
    
    2Section 1.05 No implied authority
    
    
    3Section 1.06 Legal Authority
    
    
    3Article 2. Definitions
    
    
    3Article 3. General Terms & Conditions
    
    
    15Section 3.01 Contract elements
    
    
    15Section 3.02 Term of the Contract
    
    
    15Section 3.03 Funding
    
    
    15Section 3.04 Delegation of authority
    
    
    15Section 3.05 No waiver of sovereign immunity
    
    
    15Section 3.06 Force majeure
    
    
    15Section 3.07 Publicity
    
    
    15Section 3.08 Assignment
    
    
    16Section 3.09 Cooperation with other vendors and prospective vendors
    
    
    16Section 3.10 Renegotiation and reprocurement rights
    
    
    16Section 3.11 RFP errors and omissions
    
    
    16Section 3.12 Attorneys fees
    
    
    16Section 3.13 Preferences under service contracts
    
    
    16Section 3.14 Time of the essence
    
    
    16Section 3.15 Notice
    
    
    17Article 4. Contract Administration & Management
    
    
    17Section 4.01 Qualifications, retention and replacement of HMO employees
    
    
    17Section 4.02 HMOs Key Personnel
    
    
    17Section 4.03 Executive Director
    
    
    17Section 4.04 Medical Director
    
    
    18Section 4.04.1 STAR+PLUS Service Coordinator
    
    
    18Section 4.05 Responsibility for HMO personnel and Subcontractors
    
    
    18Section 4.06 Cooperation with HHSC and state administrative agencies
    
    
    19Section 4.07 Conduct of HMO personnel
    
    
    19Section 4.08 Subcontractors
    
    
    20Section 4.09 HHSCs ability to contract with Subcontractors
    
    
    21Section 4.10 HMO Agreements with Third Parties
    
    
    21Article 5. Member Eligibility& Enrollment
    
    
    21Section 5.01 Eligibility Determination
    
    
    21Section 5.02 Member Enrollment & Disenrollment
    
    
    21Section 5.03 STAR enrollment for pregnant women and infants
    
    
    22Section 5.04 CHIP eligibility and enrollment
    
    
    22Section 5.04.1 CHIP Perinatal eligibility, enrollment and disenrollment
    
    
    22Section 5.05 Span of Coverage
    
    
    23Section 5.06 Verification of Member Eligibility
    
    
    23Section 5.07 Special Temporary STAR Default Process
    
    
    23Article 6. Service Levels& Performance Measurement
    
    
    23Section 6.01 Performance measurement
    
    
    23




---



##### 



Article 7. Governing Law & Regulations
    
    
    24Section 7.01 Governing law and venue
    
    
    24Section 7.02 HMO responsibility for compliance with laws and regulations
    
    
    24Section 7.03 TDI licensure/ANHC certification and solvency
    
    
    24Section 7.04 Immigration Reform and Control Act of 1986
    
    
    25Section 7.05 Compliance with state and federal anti-discrimination laws
    
    
    25Section 7.06 Environmental protection laws
    
    
    25Section 7.07 HIPAA
    
    
    25Article 8. Amendments & Modifications
    
    
    25Section 8.01 Mutual agreement
    
    
    25Section 8.02 Changes in law or contract
    
    
    25Section 8.03 Modifications as a remedy
    
    
    25Section 8.04 Modifications upon renewal or extension of Contract
    
    
    26Section 8.05 Modification of HHSC Uniform Managed Care Manual
    
    
    26Section 8.06 CMS approval of Medicaid amendments
    
    
    26Section 8.07 Required compliance with amendment and modification procedures
    
    
    26Article 9. Audit & Financial Compliance
    
    
    26Section 9.01 Financial record retention and audit
    
    
    26Section 9.02 Access to records, books, and documents
    
    
    26Section 9.03 Audits of Services, Deliverables and inspections
    
    
    27Section 9.04 SAO Audit
    
    
    27Section 9.05 Response/compliance with audit or inspection findings
    
    
    27Article 10. Terms& Conditions of Payment
    
    
    28Section 10.01 Calculation of monthly Capitation Payment
    
    
    28Section 10.02 Time and Manner of Payment
    
    
    28Section 10.03 Certification of Capitation Rates
    
    
    28Section 10.04 Modification of Capitation Rates
    
    
    28Section 10.05 STAR Capitation Structure
    
    
    28Section 10.05.1STAR+PLUS Capitation Structure
    
    
    29Section 10.06 CHIP Capitation Rates Structure
    
    
    29Section 10.06.01 CHIP Perinatal Program Capitation Structure
    
    
    30Section 10.07 HMO input during rate setting process
    
    
    30Section 10.08 Adjustments to Capitation Payments
    
    
    30Section 10.09 Delivery Supplemental Payment for CHIP, CHIP Perinatal and STAR HMOs
    
    
    31Section 10.10 Administrative Fee for SSI Members
    
    
    31Section 10.11 STAR, CHIP, and CHIP Perinatalal Experience Rebate
    
    
    32Section 10.11.1 STAR+PLUS Experience Rebate
    
    
    33Section 10.12 Payment by Members
    
    
    34Section 10.13 Restriction on assignment of fees
    
    
    34Section 10.14 Liability for taxes
    
    
    34Section 10.15 Liability for employment-related charges and benefits
    
    
    34Section 10.16 No additional consideration
    
    
    35Section 10.17 Federal Disallowance
    
    
    35Article 11. Disclosure & Confidentiality of Information
    
    
    35Section 11.01 Confidentiality
    
    
    35Section 11.02 Disclosure of HHSCs Confidential Information
    
    
    35Section 11.03 Member Records
    
    
    36Section 11.04 Requests for public information
    
    
    36Section 11.05 Privileged Work Product
    
    
    36Section 11.06 Unauthorized acts
    
    
    36Section 11.07 Legal action
    
    
    37Article 12. Remedies& Disputes
    
    
    37Section 12.01 Understanding and expectations
    
    
    37Section 12.02 Tailored remedies
    
    
    37Section 12.03 Termination by HHSC
    
    
    39Section 12.04 Termination by HMO
    
    
    41




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 Section 12.05 Termination by mutual agreement
    
    
    41Section 12.06 Effective date of termination
    
    
    41Section 12.07 Extension of termination effective date
    
    
    41Section 12.08 Payment and other provisions at Contract termination
    
    
    41Section 12.09 Modification of Contract in the event of remedies
    
    
    41Section 12.10 Turnover assistance
    
    
    41Section 12.11 Rights upon termination or expiration of Contract
    
    
    42Section 12.12 HMO responsibility for associated costs
    
    
    42Section 12.13 Dispute resolution
    
    
    42Section 12.14 Liability of HMO
    
    
    42Article 13. Assurances& Certifications
    
    
    43Section 13.01 Proposal certifications
    
    
    43Section 13.02 Conflicts of interest
    
    
    43Section 13.03 Organizational conflicts of interest:
    
    
    43Section 13.04 HHSC personnel recruitment prohibition
    
    
    44Section 13.05 Anti-kickback provision
    
    
    44Section 13.06 Debt or back taxes owed to State of Texas
    
    
    44Section 13.07 Certification regarding status of license, certificate, or permit
    
    
    44Section 13.08 Outstanding debts and judgments
    
    
    44Article 14. Representations& Warranties
    
    
    44Section 14.01 Authorization
    
    
    44Section 14.02 Ability to perform
    
    
    44Section 14.03 Minimum Net Worth
    
    
    44Section 14.04 Insurer solvency
    
    
    44Section 14.05 Workmanship and performance
    
    
    45Section 14.06 Warranty of deliverables
    
    
    45Section 14.07 Compliance with Contract
    
    
    45Section 14.08 Technology Access
    
    
    45Article 15. Intellectual Property
    
    
    45Section 15.01 Infringement and misappropriation
    
    
    45Section 15.02 Exceptions
    
    
    46Section 15.03 Ownership and Licenses
    
    
    46Article 16. Liability
    
    
    47Section 16.01 Property damage
    
    
    47Section 16.02 Risk of Loss
    
    
    47Section 16.03 Limitation of HHSCs Liability
    
    
    47Article 17. Insurance& Bonding
    
    
    47Section 17.01 Insurance Coverage
    
    
    47Section 17.02 Performance Bond
    
    
    48Section 17.03 TDI Fidelity Bond
    
    
    49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 Article 1. Introduction
 Section 1.01 Purpose.
  Section 1.02 Risk-based contract .
  Section 1.03 Inducements.
        Section 1.04 Construction of the Contract .
                 Page 2 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 Section 1.05 No implied authority.
      Section 1.06 Legal Authority.
   Article 2. Definitions
  1915(c)Nursing Facility Waiver
 Abuse
 Account Name
 Action (Medicaid only) means:
        Acute Care
 Acute Care Hospital
 Adjudicate
 Administrative Services
 Administrative Services Contractor
 Adverse Determination
 Affiliate
 Agreement or Contract
 Allowable Expenses
 Page 3 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 AAP
 Approved Non-Profit Health Corporation (ANHC) HMO.
 Appeal (Medicaid only)
 Appeal (CHIP and CHIP Perinatal Program only)
 Auxiliary Aids and Services
    Behavioral Health Services
 Benchmark
 Business Continuity Plan or BCP
 Business Day
 CAHPS
 Call Coverage
 Capitation Rate
 Capitation Payment
 Case Head
 C.F.R.
 Chemical Dependency Treatment means
 Childrens Health Insurance Program CHIP
 Child (or Children) with Special Health Care Needs (CSHCN)
      CHIP HMO Program, or CHIP Program,
 CHIP HMOs
 CHIP Perinatal HMOs
 CHIP Perinatal Program
 Page 4 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
  CHIP Perinate
 CHIP Perinate Newborn
 Chronic or Complex Condition
 Clean Claim
 CMS
 COLA
 Community-based Long Term Care Services
 Community Resource Coordination Groups CRCGs
 Complainant
 Complaint (CHIP and CHIP Perinatal Programs only)
 Complaint (Medicaid only)
 Complex Need
 Comprehensive Care Program:
 Confidential Information
  
     Consumer-Directed Services
 Page 5 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
  Continuity of Care
 Contract Agreement
 Contract Period Contract Term
 Contractor HMO
 Core Service Area (CSA)
 Co-payment (CHIP only)
 Corrective Action Plan
 Court-Ordered Commitment
 Covered Services Attachments B-2, B-2.1, B-2.2 and B-3 HHSC Managed Care Contract
 Credentialing
 Cultural Competency
 Date of Disenrollment
 Day
 Default Enrollment
 Deliverable
 Delivery Supplemental Payment
 DADS
 DSHS
 Disease Management
 Disproportionate Share Hospital (DSH) means
 Disabled Person or Person with Disability
 Disability
 Disability-related Access
 Disaster Recovery Plan
 Page 6 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition,
 Dual Eligibles
 seq.
 EDI
 Effective Date
 Effective Date of Coverage
 Eligibles
 Emergency Behavioral Health Condition
   Emergency Services
 Emergency Medical Condition
 
     Encounter
 Encounter Data
 Enrollment Report/Enrollment File
 EPSDT
 Exclusive Provider Organization (EPO)
 Expansion Area
 Expansion Children
 Experience Rebate
 Expedited Appeal
 Expiration Date
 External Quality Review Organization (EQRO)
 Fair Hearing
 Page 7 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
  Fee-for-Service
 Force Majeure Event
 FQHC
 FPL
 Fraud
 FSR
 Functionally Necessary Covered Services
 Habilitative and Rehabilitative Services Attachment B-2
 Health Care Services
 Health and Human Services Commission HHSC
 Health-related Materials
 HEDIS.
 HHS Agency
 HHSC Administrative Services Contractor (ASC)
 HHSC HMO Programs or HMO Programs
 HHSC Uniform Managed Care Manual
 HIPAA
 HMO Contractor
   HMO Administrative Services
 HMOs Service Area
 Home and Community Support Services Agency or HCSS
 Page 8 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
  Hospital
 ICF-MR
 Individual Family Service Plan (IFSP) means
 Initial Contract Period
 Inpatient Stay
 JCAHO
 Joint Interface Plan (JIP)
 Key HMO Personnel Article 4.
 Linguistic Access
 Local Health Department
 Local Mental Health Authority (LMHA) means
 Major Population Group
 Material Subcontractor Major Subcontractor
 Mandated or Required Services means
 Marketing
   Marketing Materials
 MCO
 Medicaid
 Medicaid HMOs
 Medical Assistance Only (MAO) means a
 Medical Home
 Medically Necessary
    Page 9 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
              Member
     Member Materials
 Member Month
 Member(s) with Special Health Care Needs (MSHCN)
   Minimum Data Set for Home Care (MDS-HC) Uniform Managed Care Manual
  National Committee for Quality Assurance (NCQA)
 Net Income before Taxes
 Network or Provider Network
 Network Provider or Provider
 Non-capitated Services
 Non-provider Subcontracts
 Page 10 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 Nursing Facility Cost Ceiling
 Nursing Facility Level of Care
 OB/GYN
 Open Panel
 Operational Start Date HHSC
Managed Care Contract
 Optional Service Area (OSA) HHSC Managed Care Contract
 Operations Phase
 Outpatient Hospital Services
 Out-of-Network (OON)
 Parties Party
 Pended Claim
 Population Risk Group
 Post-stabilization Care Services means
 Primary Care Physician or Primary Care Provider (PCP)
  Proposal
 Provider or Network Provider
 Provider Contract
 Provider Network or Network
 Proxy Claim Form
 Public Health Entity
 Page 11 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 Public Information
   Qualified and Disabled Working Individual (QDWI)
 Qualified Medicare Beneficiary (QM)
 Quality Improvement
 Rate Cell
 Rate Period 1
 Rate Period 2
 Real-Time Captioning
 Readiness Review
 Request for Proposals RFP
 Revenue
 Risk
 Routine Care
 Rural Health Clinic (RHC)
 Service Coordination
      Service Coordinator
 Scope of Work
 SDX
 SED
 Service Area
 Service Management
 Page 12 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 Service Plan (SP)
        Services
 Significant Traditional Provider or STP (for Medicaid)
 Significant Traditional Provider or STP (for CHIP)
 Skilled Nursing Facility Services (CHIP only)
 Software
 SPMI
 Specialty Hospital
 Specialty Therapy
 Specified Low-Income Medicare Beneficiary (SLMB)
 SSA
 SSI AdministrativeFee
 Stabilize
 STAR+PLUS or STAR+PLUS Program
 STAR+PLUS HMOs
 State Fiscal Year (SFY)
 Subcontract
 Subcontractor
 Subsidiary
 Supplemental Security Income (SSI)
 T.A.C.
   Temporary Assistance to Needy Families (TANF)
 Texas Health Network(THN)
 Page 13 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 Texas Health Steps (THSteps)
 Texas Medicaid Bulletin
 Texas Medicaid Provider Procedures Manual
 Texas Medicaid Service Delivery Guide
 Third Party Liability (TPL) seq.,
 Third Party Recovery (TPR)
 TP 40
 TP 45
 Transition Phase
 Turnover Phase
 Turnover Plan
    URAC /American Accreditation Health Care Commission
 Urgent Behavioral Health Situation
 Urgent Condition
 Utilization Review
 Value-added Services
 Waste
 Page 14 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 Article 3. General Terms & Conditions
 Section 3.01 Contract elements.
     HHSC Managed Care Contract
 Attachment A 
 Attachment B 
 HHSC Uniform Managed Care Manual,
 Attachment C-3 
 Attachment C-2,
 Attachment C-1 
 Section 3.02 Term of the Contract.
  Section 3.03 Funding.
 12
 Section 3.04 Delegation of authority.
  Section 3.05 No waiver of sovereign immunity.
  Section 3.06 Force majeure.
  Section 3.07 Publicity.
   Page 15 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
       the Uniform Managed Care Manuals
 Section 3.08 Assignment.
       Section 3.09 Cooperation with other vendors and prospective vendors.
  Section 3.10 Renegotiation and reprocurement rights.
  8.
    Article 12
 Section 3.11 RFP errors and omissions.
  Section 3.12 Attorneys fees.
  Section 3.13 Preferences under service contracts.
  Section 3.14 Time of the essence.
  Page 16 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 Section 3.15 Notice
      HHSC Managed
Care Contract HHSC Managed Care Contract
  Article 4. Contract Administration & Management
 Section 4.01 Qualifications, retention and replacement of HMO employees.
  Section 4.02 HMOs Key Personnel.
            Section 4.03
 Section 4.04
 Section 4.04.1
  
   Section 4.03 Executive Director.
   Page 17 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
         Section 4.04 Medical Director.
    Section 4.04.1 STAR+PLUS Service Coordinator
    Services.
 Section 4.05 Responsibility for HMO personnel and Subcontractors.
   Page 18 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
       &
  Section4.06 Cooperation with HHSC and state administrative agencies.
        Section 4.07 Conduct of HMO personnel.
         Page 19 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
    Section 4.08 Subcontractors.
               Attachment B-1, Section
       Page 20 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 HHSC
Uniform Managed Care Manual.
  Section 4.09 HHSCs ability to contract with Subcontractors.
  Section 4.10 HMO Agreements with Third Parties
    Article 9.
   Article 5. Member Eligibility & Enrollment Section 5.01 Eligibility Determination
  Section 5.02 Member Enrollment & Disenrollment.
         Page 21 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
        Section 5.03 STAR enrollment for pregnant women and infants.
   Section 5.04 CHIP eligibility and enrollment.
      Section 5.04.1 CHIP Perinatal eligibility, enrollment, and disenrollment
    Page 22 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
   Section 5.05 Span of Coverage
    
 
  Section 5.06 Verification of Member Eligibility.
  Section 5.07 Special Temporary STAR Default Process
      Article 6. Service Levels & Performance Measurement
 Section 6.01 Performance measurement.
    9
 Page 23 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
   Governing Law & Regulations
 Section 7.01 Governing law and venue.
 Section 12.13
 Section 7.02 HMO responsibility for compliance with laws and regulations.
             Section 7.03 TDI licensure/ANHC certification and solvency.
      Page 24 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
     Section 7.04 Immigration Reform and Control Act of 1986.
 et seq.)
 Section 7.05 Compliance with state and federal anti-discrimination laws.
  Section 7.06 Environmental protection laws.
            Section7.07 HIPAA.
  Article 8. Amendments Modifications Section 8.01 Mutual agreement.
  Section 8.02 Changes in law or contract.
 
 Section 8.03 Modifications as a remedy.
 Article 12 (
 Page 25 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 Section 8.04 Modifications upon renewal or extension of Contract.
   Section 8.05 Modification of HHSC Uniform Managed Care Manual.
  Article 12
 Section 12. 04(d) ,
 Section 8.06 CMS approval of Medicaid amendments
  Section 8.07 Required compliance with amendment and modification procedures.
  Article 9. Audit & Financial Compliance Section 9.01 Financial record retention and
audit.
  Section 9.02 Access to records, books, and documents.
          Page 26 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
          Section 9.03 Audits of Services, Deliverables and inspections.
            Section 9.04 SAO Audit
 Section 4.10
(a-b).
 Section 9.05 Response/compliance with audit or inspection findings.
      Page 27 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
  Article 10. Terms & Conditions of Payment
 Section 10.01 Calculation of monthly Capitation Payment.
   st
        Section 10.02 Time and Manner of Payment.
   Article 12
  Article 8,
 Article 12
 Section 10.03 Certification of Capitation Rates.
 Rates.
 Section 10.04 Modification of Capitation Rates.
 Article 8 Article 12
 Section 10.05 STAR Capitation Structure.
      Page 28 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
       Capitation Rates for Rate Periods 1 and 2 for Service Areas with
historical STAR Program participation.
         Section 10.05.1 STAR+PLUS Capitation Structure.
             Section 10.06 CHIP Capitation Rates Structure.
   Page 29 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
  (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).
      Section 10.06.1 CHIP Perinatal Program Capitation Structure.
        
 Section 10.07 HMO input during rate setting process.
 HHSCs Uniform Managed Care Manual.
   Section 10.08 Adjustments to Capitation Payments.
    Page 30 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
      Section 12.13,
 Section 10.09 Delivery Supplemental Payment for CHIP, CHIP Perinatal and STAR
HMOs.
  HHSC Managed Care Contract
 Attachment B HHSC Managed Care
Contract HHSCs
Uniform Managed Care Manual.
    Section 10.10 Administrative Fee for SS/ Members
  HHSC
Managed Care Contract
           Page 31 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
   Section 10.11 STAR, CHIP, and CHIP Perinatal Experience Rebate
    Experienceas a % of Revenues
    
    HMO Share
    
    
    HHSC Share3%
    
    
    100
    %
    
    
    0
    %> 3% and < 7%
    
    
    75
    %
    
    
    25
    %> 7% and < 10%
    
    
    50
    %
    
    
    50
    %> 10% and < 15%
    
    
    25
    %
    
    
    75
    %> 15%
    
    
    0
    %
    
    
    100
    %
 Attachment B-1 HHSC Managed Care Contract HHSCs Uniform
Managed Care Manual:
       HHSC Uniform Managed
Care Manuals Cost Principles for Administrative Expenses FSR Instructions for Completion Cost Principles for Administrative Expenses FSR
Instructions for Completion HHSCs Uniform Managed Care Manual
       Page 32 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
  HHSC Uniform Managed Care Manuals
Cost Principles for Administrative Expenses FSR Instructions for Completion
   Section 10.11.1 STAR+PLUS Experience Rebate
    Experience Rebateas a% of Revenues
    
    HMO Share
    
    
    HHSC Share< 3%
    
    
    50
    %
    
    
    50
    %> 3%
    
    
    75
    %
    
    
    25
    %
 B-1 HHSC Managed Care Contract HHSCs Uniform Managed
Care Manual:
    HHSC Uniform Managed
Care Manuals Cost Principles for Administrative Expenses FSR Instructions for Completion Cost Principles for Administrative Expenses FSR
Instructions for Completion HHSCs Uniform Managed Care Manual
       Page 33 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
     Section 10.12 Payment by Members.
       the HHSC Uniform Managed Care Manual
    g
 Section 10.13 Restriction on assignment of fees.
  Section 10.14 Liability for taxes.
  Section 10.15 Liability for employment-related charges and benefits.
  Page 34 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 Section 10.16 No additional consideration.
    Section 10.17 Federal Disallowance
  Article 11. Disclosure Confidentiality of Information
 Section 11.01 Confidentiality.
              Section 11.02 Disclosure of HHSCs Confidential Information.
  Page 35 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
   Section 11.03 Member Records
 Section 7.07,
   Section 11.04 Requests for public information.
    Section 11.05 Privileged Work Product.
    (1)
    
    Immediately notify HHSC; and(2)
    
    Use all reasonable efforts to resist providing such access.
  (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.
  Section 11.06 Unauthorized acts.
   Page 36 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
     Section 11.07 Legal action.
   Article 12. Remedies & Disputes
 Section 12.01 Understanding and expectations.
  Section 12.02 Tailored remedies.
                   Page 37 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
         Attachment B-5 HHSC Managed
Care Contract,
         Section 12.03,
        Attachment B-5 to the HHSC Managed Care Contract,
    Page 38 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
                  Section 12.03 Termination by HHSC.
      (1) Assignment for the benefit of creditors, appointment of receiver, or inability to pay
debts.
     (2) Failure to adhere to laws, rules, ordinances, or orders.
  of confidentiality.
  Failure to maintain adequate personnel or resources.
 Page 39 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
  (5) Termination for gifts and gratuities.
       (6) Termination for non-appropriation of funds.
  (7) Judgment and execution.
      (8) Termination for insolvency.
         Page 40 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
  Termination for HMOS material breach of the Contract.
  Section 12.04 Termination by HMO.
   Subsection 12. 04(d) .
       Section 12.05 Termination by mutual agreement.
  Section 12.06 Effective date of termination.
  Section 12.07 Extension of termination effective date.
  Section 12.08 Payment and other provisions at Contract termination.
 In
   Section 12.09 Modification of Contract in the event of remedies.
 Article 8.
 Section 12.10 Turnover assistance.
  Page 41 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
 Section 12.11 Rights upon termination or expiration of Contract.
  Section 12.12 HMO responsibility for associated costs.
  Section 12.13 Dispute resolution.
      requirement.
 Negotiation of claims.
   Contested proceedings.
  HHSC rules.
 HMOs duty to perform. Article 8
 Section 12.14 Liability of HMO.
      Page 42 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
   Article 13. Assurances Certifications
 Section 13.01 Proposal certifications.
  (1)
    
    Federal lobbying;(2)
    
    Debarment and suspension;(3)
    
    Child support; and(4)
    
    Nondisclosure statement.
 Section 13.02 Conflicts of interest.
     Section 13.03 Organizational conflicts of interest.
          Subsection 12. 03(b)(9) .
   Page 43 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
  Section 13.04 HHSC personnel recruitment prohibition.
   Section 13.05 Anti-kickback provision.
  Section 13.06 Debt or back taxes owed to State of Texas.
  Section 13.07 Certification regarding status of license, certificate, or permit.
  Section 13.08 Outstanding debts and judgments.
  Article 14.
 Section 14.01 Authorization.
   Section 14.02 Ability to perform.
  Section 14.03 Minimum Net Worth.
  Section 14.04 Insurer solvency.
    Page 44 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
      Section 14.05 Workmanship and performance.
    Section 14.06 Warranty of deliverables.
  Section 14.07 Compliance with Contract.
  Section 14.08 Technology Access
       Article 15. Intellectual Property
 Section 15.01 Infringement and misappropriation.
   Page 45 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
      Section 15.02 Exceptions.
     Section 15.03 Ownership and Licenses
   Custom Software" means
 HMO Proprietary Software"
 Third Party Software"
         Page 46 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
      Article 16. Liability
 Section 16.01 Property damage.
    Section 16.02 Risk of Loss.
  Section 16.03 Limitation of HHSCs Liability.
    Article 17. Insurance Bonding
 Section 17.01 Insurance Coverage.
  Statutory and General Coverage.
       (2) Professional Liability
  Page 47 of 49




---



##### 



Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
              Section 17.02 Performance Bond.
  Page 48 of 49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment A  HHSC Uniform Managed Care Contract Terms& Conditions
    
    Version 1.4
  Section 17.03 TDI Fidelity Bond
  Page 49 of 49




---



##### 



Part 1: Parties to the Contract
 Boulevard, ,
   Part 2: Effective-Date of
Amendment
    
    Part 3: Contract
Expiration Date
    
    Part 4: Operational Start Date:September 1, 2006
    
    August 31, 2008
    
    STAR and CHIP HMOs: September 1,
2006STAR+PLUS HMOs: January 1, 2007CHIP Perinatal HMOs: January 1,
2007
 Part 5: Project Managers
 HHSC:
    
    HMO:Pamela Coleman
    
    Aileen McCormickDirector of Medicaid/CHIP Health Plan Operations
    
    Amerigroup Texas, Inc.11209 Metric Boulevard, Building H
    
    6700 West Loop South, Suite 200Austin, Texas 78758
    
    Bellaire, Texas 77401Phone: 512-491-1302
    
    Phone: 713-218-5101Fax: 512-491-1966
    
    Fax: 713-218-8692E-mail: amccorm@amerigroupcorp.com
 Part 6: Deliver Legal Notices to:
 HHSC:
    
    HMO:General Counsel
    
    Amerigroup Texas, Inc.4900 North Lamar Boulevard, 4thFloor
    
    6700 West Loop South, Suite 200Austin, Texas 78751
    
    Bellaire, Texas 77401Fax: 512-424-6586
    
    Fax: 713-218-8692




---



##### 



Subject: HHSC Managed Care Contract
 Part 7: HMO Programs and Service Areas:
 Mediciad STAR HMO Program
 (check all that
apply).
 Service Areas:
    
    o
    
    Bexar
    
    o
    
    Lubbockþ
    
    Dallas
    
    þ
    
    Nueceso
    
    El Paso
    
    þ
    
    Tarrantþ
    
    Harris
    
    o
    
    Travis
  Medicaid STAR+PLUS HMO Program
 Service Areas:
    
    þ
    
    Bexar
    
    o
    
    Nuecesþ
    
    Harris
    
    þ
    
    Travis
  CHIP HMO Program
 Core Service Areas:
    
    o
    
    Bexar
    
    þ
    
    Nuecesþ
    
    Dallas
    
    þ
    
    Tarranto
    
    El Paso
    
    o
    
    Travisþ
    
    Harris
    
    o
    
    Webbo
    
    LubbockOptional Service Areas:
    
    o
    
    Bexar
    
    o
    
    Lubbocko
    
    El Paso
    
    o
    
    Nueceso
    
    Harris
    
    o
    
    Travis
  Page 2 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: HHSC Managed Care Contract
    
    HHSC Contract No. 529-06-0280-00002-D
 CHIP Perinatal Program
 Service Areas:
    
    o
    
    Bexar
    
    o
    
    Nueceso
    
    Dallas
    
    þ
    
    Tarranto
    
    El Paso
    
    o
    
    Traviso
    
    Harris
    
    o
    
    Webbo
    
    Lubbocko
    
    Bexar
    
    o
    
    Lubbocko
    
    El Paso
    
    o
    
    Nueceso
    
    Harris
    
    o
    
    Travis




---



##### 



Part 8: Payment
 *********REDACTED**********
 Part 9: Contract Attachments
  A: HHSC Uniform Managed Care Contract Terms & Conditions  Version 1.3 is replaced with Version 1.4
 B: Scope of Work/Performance Measures
 B-1: HHSC RFP 529-04-272, Sections 6-9  Version 1.3 is replaced with Version 1.4
 B-2: Covered Services  Version 1.3 is replaced with Version 1.4
 B-2.1 STAR+PLUS Covered Services  Version 1.3 is replaced
with Version 1.4 B-2.2 CHIP Perinatal Program Covered Services
- Added by Version 1.3
 B-3: Value-added Services  Version 1.3 is replaced with Version 1.4
 B-3.1 STAR+PLUS Value-added Services  Version 1.3 is replaced with Version 1.4
 B-3.2 CHIP Perinatal Program Value-added Services  Added by Version 1.3
 B-4: Performance Improvement Goals  Version 1.3 is replaced with Version 1.4
 B-4.1 SFY 2008 Performance Improvement Goals- Version 1.3 is replaced with Version 1.4
 B-5: Deliverables/Liquidated Damages Matrix  Version 1.3 is replaced with Version 1.4
 B-6: Map of Counties with HMO Program Service Areas
 B-6.1 STAR+PLUS Service Areas
 B-6.2 CHIP Perinatal Program Service Areas
 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




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: HHSC Managed Care Contract
    
    HHSC Contract No. 529-06-0280-00002-D
 Part 10: Signatures:
 
 Amerigroup Texas, Inc.Texas Health and Human Services CommissionCharles E. Bell, M.D.
    
    By: Aileen McCormickDeputy Executive Commissioner for Health Services
    
    Title: President and CEODate: 9/18/06
    
    Date: 8/28/06
 Page 10 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 6
    
    Version 1.4
 DOCUMENT HISTORY LOG
 DOCUMENT
    
    EFFECTIVESTATUS
    
    REVISION2
    
    DATE
    
    DESCRIPTION3Baseline
    
    n/a
    
    
    
    
    
    Initial version Attachment B-1, Section 6Revision
    
    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
 6-1




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject:Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 6
    
    Version 1.4
 DOCUMENT
    
    EFFECTIVESTATUS
    
    REVISION2
    
    DATE
    
    DESCRIPTION3Year 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
 
 Status should be represented as Baseline for initial issuances, Revision for changes to the Baseline version, and
Cancellation for withdrawn versions2
    
    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.Brief description of the changes to the document made in the revision.




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 6
    
    Version 1.4
 6. Premium Payment, Incentives, and Disincentives
 Uniform Managed Care Contract Terms and Conditions.
 Section 8
 6.1 Capitation Rate Development
 Attachment A, HHSC Uniform Managed Care Contract Terms Conditions, 10,
Terms Conditions of Payment,
 6.2 Financial Payment Structure and Provisions
   6-3




---



##### 



6.2.1 Capitation Payments
 HHSC Uniform Managed Care Contract Terms Conditions




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 6
    
    Version 1.4
 1)
    
    Time and Manner of Payment,2)
    
    Adjustments to Capitation Payments,3)
    
    Delivery Supplemental Payment, and4)
    
    Experience Rebate.
 6.3 Performance Incentives and Disincentives
  6.3.1 Non-financial Incentives
 6.3.1.1 Performance Profiling
  6.3.1.2 Auto-assignment Methodology for Medicaid HMOs
 Performance Indicator Dashboard. Attachment B-1, Section 8 and the Performance Indicator Dashboard. Attachment B-1, Section 8)




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 6
    
    Version 1.4
 6.3.2 Financial Incentives and Disincentives
 6.3.2.1 Experience Rebate Reward
 Uniform
Managed Care Contract Terms and Conditions, Article 10.11) Uniform Managed Care Manual.
 Section 6.3.2.2.
  6.3.2.2 Performance-Based Capitation Rate
   6-5




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 6
    
    Version 1.4
   HHSC Uniform Managed Care Manual. The Performance Indicator Dashboard
 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%.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.
 
  Will not apply in the Dallas Core Service Area. Points will be allocated proportionately
over the remaining standard performance indicators. 6-6




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 6
    
    Version 1.4
 3.
    
    56% of age-qualified child Members receive at least one well-child visit in the
3rd, 4th, 5th, or 6th year of life4.
    
    38% of adolescents receive an annual well visit.
 Additional STAR+PLUS Performance Indicators
 1.
    
    57% of adult Members report no problem with delays in getting approval from the HMO2.
    
    90% of adult Members have access to at least one adult-appropriate PCP with an
Open Panel within 30 miles travel distance3.
    
    62% of adult Members report no problem in getting a referral to a Specialty Physician4.
    
    47% of adult Members report no problem getting needed Special Therapy (physical
therapy, occupational therapy, and speech therapy) from the HMO5.
    
    57% of adult Members report no problem getting needed Behavioral Health
Services from the HMO
     HHSC Uniform Managed Care Manual.
 6.3.2.3 Quality Challenge Award
  6-7




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 6
    
    Version 1.4
  HHSC
Uniform Managed Care Manual.
 6.3.2.4 Remedies and Liquidated Damages
 Attachment A,
HHSC Uniform Managed Care Contract Terms and Conditions Attachment B-5
 6.3.2.5 STAR+PLUS Hospital Inpatient Performance-Based Capitation Rate: Hospital Inpatient Stay
Cost Incentives & Disincentives
  6.3.2.5.1 STAR+PLUS Hospital Inpatient Disincentive  Administrative Fee at Risk
 Section 6.3.25.2.
  6-8




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 6
    
    Version 1.4
 6.3.2.5.2 STAR+PLUS Hospital Inpatient Incentive  Shared Savings Award
 Section Section 6.3.2.5. 




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIPHMO RFP, Section 7
    
    Version 1.4
 DOCUMENT HISTORY LOG
 DOCUMENT
    
    EFFECTIVESTATUS
    
    REVISION
    
    DATE
    
    DESCRIPTION3Baseline
    
    n/a
    
    
    
    
    
    Initial version Attachment B-1, Section 7Revision
    
    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
 
 Status should be represented as Baseline for initial issuances, Revision for changes to
the Baseline version, andCancellation for withdrawn versions2
    
    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 B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 7
    
    Version 1.4
 7. Transition Phase Requirements
 7.1 Introduction
  
 HHSC Uniform
Managed Care Contract Terms and Conditions (Attachment A) Liquidated Damages Matrix
(Attachment B-5)
 7.2 Transition Phase Scope for HMOs
  7.3 Transition Phase Schedule and Tasks
  Attachment B-5).
 7-2




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 7
    
    Version 1.4
 7.3.1 Transition Phase Tasks
  7.3.1.1 Contract Start-Up and Planning
  
    
    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.
  7.3.1.2 Administration and Key HMO Personnel
 HHSC Uniform Managed Care Contract Terms Conditions,
Article
   7.3.1.3 Financial Readiness Review
  7-3




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 7
    
    Version 1.4
  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 allcounties 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
 ColumnA
    
    Column B
    
    
    ColumnCCore Service
    
    
    
    
    
    Counties/Partial Counties withoutaArea(CSA)
    
    TDI Certificate of Authority
    
    
    TDI Certificate of AuthorityBexarDallasEl PasoHamsLubbockNuecesTarrantTravisWebb
 If the Contractor is notcurrently 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.
 7-4




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 7
    
    Version 1.4
 Table 3: TDI Certificate of Authority in Proposed HMO Program OSAs
 CHIP ProgramColumn A
    
    Column B
    
    
    Column CCore Service Area(CSA)
    
    Affiliated CHIP OSA
    
    
    TDI Certificate of AuthorityBexarEl PasoHarrisLubbockNuecesTravis
 CHIP Perinatal ProgramColumn A
    
    Column B
    
    
    Column CCore Service Area(CSA)
    
    Affiliated CHIP OSA
    
    
    TDI Certificate of AuthorityBexarEl PasoHarrisLubbockNuecesTravis
 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.
 7-5




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 7
    
    Version 1.4
 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
   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.
 7-6




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 7
    
    Version 1.4
 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.
 7-7




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 7
    
    Version 1.4
 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
 Attachment
B-1, Section 8.1.18.  Section 8.1.18.4.
    7-8




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section7
    
    Version 1.4
  7.3.1.5 System Readiness Review
  Section 8.1.18.3,
  1.
    
    Joint Interface Plan.2.
    
    Disaster Recovery Plan3.
    
    Business Continuity Plan4.
    
    Risk Management Plan, and5.
    
    Systems Quality Assurance Plan.
  7.3.1.6 Demonstration and Assessment of System Readiness
    7-9




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 7
    
    Version 1.4
   7.3.1.7 Operations Readiness
  Readiness Review.
 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 8.1.5and
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.
 7-10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 7
    
    Version 1.4
 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.
  7-11




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section7
    
    Version 1.4
  7.3.1.8 Assurance of System and Operational Readiness
 Section 7.3.1,
 7.3.1.9 Post-Transition
   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; or4.
    
    pursue other equitable, injunctive, or regulatory relief.




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1 -HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 DOCUMENT HISTORY LOG
 DOCUMENT
    
    EFFECTIVESTATUS
    
    REVISION
    
    DATE
    
    DESCRIPTION3Baseline
    
    n/a
    
    
    
    Initial version Attachment B-1, Section 8Revision
    
    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+PLUSSection 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.
 8-1




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGCSubject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 DOCUMENT
    
    EFFECTIVESTATUS
    
    REVISION
    
    DATE
    
    DESCRIPTION3Section 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
 8-2




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject:Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 DOCUMENT
    
    EFFECTIVESTATUS
    
    REVISION
    
    DATE
    
    DESCRIPTION3Lag 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), 79thLegislature, 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
 8-3




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject:
Attachment B-1 - HHSC Joint
Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 DOCUMENT
    
    EFFECTIVESTATUS'
    

REVISION2
    
    DATE
    
    DESCRIPTION3the first full State Fiscal Year following the CHIP Perinatal Operational Start DateSection 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
ProgramSection 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
 8-4




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 DOCUMENT
    
    EFFECTIVESTATUS
    
    REVISION
    
    DATE
    
    DESCRIPTION3CHIP 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 ProgramSection 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
    
    Contract amendment did not revise Attachment
01, 2006 B-1 Section 8-Operations Phase Requirements
 
 Status should be represented as Baseline for initial issuances, Revision for changes to the Baseline version, and Cancellation
for withdrawn versions2
    
    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.
Brief description of the changes to the document made in the revision. 8-5




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8. OPERATIONS PHASE REQUIREMENTS
  Section 8.1
 Section 8.2
 Section 8.3
 Section 8.4
 Section 8.5
 Uniform Managed Care Contract Terms and
Conditions (Attachment A) Uniform Managed Care Manual. Uniform Managed Care
Contract Terms and Conditions.
 8.1 General Scope of Work
   8.1.1 Administration and Contract Management
  8-6




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8.1.1.1 Performance Evaluation
 st Attachment B-4, Performance Improvement Goals).
  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:
  Attachment B-4.1.
   8-7




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  Performance Indicator Dashboard (see HHSCs Uniform
Managed Care Manual).
 8.1.2 Covered Services
   1.
    
    previous coverage, if any, or the reason for termination of such coverage;2.
    
    health status;3.
    
    confinement in a health care facility; or4.
    
    for any other reason.
 Please Note:
   8-8




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1 - HHSC
Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
   
  Attachments B-2 and B-2.1 of the
Contract. Attachments B-2 and B-2.1, Texas Medicaid Provider Procedures Manual THSteps Manual Texas
Medicaid Bulletins, Section 8.2.2.8 Attachment B-2 of the Contract. A Attachment B-2.2 of the Contract.
 8.1.2.1 Value-added Services
   8-9




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1 - HHSC
Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  Transition Phase. Attachment B-3, Value-Added Services).
   Operations Phase. Attachment
B-3, Value-Added Services. Attachment B-3.1, STAR+PLUS Value-Added Services. Attachment B-3.2, CHIP Perinatal Value-Added Services.)
 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;
 8-10




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 h.
    
    Describe how a Member may obtain or access the Value-added Service; andi.
    
    Include a statement that the HMO will provide such Value-added
Service for at least 12 months from the September 1 effective date.
  8.1.2.2 Case-by-Case Added Services
 
 8.1.3 Access to Care
   Section 8.1.15. Section 8.2.2.1.
  8-11




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  Section 8.1.4.
     8.1.3.1 Waiting Times for Appointments
  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
 8-12




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 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
 Section 8.13.1.
 PCP Access:
 OB/GYN Access and CHIP Perinatal Program Provider Access:
  Outpatient Behavioral Health Service Provider Access:
 8-13




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-I  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  Other Specialist Physician Access:
 Hospital Access:
 All other Covered Services, except for services provided in the Members residence: Attachment B-2,
  8.1.3.3 Monitoring Access
 Sections 8.1.3.1 and 8.1.3.2, Section 8.1.4.2.
  8.1.4 Provider Network
 Uniform Managed Care Manuals
  8-14




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
   
  All Providers:
 Inpatient hospital and medical services:
 Childrens Hospitals/hospitals with specialized pediatric services:
 Trauma:
 8-15




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1 - HHSC
Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 Transplant centers:
 Hemophilia centers:
 Physician services: Section 8.1.3
   Laboratory services: Section 8.1.3.
 Diagnostic imaging: Section 8.1.3.
 Home health services:
 8-16




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  Community Long-term Care services:
 8.1.4.1 Provider Contract Requirements
  Uniform Managed Care Contract Terms and Conditions (Attachment A) HHSCs Uniform
Managed Care Manual.
  8.1.4.2 Primary Care Providers
    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
 8-17




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1 - HHSC
Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 3.
    
    the Provider has admitting privileges to a local hospital that
includes admissions to pediatric units.
     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; and3.
    
    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; and4.
    
    Returning after-hours calls outside of 30 minutes.
 8-18




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
   8.1.4.3 PCP Notification
  8.1.4.4 Provider Credentialing and Re-credentialing
    8-19




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1 - HHSC
Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8.1.4.5 Board Certification Status
  8.1.4.6 Provider Manual, Materials and Training
  Uniform Managed Care Manual. Attachment B-1,
Section
   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; and4.
    
    The HMOs policies and procedures, especially regarding
in-network and Out-of-Network referrals.
 HHSC Uniform Managed Care Contract Terms and Conditions.
 8-20




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1 - HHSC
Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8.1.4.7 Provider Hotline
    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; and4.
    
    the call abandonment rate is 7% or less.
  Section 8.1.20. Section 8.1.4.7.
 8.1.4.8 Provider Reimbursement
 Section 8.1.18.5.
 8-21




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1 - HHSC
Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8.1.4.9 Termination of Provider Contracts
  
 8.1.5 Member Services
  8.1.5.1 Member Materials
  Section 8.1.5.4.
  Uniform Managed Care Terms and Conditions,
 8-22




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 Uniform Managed Care
Manual.
 8.1.5.2 Member Identification (ID) Card
  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; and7.
    
    any other critical elements identified in the Uniform Managed Care Manual.
  8.1.5.3 Member Handbook
 Attachment B-1, Section
 Section 8.1.5.1 Uniform Managed Care Manual.
  8.1.5.4 Provider Directory
  8-23




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1 - HHSC
Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  Attachment B-1, Section Attachment B-1, Section
 Section 8.1.5.1 Uniform Managed Care Manual. Section 8.1.4.4.
    8.1.5.5 Internet Website
  
 8-24




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 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; and4.
    
    Be geared to the health needs of the enrolled HMO Program population.
  8.1.5.6 Member Hotline
     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; and
 8-25




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 9.
    
    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.)
   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; and4.
    
    the call abandonment rate is 7% or less.
   Section 8.1.20 Uniform Managed Care Manual.
 8.1.5.7 Member Education
  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, and4.
    
    How to obtain Covered Services, including:
 a.
    
    Emergency Services;b.
    
    Accessing OB/GYN and specialty care;c.
    
    Behavioral Health Services;d.
    
    Disease Management programs;
 8-26




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 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-paymentsi.
    
    Suicide prevention; andJ.
    
    Identification and health education related to Obesity.
  Section 8.1.13 and Section 8.1.
 8.1.5.8 Cultural Competency Plan
  8.1.5.9 Member Complaint and Appeal Process
 Uniform Managed
Care Contract Terms Conditions Attachment B-5, Deliverables/Liquidated Damages Matrix.
 8-27




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  Uniform Managed Care Contract Terms Conditions and
Attachment B-5, Deliverables/Liquidated Damages Matrix.
 in Section 8.2.6. in Sections 8.4.2 8.5.2,
 8.1.6 Marketing and Prohibited Practices
 HHSC Uniform Managed Care Manual.
 8.1.7 Quality Assessment and Performance Improvement
  8.1.7.1 QAPI Program Overview
   8-28




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  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; and7.
    
    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
  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; and4.
    
    Evaluates the effectiveness of clinical and non-clinical initiatives.
 8.1.7.3 Clinical Indicators
  8.1.7.4 QAPI Program Subcontracting
  8.1.7.5 Behavioral Health Integration into QAPI Program
 Attachments B-2, B-2.1, and B-2.2,
 8-29




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  8.1.7.6 Clinical Practice Guidelines
     8.1.7.7 Provider Profiling
   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; and3.
    
    Providing feedback to individual PCPs and Providers regarding the results
of their performance and the overall performance of the Provider Network.
 8-30




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8.1.7.8 Network Management
  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; and4.
    
    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
  8.1.8 Utilization Management
  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; and4.
    
    The staff position functionally responsible for the day-to-day
management of the UM function.
   8-31




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 
    
    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.
 
 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; and5.
    
    Quality is not adversely impacted by financial and reimbursement-related processes
and decisions.
  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/RDMC1in
Guide. html and9.
    
    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.
 8-32




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8.1.9 Early Childhood Intervention (ECI)
    
  
 8-33




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  8.1.10 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)  Specific Requirements
  8.1.11 Coordination with Texas Department of Family and Protective Services
   
    
    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.
    1.
    
    Providing medical records to TDFPS;2.
    
    Scheduling medical and Behavioral Health Services appointments within 14 days
unless requested earlier by TDFPS; and3.
    
    Recognition of abuse and neglect, and appropriate referral to TDFPS.
 8-34




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  8.1.12 Services for People with Special Health Care Needs
  8.1.12.1 Identification
 
 Uniform Managed Care Manual,
 8.1.12.2 Access to Care and Service Management
 
  
 CSHCN is a term often used to refer to a services program for children with special health care
needs administered by DSHS, and described in 25 TAC, Part 1, Section 38.1. Although children
served through 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. 8-35




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
   
 1.
    
    Participate in hospital discharge planning;2.
    
    Participate in pre-admission hospital planning for non-emergency hospitalizations;3.
    
    Develop specialty care and support service recommendations to be incorporated into
the Service Plan; and4.
    
    Provide information to the Member, or when applicable, the Members legal
guardian concerning the specialty care recommendations.
   Section
8.1.
  
    
    Community Resource Coordination Groups (CRCGs);
 
    
    Early Childhood Intervention (ECI) Program;
 8-36




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 
    
    Local school districts (Special Education);
    
    Texas Department of Transportation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
  Attachment B-2.2,
 1.
    
    High-cost catastrophic cases;2.
    
    Women with high-risk pregnancies (STAR and STAR+PLUS Programs only); and3.
    
    Individuals with mental illness and co-occurring substance abuse.
 8.1.14 Disease Management (DM)
 Uniform Managed Care Manual. Uniform Managed Care Manual.
  1.
    
    Patient self-management education;2.
    
    Provider education;
 8-37




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 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; and8.
    
    Mechanisms to monitor the impact of the DM Program over time, including both the clinical
and the financial impact.
   HHSC Uniform
Managed Care Manual.
 8.1.14.1 DM Services and Participating Providers
  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; and3.
    
    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
  8.1.15 Behavioral Health (BH) Network and Services
  Attachments B-2, B-2.1, and B-2.2. Section 8.1.3. Texas Medicaid Provider Procedures Manual Texas Medicaid Bulletins.
 8-38




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8.1.15.1 BH Provider Network
  8.1.15.2 Member Education and Self-referral for Behavioral Health Services
    8.1.15.3 Behavioral Health Services Hotline
 Section 8.1.4.7.
 Section 8.1.5.6
  8-39




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 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; and4.
    
    The call abandonment rate is 7% or less.
  Section 8.1.20 Uniform Managed Care Manual.
8.1.15.4 Coordination between the BH Provider and the PCP
    
  8.1.15.5 Follow-up after Hospitalization for Behavioral Health Services
  8-40




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8.1.15.6 Chemical Dependency
 et seq.,
 8.1.15.7 Court-Ordered Services
     8.1.15.8 Local Mental Health Authority (LMHA)
  Section 8.2.8.
 8.1.16 Financial Requirements for Covered Services
  8-41




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8.1.17 Accounting and Financial Reporting Requirements
 Uniform Managed Care Manual.
  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; and4.
    
    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.
  8.1.17.1
    
    General Access to Accounting Records
  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 available to HHSC or its agents within ten (10) business days 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
 8-42




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 federal representatives, or their agents, to carry out their inspection, audit,
review, analysis, and reproduction functions at the location(s) of such accounting
records; and4.
    
    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
   Uniform Managed Care Manual
 Audited Financial Statement
 Affiliate Report 
 1.
    
    A list of all Affiliates, and2.
    
    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 
 8-43




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 Uniform Managed Care Manual.
 Claims Lag Report  Uniform Managed Care Manual
 DSP Report 
 Form CMS-1513 
 FSR Reports  Uniform Managed Care Manual. Uniform Managed Care Manual.
 Uniform Managed Care Manual.
 Out-of-Network Utilization Reports  Uniform Managed Care Manual.
 8-44




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 HUB Reports   Uniform Managed Care Manual
 IBNR Plan 
 Medicaid Disproportionate Share Hospital (DSH) Reports  Uniform Managed Care Manual.
 TDI Examination Report 
 TDI Filings 
 Registration Statement (also known as the Form B) 
 Section 1318 Financial Disclosure Report 
 8-45




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 Third Party Recovery (TPR) Reports  Uniform Managed Care Manual.
 8.1.18 Management Information System Requirements
  
    Uniform Managed Care Terms and
Conditions.
  8-46




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  Attachment B-1, Section
 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; and5.
    
    An existing plan in one or two HHSC HMO Programs is initiating a Contract to
participate in any additional HMO Programs.
 Uniform Managed Care Terms and Conditions Attachment B-5
 8.1.18.1 Encounter Data
 Uniform Managed Care Manual.
 Uniform Managed Care Manual.
  8-47




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8.1.18.2 HMO Deliverables related to MIS Requirements
  1.
    
    Joint Interface Plan;2.
    
    Disaster Recovery Plan;3.
    
    Business Continuity Plan;4.
    
    Risk Management Plan; and5.
    
    Systems Quality Assurance Plan.
 Uniform Managed Care Manual.
 8.1.18.3 System-wide Functions
  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; and14.
    
    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.
 8-48




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8.1.18.4 Health Insurance Portability and Accountability Act (HIPAA) Compliance
   8.1.18.5 Claims Processing Requirements
 Uniform Managed Care Manual. Uniform Managed Care Manual.
 Uniform Managed Care Manual.
  Attachment A, Section 9.01.
  Uniform Managed Care Manual.
 8-49




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
     8.1.19 Fraud and Abuse
  Attachment B-1, Section
  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;
 8-50




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 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); and7.
    
    Require any confirmed violations or confirmed or suspected Fraud, Abuse, or
Waste under state or federal law be reported to 01G.
    8.1.20 Reporting Requirements
  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
 8-51




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 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.
   8.1.20.1 HEDIS and Other Statistical Performance Measures
 Performance Indicator Dashboard, Uniform Managed Care Manual
 8.1.20.2 Reports
 Section 8.1.17 HHSC
Uniform Managed Care Manual
  Claims Summary Report  th Uniform Managed Care Manual.
 QAPI Program Annual Summary Report 
 8-52




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 Fraudulent Practices Report 
 HHSC Uniform Managed Care Manual.
 Provider Termination Report: (CHIP (including integrated CHIP Perinatal Program
data) STAR)
  PCP Network Capacity Report: (CHIP only (including integrated CHIP Perinatal
Program data))
 
 Summary Report of Member Complaints and Appeals  HHSC Uniform Managed Care Manual,
  Summary Report of Provider Complaints  HHSC
Uniform Managed Care Manual,
  8-53




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 Hotline Reports  Sections 8.1.5.6, 8.1.14.3, and 8.1.4.7.
  
 8.2 Additional Medicaid HMO Scope of Work
  8.2.1 Continuity of Care and Out-of-Network Providers
   
 8-54




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  1.
    
    More than 90 days after a Member enrolls in the HMOs Program, or2.
    
    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.
     8.2.2 Provisions Related to Covered Services for Medicaid Members
 8.2.2.1 Emergency Services
    8-55




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
     1.
    
    The HMO does not respond to a request for pre-approval within 1 hour;2.
    
    The HMO cannot be contacted; or3.
    
    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
  8-56




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
     8.2.2.3 Texas Health Steps (EPSDT)
    8-57




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  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.
 Frew v. Hawkins, et. al.,
      8-58




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
     8.2.2.4 Perinatal 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; and6.
    
    Availability and accessibility of appropriate outpatient and inpatient facilities
capable of dealing with complicated perinatal problems.
 8-59




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
    
  8.2.2.5 Sexually Transmitted Diseases (STDs) and Human Immunodeficiency Virus (HIV)
     8-60




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
    8.2.2.6 Tuberculosis (TB)
 Section 8.2.2.8
    8-61




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8.2.2.7 Objection to Provide Certain Services
   8.2.2.8 Medicaid Non-capitated Services
 Provider Procedures Manual Texas Medicaid Bulletins
 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.
 8.2.2.9 Referrals for Non-capitated Services
  8-62




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  8.2.2.10 Cooperation with Immunization Registry
 
 8.2.2.11 Case Management for Children and Pregnant Women
 http://www.dshs.state.tx.us/caseman/default.shtm.
    8-63




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8.2.3 Medicaid Significant Traditional Providers
    
  1.
    
    Agree to accept the HMOs Provider reimbursement rate for the provider type; and2.
    
    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)
 
  8-64




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 Uniform Managed Care Manual.
 8.2.5 Provider Complaints and Appeals
 8.2.5.1 Provider Complaints
  8.2.5.2 Appeal of Provider Claims
   8.2.6 Member Rights and Responsibilities
  8.2.7 Medicaid Member Complaint and Appeal System
  8-65




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
   8.2.7.1 Member Complaint Process
 Section 8.2.7, " "
 Uniform Managed Care Contract Terms Conditions Attachment B-5, Deliverables/Liquidated
Damages Matrix.
 Section 8.2.7.2,
    8-66




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 
           Section 8.2.7.9.
 8.2.7.2 Medicaid Standard Member Appeal Process
 " HHSCs
Uniform Contract Terms and Conditions.
 Uniform Managed Care Contract Terms Conditions and Attachment B-5,
Deliverables/Liquidated Damages Matrix.
 8-67




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 
 
 in Section 8.2.7.9, to assist 
           Section
 8-68




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
     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; and5.
    
    The Member requests an extension of the benefits.
  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; or3.
    
    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.
  8-69




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
    8.2.7.3 Expedited Medicaid HMO Appeals
 Section 8.2.7.2),
 
  Section 8.2.7.5.
  8-70




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  (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
 8.2.7.5 Notices of Action and Disposition of Appeals for Medicaid Members
  1.
    
    The Action the HMO has taken or intends to take;2.
    
    The reasons for the Action;3.
    
    The Members right to access the HMOs Appeal process.4.
    
    The procedures by which the Member may Appeal the HMOs Action;5.
    
    The circumstances under which expedited resolution is available and how to request it;6.
    
    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;7.
    
    The date the Action will be taken;8.
    
    A reference to the HMO policies and procedures supporting the HMOs Action;9.
    
    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;10.
    
    An explanation that Members may represent themselves, or be represented by a
provider, a friend, a relative, legal counsel or another spokesperson;
 8-71




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 11.
    
    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;12.
    
    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; and13.
    
    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
  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;
and6.
    
    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; and8.
    
    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
  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
 8-72




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 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
  8.2.7.9 Medicaid Member Advocates
  1.
    
    Their rights and responsibilities,2.
    
    The Complaint process,3.
    
    The Appeal process,4.
    
    Covered Services available to them, including preventive services, and5.
    
    Non-capitated Services available to them.
   8.2.8 Additional Medicaid Behavioral Health Provisions
 8.2.8.1 Local Mental Health Authority (LMHA)
  8-73




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  1.
    
    Describe the Behavioral Health Services indicated in detail in the Provider
Procedures Manualand 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; and11.
    
    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.
 
   8-74




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8.2.9 Third Party Liability and Recovery
  Section 8.1.17.2,
  8.2.10 Coordination With Public Health Entities
 8.2.10.1 Reimbursed Arrangements with Public Health Entities
  1.
    
    Sexually Transmitted Diseases (STDs) services;2.
    
    Confidential HIV testing;3.
    
    Immunizations;4.
    
    Tuberculosis (TB) care;5.
    
    Family Planning services;6.
    
    THSteps medical checkups, and7.
    
    Prenatal services.
   8-75




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  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; and2.
    
    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
  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; and4.
    
    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
  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;
 8-76




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 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; and8.
    
    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.
 8.2.12 Advance Directives
 
 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.
   8-77




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  th th  th
  8.3 Additional STAR+PLUS Scope of Work
 8.3.1 Covered Community-Based Long-Term Care Services
   8.3.1.1 Community Based Long-Term Care Services Available to All Members
 Attachment B-2.1, Covered Services.
 Community Long-Term Care Services Available to All Members
 Licensee and Certification
 8-78




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 Community Long-Term Care Services Available toAll MembersService
    
    Licensure and Certification RequirementsPersonal 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
 Appendix
B-2.1, STAR+PLUS Covered Services).
 Community Long-Term Care Services Under the 1915(c) Nursing Facility WaiverService
    
    Licensure and Certification RequirementsPersonal 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
 8-79




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 Community Long-Term Care Services Under the 1915(c) Nursing Facility WaiverService
    
    Licensure and Certification RequirementsRules 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
   8-80




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  8.3.2.1 Service Coordinators
 Attachment A, HHSCs Uniform Managed Care Contract Terms and Conditions,
Section 4.02, Section 4.04.1 HHSCs Uniform Managed
Care Contract Terms and Conditions.
8.3.2.2 Referral to Community Organizations
  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; and5.
    
    consumer groups, advocates, and councils (e.g., legal aid offices,
consumer/family support groups, permanency planning, etc.).
 8.3.2.3 Discharge Planning
   8-81




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8.3.2.4 Transition Plan for New STAR+PLUS Members
  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; and4.
    
    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.
   8.3.2.5 Centralized Medical Record and Confidentiality
   8-82




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 8.3.2.6 Nursing Facilities
   Olmstead v. L.C.
 
    
    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.
  Section
   8-83




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
   8.3.2.7 HMO Four-Month Liability for Nursing Facility Care
    8.3.3 STAR+PLUS Assessment Instruments
  8-84




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
   HHSC Uniform Managed Care Manual.
 8.3.4 1915(c) Nursing Facility Waiver Service Eligibility
 8.3.4.1 For Members
   8.3.4.2 For Medical Assistance Only (MAO) Non-Member Applicants
  8-85




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
    8.3.4.3 Annual Reassessment
  1.
    
    those services are required for that individual to live in the most
integrated setting appropriate to his or her needs;2.
    
    the cost for the needed services for each six-month period of the clients ISP year,
averaged and excluding the cost of minor home modifications and adaptive aids, does not
exceed 133.3% of the Nursing Facility Cost Ceiling; and3.
    
    HHSC continues to comply with the cost-effectiveness requirements from the CMS.
  1.
    
    the clients medical condition, functional needs, or environment;2.
    
    the caregiver support or third-party resources that have been providing service
to the client; or3.
    
    the need for a service or support to adequately support the client living in
the most integrated setting appropriate to his or her needs.
  8-86




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
     8.3.5 Consumer-Directed Services  Personal Attendant Services
  1.
    
    at initial assessment for attendant care services;2.
    
    at annual reassessment for attendant care services;3.
    
    at any time when a STAR+PLUS Member so requests that information; and4.
    
    in the Member Handbook.
   8.3.6 Community Based Long-term Care Service Providers
 8.3.6.1 Training
  8-87




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  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; and6.
    
    The HMOs STAR+PLUS policies and procedures, including those relating to Network
and Out-of-Network referrals.
 8.3.7.2 LTC Provider Billing
  HHSC Uniform Managed Care Manual.
 8.3.7.3 Rate Enhancement Payments for Agencies Providing Attendant Care
 HHSC Uniform Managed Care Manual.
 8.3.7.4 Payment for 1915(c) Nursing Facility Waiver Services for Non-Members
 Disenrolled Members:
 8-88




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
  8.4 Additional CHIP Scope of Work
  8.4.1 CHIP Provider Network
  1.
    
    Agree to accept the HMOs Provider reimbursement rate for the provider type; and2.
    
    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
  8.4.3 CHIP Member Complaint and Appeal Process
 Uniform Managed Care Contract Terms Conditions Attachment
B-5, Deliverables/Liquidated Damages
 8-89




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.4
 Matrix.
 8.4.4 Dental Coverage for CHIP Members
   8.5 Additional CHIP Perinatal Scope of Work
  8.5.1 CHIP Perinatal Provider Network
   8.5.2 CHIP Perinatal Program Provider Complaint and Appeals
  8.5.3 CHIP Perinatal Program Member Complaint and Appeal Process
  8-90




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 9
    
    Version 1.4
 DOCUMENT HISTORY LOG
 DOCUMENT2
    
    EFFECTIVESTATUS'
    
    REVISION
    
    DATE
    
    DESCRIPTION3Baseline
    
    
    n/a
    
    
    
    
    Initial version Attachment B-1, Section 7Revision
    
    
    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
RequirementsRevision
    
    
    1.3
    
    
    September 1, 2006
    
    Contract amendment did not revise
Attachment B-1 Section 9  Turnover
RequirementsRevision
    
    
    1.4
    
    
    September 1, 2006
    
    Contract amendment did not revise
Attachment B-1 Section 9  Turnover
Requirements
 
 Status should be represented as Baseline for initial issuances, Revision for changes to the Baseline version, and
Cancellation for withdrawn versions2
    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.
Brief description of the changes to the document made in the revision.




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 9
    
    Version 1.4
 9. Turnover Requirements
 9.1 Introduction
  9.2 Transfer of Data
   9.3 Turnover Services
    9.4 Post-Turnover Services
   9-2




---



##### 



Contractual Document (CD)Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 9
    
    Version 1.4