##### 



HHSC Managed Care Contract
HHSC Contract No. 529-06-0280-00002-H




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 DOCUMENT HISTORY LOG
 DOCUMENT
    
    EFFECTIVESTATUS1
    
    REVISION2
    
    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.Section 8.1.14, Disease Management, is modified to include
STAR+PLUS.Section 8.2, Additional Medicaid HMO Scope of Work, is modified to
include STAR+PLUS.Section 8.3, Additional STAR+PLUS Scope of Work, is added.Revision
    
    1.2
    
    
    September 1, 2006
    
    Revised version of Attachment B-1, Section 8, that includes
provisions applicable to MCOs participating in the STAR and CHIP
Programs.Section 8.1.1.1, Performance Evaluation, is modified to clarify that the
HMOs goals are Service Area and Program specific; when the
percentages for Goals 1 and 2 are to be negotiated; and when Goal 3
is to be negotiated.
 8-1




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 DOCUMENT
    
    EFFECTIVESTATUS1
    
    REVISION2
    
    DATE
    
    DESCRIPTION3Section 8.1.2.1, Value-Added Services, is modified to add language
allowing for the addition of two Value-added Services during the
Transition Phase of the Contract and to clarify the effective dates for
Value Added Services for the Transition Phase and the Operation
Phase of the Contract.Section 8.1.3.2, Access to Network Providers, is modified to delete
references to Open Panels.Section 8.1.4, Provider Network, is modified to clarify that Out-of-
Network reimbursement arrangements with certain providers must be
in writing.Section 8.1.5.1, Member Materials, is modified to clarify the date that
the member ID card and the member handbook are to be sent to
members.Section 8.1.5.6, Member Hotline, is modified to clarify the hotline
performance requirements.Section 8.1.17.2, Financial Reporting Requirements, is modified to
clarify that the Bonus Incentive Plan refers to the Employee Bonus
Incentive Plan. It has also been modified to clarify the reports and
deliverable due dates and to change the name of the Claims
Summary Lag Report and clarify that the report format has been
moved to the Uniform Managed Care Manual.Section 8.1.18.5, Claims Processing Requirements, is modified to
revise the claims processing requirements and move many of the
specifics to the Uniform Managed Care Manual.Section 8.1.20, Reporting Requirements, is modified to clarify the
reports and deliverable due dates.Section 8.1.20.2, Reports, is modified to delete the Claims Data
Specifications Report, amend the All Claims Summary Report, and
add two new provider-related reports to the contract.Section 8.2.2.10, Cooperation with Immunization Registry, is added to
comply with legislation, SB 1188 sec. 6(e)(1), 79th Legislature,
Regular Session, 2005.Section 8.2.2.11, Case Management for Children and Pregnant
Women, is added.Section 8.2.5.1, Provider Complaints, is modified to include the 30-
day resolution requirement.Section 8.2.10.2, Non-Reimbursed Arrangements with Local Public
Health Entities, is modified to update the requirements and delete the
requirement for an MOU.Section 8.2.11, Coordination with Other State Health and Human
Services (HHS) Programs, is modified to update the requirements and
delete the requirement for an MOU.Section 8.4.2, CHIP Provider Complaint and Appeals, is modified to
include the 30-day resolution requirement.Revision
    
    1.3
    
    
    September 1, 2006
    
    Revised version of Attachment B-1, Section 8, that includes
provisions applicable to MCOs participating in the CHIP Perinatal
Program.
 8-2




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 DOCUMENT
    
    EFFECTIVESTATUS1
    
    REVISION2
    
    DATE
    
    DESCRIPTION3Section 8.1.1.1, Performance Evaluation, is modified to clarify that
HHSC will negotiate and implement Performance Improvement Goals
for the first full State Fiscal Year following the CHIP Perinatal
Operational Start 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 CHIP Perinatal Program and CHIP
Perinatal Newborn.Section 8.1.13, Service Management for Certain Populations,
modified to clarify the CHIP Perinatal Program.Section 8.1.15, Behavioral Health (BH) Network and Services,
modified to clarify between CHIP Perinatal and Perinate members.Section 8.1.17.2, Financial Reporting Requirements, modified to
include the CHIP Perinatal Program.Section 8.1.18.3, System-wide Functions, modified to include the
CHIP Perinatal Program.Section 8.1.18.5, Claims Processing Requirements, modified to
include the CHIP Perinatal Program.
 8-3




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 DOCUMENT
    
    EFFECTIVESTATUS1
    
    REVISION2
    
    DATE
    
    DESCRIPTION3Section 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 1, 2006
    
    Contract amendment did not revise Attachment B-1, Section 8-
Operations Phase Requirements.Revision
    
    1.5
    
    
    January 1, 2007
    
    Revised version of the Attachment B-1, Section 8, that includes
provisions applicable to MCOs participating in the STAR and
STAR+PLUS Program.Section 8.1.2 is modified to include a reference to STAR and
STAR+PLUS covered services.Section 8.1.20.2 is modified to update the references to the Uniform
Managed Care Manual for the Summary Report of Member
Complaints and Appeals and the Summary Report of Provider
Complaints.Section 8.2.2.5 is modified to require the Provider to coordinate with
the Regional Health Authority.Section 8.2.4 is amended to clarify cost settlements and encounter
rates for Federally Qualified Health Centers (FQHCs) and Rural
Health Clinics (RHCs) for STAR and STAR+PLUS service areas.Section 8.3.2.4 is amended to clarify the timeframe for initial
STAR+PLUS assessments.Section 8.3.3 is amended to: (1) clarify the use of the DHS Form
2060; (2) require the HMO to complete the Individual Service Plan
(ISP), Form 3671 for each Member receiving 1915(c) Nursing Facility
Waiver Services; (3) require HMOs to complete Form 3652 and Form
3671annually at reassessment; (4) allow the HMOs to administer the
Minimum Data Set for Home Care (MDS-HC) instrument for non-
waiver STAR+PLUS Members over the course of the first year of
operation; (5) allow HMOs to submit other supplemental assessment
instruments.Section 8.3.4 is modified to include the criteria for participation in
1915(c) nursing facility waiver services.Section 8.3.4.3 is amended to remove the six-month timeframe for
Nursing Facility Cost Ceiling. Deletes provision stating DADS
Commissioner may grant exceptions in individual cases.Section 8.3.5 is amended to delete the requirement that HMOs use
the Consumer Directed Services option for the delivery of Personal
Attendant Services. The new language provides HMOs with three
options for delivering these services. The options are described in the
following new subsections: 8.3.5.1, Personal Attendant Services
Delivery Option  Self-Directed Model; 8.3.5.2, Personal Attendant
Services Delivery Option  Agency Model, Self-Directed; and 8.3.5.3,
Personal Attendant Services Delivery Option  Agency Model.Section 8.3.7.3 is modified to reflect the changes made by the HMO
workgroup regarding enhanced payments for attendant care. The
section also includes a reference to new Attachment B-7, which
 8-4




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 DOCUMENT
    
    EFFECTIVESTATUS1
    
    REVISION2
    
    DATE
    
    DESCRIPTION3contains the HMOs methodology for implementing and paying the
enhanced payments.Revision
    
    1.6
    
    
    February 1, 2007
    
    Revised version of the Attachment B-1, Section 8, that includes
provisions applicable to MCOs participating in the STAR+PLUS and
CHIP Perinatal Programs.Section 8.1 is modified to clarify the Operational Start Date of the
STAR+PLUS Program.Section 8.1.3.2 is modified to allow exceptions to hospital access
standards on a case-by-case basis only for HMOs participating in the
CHIP Perinatal Program.Section 8.3.3 is modified to clarify when the 12-month period begins
for the STAR+PLUS HMOs to complete the MDS-HC instruments for
non-1915(c) Nursing Facility Waiver Members who are receiving
Community-based Long-term Care Services.Revision
    
    1.7
    
    
    July 1, 2007
    
    New Section 8.1.1.2 is added to require the HMOs to pay for any
additional readiness reviews beyond the original ones conducted
before the Operational Start Date.Section 8.1.5.5 is modified to add a requirement that all HMOs must
list Home Health Ancillary providers on their websites, with an
indicator for Pediatric services.Section 8.1.17.2 is modified to remove the requirement that the
Claims Lag Report separate claims by service categories.Section 8.1.18 is modified to update the cross-references to sections
of the contract addressing remedies and damages and to add cross-
references to sections of the contract addressing Readiness Reviews.Section 8.1.18.5 is modified to require the HMO to make an electronic
funds transfer payment process available when processing claims for
Medically Necessary covered STAR+PLUS services.Section 8.1.19 is modified to comply with a new federal law that
requires entities that receive or make Medicaid payments of at least
$5 million annually to educate employees, contractors and agents and
to implement policies and procedures for detecting and preventing
fraud, waste and abuse. Section 8.1.20.2 is modified to require
Provider Termination Reports for STAR+PLUS as required by the
Dashboard. The amendment also requires Claims Summary Reports
be submitted by claim type.Section 8.2.7.5 is modified to comply with the settlement agreement in
the Alberto N. litigation.Section 8.3.4.3 is modified to remove references to the cost cap for
1915(c) Nursing Facility Waiver services.Revision
    
    1.8
    
    
    September 1, 2007
    
    Section 8.1.2.1 is modified to reflect legislative changes required by
SB 10.Section 8.1.3.2 is modified to reflect legislative changes required by
SB 10.Section 8.1.5.6 is modified to comply with the Frew litigation
corrective action plans.New Section 8.1.5.6.1 is added to comply with the Frew litigation
corrective action plans.Section 8.1.5.7 is modified to comply with the Frew litigation
corrective action plans.
 8-5




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 DOCUMENT
    
    EFFECTIVESTATUS1
    
    REVISION2
    
    DATE
    
    DESCRIPTION3Section 8.1.11 is modified to delete language included in error and to
clarify the coverage for children in foster care.Section 8.1.13 is added to comply with the Frew litigation corrective
action plans.Section 8.1.17.2 is modified to reflect legislative changes required by
SB 10.Section 8.1.20.2 is modified to comply with the Frew litigation
corrective action plans by adding two new reports: Medicaid Medical
Check-ups Report and Medicaid FWC Report.Section 8.2.2.3 is modified to comply with Frew litigation correction
action plans.New Section 8.2.2.12 is added to comply with the Frew litigation
correction action plans to enhance care for children of Migrant
Farmworkers.Section 8.2.4 is modified to clarify cost settlement requirements and
encounter and payment reporting requirements for the Nueces
Service Area and the STAR+PLUS Service Areas.Section 8.2.7.4 is amended to reflect the new fair hearings process for
Medicaid Members that will be effective 9/1/07.Section 8.2.11 is modified to comply with the Frew litigation corrective
action plans.
 
 1
    
    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.
 8-6




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  
 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
   8-7




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  
 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 MembersGoal 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
   8-8




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  Performance Indicator Dashboard (see
HHSCs Uniform Managed Care Manual)
  
 8.1.1.2 Additional HMO Readiness Reviews
  Attachment B-1, Section 7 Attachment B-1, Section 8.1.18 Attachment A, Section 4.08(c)
    
 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:
   8-9




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  
 Attachments B-2 and B-2.1 of the
Contract (STAR and STAR+PLUS Covered Services) 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 Attachment B-2.2 of the Contract
   8-10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  
 8.1.2.1 Value-added Services
    Transition Phase. Attachment B-3, Value-Added Services
   Operations Phase
   8-11




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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;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
   8-12




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
   Section 8.1.15. Section 8.2.2.1
   Section 8.1.4.
 8-13




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  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; and8.
    
    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 8.1.3.1.
 PCP Access:
 OB/GYN Access and CHIP Perinatal Program Provider Access:
   8-14




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
   Outpatient Behavioral Health Service Provider Access
  
 Other Specialist Physician Access
 Hospital Access
 All other Covered Services, except for services provided in the Members residence Attachment B-2,
   8-15




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  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
    NOTE
 All Providers:
   8-16




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  Inpatient hospital and medical services:
 Childrens Hospitals/hospitals with specialized pediatric services:
 Trauma:
 Transplant centers:
 Hemophilia centers:
 Physician services: Section 8.1.3
 8-17




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
   Laboratory services: Section 8.1.3
 Diagnostic imaging: Section 8.1.3
 Home health services:
 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
 8-18




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  
 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, and3.
    
    the Provider has admitting privileges to a local hospital that includes admissions to
pediatric units.
   8-19




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  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.
 8-20




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 8.1.4.3 PCP Notification
  8.1.4.4 Provider Credentialing and Re-credentialing
    8.1.4.5 Board Certification Status
  
 8.1.4.6 Provider Manual, Materials and Training
   8-21




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 Uniform Managed Care Manual Attachment B-1, Section 7
   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
 8.1.4.7 Provider Hotline
   8-22




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  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.
    
 8.1.4.9 Termination of Provider Contracts
   8.1.5 Member Services
   8-23




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
    
 8.1.5.1 Member Materials
  Section 8.1.5.4.
  Uniform Managed Care Terms and Conditions 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.
   8-24




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
    
 8.1.5.3 Member Handbook
 Attachment B-1, Section 7
 Section 8.1.5.1 Uniform Managed Care Manual
    
 8.1.5.4 Provider Directory
  Attachment B-1, Section 7 Attachment B-1, Section 7
 Section 8.1.5.1 Uniform Managed Care Manual Section 8.1.4.4
   8-25




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
    
 8.1.5.5 Internet Website
   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
   8-26




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
    1.
    
    Knowledgeable about Covered Services;2.
    
    Able to answer non-technical questions pertaining to the role of the PCP, as
applicable;3.
    
    Able to answer non-clinical questions pertaining to referrals or the process for
receiving authorization for procedures or services;4.
    
    Able to give information about Providers in a particular area;5.
    
    Knowledgeable about Fraud, Abuse, and Waste and the requirements to report
any conduct that, if substantiated, may constitute Fraud, Abuse, or Waste in
the HMO Program;6.
    
    Trained regarding Cultural Competency;7.
    
    Trained regarding the process used to confirm the status of persons with
Special Health Care Needs;8.
    
    For Medicaid members, able to answer non-clinical questions pertaining to
accessing Non-capitated Services.9.
    
    For Medicaid Members, trained regarding: a) the emergency prescription process
and what steps to take to immediately address problems when pharmacies do not
provide a 72-hour supply of emergency medicines; and b) DME processes for obtaining
services and how to address common problems.10.
    
    For CHIP Members, able to give correct cost-sharing information relating to premiums,
co-pays or deductibles, as applicable. (Cost-sharing does not apply to CHIP Perinates or
CHIP Perinate Newborns.)
   8-27




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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.
    
 8.1.5.6.1 Nurseline
    
 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;e.
    
    Service Coordination, treatment for pregnant women, Members with
Special Health Care Needs, including Children with Special Health Care
Needs; and other special populations;f.
    
    Early Childhood Intervention (ECI) Services;g.
    
    Screening and preventive services, including well-child care (THSteps medical
checkups for Medicaid Members);h.
    
    For CHIP Members, Member co-payments
   8-28




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 i.
    
    Suicide prevention;j.
    
    Identification and health education related to Obesity; andk.
    
    Obtaining 72 hour supplies of emergency prescriptions from pharmacies
enrolled with HHSC as Medicaid providers.
  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.
   8-29




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  Uniform Managed Care Contract Terms &
Conditions Attachment B-5, Deliverables/Liquidated Damages Matrix.
 Section
8.2.6 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
   8-30




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  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
   8-31




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  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.
   
 8-32




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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.
   8-33




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 
    
    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/RDMClinGuide.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.
 8-34




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 8.1.9 Early Childhood Intervention (ECI)
 8-35




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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.
   8-36




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 
  
 8.1.12 Services for People with Special Health Care Needs
  8.1.12.1 Identification
 1
 Uniform Managed Care Manual
    
 8.1.12.2 Access to Care and Service Management
   
 1
    
    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.
   8-37




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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;
 8-38




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 
    
    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);3.
    
    Individuals with mental illness and co-occurring substance abuse; and4.
    
    FWC (STAR and STAR+PLUS Programs only).
    
 8.1.14 Disease Management (DM)
 Uniform Managed Care
Manual Uniform Managed Care Manual
  1.
    
    Patient self-management education;
   8-39




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 2.
    
    Provider education;3.
    
    Evidence-based models and minimum standards of care;4.
    
    Standardized protocols and participation criteria;5.
    
    Physician-directed or physician-supervised care;6.
    
    Implementation of interventions that address the continuum of care;7.
    
    Mechanisms to modify or change interventions that are not proven effective; 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
   8-40




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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
 8-41




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 
  
 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
 8-42




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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
 8-43




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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
 8-44




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 written request from HHSC for specified records or information. If such documentation
is not made available as requested, the HMO agrees to reimburse HHSC for all costs,
including, but not limited to, transportation, lodging, and subsistence for all State
and federal representatives, or their agents, to carry out their inspection, audit,
review, analysis, and reproduction functions at the location(s) of such accounting
records; and
 4.
    
    Pay any and all additional costs incurred by the State and federal government
that are the result of the HMOs failure to provide the requested accounting records
or financial information within ten (10) business days of receiving a written request
from the State or federal government.
  
 8.1.17.2 Financial Reporting Requirements
   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.
 8-45




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 Employee Bonus and/or Incentive Payment Plan  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
 8-46




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 Out-of-Network Utilization Reports Uniform Managed Care Manual
 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 
 8-47




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 Third Party Recovery (TPR) Reports  Uniform Managed Care Manual
 8.1.18 Management Information System Requirements
  1.
    
    Enrollment/Eligibility Subsystem;2.
    
    Provider Subsystem;3.
    
    Encounter/Claims Processing Subsystem;4.
    
    Financial Subsystem;5.
    
    Utilization/Quality Improvement Subsystem;6.
    
    Reporting Subsystem;7.
    
    Interface Subsystem; and8.
    
    TPR Subsystem, as applicable to each HMO Program.
     Uniform Managed Care Terms and
Conditions.
 8-48




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  Attachment B-1, Section 7
 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.
    
 Attachment A, Article 12 Attachment B-5 Refer to Attachment B-1, Section 7 Attachment B-1, Section 8.1.1.2 Attachment A, Section 4.08(c)
 8.1.18.1 Encounter Data
 Uniform Managed Care Manual
 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 1.8
  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.
   8-50




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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
   8-51




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
    
 Uniform Managed Care Manual
    
 8.1.19 Fraud and Abuse
  Attachment B-1, Section 7
   8-52




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 1.
    
    Contain procedures designed to prevent and detect potential or suspected Abuse, Fraud and
Waste in the administration and delivery of services under the Contract;2.
    
    Contain a description of the HMOs procedures for educating and training personnel to
prevent Fraud, Abuse, or Waste;3.
    
    Include provisions for the confidential reporting of plan violations to the designated
person within the HMOs organization and ensure that the identity of an individual reporting
violations is protected from retaliation;4.
    
    Include provisions for maintaining the confidentiality of any patient information
relevant to an investigation of Fraud, Abuse, or Waste;5.
    
    Provide for the investigation and follow-up of any allegations of Fraud, Abuse, or Waste
and contain specific and detailed internal procedures for officers, directors, managers and
employees for detecting, reporting, and investigating Fraud and Abuse compliance plan
violations;6.
    
    Require that confirmed violations be reported to the Office of Inspector General (OIG);
and7.
    
    Require any confirmed violations or confirmed or suspected Fraud, Abuse, or Waste under
state or federal law be reported to OIG.
    Additional Requirements for STAR and STAR+PLUS HMOs:
   8-53




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  1.
    
    Establish written policies for all employees, managers, officers, contractors,
subcontractors, and agents of the HMO, which provide detailed information about the False
Claims Act, administrative remedies for false claims and statements, any state laws
pertaining to civil or criminal penalties for false claims, and whistleblower protections
under such laws, as described in Section 1902(a)(68)(A).2.
    
    Include as part of such written policies, detailed provisions regarding the HMOs
policies and procedures for detecting and preventing fraud, waste, and abuse.3.
    
    Include in any employee handbook a specific discussion of the laws described in Section
1902(a)(68)(A), the rights of employees to be protected as whistleblowers, and the HMOs
policies and procedures for detecting and preventing fraud, waste, and abuse.
    
 8.1.20 Reporting Requirements
  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; and2.
    
    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
   8-54




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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
 Fraudulent Practices Report
 HHSC Uniform Managed Care Manual
 Provider Termination Report: (CHIP (including integrated CHIP Perinatal Program data), STAR, and
STAR+PLUS)
  PCP Network & Capacity Report: (CHIP only (including integrated CHIP Perinatal Program data))
   8-55




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  Summary Report of Member Complaints and Appeals HHSC Uniform Managed
Care Manual,
  Summary Report of Provider Complaints  HHSC
Uniform Managed Care Manual,
  Hotline Reports  Sections 8.1.5.6, 8.1.14.3, and 8.1.4.7
   Medicaid Medical Check-ups Report 
   8-56




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 (1)
    
    the total number of new Members under the age of 21 who are still enrolled with the HMO after
90 days;(2)
    
    the number and percent of new Members under the age of 21 still enrolled with the HMO after 90
days who get medical check-ups within 90 days of enrollment into the HMO;(3)
    
    the total number of Members under the age of 21 who have been enrolled continuously with the
HMO for 90 days or more (excluding the new Members); and(4)
    
    the number and percent of Members under the age of 21 who have been enrolled continuously for
90 days or more with the HMO (excluding the new Members) who get timely, age-appropriate medical
check-ups.
  Uniform Managed Care
Manual
 Medicaid FWC Report 
    
 8.2 Additional Medicaid HMO Scope of Work
  8.2.1 Continuity of Care and Out-of-Network Providers
   8-57




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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
 8-58




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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:
 8-59




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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
      8.2.2.3 Texas Health Steps (EPSDT)
 8-60




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 
  
 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
   8-61




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 8.2.2.4 Perinatal Services
 8-62




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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.
      8.2.2.5 Sexually Transmitted Diseases (STDs) and Human Immunodeficiency Virus (HIV)
 8-63




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
   
    
 8.2.2.6 Tuberculosis (TB)
 Section 8.2.2.8
   8-64




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
   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;
   8-65




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
   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
    
 8.2.2.10 Cooperation with Immunization Registry
    
 8.2.2.11 Case Management for Children and Pregnant Women
 http://www.dshs.state.tx.us/caseman/default.shtm
   8-66




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
   
    
 8.2.2.12 Children of Migrant Farmworkers (FWC)
    
    
    Identification of community and statewide groups that work with FWC Members within
the HMOs Service Areas;
    
    Participation of the community groups in assisting with the identification of FWC
Members;
    
    Appropriate aggressive efforts to reach each identified FWC to provide timely
medical checkups and follow up care if needed;
 
    
    Methods to maintain accurate, current lists of all identified FWC Members;
 
    
    Methods that the HMO and its Subcontractors will implement to maintain the
confidentiality of information about the identity of FWC; and
 
    
    Methods to provide accelerated services to FWC.
    
 8.2.3 Medicaid Significant Traditional Providers
   8-67




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
   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)
   8-68




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
   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
   8-69




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
   8.2.7 Medicaid Member Complaint and Appeal System
   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
   8-70




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
   1.
    
    Date;2.
    
    Identification of the individual filing the Complaint;3.
    
    Identification of the individual recording the Complaint;4.
    
    Nature of the Complaint;5.
    
    Disposition of the Complaint (i.e., how the HMO resolved the
Complaint);6.
    
    Corrective action required; and7.
    
    Date resolved.
    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.
   8-71




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
   Section 8.2.7.9
    1)
    
    Date notice is sent;2)
    
    Effective date of the Action;3)
    
    Date the Member or his or her representative requested the Appeal;4)
    
    Date the Appeal was followed up in writing;5)
    
    Identification of the individual filing;6)
    
    Nature of the Appeal; and7)
    
    Disposition of the Appeal, and notice of disposition to Member.
   8-72




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 Section 8.2.7.3
    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.
   8-73




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
     8.2.7.3 Expedited Medicaid HMO Appeals
 Section 8.2.7.2
   Section 8.2.7.5
   8-74




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
   (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 dates, types and amount of service requested;2.
    
    The Action the HMO has taken or intends to take;3.
    
    The reasons for the Action (If the Action taken is based upon a determination that the
requested service is not medically necessary, the HMO must provide an explanation of the
medical basis for the decision, application of policy or accepted standards of medical
practice to the individuals medical circumstances, in its notice to the member.);4.
    
    The Members right to access the HMOs Appeal process.5.
    
    The procedures by which the Member may Appeal the HMOs Action;
   8-75




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 6.
    
    The circumstances under which expedited resolution is available and how to request it;7.
    
    The circumstances under which a Member may continue to receive benefits pending
resolution of the Appeal, how to request that benefits be continued, and the circumstances
under which the Member may be required to pay the costs of these services;8.
    
    The date the Action will be taken;9.
    
    A reference to the HMO policies and procedures supporting the HMOs Action;10.
    
    An address where written requests may be sent and a toll-free number that the Member can
call to request the assistance of a Member representative, file an Appeal, or request a Fair
Hearing;11.
    
    An explanation that Members may represent themselves, or be represented by a provider, a
friend, a relative, legal counsel or another spokesperson;12.
    
    A statement that if the Member wants a Fair Hearing on the Action, the Member must make
the request for a Fair Hearing within 90 days of the date on the notice or the right to
request a hearing is waived;13.
    
    A statement explaining that the HMO must make its decision within 30 days from the date
the Appeal is received by the HMO, or 3 business days in the case of an Expedited Appeal;
and14.
    
    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; and
   8-76




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 8.
    
    For expedited service authorization decisions, within the timeframes specified in 42
C.F.R. 438.210(d).
 8.2.7.7 Notice of Disposition of Appeal
  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; and6.
    
    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.
   8-77




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  8.2.8 Additional Medicaid Behavioral Health Provisions
    
 8.2.8.1 Local Mental Health Authority (LMHA)
   1.
    
    Describe the Behavioral Health Services indicated in detail in the Provider Procedures
Manual and in the Texas Medicaid Bulletin, include the amount, duration, and scope of basic
and Value-added Services, and the HMOs responsibility to provide these services;2.
    
    Describe criteria, protocols, procedures and instrumentation for referral of Medicaid
Members from and to the HMO and the LMHA;3.
    
    Describe processes and procedures for referring Members with SPMI or SED to the LMHA for
assessment and determination of eligibility for rehabilitation or targeted case management
services;4.
    
    Describe how the LMHA and the HMO will coordinate providing Behavioral Health Services to
Members with SPMI or SED;5.
    
    Establish clinical consultation procedures between the HMO and LMHA including
consultation to effect referrals and on-going consultation regarding the Members progress;6.
    
    Establish procedures to authorize release and exchange of clinical treatment records;7.
    
    Establish procedures for coordination of assessment, intake/triage, utilization
review/utilization management and care for persons with SPMI or SED;8.
    
    Establish procedures for coordination of inpatient psychiatric services (including Court-
ordered Commitment of Members under 21) in state psychiatric facilities within the LMHAs
catchment area;9.
    
    Establish procedures for coordination of emergency and urgent services to Members;10.
    
    Establish procedures for coordination of care and transition of care for new Members who
are receiving treatment through the LMHA; 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.
   8-78




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
    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
   8-79




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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.
    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.
   8-80




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
    
 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;6.
    
    Participate, to the extent practicable, in the community-based coalitions with the
Medicaid-funded case management programs in the Department of Assistive and Rehabilitative
Services (DARS), the Department of Aging and Disability Services (DADS), and DSHS;7.
    
    Cooperate with activities required of state and local public health authorities necessary
to conduct the annual population and community based needs assessment;8.
    
    Report all blood lead results, coordinate and follow-up of suspected or confirmed cases
of childhood lead exposure with the Childhood Lead Poisoning Prevention Program in DSHS; and9.
    
    Coordinate with THSteps.
 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;
   8-81




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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.
    th th th th
    
 8.3 Additional STAR+PLUS Scope of Work
 8.3.1 Covered Community-Based Long-Term Care Services
   8-82




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  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
 Service
    
    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 Waiver
 Service
    
    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.
   8-83




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 Community Long-Term Care Services Under the 1915(c) Nursing Facility Waiver
 Service
    
    Licensure and Certification RequirementsAssisted Living
    
    The Provider must be licensed by the Texas
Department of Aging and Disability Services, Long
Term Care Regulatory Division. The type of
licensure determines what services may be
provided.Emergency Response Service Provider
    
    Texas Department of Aging and Disability Services
(DADS) Standards for Emergency Response Services
at 40 T.A.C. §52.201(a), and be licensed by the
Texas Board of Private Investigators and Private
Security Agencies, unless exempt from licensure.Adult Foster Home
    
    TDSHS Provider standards for Adult Foster Care
and TDSHS Rules at 40 T.A.C. §48.6032. Four bed
homes also licensed under TDSHS Rules at 40
T.A.C. §481.8906.DFPS licensure in accordance with 24-hour Care
Licensing requirements found in T.A.C., Title 40,
Part 19, Chapter 720.Home Delivered Meals
    
    T.A.C., Title 40, Part 1, Chapter 55.Physical Therapy
    
    Licensed Physical Therapist through the Texas
Board of Physical Therapy Examiners, Chapter 453.Occupational Therapy
    
    Licensed Occupational Therapist through the Texas
Board of Occupational Therapy Examiners, Chapter
454.Speech Therapy
    
    Licensed Speech Therapist Through the Department
of State Health Services.Consumer Directed Services
    
    Home and Community Support Services Agency (HCSSA)Transition Assistance Services
    
    No licensure or certification requirements.Minor Home Modification
    
    No licensure or certification requirements.Adaptive Aids and Medicaid Equipment
    
    No licensure or certification requirements.Medical supplies
    
    No licensure or certification requirements.
 8.3.2 Service Coordination
   8-84




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 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.).
 8-85




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 8.3.2.3 Discharge Planning
  
 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.
   8-86




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 8.3.2.5 Centralized Medical Record and Confidentiality
   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 8.3.2.7
 8-87




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 8.3.2.7 HMO Four-Month Liability for Nursing Facility Care
 8-88




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 8.3.3 STAR+PLUS Assessment Instruments
  
 
   8-89




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  
 
    
    For the 1915(c) Nursing Facility Waiver Members, the MDS-HC instrument must
be completed in conjunction with the annual reassessment. The MDS-HC instrument
must be completed annually at the time of reassessment for these Members.
    
    For the non-1915(c) Nursing Facility Waiver Members that are receiving
Community-based Long-term Care Services, the HMO must submit a schedule for
HHSCs approval that provides a plan of how the MDS-HC instruments will be
completed for these Members over a twelve-month period beginning on February 1,
2007.
    
 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
   8-90




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
    
 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; and2.
    
    HHSC continues to comply with the cost-effectiveness requirements from the CMS.
    
 8.3.5 Personal Attendant Services
  
    
    at initial assessment;
    
    at annual reassessment or annual contact with the STAR+PLUS Member;
    
    at any time when a STAR+PLUS Member receiving PAS requests the information; and
    
    in the Member Handbook.
   8-91




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  8.3.5.1 Personal Attendant Services Delivery Option  Self-Directed Model
  8.3.5.2 Personal Attendant Services Delivery Option  Agency Model, Self-Directed
  8.3.5.3 Personal Attendant Services Delivery Option  Agency Model
  8.3.6 Community Based Long-term Care Service Providers
 8.3.6.1 Training
   8-92




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
  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
  Attachment B-7 Uniform
Managed Care Manual th
   8-93




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 8.3.7.4 Payment for 1915(c) Nursing Facility Waiver Services for Non-Members
 Disenrolled Members
 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
   8-94




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 8.4.3 CHIP Member Complaint and Appeal Process
 Uniform Managed Care Contract
Terms & Conditions Attachment B-5, Deliverables/Liquidated Damages Matrix.
 8.4.4 Dental Coverage for CHIP Members
    
 8.5 Additional CHIP Perinatal Scope of Work
  8.5.1 CHIP Perinatal Provider Network
   8-95




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-1  HHSC Joint Medicaid/CHIP HMO RFP, Section 8
    
    Version 1.8
 8.5.2 CHIP Perinatal Program Provider Complaint and Appeals
  8.5.3 CHIP Perinatal Program Member Complaint and Appeal Process
   8-96




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-4  Performance Improvement Goals
    
    Version 1.8
 DOCUMENT HISTORY LOG
 DOCUMENT
    
    EFFECTIVESTATUS1
    
    REVISION2
    
    DATE
    
    DESCRIPTION3Baseline
    
    n/a
    
    
    
    
    Initial version Attachment B-4, Performance
Improvement Goals.Revision
    
    1.1
    
    
    June 30, 2006
    
    Contract amendment to include STAR+PLUS
Program. Revised Attachment B-4, Performance
Improvement Goals Template, by adding
Attachment B-4.1, FY2008 Performance
Improvement Goals Template. No change to this
Section.Revision
    
    1.2
    
    
    September 1, 2006
    
    Revised version of Attachment B-4 that includes
provisions applicable to MCOs participating in
the STAR and CHIP Programs.Updates the attachment to reflect the changes
made in Attachment B-1, Section 8.1.1.1.Revision
    
    1.3
    
    
    September 1, 2006
    
    Contract amendment did not revise Attachment
B-4, Performance Improvement Goals.Revision
    
    1.4
    
    
    September 1, 2006
    
    Contract amended to include Attachment B-4
Performance Improvement Goals for SFY2007
and format changeRevision
    
    1.5
    
    
    January 1, 2007
    
    Contract amendment did not revise Attachment
B-4, Performance Improvement Goals.Revision
    
    1.6
    
    
    February 1, 2007
    
    Contract amendment did not revise Attachment
B-4, Performance Improvement Goals.Revision
    
    1.7
    
    
    July 1, 2007
    
    Contract amendment did not revise Attachment
B-4, Performance Improvement Goals.Revision
    
    1.8
    
    
    September 1, 2007
    
    Revised Attachment B-4, to replace FY2007
Performance Improvement Goals with newly
negotiated FY2008 Performance Improvement
Goals by Program and by Service Area.
Attachment B-4.1, FY2008 Performance
Improvement Goals Template, is deleted as
duplicative.
 
 1
    
    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. Attachment
B-1, Section 8.1.1.1,
   1 of 13




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-4  Performance Improvement Goals
    
    Version 1.8
  
 Texas Health and Human Services Commission
HMO Performance Improvement Goal Template
for State Fiscal Year 2008
 (September 1, 2007  August 31, 2008)
 A.
    
    Health Plan Information
 Plan
Name: AMERIGROUP Community Care  HMO Program: CHIP  HMO Service Delivery Area: Dallas SDA
 B. Overarching Goal
    
    C. Sub Goals:Goal 1:Improve Access to Primary Care
Services for Members
    
    
    
    Increase PCPs providing after hours access by two percent
(2%) over baseline.
    
    Ninety percent (90%) of new PCPs will be credentialed,
configured, and able to see members within 90 days of
receipt of a clean and complete application.Goal 2:Improve Access to Behavioral
Health Services for Members
    
    
    
    95% of members who deliver a baby will be sent
information regarding postpartum depression.
    
    Contact 90% of members discharged from a BH inpatient
stay to remind them of the 7-day follow-up appointment.Goal 3:Increase Utilization of New
Member Medical Check-Ups
within 90 days of Enrollment
    
    
    
    Increase the number of new members for well-child exams
with their PCPs within 90 days of enrollment by 2% over
baseline.
    
    Contact 40% of new members who defaulted to a PCP to
educate on medical home and well-child exam
requirements.
 Attachment
B-1, Section 8.1.1.1,
   2 of 13




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-4  Performance Improvement Goals
    
    Version 1.8
  
 Texas Health and Human Services Commission
HMO Performance Improvement Goal Template
for State Fiscal Year 2008
 (September 1, 2007  August 31, 2008)
 A.
    
    Health Plan Information
 Plan Name: AMERIGROUP Community Care  HMO Program: CHIP  HMO Service Delivery Area: Harris Core and Optional
 B. Overarching Goal
    
    C. Sub Goals:Goal 1:Improve Access to Primary Care
Services for Members
    
    
    
    Increase PCPs providing after hours access by two percent
(2%) over baseline.
    
    Ninety percent (90%) of new PCPs will be credentialed,
configured, and able to see members within 90 days of
receipt of a clean and complete application.Goal 2:Improve Access to Behavioral
Health Services for Members
    
    
    
    95% of members who deliver a baby will be sent
information regarding postpartum depression.
    
    Contact 90% of members discharged from a BH inpatient
stay to remind them of the 7-day follow-up appointment.Goal 3:Increase Utilization of New
Member Medical Check-Ups
within 90 days of Enrollment
    
    
    
    Increase the number of new members for well-child exams
with their PCPs within 90 days of enrollment by 2% over
baseline.
    
    Contact 40% of new members who defaulted to a PCP to
educate on medical home and well-child exam
requirements.
 Attachment
B-1, Section 8.1.1.1,
   3 of 13




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-4  Performance Improvement Goals
    
    Version 1.8
  
 Texas Health and Human Services Commission
HMO Performance Improvement Goal Template
for State Fiscal Year 2008
 (September 1, 2007  August 31, 2008)
 A.
    
    Health Plan Information
 Plan Name: AMERIGROUP Community Care  HMO Program: CHIP  HMO Service Delivery Area: Nueces SDA
 B. Overarching Goal
    
    C. Sub Goals:Goal 1:Improve Access to Primary Care
Services for Members
    
    
    
    Increase PCPs providing after hours access by two percent
(2%) over baseline.
    
    Ninety percent (90%) of new PCPs will be credentialed,
configured, and able to see members within 90 days of
receipt of a clean and complete application.Goal 2:Improve Access to Behavioral
Health Services for Members
    
    
    
    95% of members who deliver a baby will be sent
information regarding postpartum depression.
    
    Contact 90% of members discharged from a BH inpatient
stay to remind them of the 7-day follow-up appointment.Goal 3:Increase Utilization of New
Member Medical Check-Ups
within 90 days of Enrollment
    
    
    
    Increase the number of new members for well-child exams
with their PCPs within 90 days of enrollment by 2% over
baseline.
    
    Contact 40% of new members who defaulted to a PCP to
educate on medical home and well-child exam
requirements.
 Attachment
B-1, Section 8.1.1.1,
   4 of 13




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-4  Performance Improvement Goals
    
    Version 1.8
  
 Texas Health and Human Services Commission
HMO Performance Improvement Goal Template
for State Fiscal Year 2008
 (September 1, 2007  August 31, 2008)
 A. Health Plan Information
 Plan Name: AMERIGROUP Community Care  HMO Program: CHIP  HMO Service Delivery Area: Tarrant SDA
 B. Overarching Goal
    
    C. Sub Goals:Goal 1:Improve Access to Primary Care
Services for Members
    
    
    
    Increase PCPs providing after hours access by two percent
(2%) over baseline.
    
    Ninety percent (90%) of new PCPs will be credentialed,
configured, and able to see members within 90 days of
receipt of a clean and complete application.Goal 2:Improve Access to Behavioral
Health Services for Members
    
    
    
    95% of members who deliver a baby will be sent
information regarding postpartum depression.
    
    Contact 90% of members discharged from a BH inpatient
stay to remind them of the 7-day follow-up appointment.Goal 3:Increase Utilization of New
Member Medical Check-Ups
within 90 days of Enrollment
    
    
    
    Increase the number of new members for well-child exams
with their PCPs within 90 days of enrollment by 2% over
baseline.
    
    Contact 40% of new members who defaulted to a PCP to
educate on medical home and well-child exam
requirements.
 Attachment
B-1, Section 8.1.1.1,
   5 of 13




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-4  Performance Improvement Goals
    
    Version 1.8
  
 Texas Health and Human Services Commission
HMO Performance Improvement Goal Template
for State Fiscal Year 2008
 (September 1, 2007  August 31, 2008)
 A.
    
    Health Plan Information
 Plan Name: AMERIGROUP Community Care  HMO Program: STAR  HMO Service Delivery Area: Dallas SDA
 B. Overarching Goal
    
    C. Sub Goals:Goal 1:Improve Access to Primary Care
Services for Members
    
    
    
    Increase PCPs providing after hours access by two percent
(2%) over baseline.
    
    Ninety percent (90%) of new PCPs will be credentialed,
configured, and able to see members within 90 days of
receipt of a clean and complete application.Goal 2:Improve Access to Behavioral
Health Services for Members
    
    
    
    95% of members who deliver a baby will be sent
information regarding postpartum depression.
    
    Ensure that 100% of all new members are informed about
how to access BH services.Goal 3:Increase Utilization of New
Member Medical Check-Ups
within 90 days of Enrollment
    
    
    
    Increase the number of new members for well-child exams
with their PCPs within 90 days of enrollment by 2% over
baseline.
    
    Contact 40% of new members who defaulted to a PCP to
educate on medical home and well-child exam
requirements.
 Attachment
B-1, Section 8.1.1.1,
   6 of 13




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-4  Performance Improvement Goals
    
    Version 1.8
  
 Texas Health and Human Services Commission
HMO Performance Improvement Goal Template
for State Fiscal Year 2008
 (September 1, 2007  August 31, 2008)
 A.
    
    Health Plan Information
 Plan Name: AMERIGROUP Community Care  HMO Program: STAR  HMO Service Delivery Area: Harris SDA and Harris Expansion SDA
 B. Overarching Goal
    
    C. Sub Goals:Goal 1:Improve Access to Primary Care
Services for Members
    
    
    
    Increase PCPs providing after hours access by two percent
(2%) over baseline.
    
    Ninety percent (90%) of new PCPs will be credentialed,
configured, and able to see members within 90 days of
receipt of a clean and complete application.Goal 2:Improve Access to Behavioral
Health Services for Members
    
    
    
    95% of members who deliver a baby will be sent
information regarding postpartum depression.
    
    Ensure that 100% of all new members are informed about
how to access BH services.Goal 3:Increase Utilization of New
Member Medical Check-Ups
within 90 days of Enrollment
    
    
    
    Increase the number of new members for well-child exams
with their PCPs within 90 days of enrollment by 2% over
baseline.
    
    Contact 40% of new members who defaulted to a PCP to
educate on medical home and well-child exam
requirements.
 Attachment
B-1, Section 8.1.1.1,
   7 of 13




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-4  Performance Improvement Goals
    
    Version 1.8
  
 Texas Health and Human Services Commission
HMO Performance Improvement Goal Template
for State Fiscal Year 2008
 (September 1, 2007  August 31, 2008)
 A.
    
    Health Plan Information
 Plan Name: AMERIGROUP Community Care  HMO Program: STAR  HMO Service Delivery Area: Nueces SDA
 B. Overarching Goal
    
    C. Sub Goals:Goal 1:Improve Access to Primary Care
Services for Members
    
    
    
    Increase PCPs providing after hours access by two percent
(2%) over baseline.
    
    Ninety percent (90%) of new PCPs will be credentialed,
configured, and able to see members within 90 days of
receipt of a clean and complete application.Goal 2:Improve Access to Behavioral
Health Services for Members
    
    
    
    95% of members who deliver a baby will be sent
information regarding postpartum depression.
    
    Ensure that 100% of all new members are informed about
how to access BH services.Goal 3:Increase Utilization of New
Member Medical Check-Ups
within 90 days of Enrollment
    
    
    
    Increase the number of new members for well-child exams
with their PCPs within 90 days of enrollment by 2% over
baseline.
    
    Contact 40% of new members who defaulted to a PCP to
educate on medical home and well-child exam
requirements.
 Attachment
B-1, Section 8.1.1.1,
   8 of 13




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-4  Performance Improvement Goals
    
    Version 1.8
  
 Texas Health and Human Services Commission
HMO Performance Improvement Goal Template
for State Fiscal Year 2008
 (September 1, 2007  August 31, 2008)
 A.
    
    Health Plan Information
 Plan Name: AMERIGROUP Community Care  HMO Program: STAR  HMO Service Delivery Area: Tarrant SDA
 B. Overarching Goal
    
    C. Sub Goals:Goal 1:Improve Access to Primary Care
Services for Members
    
    
    
    Increase PCPs providing after hours access by two percent
(2%) over baseline.
    
    Ninety percent (90%) of new PCPs will be credentialed,
configured, and able to see members within 90 days of
receipt of a clean and complete application.Goal 2:Improve Access to Behavioral
Health Services for Members
    
    
    
    95% of members who deliver a baby will be sent
information regarding postpartum depression.
    
    Ensure that 100% of all new members are informed about
how to access BH services.Goal 3:Increase Utilization of New
Member Medical Check-Ups
within 90 days of Enrollment
    
    
    
    Increase the number of new members for well-child exams
with their PCPs within 90 days of enrollment by 2% over
baseline.
    
    Contact 40% of new members who defaulted to a PCP to
educate on medical home and well-child exam
requirements.
 Attachment
B-1, Section 8.1.1.1,
   9 of 13




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-4  Performance Improvement Goals
    
    Version 1.8
  
 Texas Health and Human Services Commission
HMO Performance Improvement Goal Template
for State Fiscal Year 2008
 (September 1, 2007  August 31, 2008)
 A.
    
    Health Plan Information
 Plan Name: AMERIGROUP Community Care  HMO Program: STAR  HMO Service Delivery Area: Travis SDA
 B. Overarching Goal
    
    C. Sub Goals:Goal 1:Improve Access to Primary Care
Services for Members
    
    
    
    Increase PCPs providing after hours access by two percent
(2%) over baseline.
    
    Ninety percent (90%) of new PCPs will be credentialed,
configured, and able to see members within 90 days of
receipt of a clean and complete application.Goal 2:Improve Access to Behavioral
Health Services for Members
    
    
    
    95% of members who deliver a baby will be sent
information regarding postpartum depression.
    
    Ensure that 100% of all new members are informed about
how to access BH services.Goal 3:Increase Utilization of New
Member Medical Check-Ups
within 90 days of Enrollment
    
    
    
    Increase the number of new members for well-child exams
with their PCPs within 90 days of enrollment by 2% over
baseline.
    
    Contact 40% of new members who defaulted to a PCP to
educate on medical home and well-child exam
requirements.
 Attachment
B-1, Section 8.1.1.1,
   10 of 13




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-4  Performance Improvement Goals
    
    Version 1.8
  
 Texas Health and Human Services Commission
HMO Performance Improvement Goal Template
for State Fiscal Year 2008
 (September 1, 2007  August 31, 2008)
 A.
    
    Health Plan Information
 Plan Name: AMERIGROUP Community Care  HMO Program: STAR+PLUS  HMO Service Delivery Area: Bexar SDA
 B. Overarching Goal
    
    C. Sub Goals:Goal 1:Improve Access to Primary Care
Services for Members
    
    
    
    Increase PCPs providing after hours access by two percent
(2%) over baseline.
    
    Ninety percent (90%) of new PCPs will be credentialed,
configured, and able to see members within 90 days of
receipt of a clean and complete application.Goal 2:Improve Access to Behavioral
Health Services for Members
    
    
    
    95% of members who deliver a baby will be sent
information regarding postpartum depression.
    
    Contact 90% of members discharged from a BH inpatient
stay to remind them of the 7-day follow-up appointment.Goal 3:Improve Member Understanding
of Service Coordination
    
    
    
    100% of STAR+PLUS members receiving LTSS will
receive a personalized letter/training explaining service
coordination.
    
    100% of all members NOT receiving Service Coordination
are mailed an informational pamphlet.
 Attachment
B-1, Section 8.1.1.1,
   11 of 13




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-4  Performance Improvement Goals
    
    Version 1.8
  
 Texas Health and Human Services Commission
HMO Performance Improvement Goal Template
for State Fiscal Year 2008
 (September 1, 2007  August 31, 2008)
 A.
    
    Health Plan Information
 Plan Name: AMERIGROUP Community Care  HMO Program: STAR+PLUS  HMO Service Delivery Area: Harris SDA and Harris Expansion SDA
 B. Overarching Goal
    
    C. Sub Goals:Goal 1:Improve Access to Primary Care
Services for Members
    
    
    
    Increase PCPs providing after hours access by two percent
(2%) over baseline.
    
    Ninety percent (90%) of new PCPs will be credentialed,
configured, and able to see members within 90 days of
receipt of a clean and complete application.Goal 2:Improve Access to Behavioral
Health Services for Members
    
    
    
    95% of members who deliver a baby will be sent
information regarding postpartum depression.
    
    Contact 90% of members discharged from a BH inpatient
stay to remind them of the 7-day follow-up appointment.Goal 3:Improve Member Understanding
of Service Coordination
    
    
    
    100% of STAR+PLUS members receiving LTSS will
receive a personalized letter/training explaining service
coordination.
    
    100% of all members NOT receiving Service Coordination
are mailed an informational pamphlet.
 Attachment
B-1, Section 8.1.1.1,
   12 of 13




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-4  Performance Improvement Goals
    
    Version 1.8
  
 Texas Health and Human Services Commission
HMO Performance Improvement Goal Template
for State Fiscal Year 2008
 (September 1, 2007  August 31, 2008)
 A.
    
    Health Plan Information
 Plan Name: AMERIGROUP Community Care  HMO Program: STAR+PLUS  HMO Service Delivery Area: Travis SDA
 B. Overarching Goal
    
    C. Sub Goals:Goal 1:Improve Access to Primary Care
Services for Members
    
    
    
    Increase PCPs providing after hours access by two percent
(2%) over baseline.
    
    Ninety percent (90%) of new PCPs will be credentialed,
configured, and able to see members within 90 days of
receipt of a clean and complete application.Goal 2:Improve Access to Behavioral
Health Services for Members
    
    
    
    95% of members who deliver a baby will be sent
information regarding postpartum depression.
    
    Contact 90% of members discharged from a BH inpatient
stay to remind them of the 7-day follow-up appointment.Goal 3:Improve Member Understanding
of Service Coordination
    
    
    
    100% of STAR+PLUS members receiving LTSS will
receive a personalized letter/training explaining service
coordination.
    
    100% of all members NOT receiving Service Coordination
are mailed an informational pamphlet.
 Attachment
B-1, Section 8.1.1.1,
   13 of 13




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-5  Deliverables/Liquidated Damages Matrix
    
    Version 1.8
 DOCUMENT HISTORY LOG
 DOCUMENTSTATUS1
    
    REVISION2
    
    EFFECTIVE DATE
    
    DESCRIPTION3Baseline
    
    
    n/a
    
    
    
    
    Initial version of Attachment B-5, Deliverables/Liquidated Damage Matrix.Revision
    
    
    1.1
    
    
    June 30, 2006
    
    Contract amendment did not revise Attachment B-5, Deliverables/Liquidated
Damage Matrix.Revision
    
    
    1.2
    
    
    September 1, 2006
    
    Amended Attachment B-5, Deliverables/Liquidated Damages Matrix, to add a
footnote clarifying the deliverable due dates. Also amended the provisions regarding
Claims Processing Requirements and the Reporting Requirements for the Claims
Summary Report.Revision
    
    
    1.3
    
    
    September 1, 2006
    
    Amended Attachment B-5, Deliverables/Liquidated Damages Matrix, performance
standard for Provider Directories for the CHIP Perinatal Program.Revision
    
    
    1.4
    
    
    September 1, 2006
    
    Contract amendment did not revise Attachment B-5, Deliverables/Liquidated
Damage Matrix.Revision
    
    
    1.5
    
    
    January 1, 2007
    
    Contract amendment did not revise Attachment B-5, Deliverables/Liquidated
Damage Matrix.Revision
    
    
    1.6
    
    
    February 1, 2007
    
    Contract amendment did not revise Attachment B-5, Deliverables/Liquidated
Damage Matrix.Revision
    
    
    1.7
    
    
    July 1, 2007
    
    Amended Attachment B-5, Deliverables/Liquidated Damages Matrix, to add
clarifications to the provisions addressing Claims Processing Requirements and the
Reporting Requirements for the Claims Summary Report.




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-5  Deliverables/Liquidated Damages Matrix
    
    Version 1.8
 DOCUMENT HISTORY LOG
 DOCUMENTSTATUS1
    
    REVISION2
    
    EFFECTIVE DATE
    
    DESCRIPTION3Revision
    
    
    1.8
    
    
    September 1, 2007
    
    Contract amendment did not revise Attachment B-5, Deliverables/Liquidated
Damage Matrix.
 
 1
    
    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.
  
 1
    
    Derived from the Contract or HHSCs Uniform Managed Care Manual.2
    
    Standard specified in the Contract. Note: Where the due date states 30 days, the HMO is to
provide the deliverable by the last day of the month following the end of the reporting period.
Where the due date states 45 days, the HMO is to provide the deliverable by the 15th day of the
second month following the end of the reporting period.3
    
    Period during which HHSC will evaluate service for purposes of tailored
remedies.4
    
    Measure against which HHSC will apply remedies.
   Page 2 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-5 Deliverables/Liquidated Damages Matrix
    
    Version 1.8
 Deliverables/Liquidated Damages Matrix
 Service/
    
    
    
    Measurement
    
    MeasurementComponent1
    
    Performance Standard2
    
    Period3
    
    Assessment4
    
    Liquidated DamagesContract
Attachment B-1,
RFP §7.3 
Transition Phase
Schedule
    
    The HMO must be operational no
later than the agreed upon
Operations Start Date. HHSC, or
its agent, will determine when the
HMO is considered to be
operational based on the
requirements in Section 7 and 8 of
Attachment B-1.
    
    Operations Start
Date
    
    Each calendar day of
non-compliance, per
HMO Program, per
Service Area (SA).
    
    HHSC may assess up to $10,000 per
calendar day for each day beyond the
Operations Start date that the HMO is
not operational until the day that the
HMO is operational, including all
systems.Contract
Attachment B-1,
RFP §7.3.1 
Transition Phase
Tasks

Contract
Attachment B-1,
RFP §8.1 
General Scope
  
 Contract
Attachment B-1
RFP §7.3.1.5 
Systems
Readiness
Review
    
    The HMO must submit to HHSC or
to the designated Readiness
Review Contractor the following
plans for review, by December 14,
2005 for STAR and CHIP, and by
July 31, 2006 for STAR+PLUS:
    
    Transition Period
    
    Each calendar day of
non-compliance, per
report, per HMO
Program, and per SA.
    
    HHSC may assess up to $1,000 per
calendar day for each day a
deliverable is late, inaccurate or
incomplete.    Joint Interface Plan;    Disaster Recovery Plan;
    
 1
    
    Derived from the Contract or HHSCs Uniform Managed Care Manual.2
    
    Standard specified in the Contract. Note: Where the due date states 30 days, the HMO is to
provide the deliverable by the last day of the month following the end of the reporting period.
Where the due date states 45 days, the HMO is to provide the deliverable by the 15th day of the
second month following the end of the reporting period.3
    
    Period during which HHSC will evaluate service for purposes of tailored remedies.4
    
    Measure against which HHSC will apply remedies.
   Page 3 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-5 Deliverables/Liquidated Damages Matrix
    
    Version 1.8
 Service/
    
    
    
    Measurement
    
    MeasurementComponent1
    
    Performance Standard2
    
    Period3
    
    Assessment4
    
    Liquidated Damages    Business Continuity Plan;    Risk Management Plan; and    Systems Quality Assurance      
Plan.
  
 Contract
Attachment B-1
RFP §7.3.1.7 
Operations
Readiness
    
    Final versions of the Provider
Directory must be submitted to the
Administrative Services Contractor
no later than 95 days prior to the
Operational Start Date for the CHIP,
STAR, and STAR+PLUS HMOs,
and no later than 30 days prior to
the Operational Start Date for the
CHIP Perinatal HMOs.
    
    Transition Period
    
    Each calendar day of
non-compliance, per
directory, per HMO
Program and per SA.
    
    HHSC may assess up to $1,000 per
calendar day for each day the
directory is late, inaccurate or
incomplete.Contract
Attachment B-1
RFP §§ 6, 7, 8
and 9
Uniform
Managed Care
Manual
    
    All reports and deliverables as
specified in Sections 6, 7, 8 and 9
of Attachment B-1 must be
submitted according to the
timeframes and requirements stated
in the Contract (including all
attachments) and HHSCs Uniform
Managed Care Manual. (Specific
Reports or deliverables listed
separately in this matrix are subject
to the specified liquidated
damages.)
    
    Transition Period,
Quarterly during
Operations Period
    
    Each calendar day of
non-compliance, per
HMO Program, per SA.
    
    HHSC may assess up to $250 per
calendar day if the report/deliverable
is late, inaccurate, or incomplete.Contract
    
    The HMO may not engage in
    
    Transition,
    
    Per incident of non-
    
    HHSC may assess up to $1,000 per
    
 1
    
    Derived from the Contract or HHSCs Uniform Managed Care Manual.2
    
    Standard specified in the Contract. Note: Where the due date states 30 days, the HMO is to
provide the deliverable by the last day of the month following the end of the reporting period.
Where the due date states 45 days, the HMO is to provide the deliverable by the 15th day of the
second month following the end of the reporting period.3
    
    Period during which HHSC will evaluate service for purposes of tailored remedies.4
    
    Measure against which HHSC will apply remedies.
   Page 4 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-5 Deliverables/Liquidated Damages Matrix
    
    Version 1.8
 Service/
    
    
    
    Measurement
    
    MeasurementComponent1
    
    Performance Standard2
    
    Period3
    
    Assessment4
    
    Liquidated DamagesAttachment B-1
RFP §8.1.6 
Marketing &
Prohibited
Practices
Uniform
Managed Care
Manual
    
    prohibited marketing practices.
    
    Measured
Quarterly during
the Operations
Period
    
    compliance.
    
    incident of non-compliance.Contract
Attachment B-1
RFP §8.1.17.2 
Financial
Reporting
Requirements
Uniform
Managed Care
Manual 
Chapter 5
    
    Financial Statistical Reports (FSR):
For each SA, the HMO must file
quarterly and annual FSRs.
Quarterly reports are due no later
than 30 days after the conclusion of
each State Fiscal Quarter (SFQ).
The first annual report is due no
later than 120 days after the end of
each Contract Year and the second
annual report is due no later than
365 days after the end of each
Contract Year.
    
    Quarterly during
the Operations
Period
    
    Per calendar day of
non-compliance, per
HMO Program, per SA.
    
    HHSC may assess up to $1,000 per
calendar day a quarterly or annual
report is late, inaccurate or
incomplete.Contract
Attachment B-1
RFP §8.1.17.2 
Financial
Reporting
Requirements:
    
    Medicaid Disproportionate Share
Hospital (DSH) Reports: The
Medicaid HMO must submit, on an
annual basis, preliminary and final
DSH Reports. The Preliminary
report is due no later than June 1st
after each reporting year, and the
    
    Measured during
4th Quarter of the
Operations Period
(6/1-8/31)
    
    Per calendar day of
non-compliance, per
HMO Program, per SA.
    
    HHSC may assess up to $1,000 per
calendar day, per program, per
service area, for each day the report
is late, incorrect, inaccurate or
incomplete.
  
 1
    
    Derived from the Contract or HHSCs Uniform Managed Care Manual.2
    
    Standard specified in the Contract. Note: Where the due date states 30 days, the HMO is to
provide the deliverable by the last day of the month following the end of the reporting period.
Where the due date states 45 days, the HMO is to provide the deliverable by the 15th day of the
second month following the end of the reporting period.3
    
    Period during which HHSC will evaluate service for purposes of tailored remedies.4
    
    Measure against which HHSC will apply remedies.
   Page 5 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-5 Deliverables/Liquidated Damages Matrix
    
    Version 1.8
 Service/
    
    
    
    Measurement
    
    MeasurementComponent1
    
    Performance Standard2
    
    Period3
    
    Assessment4
    
    Liquidated DamagesUniform
Managed Care
Manual 
Chapter 5
    
    final report is due no later than July
15thafter each reporting year.
This standard does not apply to CHIP HMOs.Contract
Attachment B-1
RFP §8.1.18 
Management
Information
System (MIS)
Requirements
    
    The HMOs MIS must be able to
resume operations within 72 hours
of employing its Disaster Recovery
Plan.
    
    Measured
Quarterly during
the Operations
Period
    
    Per calendar day of
non-compliance, per
HMO Program, per SA.
    
    HHSC may assess up to $5,000 per
calendar day of non-complianceContract
Attachment B-1
RFP §8.1.18.3 
Management
Information
System (MIS)
Requirements:
    
    The HMOs MIS system must meet
all requirements in Section 8.1.18.3
of Attachment B-1.
    
    Measured
Quarterly during
the Operations
Period
    
    Per calendar day of
non-compliance, per
HMO Program, per SA.
    
    HHSC may assess up to $5,000 per
calendar day of non-compliance.System-Wide 
Functions
  
 Contract
Attachment B-1
RFP §8.1.18.5 
Claims
Processing
Requirements
    
    The HMO must adjudicate all provider
Clean Claims within 30
days of receipt by the HMO.The
HMO must pay providers interest at
an 18% per annum, calculated daily
for the full period in which the Clean
    
    Measured
Quarterly during
the Operations
Period
    
    Per incident of non-
compliance.
    
    HHSC may assess up to $1,000 per
claim if the HMO fails to timely pay
interest.
    
 1
    
    Derived from the Contract or HHSCs Uniform Managed Care Manual.2
    
    Standard specified in the Contract. Note: Where the due date states 30 days, the HMO is to
provide the deliverable by the last day of the month following the end of the reporting period.
Where the due date states 45 days, the HMO is to provide the deliverable by the 15th day of the
second month following the end of the reporting period.3
    
    Period during which HHSC will evaluate service for purposes of tailored remedies.4
    
    Measure against which HHSC will apply remedies.
   Page 6 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-5 Deliverables/Liquidated Damages Matrix
    
    Version 1.8
 Service/
    
    
    
    Measurement
    
    MeasurementComponent1
    
    Performance Standard2
    
    Period3
    
    Assessment4
    
    Liquidated DamagesUniform 
Managed Care 
Manual Chapter 
2
    
    Claim remains unadjudicated beyond the
30-day claims processing deadline. Interest
owed the provider
must be paid on the same date that
the claim is adjudicated.
  
 Contract
Attachment B-1
RFP §8.1.18.5 
Claims
Processing
Requirements
Uniform
Managed Care
Manual 
Chapter 2
    
    The HMO must comply with the
claims processing requirements and
standards as described in Section
8.1.18.5 of Attachment B-1 and in
Chapter 2 of the Uniform Managed
Care Manual.
    
    Measured
Quarterly during
the Operations
Period
    
    Per quarterly reporting
period, per HMO
Program, per Service
Area, per claim type.
    
    HHSC may assess liquidated
damages of up to $5,000 for the first
quarter that an HMOs Claims
Performance percentages by claim
type, by Program, and by service
area, fall below the performance
standards. HHSC may assess up to
$25,000 per quarter for each
additional quarter that the Claims
Performance percentages by claim
type, by Program, and by service
area, fall below the performance
standards.
    
 Contract
Attachment B-1
RFP §8.1.20.2
Reporting
Requirements
Uniform
Managed Care
    
    Claims Summary Report:
The HMO must submit quarterly,
Claims Summary Reports to HHSC
by HMO Program, by Service Area,
and by claim type, by the 30th day
following the reporting period unless
otherwise specified.
    
    Measured
Quarterly during
the Operations
Period
    
    Per calendar day of
non-compliance, per
HMO Program, per
Service Area, per claim
type.
    
    HHSC may assess up to $1,000 per
calendar day the report is late,
inaccurate, or incomplete.
    
 1
    
    Derived from the Contract or HHSCs Uniform Managed Care Manual.2
    
    Standard specified in the Contract. Note: Where the due date states 30 days, the HMO is to
provide the deliverable by the last day of the month following the end of the reporting period.
Where the due date states 45 days, the HMO is to provide the deliverable by the 15th day of the
second month following the end of the reporting period.3
    
    Period during which HHSC will evaluate service for purposes of tailored remedies.4
    
    Measure against which HHSC will apply remedies.
   Page 7 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-5 Deliverables/Liquidated Damages Matrix
    
    Version 1.8
 Service/
    
    
    
    Measurement
    
    MeasurementComponent1
    
    Performance Standard2
    
    Period3
    
    Assessment4
    
    Liquidated DamagesManual
Chapters 2 and
5Contract
Attachment B-1
RFP §8.1.5.9
Member
Complaint and
Appeal Process
Contract
Attachment B-1
RFP §8.2.7.1 
Member
Complaint
Process
Contract
Attachment B-1
RFP §8.4.3 
CHIP Member
Complaint and
Appeal Process
    
    The HMO must resolve at least
98% of Member Complaints within
30 calendar days from the date the
Complaint is received by the HMO.
    
    Measured
Quarterly during
the Operations
Period
    
    Per reporting period,
per HMO Program, per
SA.
    
    HHSC may assess up to $250 per
reporting period if the HMO fails to
meet the performance standard.
  
 Contract
Attachment B-1
RFP §8.3.3 
STAR+PLUS
Assessment
Instruments
Uniform
    
    The MDS-HC instrument must be
completed and electronically
submitted to HHSC in the specified
format within 30 days of enrollment
for every Member receiving
Community-based Long-term Care
Services, and then each year by the
    
    Operations,
Turnover
    
    Per calendar day of
non-compliance, per
Service Area.
    
    HHSC may assess up to $500 per
calendar day per Service Area, for
each day a report is late, inaccurate
or incomplete.
    
 1
    
    Derived from the Contract or HHSCs Uniform Managed Care Manual.2
    
    Standard specified in the Contract. Note: Where the due date states 30 days, the HMO is to
provide the deliverable by the last day of the month following the end of the reporting period.
Where the due date states 45 days, the HMO is to provide the deliverable by the 15th day of the
second month following the end of the reporting period.3
    
    Period during which HHSC will evaluate service for purposes of tailored remedies.4
    
    Measure against which HHSC will apply remedies.
   Page 8 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-5 Deliverables/Liquidated Damages Matrix
    
    Version 1.8
 Service/
    
    
    
    Measurement
    
    MeasurementComponent1
    
    Performance Standard2
    
    Period3
    
    Assessment4
    
    Liquidated DamagesManaged Care 
Manual
    
    anniversary of the Members date of
enrollment.Contract
Attachment B-1
RFP §8.1.5.9
Member
Complaint and
Appeal Process
Contract
Attachment B-1
RFP §8.2.7.2 
Medicaid
Standard
Member Appeal
Process
Contract
Attachment B-1
RFP § 8.4.3
CHIP Member
Complaint and
Appeal Process
    
    The HMO must resolve at least
98% of Member Appeals within 30
calendar days from the date the
Appeal is filed with the HMO.
    
    Measured
Quarterly during
the Operations
Period
    
    Per reporting period,
per HMO Program, per
SA.
    
    HHSC may assess up to $500 per
reporting period if the HMO fails to
meet the performance standard.Contract
Attachment B-1
RFP §9.2 
Transfer of Data
    
    The HMO must transfer all data
regarding the provision of Covered
Services to Members to HHSC or a
new HMO, at the sole discretion of
HHSC and as directed by HHSC.
All transferred data must comply
with the Contract requirements,
    
    Measured at Time
of Transfer of Data
and ongoing after
the Transfer of
Data until
satisfactorily
completed
    
    Per incident of non-compliance (failure to
provide data and/or
failure to provide data
in required format), per
HMO Program, per SA.
    
    HHSC may assess up to $10,000 per
calendar day the data is late,
inaccurate or incomplete.
  
 1
    
    Derived from the Contract or HHSCs Uniform Managed Care Manual.2
    
    Standard specified in the Contract. Note: Where the due date states 30 days, the HMO is to
provide the deliverable by the last day of the month following the end of the reporting period.
Where the due date states 45 days, the HMO is to provide the deliverable by the 15th day of the
second month following the end of the reporting period.3
    
    Period during which HHSC will evaluate service for purposes of tailored remedies.4
    
    Measure against which HHSC will apply remedies.
   Page 9 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: Attachment B-5 Deliverables/Liquidated Damages Matrix
    
    Version 1.8
 Service/
    
    
    
    Measurement
    
    MeasurementComponent1
    
    Performance Standard2
    
    Period3
    
    Assessment4
    
    Liquidated Damagesincluding HIPAA.Contract
Attachment B-1
RFP §9.3 
Turnover
Services
    
    Six months prior to the end of the
contract period or any extension
thereof, the HMO must propose a
Turnover Plan covering the possible
turnover of the records and
information maintained to either the
State (HHSC) or a successor HMO.
    
    Measured at Six
Months prior to the
end of the contract
period or any
extension thereof
and ongoing until
satisfactorily
completed
    
    Each calendar day of
non-compliance, per
HMO Program, per SA.
    
    HHSC may assess up to $1,000 per
calendar day the Plan is late,
inaccurate, or incomplete.Contract
Attachment B-1
RFP §9.4 
Post-Turnover
Services
    
    The HMO must provide the State
(HHSC) with a Turnover Results
report documenting the completion
and results of each step of the
Turnover Plan 30 days after the
Turnover of Operations.
    
    Measured 30 days
after the Turnover
of Operations
    
    Each calendar day of
non-compliance, per
HMO program, per SA.
    
    HHSC may assess up to $250 per
calendar day the report is late,
inaccurate or incomplete.Contract
Attachment A
HHSC Uniform
Managed Care
Contract Terms
and Conditions,
Section 4.08
Subcontractors
    
    The HMO must notify HHSC in
writing immediately upon making a
decision to terminate a subcontract
with a Material Subcontractor or
upon receiving notification from the
Material Subcontractor of its intent
to terminate such subcontract.
    
    Transition,
Measured
Quarterly during
the Operations
Period
    
    Each calendar day of
non-compliance, per
HMO Program, per SA.
    
    HHSC may assess up to $5,000 per
calendar day of non-compliance.
  
 1
    
    Derived from the Contract or HHSCs Uniform Managed Care Manual.2
    
    Standard specified in the Contract. Note: Where the due date states 30 days, the HMO is to
provide the deliverable by the last day of the month following the end of the reporting period.
Where the due date states 45 days, the HMO is to provide the deliverable by the 15th day of the
second month following the end of the reporting period.3
    
    Period during which HHSC will evaluate service for purposes of tailored remedies.4
    
    Measure against which HHSC will apply remedies.
   Page 10 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: HHSC Managed Care Contract
    
    HHSC Contract No. 529-06-0280-00002-H
 Part 1: Parties to the Contract:
 Amerigroup
Texas, Inc. 1200 East Copeland Road, Suite 200, Arlington, Texas 76011
   Part 2: Effective
Date of Amendment:
    
    Part 3: Contract Expiration Date:
    
    Part 4: Operational Start Date:September 1, 2007
    
    August 31, 2008
    
    STAR and CHIP HMOs: September 1, 2006STAR+PLUS HMOs: February 1, 2007CHIP Perinatal HMOs: January 1, 2007
 Part 5: Project Managers:
 HHSC:
    
    HMO:Cindy Jorgensen
    
    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, 4th Floor
    
    6700 West Loop South, Suite 200Austin, Texas 78751
    
    Bellaire, Texas 77401Fax: 512-424-6586
    
    Fax:713-218-8692
 Part 7: HMO Programs and Service Areas:
 (check all that apply)
 Page 1 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: HHSC Managed Care Contract
    
    HHSC Contract No. 529-06-0280-00002-H
 þ Medicaid STAR HMO Program
 Service Areas:
    
    o Bexar
    
    o Lubbockþ Dallas
    
    þ Nueceso El Paso
    
    þ Tarrantþ Harris
    
    þ Travis
  þ Medicaid STAR+PLUS HMO Program
 Service Areas:
    
    þ Bexar
    
    o Nuecesþ Harris
    
    þ Travis
  þ 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-H
 þ CHIP Perinatal Program
 Core Service Areas:
    
    o Bexar
    
    o Nueceso Dallas
    
    þ Tarranto El Paso
    
    o Traviso Harris
    
    o Webbo LubbockOptional Service Areas:
    
    o Bexar
    
    o Lubbocko El Paso
    
    o Nueceso Harris
    
    o Travis
  Part 8: Payment
  þ Medicaid STAR HMO PROGRAM
 Capitation :
 Service Area: DALLAS
 Rate Period 1Rate Cell
    
    Capitation Rates




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: HHSC Managed Care Contract
    
    HHSC Contract No. 529-06-0280-00002-H
 Service Area: HARRIS
 Rate Period 2Rate Cell
    
    Capitation Rates
  Service Area: NUECES
 Rate Period 2Rate Cell
    
    Capitation Rates
 Page 4 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: HHSC Managed Care Contract
    
    HHSC Contract No. 529-06-0280-00002-H
 Service Area: TARRANT
 Rate Period 2Rate Cell
    
    Capitation Rates
  Service Area: TRAVIS
 Rate Period 2Rate Cell
    
    Capitation Rates
 Page 5 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: HHSC Managed Care Contract
    
    HHSC Contract No. 529-06-0280-00002-H
 þ Medicaid STAR+PLUS HMO Program
 Capitation :
 STAR+PLUS Service Area: BEXAR
 Rate Period 2Rate Cell
    
    Capitation Rates
  STAR+PLUS Service Area: HARRIS
 Rate Period 2Rate Cell
    
    Capitation Rates
 Page 6 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: HHSC Managed Care Contract
    
    HHSC Contract No. 529-06-0280-00002-H
 STAR+PLUS Service Area: TRAVIS
 Rate Period 2Rate Cell
    
    Capitation Rates
  Capitation :
 Service Area: DALLAS
 Rate Period 1Rate Cell
    
    Capitation Rates
 Page 7 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: HHSC Managed Care Contract
    
    HHSC Contract No. 529-06-0280-00002-H
 Service Area: HARRIS
 Rate Period 2Rate Cell
    
    Capitation Rates
 Page 8 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: HHSC Managed Care Contract
    
    HHSC Contract No. 529-06-0280-00002-H
 þ CHIP Perinatal- Program
 Capitation :
 Service Area: TARRANT
 Rate Period 2Rate Cell
    
    Capitation Rates
  Part 9: Contract Attachments:
  Version 1.7 is replaced with Version 1.8
 Version 1.7 is replaced with Version 1.8 for all
attachments, except if noted.
 Page 9 of 10




---



##### 



Responsible Office: HHSC Office of General Counsel (OGC)Subject: HHSC Managed Care Contract
    
    HHSC Contract No. 529-06-0280-00002-H
 Part 10: Special Provision for Nueces Service Area
 Attachment A, Section 10.04 is amended to include sub-part (b) as follows:
  
 Part 11: Signatures
  Texas Health and Human Services Commission
    
    
    
    Amerigroup Texas, Inc./s/ Aileen McCormickCharles E. Bell, M.D.
    
    
    
    By: Aileen McCormickDeputy Executive Commissioner for Health Services
    
    
    
    Title: President and CEODate: ____________
    
    
    
    Date: 8/21/07
   Page 10 of 10