exhibit102.htm


    Exhibit
      10.2

     

    
      	
              Contractual
                Document (CD)

            	
               

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                HHSC Managed Care Contract

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

            	 


    

    


    
      	
              Part
                1:  Parties to the Contract:

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

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

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

            
	
              Part
                2:  Effective Date of Amendment:

            	
              Part
                3:  Contract Expiration Date

            	
              Part
                4:  Operational Start Date:

            
	
              CHIP
                Perinatal rates effective April 1, 2007.

              STAR+PLUS
                rates and inpatient behavioral health services for Harris Service
                Area
                effective June 1, 2007.

              All
                other provisions effective July 1, 2007.

            	
              August
                31, 2008

            	
              STAR
                and CHIP HMOs:  September 1, 2006

              STAR+PLUS
                HMOs:  February 1, 2007

              CHIP
                Perinatal HMOs:  January 1, 2007

               

            
	
              Part
                5:  Project Managers:

            
	
              HHSC:

              Cindy
                Jorgensen

              Director
                of Medicaid/CHIP Health Plan Operations

              11209
                Metric Boulevard, Building H

              Austin,
                Texas 78758

              Phone:  512-491-1302

              Fax:  512-491-1966

            	
              HMO:

              Stacey
                Hull

              Vice
                President of Regulatory Affairs

              2100
                South IH-35, Suite 202

              Austin,
                Texas 78704

              Phone:
                512-692-1465

              Fax:  512-692-1474

              E-mail:
                shull@centene.com

               

               

            
	
              Part
                6:  Deliver Legal Notices to:

            
	
              HHSC:

              General
                Counsel

              4900
                North Lamar Boulevard, 4th
                Floor

              Austin,
                Texas 78751

              Fax:  512-424-6586

               

            	
              HMO:

              Superior
                HealthPlan

              2100
                South IH-35, Suite 202

              Austin,
                Texas 78704

              Fax:  512-692-1435

               

               

            


    

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      	
              Contractual
                Document (CD)

            	
              

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                HHSC Managed Care Contract

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

            	 


    

    


    
      	
              Part
                7:  HMO Programs and Service Areas:

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

            
	
              x Medicaid
                STAR HMO Program

            
	 
	 	
              Service
                Areas

            	
              x
                Bexar

            	 	
              x
                Lubbock

            
	 	 	
               ̈
                Dallas

            	 	
              x
                Nueces

            
	 	 	
              x
                El
                Paso

            	 	
               ̈
                Tarrant

            
	 	 	
               ̈
                Harris

            	 	
              x
                Travis

            
	 	 	 	 	 
	
              See
                attachment B-6, "Map of Counties with HMO Program Services Areas,"
                for
                listing of counties included within the STAR Services
                Areas.

            
	 	 	 	 	 
	
              x Medicaid
                STAR+PLUS HMO Program

            
	 	 	 	 	 
	 	
              Service
                Areas

            	
              x
                Bexar

            	 	
              x Nueces

            
	 	 	
               ̈
                Harris

            	 	
               ̈ Travis

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

            
	 	 	 	 	 
	
              x CHIP
                HMO Program

            
	 	 	 	 	 
	 	
              Core
                Service Areas:

            	
              x
                Bexar

            	 	
              x Nueces

            
	 	 	
               ̈ Dallas

            	 	
               ̈
                Tarrant

            
	 	 	
              x El
                Paso

            	 	
              xTravis

            
	 	 	
               ̈
                Harris

            	 	
               ̈
                Webb

            
	 	 	
              x Lubbock

            	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	
              Optional
                Service Areas:

            	
              x
                Bexar

            	 	
              x Lubbock

            
	 	 	
              x El
                Paso

            	 	
              x Nueces

            
	 	 	
               ̈
                Harris

            	 	
              x
                Travis

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

            


    

    


    
      	
              x CHIP
                Perinatal Program

            
	 	 	 	 	 
	 	
              Core
                Service Areas:

            	
              x
                Bexar

            	 	
              x Nueces

            
	 	 	
               ̈ Dallas

            	 	
               ̈
                Tarrant

            
	 	 	
              x El
                Paso

            	 	
              xTravis

            
	 	 	
               ̈
                Harris

            	 	
               ̈
                Webb

            
	 	 	
              x Lubbock

            	 	 
	 	 	 	 	 
	 	
              Optional
                Service Areas:

            	
              x
                Bexar

            	 	
              x
                Lubbock

            
	 	 	
              x El
                Paso

            	 	
              x Nueces

            
	 	 	
               ̈
                Harris

            	 	
              x
                Travis

            
	 	 	 	 	 
	 	 	 	 	 
	 See
              Attachment B:6.2, "Map of Counties with CHIOP Perinatal HMO Program
              Service Areas,: for a list of counties included within the CHIP Perinatal
              Service Areas.    
	 	 	 	 	 


    

    


    


    
      	
              Part
                8: Payment

            


    

     

    Part
      8 of
      the HHSC Managed Care Contract document, “Payment,” is modified to add the
      capitation rates for Rate Period 1.

     

    
      	 	
              x
                Medicaid
                STAR HMO PROGRAM

            
	 	 	 	 	 
	 	
              Capitation:
                See Attachment A, “HHSC Uniform Managed Care Contract Terms and
                Conditions,” Article 10, for a description of the Capitation Rate-setting
                methodology and the Capitation Payment requirements for the STAR
                Program.
                The following Rate Cells and Capitation Rates will apply to Rate
                Period
                1:

            
	 	 
	 	
              Service
                Area: BEXAR

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            
	 	
              1

            	
              TANF
                Adult

            	
              $261.68

            
	 	
              2

            	
              TANF
                Child >
                12 months

            	
              $87.11

            
	 	
              3

            	
              Expansion
                Child >12 months

            	
              $87.41

            
	 	
              4

            	
              Newborn
                < 12 months

            	
              $650.47

            
	 	
              5

            	
              TANF
                child <12 months

            	
              $280.34

            
	 	
              6

            	
              Expansion
                Child <12 months

            	
              $184.41

            
	 	
              7

            	
              Federal
                Mandate child

            	
              $67.40

            
	 	
              8

            	
              Pregnant
                Woman

            	
              $399.99

            
	 	
              9

            	
              Delivery
                Supplemental Payment

            	
              $3,166.59

            


    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      	
              Contractual
                Document (CD)

            	
               

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                HHSC Managed Care Contract

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

            	 


    

     

    
      	 	
              Service
                Area: EL PASO

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            
	 	
              1

            	
              TANF
                Adult

            	
              $219.32

            
	 	
              2

            	
              TANF
                Child>12 months

            	
              $75.90

            
	 	
              3

            	
              Expansion
                Child>12 months

            	
              $90.95

            
	 	
              4

            	
              Newborn
                < 12 months

            	
              $556.63

            
	 	
              5

            	
              TANF
                child <12 months

            	
              $238.42

            
	 	
              6

            	
              Expansion
                Child <12 months

            	
              $181.32

            
	 	
              7

            	
              Federal
                Mandate child

            	
              $66.95

            
	 	
              8

            	
              Pregnant
                Woman

            	
              $380.91

            
	 	
              9

            	
              Delivery
                Supplemental Payment

            	
              $3,343.04

            


    

     

    
      	 	
              Service
                Area: LUBBOCK

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            
	 	
              1

            	
              TANF
                Adult

            	
              $253.16

            
	 	
              2

            	
              TANF
                Child>12 months

            	
              $86.38

            
	 	
              3

            	
              Expansion
                Child>12 months

            	
              $88.21

            
	 	
              4

            	
              Newborn
                < 12 months

            	
              $416.38

            
	 	
              5

            	
              TANF
                child <12 months

            	
              $207.08

            
	 	
              6

            	
              Expansion
                Child <12 months

            	
              $238.86

            
	 	
              7

            	
              Federal
                Mandate child

            	
              $76.09

            
	 	
              8

            	
              Pregnant
                Woman

            	
              $510.74

            
	 	
              9

            	
              Delivery
                Supplemental Payment

            	
              $3,130.39

            


    

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      	
              Contractual
                Document (CD)

            	
               

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                HHSC Managed Care Contract

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

            	 


    

     

    
      	 	
              Service
                Area: NUECES

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            
	 	
              1

            	
              TANF
                Adult

            	
              $230.50

            
	 	
              2

            	
              TANF
                Child>12 months

            	
              $88.46

            
	 	
              3

            	
              Expansion
                Child>12 months

            	
              $92.31

            
	 	
              4

            	
              Newborn
                < 12 months

            	
              $670.99

            
	 	
              5

            	
              TANF
                child <12 months

            	
              $322.76

            
	 	
              6

            	
              Expansion
                Child <12 months

            	
              $322.76

            
	 	
              7

            	
              Federal
                Mandate child

            	
              $67.25

            
	 	
              8

            	
              Pregnant
                Woman

            	
              $292.08

            
	 	
              9

            	
              Delivery
                Supplemental Payment

            	
              $3,103.82

            


    

     

    
      	 	
              Service
                Area: TRAVIS

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            
	 	
              1

            	
              TANF
                Adult

            	
              $195.85

            
	 	
              2

            	
              TANF
                Child>12 months

            	
              $73.05

            
	 	
              3

            	
              Expansion
                Child>12 months

            	
              $86.18

            
	 	
              4

            	
              Newborn
                < 12 months

            	
              $740.08

            
	 	
              5

            	
              TANF
                child <12 months

            	
              $213.76

            
	 	
              6

            	
              Expansion
                Child <12 months

            	
              $215.26

            
	 	
              7

            	
              Federal
                Mandate child

            	
              $64.06

            
	 	
              8

            	
              Pregnant
                Woman

            	
              $417.81

            
	 	
              9

            	
              Delivery
                Supplemental Payment

            	
              $3,147.49

            


    

     

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

     

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    


     

    
      	
              Contractual
                Document (CD)

            	
               

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                HHSC Managed Care Contract

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

            	 


    

     

    xMedicaid
      STAR+PLUS HMO Program

     

    Capitation:See
      Attachment A, "HHSC Uniform Managed Care Contract Terms and Conditions," Article
      10, for a description of the Capitation Rate-setting methodology and the
      Capitation Payment requirements for the STAR+PLUS Program.  The
      following Rate Cells and Capitation Rates will apply to Rate Periods 1 and
      2.

     

    
      	 	
              STAR+PLUS
                Service Area: BEXAR

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            	
              Rate
                Period 2 Capitation Rates

            
	 	
              1.

            	
              Medicaid
                Only Standard Rate

            	
              $388.93

            	
              $403.69

            
	 	
              2.

            	
              Medicaid
                Only 1915 (C)Nursing Facility Waiver Rate

            	
              $2,755.92

            	
              $2,873.79

            
	 	
              3.

            	
              Dual
                Eligible Standard Rate

            	
              $251.00

            	
              $259.76

            
	 	
              4.

            	
              Dual
                Eligible 1915 (C) Nursing Facility Waiver Rate

            	
              $1,704.74

            	
              $1,776.84

            
	 	
              5.

            	
              Nursing
                Facility - Medicaid Only

            	
              $388.93

            	
              $403.69

            
	 	
              6.

            	
              Nursing
                Facility - Dual Eligible

            	
              $251.00

            	
              $259.76

            


    

     

    
      	 	
              STAR+PLUS
                Service Area: NUECES

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            	
              Rate
                Period 2 Capitation Rates

            
	 	
              1.

            	
              Medicaid
                Only Standard Rate

            	
              $453.61

            	
              $471.19

            
	 	
              2.

            	
              Medicaid
                Only 1915 (C) Nursing Facility Waiver Rate

            	
              $2,689.23

            	
              $2,804.20

            
	 	
              3.

            	
              Dual
                Eligible Standard Rate

            	
              $311.35

            	
              $322.73

            
	 	
              4.

            	
              Dual
                Eligible 1915 (C) Nursing Facility Waiver Rate

            	
              $1,666.27

            	
              $1,736.68

            
	 	
              5.

            	
              Nursing
                Facility - Medicaid Only

            	
              $453.61

            	
              $471.19

            
	 	
              6.

            	
              Nursing
                Facility -  Dual Eligible

            	
              $311.35

            	
              $322.73

            


    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      	
              Contractual
                Document (CD)

            	
               

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                HHSC Managed Care Contract

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

            	 


    

     

    xCHIP
      HMO
      PROGRAM

     

    Capitation: See
      Attachment A, "HHSC Uniform Managed Care Contract Terms and Conditions," Article
      10, for a description of the Capitation Rate-setting methodology and the
      Capitation Payment requirements for the CHIP Program.  The following
      Rate Cells and Capitation Rates will apply to Rate Period 1:

     

    
      	 	
              Service
                Area: BEXAR

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            
	 	
              1

            	
              <
                Age 1

            	
              $100.58

            
	 	
              2

            	
              Ages
                1 through 5

            	
              $78.71

            
	 	
              3

            	
              Ages
                6 through 14

            	
              $61.06

            
	 	
              4

            	
              Ages 15
                through 18

            	
              $84.70

            


    

     

    
      	 	
              Service
                Area: EL PASO

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            
	 	
              1

            	
              <
                Age 1

            	
              $61.24

            
	 	
              2

            	
              Ages
                1 through 5

            	
              $73.74

            
	 	
              3

            	
              Ages
                6 through 14

            	
              $57.09

            
	 	
              4

            	
              Ages 15
                through 18

            	
              $67.88

            


    

     

    
      	 	
              Service
                Area: LUBBOCK

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            
	 	
              1

            	
              <
                Age 1

            	
              $56.26

            
	 	
              2

            	
              Ages
                1 through 5

            	
              $76.79

            
	 	
              3

            	
              Ages
                6 through 14

            	
              $68.04

            
	 	
              4

            	
              Ages 15
                through 18

            	
              $93.75

            


    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      	
              Contractual
                Document (CD)

            	
               

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                HHSC Managed Care Contract

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

            	 


    

     

    
      	 	
              Service
                Area: NUECES

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            
	 	
              1

            	
              <
                Age 1

            	
              $89.40

            
	 	
              2

            	
              Ages
                1 through 5

            	
              $93.77

            
	 	
              3

            	
              Ages
                6 through 14

            	
              $78.78

            
	 	
              4

            	
              Ages 15
                through 18

            	
              $97.60

            


    

    


    
      	 	
              Service
                Area: TRAVIS

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            
	 	
              1

            	
              <
                Age 1

            	
              $63.15

            
	 	
              2

            	
              Ages
                1 through 5

            	
              $90.64

            
	 	
              3

            	
              Ages
                6 through 14

            	
              $83.08

            
	 	
              4

            	
              Ages
                15 through 18

            	
              $124.32

            


    

     

    Delivery
      Supplemental Payment: See Attachment A, "HHSC Uniform Managed Care
      Contract Terms and Conditions," Article 10, for a description of the methodology
      for establishing the Delivery Supplemental Payment for the CHIP Program. The
      Chip Delivery Supplement Payment is $3,000.00 for all Service
      Areas.

     

    
      	
              xCHIP
                Perinatal
                Program

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

            
	 	 	 	 	 
	 	
              Service
                Area: BEXAR

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            
	 	
              1

            	
              Perinate
                0% - 185%

            	
              $417.19

            
	 	
              2

            	
              Perinate
                186% - 200%

            	
              $152.35

            
	 	
              3

            	
              Perinate
                Newborn 0% - 185%

            	
              $335.90

            
	 	
              4

            	
              Perinate
                Newborn 186% - 200%

            	
              $683.52

            


    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      	
              Contractual
                Document (CD)

            	
               

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                HHSC Managed Care Contract

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

            	 


    

     

    
      	 	
              Service
                Area: EL PASO

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            
	 	
              1

            	
              Perinate
                0% - 185%

            	
              $417.19

            
	 	
              2

            	
              Perinate
                186% - 200%

            	
              $152.35

            
	 	
              3

            	
              Perinate
                Newborn 0% - 185%

            	
              $287.45

            
	 	
              4

            	
              Perinate
                Newborn 186% - 200%

            	
              $584.91

            


    

    


    
      	 	
              Service
                Area: LUBBOCK

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            
	 	
              1

            	
              Perinate
                0% - 185%

            	
              $417.19

            
	 	
              2

            	
              Perinate
                186% - 200%

            	
              $152.35

            
	 	
              3

            	
              Perinate
                Newborn 0% - 185%

            	
              $215.02

            
	 	
              4

            	
              Perinate
                Newborn 186% - 200%

            	
              $437.53

            


    

    


    
      	 	
              Service
                Area: NUECES

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            
	 	
              1

            	
              Perinate
                0% - 185%

            	
              $417.19

            
	 	
              2

            	
              Perinate
                186% - 200%

            	
              $152.35

            
	 	
              3

            	
              Perinate
                Newborn 0% - 185%

            	
              $346.50

            
	 	
              4

            	
              Perinate
                Newborn 186% - 200%

            	
              $705.08

            


    

     

    
      	 	
              Service
                Area: TRAVIS

            
	 	 	
              Rate
                Cell

            	
              Rate
                Period 1 Capitations Rates

            
	 	
              1

            	
              Perinate
                0% - 185%

            	
              $417.19

            
	 	
              2

            	
              Perinate
                186% - 200%

            	
              $152.35

            
	 	
              3

            	
              Perinate
                Newborn 0% - 185%

            	
              $380.66

            
	 	
              4

            	
              Perinate
                Newborn 186% - 200%

            	
              $774.58

            


    

     

    Delivery
      Supplemental Payment: See Attachment A, “HHSC
      Uniform Managed Care Contract Terms and Conditions,” Article 10, for a
      description of the methodology for establishing the Delivery Supplemental
      Payment for the CHIP Perinatal Program. The CHIP Perinatal Delivery Supplemental
      Payment is $3,000.00 for Perinates between 186% and 200% of the Federal Poverty
      Level for all Service Areas.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      	
              Contractual
                Document (CD)

            	
               

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                HHSC Managed Care Contract

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

            	 


    

     

    
      	
              Part
                9:  Contract Attachments:

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

              A:  HHSC
                Uniform Managed Care Contract Terms & Conditions - Version 1.6 is
                replaced with Version 1.7

              B:  Scope
                of Work/Performance Measures – Version 1.6 is replaced with Version
                1.7 for all attachments, except if noted.

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

              B-2:  Covered
                Services

                  B-2.1
                STAR+PLUS Covered Services

                  B-2.2
                CHIP Perinatal Program Covered Services  

              B-3:  Value-added
                Services

              B-3.1
                STAR+PLUS Value-added Services

              B-3.2
                CHIP Perinatal Program Value-added Services  

              B-4:  Performance
                Improvement Goals 

              B-4.1
                SFY 2008 Performance Improvement Goals 

              B-5:  Deliverables/Liquidated
                Damages Matrix 

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

              B-6.1
                STAR+PLUS Service Areas

                  B-6.2
                CHIP Perinatal Program Service Areas

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

              C:  HMO’s
                Proposal and Related Documents

              C-1:  HMO’s
                Proposal

              C-2:  HMO
                Supplemental Responses

              C-3:  Agreed
                Modifications to HMO’s Proposal

               

            


    

    


    
      	
              Part
                10:  Signatures:

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

            
	
              Texas
                Health and Human Services Commission

            	 	
              Superior
                HealthPlan, Inc.

            
	 	 	 
	 	 	 
	
              Charles
                E. Bell, M.D.

            	 	
              By:   Christopher
                Bowers

            
	
              Deputy
                Executive Commissioner for Health Services

            	 	
              Title:
                President and CEO

            
	
              Date:

            	 	 	
              Date:

            	 


    

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    


     

    


    


    Texas
      Health & Human Services Commission

    


    


    Uniform
      Managed Care Contract Terms & Conditions

    


    Version
      1.7


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    


    DOCUMENT
      HISTORY LOG

    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	
              Baseline

            	
              n/a

            	 	
              Initial
                version of the Uniform Managed Care Contract Terms &
                Conditions

            
	
              Revision

            	
              1.1

            	
              June
                30, 2006

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

               

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

               

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

               

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

               

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

               

            
	
              Revision

            	
              1.2

            	
              September
                1, 2006

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

               

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

               

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

               

              Article
                10 is amended to clarify the following sections: 10.01(d), regarding
                the
                fixed monthly Capitation Rate components; 10.10(c), regarding updating
                the
                state

            


    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    
      	 	 	 	
              system
                for Members who become eligible for SSI.  Section 10.17 is added
                regarding recoupment for federal disallowance.

               

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

               

            
	
              Revision

            	
              1.3

            	
              September
                1, 2006

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

               

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

               

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

               

            
	
              Revision

            	
              1.4

            	
              September,
                1 2006

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

               

            
	
              Revision

            	
              1.5

            	
              January
                1, 2007

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

               

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

               

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

               

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

               

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

               

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

               

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

               

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

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

               

            
	
              Revision

            	
              1.7

            	
              July
                1, 2007

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

               

               Section
                4.08(c) is modified to add a cross-reference
                to

            


    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    
      	 	 	 	
              new
                Attachment B-1, Section 8.1.1.2.

               

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

               

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

               

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

               

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

               

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

               

            
	
              1
                Status should
                be represented as “Baseline” for initial issuances, “Revision” for changes
                to the Baseline version, and “Cancellation” for withdrawn
                versions

              2
                Revisions
                should be numbered in accordance according to the version of the
                issuance
                and sequential numbering of the revision—e.g., “1.2” refers to the first
                version of the document and the second revision.

              3
                Brief
                description of the changes to the document made in the
                revision.

            


    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    TABLE
      OF CONTENTS

    


    
      	
              Article1.Introduction

            	
              2

            
	 	 
	
              Section
                1.01 Purpose

            	
              2

            
	
              Section
                1.02 Risk-based contract

            	
              2

            
	
              Section
                1.03 Inducements

            	
              2

            
	
              Section
                1.04 Construction of the Contract

            	
              2

            
	
              Section
                1.05 No implied authority

            	
              3

            
	
              Section
                1.06 Legal Authority

            	
              3

            
	 	 
	
              Article
                2. Definitions

            	
              3

            
	 	 
	
              Article
                3. General Terms & Conditions

            	
              15

            
	 	 
	
              Section
                3.01 Contract elements

            	
              15

            
	
              Section
                3.02 Term of the Contract

            	
              15

            
	
              Section
                3.03 Funding

            	
              15

            
	
              Section
                3.04 Delegation of authority

            	
              15

            
	
              Section
                3.05 No waiver of sovereign immunity

            	
              15

            
	
              Section
                3.06 Force majeure

            	
              15

            
	
              Section
                3.07 Publicity

            	
              15

            
	
              Section
                3.08 Assignment

            	
              16

            
	
              Section
                3.09 Cooperation with other vendors and prospective
                vendors

            	
              16

            
	
              Section
                3.10 Renegotiation and reprocurement rights

            	
              16

            
	
              Section
                3.11 RFP errors and omissions

            	
              16

            
	
              Section
                3.12 Attorneys’ fees

            	
              16

            
	
              Section
                3.13 Preferences under service contracts

            	
              17

            
	
              Section
                3.14 Time of the essence

            	
              17

            
	
              Section
                3.15 Notice

            	
              17

            
	 	 
	
              Article
                4. Contract Administration & Management

            	
              17

            
	 	 
	
              Section
                4.01 Qualifications, retention and replacement of HMO
                employees

            	
              17

            
	
              Section
                4.02 HMO’s Key Personnel

            	
              17

            
	
              Section
                4.03 Executive Director

            	
              17

            
	
              Section
                4.04 Medical Director

            	
              18

            
	
              Section
                4.04.1 STAR+PLUS Service Coordinator

            	
              18

            
	
              Section
                4.05 Responsibility for HMO personnel and Subcontractors

            	
              19

            
	
              Section
                4.06 Cooperation with HHSC and state administrative
                agencies

            	
              19

            
	
              Section
                4.07 Conduct of HMO personnel

            	
              19

            
	
              Section
                4.08 Subcontractors

            	
              20

            
	
              Section
                4.09 HHSC’s ability to contract with Subcontractors

            	
              21

            
	
              Section
                4.10 HMO Agreements with Third Parties

            	
              21

            
	 	 
	
              Article
                5. Member Eligibility & Enrollment

            	
              21

            
	 	 
	
              Section
                5.01 Eligibility Determination

            	
              21

            
	
              Section
                5.02 Member Enrollment & Disenrollment

            	
              21

            
	
              Section
                5.03 STAR enrollment for pregnant women and infants

            	
              22

            
	
              Section
                5.04 CHIP eligibility and enrollment

            	
              22

            
	
              Section
                5.05 Span of Coverage

            	
              23

            
	
              Section
                5.06 Verification of Member Eligibility

            	
              23

            
	
              Section
                5.07 Special Temporary STAR Default Process

            	
              23

            
	
              Section
                5.08 Special Temporary STAR+PLUS Default Process

            	
              24

            
	 	 
	
              Article
                6. Service Levels & Performance Measurement

            	
              24

            
	 	 
	
              Section
                6.01 Performance measurement

            	
              24

            
	 	 
	
              Article
                7. Governing Law & Regulations

            	
              24

            
	 	 
	
              Section
                7.01 Governing law and venue

            	
              24

            
	
              Section
                7.02 HMO responsibility for compliance with laws and
                regulations

            	
              24

            


    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    
      	
              Section
                7.03 TDI licensure/ANHC certification and solvency

            	
              25

            
	
              Section
                7.04 Immigration Reform and Control Act of 1986

            	
              25

            
	
              Section
                7.05 Compliance with state and federal anti-discrimination
                laws

            	
              25

            
	
              Section
                7.06 Environmental protection laws

            	
              25

            
	
              Section
                7.07 HIPAA

            	
              26

            
	 	 
	
              Article
                8. Amendments & Modifications

            	
              26

            
	 	 
	
              Section
                8.01 Mutual agreement

            	
              26

            
	
              Section
                8.02 Changes in law or contract

            	
              26

            
	
              Section
                8.03 Modifications as a remedy

            	
              26

            
	
              Section
                8.04 Modifications upon renewal or extension of Contract

            	
              26

            
	
              Section
                8.05 Modification of HHSC Uniform Managed Care Manual

            	
              26

            
	
              Section
                8.06 CMS approval of Medicaid amendments

            	
              27

            
	
              Section
                8.07 Required compliance with amendment and modification
                procedures

            	
              27

            
	 	 
	
              Article
                9. Audit & Financial Compliance

            	
              27

            
	 	 
	
              Section
                9.01 Financial record retention and audit

            	
              27

            
	
              Section
                9.02 Access to records, books, and documents

            	
              27

            
	
              Section
                9.03 Audits of Services, Deliverables and inspections

            	
              27

            
	
              Section
                9.04 SAO Audit

            	
              28

            
	
              Section
                9.05 Response/compliance with audit or inspection findings

            	
              28

            
	 	 
	
              Article
                10. Terms & Conditions of Payment

            	
              28

            
	 	 
	
              Section
                10.01 Calculation of monthly Capitation Payment

            	
              28

            
	
              Section
                10.02 Time and Manner of Payment

            	
              29

            
	
              Section
                10.03 Certification of Capitation Rates

            	
              29

            
	
              Section
                10.04 Modification of Capitation Rates

            	
              29

            
	
              Section
                10.05 STAR Capitation Structure

            	
              29

            
	
              Section
                10.05.1STAR+PLUS Capitation Structure

            	
              30

            
	
              Section
                10.06 CHIP Capitation Rates Structure

            	
              30

            
	
              Section
                10.07 HMO input during rate setting process

            	
              31

            
	
              Section
                10.08 Adjustments to Capitation Payments

            	
              31

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

            	
              31

            
	
              Section
                10.10 Administrative Fee for SSI Members

            	
              32

            
	
              Section
                10.11 STAR, CHIP, and CHIP Perinatal Experience Rebate

            	
              32

            
	
              Section
                10.11.1 STAR+PLUS Experience Rebate

            	
              34

            
	
              Section
                10.12 Payment by Members

            	
              36

            
	
              Section
                10.13 Restriction on assignment of fees

            	
              36

            
	
              Section
                10.14 Liability for taxes

            	
              36

            
	
              Section
                10.15 Liability for employment-related charges and
                benefits

            	
              36

            
	
              Section
                10.16 No additional consideration

            	
              37

            
	
              Section
                10.17 Federal Disallowance

            	
              37

            
	 	 
	
              Article
                11. Disclosure & Confidentiality of
                Information

            	
              37

            
	 	 
	
              Section
                11.01 Confidentiality

            	
              37

            
	
              Section
                11.02 Disclosure of HHSC’s Confidential Information

            	
              38

            
	
              Section
                11.03 Member Records

            	
              38

            
	
              Section
                11.04 Requests for public information

            	
              38

            
	
              Section
                11.05 Privileged Work Product

            	
              38

            
	
              Section
                11.06 Unauthorized acts

            	
              39

            
	
              Section
                11.07 Legal action

            	
              39

            
	 	 
	
              Article
                12. Remedies & Disputes

            	
              39

            
	 	 
	
              Section
                12.01 Understanding and expectations

            	
              39

            
	
              Section
                12.02 Tailored remedies

            	
              39

            
	
              Section
                12.03 Termination by HHSC

            	
              41

            
	
              Section
                12.04 Termination by HMO

            	
              43

            
	
              Section
                12.05 Termination by mutual agreement

            	
              43

            


    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    
      	
              Section
                12.06 Effective date of termination

            	
              43

            
	
              Section
                12.07 Extension of termination effective date

            	
              43

            
	
              Section
                12.08 Payment and other provisions at Contract termination

            	
              43

            
	
              Section
                12.09 Modification of Contract in the event of remedies

            	
              43

            
	
              Section
                12.10 Turnover assistance

            	
              43

            
	
              Section
                12.11 Rights upon termination or expiration of Contract

            	
              44

            
	
              Section
                12.12 HMO responsibility for associated costs

            	
              44

            
	
              Section
                12.13 Dispute resolution

            	
              44

            
	
              Section
                12.14 Liability of HMO

            	
              44

            
	 	 
	
              Article
                13. Assurances & Certifications

            	
              45

            
	 	 
	
              Section
                13.01 Proposal certifications

            	
              45

            
	
              Section
                13.02 Conflicts of interest

            	
              45

            
	
              Section
                13.03 Organizational conflicts of interest

            	
              45

            
	
              Section
                13.04 HHSC personnel recruitment prohibition

            	
              46

            
	
              Section
                13.05 Anti-kickback provision

            	
              46

            
	
              Section
                13.06 Debt or back taxes owed to State of Texas

            	
              46

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

            	
              46

            
	
              Section
                13.08 Outstanding debts and judgments

            	
              46

            
	 	 
	
              Article
                14. Representations & Warranties

            	
              46

            
	 	 
	
              Section
                14.01 Authorization

            	
              46

            
	
              Section
                14.02 Ability to perform

            	
              46

            
	
              Section
                14.03 Minimum Net Worth

            	
              46

            
	
              Section
                14.04 Insurer solvency

            	
              46

            
	
              Section
                14.05 Workmanship and performance

            	
              47

            
	
              Section
                14.06 Warranty of deliverables

            	
              47

            
	
              Section
                14.07 Compliance with Contract

            	
              47

            
	
              Section
                14.08 Technology Access

            	
              47

            
	 	 
	
              Article
                15. Intellectual Property

            	
              47

            
	 	 
	
              Section
                15.01 Infringement and misappropriation

            	
              47

            
	
              Section
                15.02 Exceptions

            	
              48

            
	
              Section
                15.03 Ownership and Licenses

            	
              48

            
	 	 
	
              Article
                16. Liability

            	
              49

            
	 	 
	
              Section
                16.01 Property damage

            	
              49

            
	
              Section
                16.02 Risk of Loss

            	
              49

            
	
              Section
                16.03 Limitation of HHSC’s Liability

            	
              49

            
	 	 
	
              Article
                17. Insurance & Bonding

            	
              49

            
	 	 
	
              Section
                17.01 Insurance Coverage

            	
              49

            
	
              Section
                17.02 Performance Bond

            	
              50

            
	
              Section
                17.03 TDI Fidelity Bond

            	
              51

            


    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    Article
      1 Introduction

    


    Section
      1.01Purpose.

    


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

    


    Section
      1.02Risk-based contract.

    


    This
      is a Risk-based
      contract.

    


    Section
      1.03Inducements.

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    Section
      1.04Construction of the Contract.

    


    (a)
      Scope
      of Introductory Article.

    


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

    


    (b)
      References to the “State.”

    


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

    


    (c)
      Severability.

    


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

    


    (d)
      Survival of terms.

     

    Termination
      or expiration of this
      Contract for any reason will not release either Party from any liabilities
      or
      obligations set forth in this Contract that:

    


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

    


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

    


    (e)
      Headings.

    


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

    


    (f)
      Global drafting conventions.

    


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

    


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

    


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


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    Section
      1.05No implied authority.

    


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

    


    (1)
      make public policy;

    


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

    


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

    


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

    


    Section
      1.06Legal Authority.

    


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

    


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

    


    Article
      2. Definitions

    


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

    


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

    


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

    


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

    


    Action
      (Medicaid only) means:

    


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

    


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

    


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

    


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

    


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

    


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

    


    An
      Adverse Determination is one type of Action.

    


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

    


    Acute
      Care
      Hospital means a hospital that provides acute care
      services

    


    Adjudicate
      means to deny or pay a clean claim.

    


    Administrative
      Services
see HMO Administrative Services.

    


    Administrative
      Services
      Contractor see HHSC Administrative Services
      Contractor.

    


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

    


    Affiliate
means
      any individual or entity owning or holding more than a five percent (5%)
      interest in the HMO or in which the HMO owns or holds more than a five percent
      (5%) interest; any parent entity; or subsidiary entity of the HMO, regardless
      of
      the organizational structure of the entity.

    


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

    


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


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    AAP
means
      the
      American Academy of Pediatrics.

    


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

    


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

    


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

    


    Auxiliary
      Aids and
      Services includes:

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    Capitation
      Rate
means a fixed predetermined fee paid by HHSC to the HMO each month
      in accordance with the Contract, for each enrolled Member in a defined Rate
      Cell, in exchange for the HMO arranging for or providing a defined set of
      Covered Services to such a Member, regardless of the amount of Covered Services
      used by the enrolled Member.

    


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

    


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

    


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

     

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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    CHIP
      HMOs means
      HMOs participating in the CHIP HMO Program.

    


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

    


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


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    Perinatal
      Program is part of the CHIP Program, for Contract administration purposes it
      is
      identified independently in this Contract. An HMO must specifically contract
      with HHSC as a CHIP Perinatal HMO in order to participate in this part of the
      CHIP Program.

    


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

    


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

    


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

    


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

    


    (1)
      837 Professional Combined
      Implementation Guide

    


    (2)
      837 Institutional Combined
      Implementation Guide

    


    (3)
      837 Professional Companion
      Guide

    


    (4)
      837 Institutional Companion
      Guide

    


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

    


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

    


    COLA
      means the
      Cost of Living Adjustment.

    


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

    


    Community
      Resource
      Coordination Groups (CRCGs) means a statewide system of local
      interagency groups, including both public and private providers, which
      coordinate services for ”multi-need” children and youth. CRCGs develop
      individual service plans for children and adolescents whose needs can be met
      only through interagency cooperation. CRCGs address Complex Needs in a model
      that promotes local decision-making and ensures that children receive the
      integrated combination of social, medical and other services needed to address
      their individual problems.

    


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

    


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

    


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

    


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

    


    Comprehensive
      Care
      Program: See definition for Texas Health Steps.

    


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

    


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

    


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

    


    (3)
      All
      Privileged Work Product;

    


    (4)
      All
      information designated by HHSC or any other State agency as confidential, and
      all information designated as confidential under the


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    Texas
      Public Information Act, Texas Government Code, Chapter 552;

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    Covered
      Services means Health Care Services the HMO must arrange to provide
      to Members, including all services required by the Contract and state and
      federal law, and all Value-added Services negotiated by the Parties (see
Attachments B-2, B-2.1, B-2.2 and B-3 of the HHSC
      Managed Care Contract relating to “Covered Services” and “Value-added
      Services”).  Covered Services include Behavioral Health
      Services.

    


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

    


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

    


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

    


    Day
      means a
      calendar day unless specified otherwise.

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


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

    


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

    


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

    


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

    


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

    


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

    


    EDI
      means
      electronic data interchange.

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

    


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

    


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

    


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

    


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

    


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

    


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

    


    Emergency
      Medical
      Condition means a medical condition manifesting itself by acute
      symptoms of recent onset and sufficient severity (including severe pain), such
      that a prudent layperson, who possesses an average knowledge of health and
      medicine, could reasonably expect the absence of immediate medical care could
      result in:

    


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

    


    (2)
      serious impairment to bodily functions;

    


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

    


    (4)
      serious disfigurement; or

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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


    
      
        
        

      

      
        7

        
          

        

      

      
        
        

      

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    FPL means
      the Federal Poverty Level.

    


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

    


    FSR
      means
      Financial Statistical Report.

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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


    
      
        
        

      

      
        8

        
          

        

      

      
        
        

      

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


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

    


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

    


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

    I

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

    


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

    


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

    


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

    


    JCAHO
      means
      Joint Commission on Accreditation of Health Care Organizations.

    


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

    


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

    


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

    


    Local
      Health Department
means a local health department established pursuant to Health
      and
      Safety Code, Title 2, Local Public Health Reorganization Act
§121.031.

    


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

    


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

    


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

    


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

    


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

    


    (1)           enroll
      with the HMO; or

    


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

    


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

    


    MCO
means
      managed care organization.

    


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

    


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

    


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

    


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

    


    Medically
      Necessary
means:

    


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


    
      
        
        

      

      
        9

        
          

        

      

      
        
        

      

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


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

    


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

    


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

    


    (d)
      consistent with the diagnoses of the conditions;

    


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

    


    (f)
      are
      not experimental or investigative; and

    


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

    


    (2)
      Behavioral Health Services that are:

    


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

    


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

    


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

    


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

    


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

    


    (f)
      are
      not experimental or investigative; and

    


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

    


    Member
      means a
      person who:

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    MIS
      means
      Management Information System.

    


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

    


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

    


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

    


    Network
      Provider or
      Provider means an appropriately credentialed and licensed
      individual,


    
      
        
        

      

      
        10

        
          

        

      

      
        
        

      

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    facility,
      agency, institution, organization or other entity, and its employees and
      subcontractors, that has a contract with the HMO for the delivery of Covered
      Services to the HMO’s Members.

    


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

    


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

    


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

    


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

    


    OB/GYN
      means
      obstetrician-gynecologist.

    


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

    


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

    


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

    


    Operations
      Phase means the period of time when HMO is responsible for
      providing the Covered Services and all related Contract functions for a Service
      Area.  The Operations Phase begins on the Operational Start Date, and
      may vary by HMO Program and Service Area.

    


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

    


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

    


    Parties
      means
      HHSC and HMO, collectively.

    


    Party
      means
      either HHSC or HMO, individually.

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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


    
      
        
        

      

      
        11

        
          

        

      

      
        
        

      

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


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

    


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

    


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

    


    Public
      Information means information that:

    


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

    


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

    


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

    


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

    the
      SSI
      program.

     

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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    SDX
      means State
      Data Exchange.

    


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


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


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

    


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

    


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

    


    (1)
      the Member’s history;

    


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

    


    (3)
      short and long term needs and
      goals;

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    SSA
      means the
      Social Security Administration.

    


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

    


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

    


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

    


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

     

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

    


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

    


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

    


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

    


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


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    T.A.C.
means
      Texas Administrative Code. 

       

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

    


    TDI
      means the
      Texas Department of Insurance.

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

     

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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    Value-added
      Services means additional services for coverage beyond those
      specified in the


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    RFP.  Value-added
      Services must be actual health care services or benefits rather than gifts,
      incentives, health assessments or educational classes. Temporary phones, cell
      phones, additional transportation benefits, and extra home health services
      may
      be Value-added Services, if approved by HHSC.  Best practice
      approaches to delivering Covered Services are not considered Value-added
      Services.

    


    Waste
      means
      practices that are not cost-efficient.

    


    Article
      3. General Terms &
Conditions

    


    Section
      3.01Contract
      elements.

    


    (a)
      Contract documentation.

    


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

    


    (b)
      Order
      of documents.

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    (7)
      HHSC Managed Care Contract
Attachment C-1– “HMO’s Proposal.”

    


    Section
      3.02 Term of the Contract.

    


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

    


    Section
      3.03Funding.

    


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

    


    Section
      3.04Delegation of authority.

    


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

    


    Section
      3.05No waiver of sovereign
      immunity.

    


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

    


    Section
      3.06Force majeure.

    


    Neither
      Party will be liable for any
      failure or delay in performing its obligations under the Contract if such
      failure or delay is due to any cause beyond the reasonable control of such
      Party, including, but not limited to, unusually severe weather, strikes, natural
      disasters, fire, civil disturbance, epidemic, war, court order, or acts of
      God.  The existence of such causes of delay or failure will extend the
      period of performance in the exercise of reasonable diligence until after the
      causes of delay or failure have been removed.  Each Party must inform
      the other in writing with proof of receipt within five (5) Business Days of
      the
      existence of a force majeure event or otherwise waive this right as a
      defense.

    


    Section
      3.07Publicity.

    


    (a)
      HMO may use the name of HHSC, the
      State of Texas, any HHS Agency, and the name of the HHSC HMO Program in any
      media release, public announcement, or public disclosure relating to
      the


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    Contract
      or its subject matter only if, at least seven (7) calendar days prior to
      distributing the material, the HMO submits the information to HHSC for review
      and comment. If HHSC has not responded within seven (7) calendar days, the
      HMO
      may use the submitted information.  HHSC reserves the right to object
      to and require changes to the publication if, at HHSC’s sole discretion, it
      determines that the publication does not accurately reflect the terms of the
      Contract or the HMO’s performance under the Contract. .

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    Section
      3.08Assignment.

    


    (a)
      Assignment by HMO.

    


    HMO
      shall not assign all or any portion
      of its rights under or interests in the Contract or delegate any of its duties
      without prior written consent of HHSC. Any written request for assignment or
      delegation must be accompanied by written acceptance of the assignment or
      delegation by the assignee or delegation by the delegate.  Except
      where otherwise agreed in writing by HHSC, assignment or delegation will not
      release HMO from its obligations pursuant to the Contract. An HHSC-approved
      Material Subcontract will not be considered to be an assignment or delegation
      for purposes of this section.

    


    (b)
      Assignment by HHSC.

    


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

    


    (c)
      Assumption.

    


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

    


    Section
      3.09Cooperation with other vendors and prospective
      vendors.

    


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

    


    Section
      3.10Renegotiation and reprocurement
      rights.

    


    (a)
      Renegotiation of Contract terms.

    


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

    


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

    


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

    


    (c)
      Termination rights upon reprocurement.

    


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

    


    Section
      3.11 RFP errors and
      omissions.

    


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

    


    Section
      3.12Attorneys’ fees.

    


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


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    Section
      3.13Preferences under service
      contracts.

    


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

    


    Section
      3.14Time of the essence.

    


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

    


    Section
      3.15Notice

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    Article
      4. Contract Administration &
Management

    


    Section
      4.01Qualifications, retention and replacement of HMO
      employees.

    


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

    


    Section
      4.02 HMO’s Key Personnel.

    


    (a)
      Designation of Key Personnel.

    


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

    


    (1)
      Member Services;

    


    (2)
      Management Information
      Systems;

    


    (3)
      Claims Processing,

    


    (4)
      Provider Network Development and
      Management;

    


    (5)
      Benefit Administration and
      Utilization and Care Management;

    


    (6)
      Quality Improvement;

    


    (7)
      Behavioral Health
      Services;

    


    (8)
      Financial Functions;

    


    (9)
      Reporting;

    


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

    


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

    


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

    


    (b)
      Support and Replacement of Key Personnel.

    


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

    


    (c)
      Notification of replacement of Key Personnel.

    


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

    


    Section
      4.03Executive Director.

    


    (a)
      The HMO must employ a qualified
      individual to serve as the Executive Director for its HHSC HMO Program(s).
      Such
      Executive Director must be


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


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

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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    Section
      4.04Medical Director.

    


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

    


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

    


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

    


    Section
      4.04.1STAR+PLUS Service
      Coordinator

    


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

    


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

    


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

    


    (d)
      The STAR+PLUS HMO must empower its
      Service Coordinators to authorize the provision and


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    delivery
      of Covered Services, including Community Long-term Care Covered
      Services.

    


    Section
      4.05Responsibility for HMO personnel and
      Subcontractors.

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    Section
      4.06Cooperation with HHSC and state administrative
      agencies.

    


    (a)
      Cooperation with Other MCOs.

    


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

    


    (b)
      Cooperation with state and federal administrative agencies.

    


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

    


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

    


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

    


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

    


    Section
      4.07Conduct of HMO
      personnel.

    


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

    


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

    


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

    


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

    


    (1)
      Removing the employee from the project;

    


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


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


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

    


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

    


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

    


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

    


    Section
      4.08Subcontractors.

    


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

    


    (b)
      HMO must:

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    (6)
      a
      Readiness Review is requested by HHSC.

    


    The
      HMO
      must submit information required by HHSC for each proposed Material
      Subcontractor as indicated in Attachment B-1, Section 7. Refer
      to Attachment B-1, Sections 8.1.1.2 and

    8.1.18
      for additional information regarding HMO Readiness Reviews during the Contract
      Period.

    


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

    


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

    


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

    


    (g)
      A Subcontract whereby HMO receives
      rebates, recoupments, discounts, payments, or other consideration from a
      Subcontractor (including without


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    limitation
      Affiliates) pursuant to or related to the execution of this Contract must be
      in
      writing and must provide HHSC the right to examine the Subcontract and all
      records relating to such consideration.

    


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

    


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

    


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

    


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

    


    Section
      4.09HHSC’s ability to contract with
      Subcontractors.

    


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

    


    Section
      4.10HMO Agreements with Third
      Parties

    


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

    


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


    


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

    


    (d)
      HMO must submit a copy of each
      third party agreement described in subsections (a) and (b) to HHSC. If the
      third
      party agreement is entered into prior to the Effective Date of the Contract,
      HMO
      must submit a copy no later than thirty (30) days after the Effective Date
      of
      the Contract.  If the third party agreement is executed after the
      Effective Date of the Contract, HMO must submit a copy no later than five (5)
      Business Days after execution. (e) For third party agreements valued under
      $100,000 per State Fiscal Year that are reported as Allowable Expenses, the
      HMO
      must maintain financial records and data sufficient to verify the accuracy
      of
      such expenses in accordance with the requirements of Article
      9.

    


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

    


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

    


    Article
      5. Member Eligibility & Enrollment

    


    Section
      5.01Eligibility
      Determination

    


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

    


    Section
      5.02Member Enrollment &
Disenrollment.

    


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

    


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

    


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

    


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

    


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


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    permit
      disenrollment of a Member under the following circumstances:

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    Section
      5.03STAR enrollment for pregnant women and
      infants.

    


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

    


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

    


    Section
      5.04 CHIP eligibility and
      enrollment.

    


    (a)
      Continuous coverage.

    


    Except
      as provided in 1 T.A.C.
§370.307, a child who is CHIP-eligible will have six (6) months of continuous
      coverage. Children enrolling in CHIP for the first time, or returning to CHIP
      after disenrollment, will be subject to a waiting period before coverage
      actually begins, except as provided in 1 T.A.C. §370.46. The waiting period for
      a child is determined by the date on which he/she is found eligible for CHIP,
      and extends for a duration of three months.  If the child is found
      eligible for CHIP on or before the 15th day of a month, then the waiting period
      begins on the first day of that same month.  If the child is found
      eligible on or after the 16th day of a month, then the waiting period begins
      on
      the first day of the next month.

    


    (b)
      Pregnant Members and Infants.

    


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

    


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

    


    Section
      5.04.1CHIP Perinatal eligibility, enrollment, and
      disenrollment

    


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

    


    (b)
      CHIP Perinate Newborns are eligible
      for 12 months continuous enrollment, beginning with the month of enrollment
      as a
      CHIP Perinate (month of enrollment plus 11 months).  A CHIP
      Perinate


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    Newborn
      will maintain coverage in his or her CHIP Perinatal health plan.

    


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

    


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

    


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

    


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

    


    Section
      5.05Span of Coverage

    


    (a)
      Medicaid HMOs.

    


    (1)
      HHSC will conduct continuous open
      enrollment for Medicaid Eligibles and the HMO must accept all persons who choose
      to enroll as Members in the HMO or who are assigned as Members in the HMO by
      HHSC, without regard to the Member’s health status, inpatient status, or any
      other factor.

    


    (2)
      Members who are disenrolled because
      they are temporarily ineligible for Medicaid will be automatically re-enrolled
      into the same health plan, if available.  Temporary loss of
      eligibility is defined as a period of six months or less.

    


    (3)
      A Member cannot change from one
      Medicaid HMO to another Medicaid HMO during an inpatient hospital
      stay.  Medicaid HMOs are responsible for professional charges during
      every month for which the HMO receives a full capitation for a
      Member.

    


    (4)
      The payor responsible for the
      hospital charges at the start of an Inpatient Stay remains responsible for
      hospital charges until the time of discharge, or until such time that there
      is a
      loss of Medicaid eligibility.  Medicaid HMOs are not responsible for
      any services after the effective date of loss of Medicaid
      eligibility.

     

    (b)
      CHIP
      HMOs.

    


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

    


    (c)
      CHIP
      Perinatal HMOs.

    


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

    


    Section
      5.06Verification of Member
      Eligibility.

    


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

    


    Section
      5.07Special Temporary STAR Default
      Process

    


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

    


    (b)
      For the Bexar, Dallas, El Paso,
      Harris, Tarrant, and Travis Service Areas, the special default process will
      begin with the Operational Start Date and conclude when the HMO has achieved
      an
      enrollment


    
      
        
        

      

      
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                Conditions

            	
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    of
      15,000
      mandatory STAR members, or at the end of six months, whichever comes
      first.

    


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

    


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

    


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

    


    Section
      5.08Special Temporary STAR+PLUS Default
      Process

    


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

    


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

    


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

    


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

    


    Article
      6. Service Levels & Performance Measurement

    


    Section
      6.01Performance measurement.

    


    Satisfactory
      performance of this
      Contract will be measured by:

    


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

    


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

    


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

    


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

    


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

    


    Article
      7. Governing Law & Regulations

    


    Section
      7.01Governing law and venue.

    


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

    


    Section
      7.02HMO responsibility for compliance with laws and
      regulations.

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    (7)
      1 T.A.C. Part 15, Chapters 361,
      370, 3491, and 392; and

    


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

    


    (b)
      The Parties acknowledge that the
      federal and/or state laws, rules, regulations, policies, or guidelines, and
      court-ordered consent decrees, settlement agreements, or other court orders
      that
      affect the performance of the Scope of Work may change from time to time or
      be
      added, judicially interpreted, or amended by competent authority.  HMO
      acknowledges that the HMO Programs will be subject to continuous change during
      the term of the Contract and, except as provided in Section 8.02, HMO has
      provided for or will provide for adequate resources, at no additional charge
      to
      HHSC, to reasonably accommodate such changes.  The Parties further
      acknowledge that HMO was selected, in part, because of its expertise,
      experience, and knowledge concerning applicable Federal and/or state
      laws,


    
      
        
        

      

      
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                Conditions

            	
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    regulations,
      policies, or guidelines that affect the performance of the Scope of
      Work.  In keeping with HHSC’s reliance on this knowledge and
      expertise, HMO is responsible for identifying the impact of changes in
      applicable Federal or state legislative enactments and regulations that affect
      the performance of the Scope of Work or the State’s use of the Services and
      Deliverables. HMO must timely notify HHSC of such changes and must work with
      HHSC to identify the impact of such changes on how the State uses the Services
      and Deliverables.

    


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

    


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

    


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

    


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

    


    Section
      7.03TDI licensure/ANHC certification and
      solvency.

    


    (a)
      Licensure

    


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

    


    (b)
      Solvency

    


    HMO
      must maintain compliance with the
      Texas Insurance Code and rules promulgated and administered by the TDI requiring
      a fiscally sound operation.  HMO must have a plan and takeappropriate
      measures to ensure adequate provision against the risk of insolvency as required
      by TDI. Such provision must be adequate to provide for the following in the
      event of insolvency:

    


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

    


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

    


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

    


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

    


    Section
      7.04Immigration Reform and Control Act of
      1986.

    


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

    


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

    


    HMO
      shall comply with Title VI of the
      Civil Rights Act of 1964, Executive Order 11246 (Public Law 88-352), Section
      504
      of the Rehabilitation Act of 1973 (Public Law 93-112), the Americans with
      Disabilities Act of 1990 (Public Law 101-336), and all amendments to each,
      and
      all requirements imposed by the regulations issued pursuant to these
      Acts.  In addition, HMO shall comply with Title 40, Chapter 73 of the
      Texas Administrative Code, “Civil Rights,” to the extent applicable to this
      Contract.  These provide in part that no persons in the United States
      must, on the grounds of race, color, national origin, sex, age, disability,
      political beliefs, or religion, be excluded from participation in, or denied,
      any aid, care, service or other benefits provided by Federal or State funding,
      or otherwise be subjected to any discrimination.

    


    Section
      7.06Environmental protection
      laws.

    


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

    


    (a)
      Pro-Children Act of 1994.

    


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

    


    (b)
      National Environmental Policy Act of 1969.

    


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


    
      
        
        

      

      
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                Conditions

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

    


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

    


    (d)
      State
      Clean Air Implementation Plan.

    


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

    


    (e)
      Safe
      Drinking Water Act of 1974.

    


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

    


    Section
      7.07HIPAA.

    


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

    


    Article
      8. Amendments & Modifications

    


    Section
      8.01Mutual agreement.

    


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

    


    Section
      8.02Changes in law or
      contract.

    


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

    


    Section
      8.03Modifications as a remedy.

    


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

    


    Section
      8.04Modifications upon renewal or extension of
      Contract.

    


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

    


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

    


    Section
      8.05Modification of HHSC Uniform Managed Care
      Manual.

    


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

    


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

    


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


    
      
        
        

      

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

            	
              Version
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    Section
      8.06 CMS approval of Medicaid amendments

    


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

    


    Section
      8.07Required compliance with amendment and modification
      procedures.

    


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

    


    Article
      9. Audit & Financial
      Compliance

    


    Section
      9.01Financial record retention and audit.

    


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

    


    Section
      9.02 Access to records, books, and documents.

    


    (a)
      Upon reasonable notice, HMO must
      provide, and cause its Subcontractors to provide, the officials and entities
      identified in this Section with prompt, reasonable, and adequate access to
      any
      records, books, documents, and papers that are related to the performance of
      the
      Scope of Work.

    


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

    


    (1)
      Examination;

    


    (2)
      Audit;

    


    (3)
      Investigation;

    


    (4)
      Contract administration; or

    


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

    


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

    


    


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

    


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

    


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

    


    (4)
      The
      Office of Inspector General;

    


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

    


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

    


    (7)
      A
      State or Federal law enforcement agency;

    


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

    


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

    


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

    


    Section
      9.03Audits of Services, Deliverables and
      inspections.

    


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

    


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

    


    (2)
      HMO
      Software and Equipment.

    


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

    


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

    


    (2)
      the
      Services and Deliverables provided;

    


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

    


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

    


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

    


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


    
      
        
        

      

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

            	
              Version
                1.7

            


    

    


    (d)
      If, as a result of an audit or
      review of payments made to the HMO, HHSC discovers a payment error or
      overcharge, HHSC will notify the HMO of such error or
      overcharge.  HHSC will be entitled to recover such funds as an offset
      to future payments to the HMO, or to collect such funds directly from the HMO.
      HMO must return funds owed to HHSC within thirty (30) days after receiving
      notice of the error or overcharge, or interest will accrue on the amount
      due.  HHSC will calculate interest at the Department of Treasury’s
      Median Rate (resulting from the Treasury’s auction of 13-week bills) for the
      week in which liability is assessed. In the event that an audit reveals that
      errors in reporting by the HMO have resulted in errors in payments to the HMO
      or
      errors in the calculation of the Experience Rebate, the HMO will indemnify
      HHSC
      for any losses resulting from such errors, including the cost of
      audit.

    


    Section
      9.04SAO Audit

    


    The
      HMO
      understands that acceptance of funds under this Contract acts as acceptance
      of
      the authority of the State Auditor’s Office (“SAO”), or any successor agency, to
      conduct an investigation in connection with those funds.  The HMO
      further agrees to cooperate fully with the SAO or its successor in the conduct
      of the audit or investigation, including providing all records
      requested.  The HMO will ensure that this clause concerning the
      authority to audit funds received indirectly by Subcontractors through HMO
      and
      the requirement to cooperate is included in any Subcontract it awards, and
      in
      any third party agreements described in Section 4.10 (a-b).

    


    Section
      9.05Response/compliance with audit or inspection
      findings.

    


    (a)
      HMO must take action to ensure its
      or a Subcontractor’s compliance with or correction of any finding of
      noncompliance with any law, regulation, audit requirement, or generally accepted
      accounting principle relating to the Services and Deliverables or any other
      deficiency contained in any audit, review, or inspection conducted under this
      Article.  This action will include HMO’S delivery to HHSC, for HHSC’S
      approval, a Corrective Action Plan that addresses deficiencies identified in
      any
      audit(s), review(s), or inspection(s) within thirty (30)calendar days of the
      close of the audit(s), review(s), or inspection(s).

    


    (b)
      HMO must bear the expense of
      compliance with any finding of noncompliance under this Section that
      is:

    


    (1)
      Required by Texas or Federal law, regulation, rule or other audit requirement
      relating to HMO's business;

    


    (2)
      Performed by HMO as part of the Services or Deliverables; or

    


    (3)
      Necessary due to HMO's noncompliance with any law, regulation, rule or audit
      requirement imposed on HMO.

    


    (c)
      As part of the Scope of Work, HMO
      must provide to HHSC upon request a copy of those portions of HMO's and its
      Subcontractors' internal audit reports relating to the Services and Deliverables
      provided to HHSC under the Contract.

    


    Article
      10. Terms & Conditions of
      Payment

    


    Section
      10.01 Calculation of monthly
      Capitation Payment.

    


    (a)
      This is a Risk-based
      contract.  For each applicable HMO Program, HHSC will pay the HMO
      fixed monthly Capitation Payments based on the number of eligible and enrolled
      Members. HHSC will calculate the monthly Capitation Payments by multiplying
      the
      number of Members by each applicable Member Rate Cell.  In
      consideration of the Monthly Capitation Payment(s), the HMO agrees to provide
      the Services and Deliverables described in this Contract.

    


    (b)
      HMO will be required to provide
      timely financial and statistical information necessary in the Capitation Rate
      determination process.  Encounter Data provided by HMO must conform to
      all HHSC requirements. Encounter Data containing non-compliant information,
      including, but not limited to, inaccurate client or member identification
      numbers, inaccurate provider identification numbers, or diagnosis or procedures
      codes insufficient to adequately describe the diagnosis or medical procedure
      performed, will not be considered in the HMO’s experience for rate-setting
      purposes.

    


    (c)
      Information or data, including
      complete and accurate Encounter Data, as requested by HHSC for rate-setting
      purposes, must be provided to HHSC: (1) within thirty (30) days of receipt
      of
      the letter from HHSC requesting the information or data; and (2) no later than
      March 31st of each year.

    


    (d)
      The fixed monthly Capitation Rate
      consists of the following components:

    


    (1)
      an
      amount for Health Care Services performed during the month;

    


    (2)
      an
      amount for administering the program,

    


    (3)
      an
      amount for the HMO’s Risk margin,  and

    


    (4)
      with
      respect to the Medicaid program,pass through funds for high-volume
      providers.

    


    Capitation
      Rates for each HMO Program may vary by Service Area and MCO.  HHSC
      will employ or retain qualified actuaries to perform data analysis and calculate
      the Capitation Rates for each Rate Period.

    


    (e)
      HMO understands and expressly
      assumes the risks associated with the performance of the duties and
      responsibilities under this Contract, including the failure, termination or
      suspension of funding to HHSC, delays or denials of required


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    approvals,
      and cost overruns not reasonably attributable to HHSC.

    


    Section
      10.02Time and Manner of
      Payment.

    


    (a)
      During the Contract Term and
      beginning after the Operational Start Date, HHSC will pay the monthly Capitation
      Payments by the 10th Business Day of each month.

    


    (b)
      The HMO must accept Capitation
      Payments by direct deposit into the HMO’s account.

    


    (c)
      HHSC may adjust the monthly
      Capitation Payment to the HMO in the case of an overpayment to the HMO, for
      Experience Rebate amounts due and unpaid, and if money damages are assessed
      in
      accordance with Article 12 (“Remedies and
      Disputes”).

    


    (d)
      HHSC’s payment of monthly
      Capitation Payments is subject to availability of federal and state
      appropriations. If appropriations are not available to pay the full monthly
      Capitation Payment, HHSC may:

    


    (1)
      equitably adjust Capitation Payments for all participating Contractors, and
      reduce scope of service requirements as appropriate in accordance with
Article 8, or

    


    (2)
      terminate the Contract in accordance with Article 12 (“Remedies
      and Disputes”).

    


    Section
      10.03Certification of Capitation
      Rates.

    


    HHSC
      will employ or retain a qualified
      actuary to certify the actuarial soundness of the Capitation Rates contained
      in
      this Contract.  HHSC will also employ or retain a qualified actuary to
      certify all revisions or modifications to the Capitation Rates.

    


    Section
      10.04Modification of Capitation
      Rates.

    


    The
      Parties expressly understand and
      agree that the agreed Capitation Rates are subject to modification in accordance
      with Article 8 (“Amendments and Modifications,”) if changes in state or federal
      laws, rules, regulations or policies affect the rates or the actuarial soundness
      of the rates.  HHSC will provide the HMO notice of a modification to
      the Capitation Rates 60 days prior to the effective date of the change, unless
      HHSC determines that circumstances warrant a shorter notice
      period.  If the HMO does not accept the rate change, either Party may
      terminate the Contract in accordance with Article 12 (“Remedies
      and Disputes”).

    


    Section
      10.05STAR Capitation
      Structure.

    


    (a)
      STAR
      Rate Cells.

    


    STAR
      Capitation Rates are defined on a
      per Member per month basis by Rate Cells and Service Areas. STAR Rate Cells
      are:

    


    (1)
      TANF
      adults;

    


    (2)
      TANF
      children over 12 months of age;

    


    


    (3)
      Expansion children over 12 months of age;

    


    (4)
      Newborns less than or equal to 12 months of age;

    


    (5)
      TANF
      children less than or equal to 12 months of age;

    


    (6)
      Expansion children less than or equal to 12 months of age;

    


    (7)
      Federal mandate children; and

    


    (8)
      Pregnant women.

    


    (b)
      STAR
      Capitation Rate development:

    


    (1)
      Capitation Rates for Rate Periods 1 and 2 for Service Areas with historical
      STAR
      Program participation.

    


    For
      Service Areas where HHSC operated the STAR Program prior to the Effective Date
      of this Contract, HHSC will develop base Capitation Rates by analyzing
      historical STAR Encounter Data and financial data for the Service
      Area.  This analysis will apply to all MCOs in the Service Area,
      including MCOs that have no historical STAR Program participation in the Service
      Area.  The analysis will include a review of historical enrollment and
      claims experience information; any changes to Covered Services and covered
      populations; rate changes specified by the Texas Legislature; and any other
      relevant information. If the HMO participated in the STAR Program in the Service
      Area prior to the Effective Date of this Contract, HHSC may modify the Service
      Area base Capitation Rates using diagnosis-based risk adjusters to yield the
      final Capitation Rates.

    


    (2)
      Capitation Rates for Rate Periods 1 and 2 for Service Areas with no historical
      STAR Program participation.

    


    For
      Service Areas where HHSC has not operated the STAR Program prior to the
      Effective Date of this Contract, HHSC will establish base Capitation Rates
      for
      Rate Periods 1 and 2 by analyzing Fee-for-Service claims data for the Service
      Area.  This analysis will include a review of historical enrollment
      and claims experience information; any changes to Covered Services and covered
      populations; rate changes specified by the Texas Legislature; and any other
      relevant information.

    


    (3)
      Capitation Rates for subsequent Rate Periods for Service Areas with no
      historical STAR Program participation.

    


    For
      Service Areas where HHSC has not operated the STAR Program prior to the
      Effective Date of this Contract, HHSC will establish base Capitation Rates
      for
      the Rate Periods following Rate Period 2 by analyzing historical STAR Encounter
      Data and financial data for the Service Area.  This analysis will
      include a review of historical enrollment and


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    claims
      experience information; any changes to Covered Services and covered populations;
      rate changes specified by the Texas Legislature; and any other relevant
      information.

    


    (c)
      Acuity adjustment.

    


    HHSC
      may evaluate and implement an
      acuity adjustment methodology, or alternative reasonable methodology, that
      appropriately reimburses the HMO for acuity and cost differences that deviate
      from that of the community average, if HHSC in its sole discretion determines
      that such a methodology is reasonable and appropriate.  The community
      average is a uniform rate for all HMOs in a Service Area, and is determined
      by
      combining all the experience for all HMOs in a Service Area to get an average
      rate for the Service Area.

    


    Value-added
      Services will not be included in the rate-setting process.

    


    Section
      10.05.1  STAR+PLUS Capitation
      Structure.

    


    (a)
      STAR+PLUS Rate Cells.

    


    STAR+PLUS
      Capitation Rates are defined
      on a per Member per month basis by Rate Cells.

    STAR+PLUS
      Rate Cells are based on client category as follows:

    


    
      	
               

            	
              (1)

            	
              Medicaid
                Only Standard Rate

            


    

    


    
      	
               

            	
              (2)

            	
              Medicaid
                Only 1915 (c) Nursing Facility Waiver
                Rate

            


    

    


    
      	
               

            	
              (3)

            	
              Dual
                Eligible Standard Rate

            


    

    


    
      	
               

            	
              (4)

            	
              Dual
                Eligible 1915(c) Nursing Facility Waiver
                Rate

            


    

    


    
      	
               

            	
              (5)

            	
              Nursing
                Facility – Medicaid only

            


    

    


    
      	
               

            	
              (6)

            	
              Nursing
                Facility - Dual Eligible

            


    

    


    These
      Rate Cells are subject to change after Rate Period 2.

    


    (b)
      STAR+PLUS Capitation Rates

    


      For
      All Service Areas, HHSC
      will establish base Capitation Rates by Service Area based on fee-for-service
      experience in the counties included in the Service Area. For the base Capitation
      Rate in the Harris Service Area, the encounter data from existing STAR+PLUS
      plans in Harris County will be blended with the fee-for-service experience
      from
      the balance of counties in the Harris Service Area. HHSC may adjust the base
      Capitation Rate by the HMO’s Case Mix Index to yield the final Capitation
      Rates.

    


    HHSC
      reserves the right to trend
      forward these rates until sufficient Encounter Data is available to base
      Capitation Rates on Encounter Data.

    


    (c)
      Delay
      in Increased Capitation Level for Certain Members Receiving Waiver
      Services

    


    Once
      a current HMO Member has been
      certified to receive STAR+PLUS Waiver (SPW) services, there is a two-month
      delay
      before the HMO will begin receiving the higher capitation payment.

    


    Non-Waiver
      Members who qualify for
      STAR+PLUS based on eligibility for SPW services and Waiver recipients who
      transfer from another region will not be subject to this two-month delay in
      the
      increased capitation payment.

    


    All
      SPW recipients will be registered
      into Service Authorization System Online (SASO).  The Premium Payment
      System (PPS) will process data from the SASO system in establishing a Member’s
      correct capitation payment.

    


    Section
      10.06CHIP Capitation Rates
      Structure.

    


    (a)
      CHIP
      Rate Cells.

    


    CHIP
      Capitation Rates are defined on a
      per Member per month basis by the Rate Cells applicable to a Service
      Area.  CHIP Rate Cells are based on the Member’s age group as
      follows:

    


    (1)
      under
      age one (1);

    


    (2)
      ages
      one (1) through five (5);

    


    (3)
      ages
      six (6) through fourteen (14); and

    


    (4)
      ages
      fifteen (15) through eighteen (18).

    


    (b)
      CHIP
      Capitation Rate development:

    


    HHSC
      will establish base Capitation
      Rates by analyzing Encounter Data and financial data for each Service
      Area.  This analysis will include a review of historical enrollment
      and claims experience information; any changes to Covered Services and covered
      populations; rate changes specified by the Texas Legislature; and any other
      relevant information.  HHSC may modify the Service Area base
      Capitation Rate using diagnosis based risk adjusters to yield the final
      Capitation Rates.

    


    (c)
      Acuity adjustment.

    


    HHSC
      may evaluate and implement an
      acuity adjustment methodology, or alternative reasonable methodology, that
      appropriately reimburses the HMO for acuity and cost differences that deviate
      from that of the community average, if HHSC in its sole discretion determines
      that such a methodology is reasonable and appropriate.  The community
      average is a uniform rate for all HMOs in a Service Area, and is determined
      by
      combining all the experience for all HMOs in a Service Area to get an average
      rate for the Service Area.

    


    (d)
      Value-added Services will not be included in the rate-setting
      process.

    


    Section
      10.06.1 CHIP Perinatal Program Capitation
      Structure.

    


    (a)
      CHIP
      Perinatal Program Rate Cells.

    


    CHIP
      Perinatal Capitation Rates are
      defined on a per Member per month basis by the Rate Cells applicable to a
      Service Area.  CHIP Perinatal Rate


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    Cells
      are
      based on the Member’s birth status and household income as follows:

    


    (1)
      CHIP Perinate 0% - 185% of
      FPL;

    


    (2)
      CHIP Perinate 186% - 200% of
      FPL;

    


    (3)
      CHIP Perinate Newborn 0% - 185% of
      FPL; and

    


    4)
      CHIP Perinate Newborn 186% - 200% of
      FPL.

    


    (b)
      CHIP
      Perinatal Program Capitation Rate Development

    


    (1)
      Until such time as adequate
      encounter data is available to set rates, CHIP Perinatal Program

    capitation
      rates will be established based on experience from comparable populations in
      the
      Medicaid Fee-for-Service and STAR programs.  This analysis will
      include: a review of historical enrollment and claims experience information;
      changes to Covered Services and covered populations; rate changes specified
      by
      the Texas Legislature; and any other relevant information.  HHSC may
      modify the Service Area based Capitation Rate using diagnosis-based risk
      adjusters to yield the final Capitation Rates.

    


    (2)
      Effective 4/1/07, on a prospective
      basis, the monthly premium rate for Perinatal expectant mothers at or below
      185%
      of FPL has been increased. The rate increase is to be passed on to all
      physicians involved in the labor with delivery for members at or below 185%
      FPL.
      The average increase for the fee schedule for the procedure codes related to
      labor with delivery is 26.1%.

    


    (c)
      Value-added Services will not be included in the rate-setting
      process.

    


    Section
      10.07 HMO input during rate setting process.

    


    (1)
      In Service Areas with historical
      STAR or CHIP Program participation, HMO must provide certified Encounter Data
      and financial data as prescribed in HHSC’s Uniform Managed Care
      Manual. Such information may include, without limitation: claims lag
      information by Rate Cell, capitation expenses, and stop loss reinsurance
      expenses.  HHSC may request clarification or for additional financial
      information from the HMO.  HHSC will notify the HMO of the deadline
      for submitting a response, which will include a reasonable amount of time for
      response.

    


    (2)
      HHSC will allow the HMO to review
      and comment on data used by HHSC to determine base Capitation
      Rates.  In Service Areas with no historical STAR Program
      participation, this will include Fee-for-Service data for Rate Periods 1 and
      2.  HHSC will notify the HMO of deadline for submitting comments,
      which will include a reasonable amount of time for response.  HHSC
      will not consider comments received after the deadline in its rate
      analysis.

    


    (3)
      During the rate setting process,
      HHSC will conduct at least two (2) meetings with the HMO.  HHSC may
      conduct the meetings in person, via teleconference, or by another method deemed
      appropriate by HHSC.  Prior to the first meeting, HHSC will provide
      the HMO with proposed Capitation Rates. During the first meeting, HHSC will
      describe the process used to generate the proposed Capitation Rates, discuss
      major changes in the rate setting process, and receive input from the
      HMO.  HHSC will notify the HMO of the deadline for submitting
      comments, which will include a reasonable amount of time to review and comment
      on the proposed Capitation Rates and rate setting process.  After
      reviewing such comments, HHSC will conduct a second meeting to discuss the
      final
      Capitation Rates and changes resulting from HMO comments, if any.

    


    Section
      10.08 Adjustments to
      CapitationPayments.

    


    (a)
      Recoupment.

    


    HHSC
      may recoup a payment made to the
      HMO for a Member if:

    


    (1)
      the Member is enrolled into the HMO
      in error, and the HMO provided no Covered Services to the Member during the
      month for which the payment was made;

    


    (2)
      the Member moves outside the United
      States, and the HMO has not provided Covered Services to the Member during
      the
      month for which the payment was made;

    


    (3)
      the Member dies before the first
      day of the month for which the payment was made; or

    


    (4)
      a Medicaid Member’s eligibility
      status or program type is changed, corrected as a result of error, or is
      retroactively adjusted.

    


    (b)
      Appeal of recoupment.

    


     The
      HMO may appeal the recoupment
      or adjustment of capitations in the above circumstances using the HHSC dispute
      resolution process set forth in Section 12.13, (“Dispute
      Resolution”).

    


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

    


    (a)
      The Delivery Supplemental Payment
      (DSP) is a function of the average delivery cost in each Service
      Area.  Delivery costs include facility and professional
      charges.

    


    (b)
      CHIP and STAR HMOs will receive a
      Delivery Supplemental Payment (DSP) from HHSC for each live or stillbirth by
      a
      Member. CHIP Perinatal HMOs will receive a DSP from HHSC for each live or
      stillbirth by a mother of a CHIP Perinatal Program Member in the 186% to 200%
      FPL (measured at the time of enrollment in the CHIP Perinatal
      Program).   CHIP Perinatal HMOs will not receive a DSP
      from


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    HHSC
      for
      a live or stillbirth by the mother of a CHIP Perinatal Program Member in the
      100%-185% FPL.  For STAR, CHIP and CHIP Perinatal Program HMOs, the
      one-time DSP payment is made in the amount identified in the HHSC Managed Care
      Contract document regardless of whether there is a single birth or there are
      multiple births at time of delivery.  A delivery is the birth of a
      live born infant, regardless of the duration of the pregnancy, or a stillborn
      (fetal death) infant of twenty (20) weeks or more of gestation.  A
      delivery does not include a spontaneous or induced abortion, regardless of
      the
      duration of the pregnancy.

    


    (c)
      HMO must submit a monthly DSP
      Report as described in Attachment B-1, Section 8 to the
HHSC Managed Care Contract document, in the format prescribed
      in HHSC’s Uniform Managed Care Manual.

    


    (d)
      HHSC will pay the Delivery
      Supplemental Payment within twenty (20) Business Days after receipt of a
      complete and accurate report from the HMO.

    


    (e)
      The HMO will not be entitled to
      Delivery Supplemental Payments for deliveries that are not reported to HHSC
      within 210 days after the date of delivery, or within thirty (30) days from
      the
      date of discharge from the hospital for the stay related to the delivery,
      whichever is later.

    


    (f)
      HMO must maintain complete claims
      and adjudication disposition documentation, including paid and denied amounts
      for each delivery. The HMO must submit the documentation to HHSC within five
      (5)
      Business Days after receiving a request for such information from
      HHSC.

    


    Section
      10.10Administrative Fee for SSI
      Members

    


    (a)
      Administrative Fee.

    


    STAR
      HMOs will receive a monthly fee
      for administering benefits to each SSI Beneficiary who voluntarily enrolls
      in
      the HMO (a “Voluntary SSI Member”), in the amount identified in the HHSC
      Managed Care Contract document. The HHSC will pay for Health Care
      Services for such Voluntary SSI Members under the Medicaid Fee-for-Services
      program.  SSI Beneficiaries in all Service Areas except Nueces may
      voluntarily participate in the STAR Program; however, HHSC reserves the right
      to
      discontinue such voluntary participation.

    


    (b)
      Administrative services and functions.

    


    (1)
      HMO must perform the same
      administrative services and functions for Voluntary SSI Members as are performed
      for other Members under this contract. These administrative services and
      functions include, but are not limited to:

    


    (i)
      prior
      authorization of services; (ii) all Member services functions, including
      linguistic services and Member materials in alternative formats for the blind
      and disabled;

    


    (iii)
      health education;

    


    (iv)
      utilization management using HHSC Administrative Services Contractor encounter
      data to provide service management and appropriate interventions;

    


    (v)
      quality assessment and performance improvement activities;

    


    (vi)
      coordination to link Voluntary SSI Members with applicable community resources
      and Non-capitated services.

    


    
      	
               

            	
              (2)
                HMO must require Network Providers to submit claims for health and
                health-related services to the HHSC Administrative Services Contractor
                for
                claims adjudication and payment.

            


    

    


    (3)
      HMO must provide services to
      Voluntary SSI Members within the HMO’s Network unless necessary services are
      unavailable within Network. HMO must also allow referrals to Out-of-Network
      providers if necessary services are not available within the HMO’s Network.
      Records must be forwarded to Member’s PCP following a referral
      visit.

    


    (c)
      Members who become eligible for SSI

    


    A
      Member’s SSI status is effective the
      date the State’s eligibility system identifies the Member as Type Program 13
      (TP13). On this effective date, the Member becomes a voluntary STAR
      enrollee.  The State is responsible for updating the State's
      eligibility system within 45 days of official notice of the Member’s Federal SSI
      eligibility by the Social Security Administration (SSA).

    


    Section
      10.11STAR, CHIP, and CHIP Perinatal Experience
      Rebate

    


    (a)
      HMO’s
      duty to pay.

    


    At
      the end of each Rate Year beginning
      with Rate Year 1, the HMO must pay an Experience Rebate for the STAR, CHIP,
      and
      CHIP Perinatal Programs to HHSC if the HMO’s Net Income before Taxes is greater
      than 3% of the total Revenue for the period.  The Experience Rebate is
      calculated in accordance with the tiered rebate method set forth below based
      on
      the consolidated Net Income before Taxes for all of the HMO’s STAR, CHIP, and
      CHIP Perinatal Service Areas included within the scope of the Contract, as
      measured by any positive amount on the Financial-Statistical Report (FSR) as
      reviewed and confirmed by HHSC.

    


    (b)
      Graduated Experience Rebate Sharing Method.


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    
      	
              Experience
                Rebate as a % of Revenues

            	
              HMO
                Share

            	
              HHSC
                Share

            
	
              ≤
                3%

            	
              100%

            	
              0%

            
	
              >
                3% and ≤ 7%

            	
              75%

            	
              25%

            
	
              >
                7% and ≤ 10%

            	
              50%

            	
              50%

            
	
              >
                10% and ≤ 15%

            	
              25%

            	
              75%

            
	
              >
                15%

            	
              0%

            	
              100%

            


    

    


    HHSC
      and
      the HMO will share the Net Income before Taxes for the STAR, CHIP, and CHIP
      Perinatal Programs as follows, unless HHSC provides the HMO an Experience Rebate
      Reward in accordance with Section 6 of Attachment B-1 to the
HHSC Managed Care Contract document and HHSC’s Uniform
      Managed Care Manual:

    


    (1)
      The HMO will retain all Net Income
      before Taxes that is equal to or less than 3% of the total Revenues received
      by
      the HMO.

    


    (2)
      HHSC and the HMO will share that
      portion of the Net Income before Taxes that is over 3% but less than or equal to
      7% of the total Revenues received with 75% to the HMO and 25% to
      HHSC.

    


    (3)
      HHSC and the HMO will share that
      portion of the Net Income before Taxes that is over 7% but less than or equal
      to
      10% of the total Revenues received with 50% to the HMO and 50% to
      HHSC.

    


    (4)
      HHSC and the HMO will share that
      portion of the Net Income before Taxes that is over 10% but less than or equal
      to 15% of the total Revenues received with 25% to the HMO and 75% to
      HHSC.

    


    (5)
      HHSC will be paid the entire
      portion of the Net Income before Taxes that exceeds 15% of the total
      Revenues.

    


    (c)
      Net
      income before taxes.

    


    (1)
      The HMO must compute the Net Income
      before Taxes in accordance with the HHSC Uniform Managed Care Manual’s
“Cost Principles for Administrative Expenses” and “FSR
      Instructions for Completion” and applicable federal regulations. The
      Net Income before Taxes will be confirmed by HHSC or its agent for the Rate
      Year
      relating to all revenues and expenses incurred pursuant to the Contract. HHSC
      reserves the right to modify the “Cost Principles for Administrative
      Expenses” and “FSR Instructions for Completion” found
      in HHSC’s Uniform Managed Care Manual in accordance with
      Section 8.05.

    


    (2)
      For purposes of calculating Net
      Income before Taxes, the following items are not Allowable
      Expenses:

    


    (i)
      the
      payment of an Experience Rebate;

    


    (ii)
      any
      interest expense associated with late or underpayment of the Experience
      Rebate;

    


    (iii)
      financial incentives, including without limitation the Quality Challenge Award
      described in Attachment B-1, Section 6.3.2.3; and

    


    (iv)
      financial disincentives, including without limitation: the Performance-based
      Capitation Rate described in Attachment B-1, Section 6.3.2.2; and the liquidated
      damages described in Attachment B-5.

    


    (3)
      Financial incentives are true net
      bonuses and shall not be reduced by the potential increased Experience Rebate
      payments.  Financial disincentives are true net disincentives, and
      shall not be offset in whole or part by potential decreases in Experience Rebate
      payments.

    


    (4)
      For FSR reporting purposes,
      financial incentives incurred shall not be reported as an increase in Revenues
      or as an offset to costs, and any award of such will not increase reported
      income.  Financial disincentives incurred shall not be included as
      reported expenses, and shall not reduce reported income.  The
      reporting or recording of any of these incurred items will be done on a memo
      basis, which is below the income line, and will be listed as separate
      items.

    


    (d)
      Carry
      forward of prior Rate Year losses.

    


    Losses
      incurred by a STAR, CHIP, or
      CHIP Perinatal HMO for one Rate Year may be carried forward to the next Rate
      Year, and applied as an offset against a STAR, CHIP, or CHIP Perinatal
      Experience Rebate. Prior losses may be carried forward for only one Rate Year
      for this purpose.  If the HMO offsets a loss against another STAR,
      CHIP, or CHIP Perinatal Service Area, only that portion of the loss that was
      not
      used as an offset may be carried forward to the next Rate Year. Losses incurred
      by a

    STAR,
      CHIP, CHIP Perinatal HMO cannot be offset against the STAR+PLUS
      Program.

    


    (e)
      Settlements for payment.

    


    (1)
      There will be at least two
      settlements for HMO payment(s) of the State share of the Experience Rebate
      for
      the STAR, CHIP, and CHIP Perinatal Programs. The first scheduled settlement
      shall equal 100% of the State share of the Experience Rebate as derived from
      the
      FSR, and shall be paidon the same day the 90-day FSR Report is submitted to
      HHSC, accompanied by an actuarial opinion certifying the reserve.

    


    (2)
      The second scheduled settlement
      shall be an adjustment to the first settlement and shall be paid by the HMO
      to
      HHSC on the same day that the 334-day FSR Report is submitted to HHSC if the
      adjustment is a payment from the HMO to HHSC.

    


    (3)
      HHSC or its agent may audit or
      review the FSRs. If HHSC determines that corrections to the


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    FSRs
      are
      required, based on an HHSC audit/review or other documentation acceptable to
      HHSC, to determine an adjustment to the amount of the second settlement, then
      final adjustment shall be made by HHSC within three years from the date that
      the
      HMO submits the 334-day FSR.  Any settlement payment resulting from an
      audit or final adjustment shall be due from the HMO within 30 days of the
      earlier of:

    


    (i)
      the
      date of the management representation letter resulting from the audit;
      or

    


    (ii)
      the
      date of any invoice issued by HHSC.

    


    Payment
      within the 30-day timeframe will not relieve the HMO of any interest payment
      obligation that may exist under Section 10.11(f).

    


    (4)
      HHSC may offset any Experience
      Rebates and/or corresponding interest payments owed to the State from any future
      Capitation Payments, or collect such sums directly from the HMO. HHSC must
      receive the settlements by their due dates or HHSC will assess interest on
      the
      amounts due at the current prime interest rate as set forth below. HHSC may
      adjust the Experience Rebate if HHSC determines the HMO has paid amounts for
      goods or services that are not reasonable, necessary, and allowable in
      accordance with the HHSC Uniform Managed Care Manual’s “Cost Principles
      for Administrative Expenses” and “FSR Instructions for
      Completion” and applicable federal regulations. HHSC has final
      authority in auditing and determining the amount of the Experience
      Rebate.

    


    (f)
      Interest on Experience Rebate.

    


    (1)
      Interest on any Experience Rebate
      owed to HHSC shall be charged beginning thirty (30) days after the due date
      for
      each settlement, as described in Section 10.11(e).  In addition, if
      any adjusted amount is owed to HHSC at the final settlement date, then interest
      will be charged on the adjusted amount owed beginning thirty (30) days after
      the
      second settlement date to the date of the final settlement
      payment.  HHSC will calculate interest at the Department of Treasury’s
      Median Rate (resulting from the Treasury’s auction of 13-week bills) for the
      week in which the liability is assessed.

    


    (2)
      If an audit or adjustment
      determines a downward revision of income after an interest payment has
      previously been required for the same State Fiscal Year, then HHSC will
      recalculate the interest and, if necessary, issue a full or partial refund
      or
      credit to the HMO.

    


    (3)
      Any interest obligations that are
      incurred pursuant to Section 10.11 that are not timely paid will be subject
      to
      accumulation of interest as well, at the same rate as applicable to the
      underlying Experience Rebate.

    


    (4)
      All interest assessed pursuant to
      Section 10.11
      will continue to accrue until such point as a payment is received by HHSC,
      at
      which point interest on the amount received will stop accruing.  If a
      balance remains at that point that is subject to interest, then the balance
      shall continue to accrue interest. If interim payments are made, such as between
      the first and second settlements, then any interest that may be due will only
      be
      charged on amounts for the time period during which they remained
      unpaid.  By way of example only, if $100,000 is subject to interest
      commencing on a given day, and a payment is received for $75,000 35 days after
      the start of interest, then the $75,000 will be subject to 35 days of interest,
      and the $25,000 balance will continue to accrue interest until
      paid.

    


    Section
      10.11.1STAR+PLUS Experience
      Rebate

    


    (a)
      HMO’s
      duty to pay.

    


    At
      the end of each Rate Year beginning
      with Rate Year 1, the HMO must pay an Experience Rebate to HHSC for the
      STAR+PLUS Program if the HMO produces a positive Net Income in STAR+PLUS. The
      STAR+PLUS Experience Rebate is calculated in accordance with the tiered rebate
      method set forth below based on the consolidated Net Income before Taxes for
      all
      of the HMO’s STAR+PLUS Service Areas included within the scope of the Contract,
      as measured by any positive amount on the Financial-Statistical Report (FSR)
      as
      reviewed and confirmed by HHSC.

    (b)
      Graduated STAR+PLUS Experience Rebate Sharing Method.

    


    
      	
              Experience
                Rebate as a % of Revenues

            	
              HMO
                Share

            	
              HHSC
                Share

            
	
              ≤
                3%

            	
              50%

            	
              50%

            
	
              >
                3%

            	
              75%

            	
              25%

            


    

    


    HHSC
      and the HMO will share the Net
      Income before Taxes for the STAR+PLUS Program as follows, unless HHSC provides
      the HMO an Experience Rebate Reward in accordance with Section 6 of
Attachment B-1 to the HHSC Managed Care Contract
document and HHSC’s Uniform Managed Care
      Manual:

    


    (1)
      HHSC and the STAR+PLUS HMO will
      share that portion of the Net Income before Taxes that is equal to or less
      than
      3% of the total STAR+PLUS Revenues received with 50% to the HMO and 50% to
      HHSC.

    


    (2)
      HHSC and the STAR+PLUS HMO will
      share that portion of the Net Income before Taxes that is over 3% of the total
      STAR+PLUS Revenues received with 75% to the HMO and 25% to HHSC.

    


    (c)
      Net
      income before taxes.

    


    1)
      The HMO must compute the Net Income
      before Taxes in accordance with the HHSC Uniform Managed Care Manual’s
“Cost Principles for Administrative Expenses” and “FSR
      Instructions


    
      
        
        

      

      
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              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    for
      Completion” and applicable federal regulations. The Net Income before
      Taxes will be confirmed by HHSC or its agent for the Rate Year relating to
      all
      revenues and expenses incurred pursuant to the Contract. HHSC reserves the
      right
      to modify the “Cost Principles for Administrative Expenses” and
“FSR Instructions for Completion” found in HHSC’s
      Uniform Managed Care Manual in accordance with Section
      8.05.

    


    (2)
      For purposes of calculating Net
      Income before Taxes, the following items are not Allowable
      Expenses:

    


    (i)
      the payment of an Experience
      Rebate;

    


    (ii)
      any interest expense associated
      with late or underpayment of the Experience Rebate;

    


    (iii)
      financial incentives, including
      without limitation the Quality Challenge Award described in Attachment B-1,
      Section 6.3.2.3, and the STAR+PLUS Hospital Inpatient Incentive Shared Savings
      Award described in Attachment B-1, Section 6.3.2.5.2; and

    


    (iv)
      financial disincentives, including
      without limitation: the Performance-based Capitation Rate described in
      Attachment B-1, Section 6.3.2.2; the STAR+PLUS Hospital Inpatient Disincentive
      Administrative Fee at Risk described in Attachment B-1, Section 6.3.2.5.1;
      and
      the liquidated damages described in Attachment B-5.

    


    (3)
      Financial incentives are true net
      bonuses and shall not be reduced by the potential increased Experience Rebate
      payments.  Financial disincentives are true net disincentives, and
      shall not be offset in whole or part by potential decreases in Experience Rebate
      payments.

    


    (4)
      For FSR reporting purposes,
      financial incentives incurred shall not be reported as an increase in Revenues
      or as an offset to costs, and any award of such will not increase reported
      income.  Financial disincentives incurred shall not be included as
      reported expenses, and shall not reduce reported income.  The
      reporting or recording of any of these incurred items will be done on a memo
      basis, which is below the income line, and will be listed as separate
      items.

    


    (d)
      Carry
      forward of prior Rate Year losses.

    


    Losses
      incurred by a STAR+PLUS HMO for one Rate Year may be carried forward to the
      next
      Rate Year, and applied as an offset against a STAR+PLUS Experience
      Rebate.  Prior losses may be carried forward for only one Rate Year
      for this purpose.  If the HMO offsets a loss against another STAR+PLUS
      Service Area, only that portion of the loss that was not used as an offset
      may
      be carried forward to the next Rate Year. Losses incurred by a STAR+PLUS HMO
      cannot be offset against the STAR or CHIP Programs.

    


    (e)
      Settlements for payment.

    


    (1)
      There will be at least two
      settlements for HMO payment(s) of the State share of the Experience Rebate
      for
      the STAR, CHIP, and CHIP Perinatal Programs. The first scheduled settlement
      shall equal 100% of the State share of the Experience Rebate as derived from
      the
      FSR, and shall be paid on the same day the 90-day FSR Report is submitted to
      HHSC, accompanied by an actuarial opinion certifying the reserve.

    


    (2)
      The second scheduled settlement
      shall be an adjustment to the first settlement and shall be paid by the HMO
      to
      HHSC on the same day that the 334-day FSR Report is submitted to HHSC if the
      adjustment is a payment from the HMO to HHSC.

    


    (3)
      HHSC or its agent may audit or
      review the FSRs. If HHSC determines that corrections to the FSRs are required,
      based on an HHSC audit/review or other documentation acceptable to HHSC, to
      determine an adjustment to the amount of the second settlement, then final
      adjustment shall be made by HHSC within three years from the date that the
      HMO
      submits the 334-day FSR.  Any settlement payment resulting from an
      audit or final adjustment shall be due from the HMO within 30 days of the
      earlier of:

    


    (i)
      the
      date of the management representation letter resulting from the audit;
      or

    


    (ii)
      the
      date of any invoice issued by HHSC. Payment within the 30-day timeframe will
      not
      relieve the HMO of any interest payment obligation that may exist under Section
      10.11.1(f).

    


    (4)
      HHSC may offset any Experience
      Rebates and/or corresponding interest payments owed to the State from any future
      Capitation Payments, or collect such sums directly from the HMO.  HHSC
      must receive settlements by their due dates or HHSC will assess interest on
      the
      amounts due at the current prime interest rate as set forth below. HHSC may
      adjust the Experience Rebate if HHSC determines the HMO has paid amounts for
      goods or services that are not reasonable, necessary, and allowable in
      accordance with the HHSC Uniform Managed Care Manual’s “Cost Principles
      for Administrative Expenses” and “FSR Instructions for
      Completion” and applicable federal regulations. HHSC has final
      authority in auditing and determining the amount of the Experience
      Rebate.

    


    (f)
      Interest on Experience Rebate.

    


    (1)
      Interest on any Experience Rebate
      owed to HHSC shall be charged beginning thirty (30) days after the due date
      for
      each settlement, as described in Section 10.11.1(e).  In addition, if
      any adjusted amount is owed to HHSC at the final settlement date, then interest
      will be charged on the adjusted amount owed beginning thirty (30) days after
      the
      second settlement date to the date of the final settlement


    
      
        
        

      

      
        35

        
          

        

      

      
        
        

      

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    payment.  HHSC
      will calculate interest at the Department of Treasury’s Median Rate (resulting
      from the Treasury’s auction of 13-week bills) for the week in which the
      liability is assessed.

    


    (2)
      If an audit or adjustment
      determines a downward revision of income after an interest payment has
      previously been required for the same State Fiscal Year, then HHSC will
      recalculate the interest and, if necessary, issue a full or partial refund
      or
      credit to the HMO.

    


    (3)
      Any interest obligations that are
      incurred pursuant to Section 10.11.1 that are not timely paid will be subject
      to
      accumulation of interest as well, at the same rate as applicable to the
      underlying Experience Rebate.

    


    (4)
      All interest assessed pursuant to
      Section 10.11.1 will continue to accrue until such point as a payment is
      received by HHSC, at which point interest on the amount received will stop
      accruing.  If a balance remains at that point that is subject to
      interest, then the balance shall continue to accrue interest. If interim
      payments are made, such as between the first and second settlements, then any
      interest that may be due will only be charged on amounts for the time period
      during which they remained unpaid.  By way of example only, if
      $100,000 is subject to interest commencing on a given day, and a payment is
      received for $75,000 35 days after the start of interest, then the $75,000
      will
      be subject to 35 days of interest, and the $25,000 balance will continue to
      accrue interest until paid.

    


    Section
      10.12Payment by Members.

    


    (a)
      Medicaid HMOs

    


    Medicaid
      HMOs and their Network
      Providers are prohibited from billing or collecting any amount from a Member
      for
      Health Care Services covered by this Contract. HMO must inform Members of costs
      for non-covered services, and must require its Network Providers
      to:

    


    (1)
      inform Members of costs for non-covered services prior to rendering such
      services; and

    


    (2)
      obtain a signed Private Pay form from such Members.

    


    (b)
      CHIP
      HMOs.

    


    (1)
      Families that meet the enrollment
      period cost share limit requirement must report it to the HHSC Administrative
      Services Contractor. The HHSC Administrative Service Contractor notifies the
      HMO
      that a family’s cost share limit has been reached. Upon notification from the
      HHSC Administrative Services Contractor that a family has reached its
      cost-sharing limit for the term of coverage, the HMO will generate and mail
      to
      the CHIP Member a new Member ID card within five days, showing that the CHIP
      Member’s cost-sharing obligation for that term of coverage has been
      met.  No cost-sharing may be collected from these CHIP Members for the
      balance of their term of coverage.

    


    (2)
      Providers are responsible for
      collecting all CHIP Member co-payments at the time of service. Co-payments
      that
      families must pay vary according to their income level. No co-payments apply,
      at
      any income level, to well-child or well-baby visits or immunizations. Except
      for
      costs associated with unauthorized non-emergency services provided to a Member
      by Out-of-Network providers and for non-covered services, the co-payments
      outlined in the CHIP Cost Sharing table in the HHSC Uniform Managed Care
      Manual are the only amounts that a provider may collect from a
      CHIP-eligible family.

    


    (3)
      Federal law prohibits charging
      cost-sharing or deductibles to CHIP Members of Native Americans or Alaskan
      Natives. The HHSC Administrative Services Contractor will notify the HMO of
      CHIP
      Members who are not subject to cost-sharing requirements.  The HMO is
      responsible for educating Providers regarding the cost-sharing waiver for this
      population.

    


    (4)
      An HMO’s monthly Capitation Payment
      will not be reduced for a family’s failure to make its CHIP premium
      payment.  There is no relationship between the per Member/per month
      amount owed to the HMO for coverage provided during a month and the family’s
      payment of its CHIP premium obligation for that month.

    


    (c)
      CHIP
      Perinatal HMOs

    


    Cost-sharing
      does not apply to CHIP
      Perinatal Program Members.  The exemption from cost-sharing applies
      through the end of the original 12-month enrollment period.

    


    Section
      10.13 Restriction on assignment of
      fees.

    


    During
      the term of the Contract, HMO
      may not, directly or indirectly, assign to any third party any beneficial or
      legal interest of the HMO in or to any payments to be made by HHSC pursuant
      to
      this Contract. This restriction does not apply to fees paid to
      Subcontractors.

    


    Section
      10.14 Liability for taxes.

    


    HHSC
      is not responsible in any way for
      the payment of any Federal, state or local taxes related to or incurred in
      connection with the HMO’s performance of this Contract. HMO must pay and
      discharge any and all such taxes, including any penalties and interest. In
      addition, HHSC is exempt from Federal excise taxes, and will not pay any
      personal property taxes or income taxes levied on HMO or any taxes levied on
      employee wages.

    


    Section
      10.15Liability for employment-related charges and
      benefits.

    


    HMO
      will perform work under this
      Contract as an independent contractor and not as agent or representative of
      HHSC. HMO is solely and exclusively liable for payment of all
      employment-


    
      
        
        

      

      
        36

        
          

        

      

      
        
        

      

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    related
      charges incurred in connection with the performance of this Contract, including
      but not limited to salaries, benefits, employment taxes, workers compensation
      benefits, unemployment insurance and benefits, and other insurance or fringe
      benefits for Staff.

    


    Section
      10.16No additional
      consideration.

    


    (a)
      HMO will not be entitled to nor
      receive from HHSC any additional consideration, compensation, salary, wages,
      charges, fees, costs, or any other type of remuneration for Services and
      Deliverables provided under the Contract, except by properly authorized and
      executed Contract amendments.

    


    (b)
      No other charges for tasks,
      functions, or activities that are incidental or ancillary to the delivery of
      the
      Services and Deliverables will be sought from HHSC or any other state agency,
      nor will the failure of HHSC or any other party to pay for such incidental
      or
      ancillary services entitle the HMO to withhold Services and Deliverables due
      under the Agreement.

    


    (c)
      HMO will not be entitled by virtue
      of the Contract to consideration in the form of overtime, health insurance
      benefits, retirement benefits, disability retirement benefits, sick leave,
      vacation time, paid holidays, or other paid leaves of absence of any type or
      kind whatsoever.

    


    Section
      10.17Federal Disallowance

    


    If
      the federal government recoups money
      from the state for expenses and/or costs that are deemed unallowable by the
      federal government, the state has the right to, in turn, recoup payments made
      to
      the HMOs for these same expenses and/or costs, even if they had not been
      previously disallowed by the state and were incurred by the HMO, and any such
      expenses and/or costs would then be deemed unallowable by the
      state.  If the state retroactively recoups money from the HMOs due to
      a federal disallowance, the state will recoup the entire amount paid to the
      HMO
      for the federally disallowed expenses and/or costs, not just the federal
      portion.

    


    Article
      11. Disclosure & Confidentiality of Information

    


    Section
      11.01Confidentiality.

    


    (a)
      HMO and all Subcontractors,
      consultants, or agents under the Contract must treat all information that is
      obtained through performance of the Services under the Contract, including,
      but
      not limited to, information relating to applicants or recipients of HHSC
      Programs as Confidential Information to the extent that confidential treatment
      is provided under law and regulations.

    


    (b)
      HMO is responsible for
      understanding the degree to which information obtained through performance
      of
      this Contract is confidential under State and Federal law, regulations, or
      administrative rules.

    


    (c)
      HMO and all Subcontractors,
      consultants, or agents under the Contract may not use any information obtained
      through performance of this Contract in any manner except as is necessary for
      the proper discharge of obligations and securing of rights under the
      Contract.

    


    (d)
      HMO must have a system in effect to
      protect all records and all other documents deemed confidential under this
      Contract maintained inconnection with the activities funded under the Contract.
      Any disclosure or transfer of Confidential Information by HMO, including
      information required by HHSC, will be in accordance with applicable law. If
      the
      HMO receives a request for information deemed confidential under this Contract,
      the HMO will immediately notify HHSC of such request, and will make reasonable
      efforts to protect the information from public disclosure.

    


    (e)
      In addition to the requirements
      expressly stated in this Section, HMO must comply with any policy, rule, or
      reasonable requirement of HHSC that relates to the safeguarding or disclosure
      of
      information relating to Members, HMO’S operations, or HMO’s performance of the
      Contract.

    


    (f)
      In the event of the expiration of
      the Contract or termination of the Contract for any reason, all Confidential
      Information disclosed to and all copies thereof made by the HMOI shall be
      returned to HHSC or, at HHSC’s option, erased or destroyed.  HMO shall
      provide HHSC certificates evidencing such destruction.

    


    (g)
      The obligations in this Section
      shall not restrict any disclosure by the HMO pursuant to any applicable law,
      or
      by order of any court or government agency, provided that the HMO shall give
      prompt notice to HHSC of such order.

    


    (h)
      With the exception of confidential
      Member information, Confidential Information shall not be afforded the
      protection of the Contract if such data was:

    


    (1)
      Already known to the receiving Party without restrictions at the time of its
      disclosure by the furnishing Party;

    


    (2)
      Independently developed by the receiving Party without reference to the
      furnishing Party’s Confidential Information;

    


    (3)
      Rightfully obtained by the other Party without restriction from a third party
      after its disclosure by the furnishing Party;

    


    (4)
      Publicly available other than through the fault or negligence of the other
      Party; or

    


    (5)
      Lawfully released without restriction to anyone.


    
      
        
        

      

      
        37

        
          

        

      

      
        
        

      

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

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

            	
              Version
                1.7

            


    

    


    Section
      11.02 Disclosure of HHSC’s Confidential Information.

    


    (a)
      HMO will immediately report to HHSC
      any and all unauthorized disclosures or uses of HHSC’s Confidential Information
      of which it or its Subcontractor(s), consultant(s), or agent(s) is aware or
      has
      knowledge.  HMO acknowledges that any publication or disclosure of
      HHSC’s Confidential Information to others may cause immediate and irreparable
      harm to HHSC and may constitute a violation of State or federal
      laws.  If HMO, its Subcontractor(s), consultant(s), or agent(s) should
      publish or disclose such Confidential Information to others without
      authorization, HHSC will immediately be entitled to injunctive relief or any
      other remedies to which it is entitled under law or equity.  HHSC will
      have the right to recover from HMO all damages and liabilities caused by or
      arising from HMO’s, its Subcontractors’, consultants’, or agents’ failure to
      protect HHSC’s Confidential Information.  HMO will defend with counsel
      approved by HHSC, indemnify and hold harmless HHSC from all damages, costs,
      liabilities, and expenses (including without limitation reasonable attorneys’
fees and costs) caused by or arising from HMO’s or its Subcontractors’,
      consultants’ or agents’ failure to protect HHSC’s Confidential
      Information.  HHSC will not unreasonably withhold approval of counsel
      selected by the HMO.

    


    (b)
      HMO will require its
      Subcontractor(s), consultant(s), and agent(s) to comply with the terms of this
      provision.

    


    Section
      11.03Member Records

    


    (a)
      HMO must comply with the
      requirements of state and federal laws, including the HIPAA requirements set
      forth in Section 7.07, regarding the transfer of Member Records.

    


    (b)
      If at any time during the Contract
      Term this Contract is terminated, HHSC may require the transfer of Member
      Records, upon written notice to HMO, to another entity, as consistent with
      federal and state laws and applicable releases.

    


    (c)
      The term “Member Record” for this
      Section means only those administrative, enrollment, case management and other
      such records maintained by HMO and is not intended to include patient records
      maintained by participating Network Providers.

    


    Section
      11.04Requests for public
      information.

    


    (a)
      HHSC agrees that it will promptly
      notify HMO of a request for disclosure of information filed in accordance with
      the Texas Public Information Act, Chapter 552 of the Texas Government Code,
      that
      consists of the HMO’S confidential information, including without limitation,
      information or data to which HMO has a proprietary or commercial
      interest.  HHSC will deliver a copy of the request for public
      information to HMO.

    


    (b)
      With respect to any information
      that is the subject of a request for disclosure, HMO is required to demonstrate
      to the Texas Office of Attorney General the specific reasons why the requested
      information is confidential or otherwise excepted from required public
      disclosure under law.  HMO will provide HHSC with copies of all such
      communications.

    


    (c)
      To the extent authorized under the
      Texas Public Information Act, HHSC agrees to safeguard from disclosure
      information received from HMO that the

    HMO
      believes to be confidential information.  HMO must clearly mark such
      information as confidential information or provide written notice to HHSC that
      it considers the information confidential.

    


    Section
      11.05Privileged Work
      Product.

    


    (a)
      HMO acknowledges that HHSC asserts
      that privileged work product may be prepared in anticipation of litigation
      and
      that HMO is performing the Services with respect to privileged work product
      as
      an agent of HHSC, and that all matters related thereto are protected from
      disclosure by the Texas Rules of Civil Procedure, Texas Rules of Evidence,
      Federal Rules of Civil Procedure, or Federal Rules of Evidence.

    


    (b)
      HHSC will notify HMO of any
      privileged work product to which HMO has or may have access.  After
      the HMO is notified or otherwise becomes aware that such documents, data,
      database, or communications are privileged work product, only HMO personnel,
      for
      whom such access is necessary for the purposes of providing the Services, may
      have access to privileged work product.

    


    (c)
      If HMO receives notice of any
      judicial or other proceeding seeking to obtain access to HHSC’s privileged work
      product, HMO will:

    


    (1)
      Immediately notify HHSC; and

    


    (2)
      Use
      all reasonable efforts to resist providing such access.

    


    (d)
      If HMO resists disclosure of HHSC’s
      privileged work product in accordance with this Section, HHSC will, to the
      extent authorized under Civil Practices and Remedies Code or other applicable
      State law, have the right and duty to:

    


    (1)
      represent HMO in such resistance;

    


    (2)
      to
      retain counsel to represent HMO; or

    


    (3)
      to
      reimburse HMO for reasonable attorneys' fees and expenses incurred in resisting
      such access.

    


    (e)
      If a court of competent
      jurisdiction orders HMO to produce documents, disclose data, or otherwise breach
      the confidentiality obligations imposed in the Contract, or otherwise with
      respect to maintaining the confidentiality, proprietary nature, and secrecy
      of
      privileged work product, HMO will not be liable for breach of such
      obligation.


    
      
        
        

      

      
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    Section
      11.06Unauthorized acts.

    


    Each
      Party agrees to:

    


    (1)
      Notify the other Party promptly of
      any unauthorized possession, use, or knowledge, or attempt thereof, by any
      person or entity that may become known to it, of any HHSC Confidential
      Information or any information identified by the HMO as confidential or
      proprietary;

    


    (2)
      Promptly furnish to the other Party
      full details of the unauthorized possession, use, or knowledge, or attempt
      thereof, and use reasonable efforts to assist the other Party in investigating
      or preventing the reoccurrence of any unauthorized possession, use, or
      knowledge, or attempt thereof, of Confidential Information;

    


    (3)
      Cooperate with the other Party in
      any litigation and investigation against third Parties deemed necessary by
      such
      Party to protect its proprietary rights; and

    


    (4)
      Promptly prevent a reoccurrence of
      any such unauthorized possession, use, or knowledge such
      information.

    


    Section
      11.07Legal action.

    


    Neither
      party may commence any legal
      action or proceeding in respect to any unauthorized possession, use, or
      knowledge, or attempt thereof by any person or entity of HHSC’s Confidential
      Information or information identified by the HMO as confidential or proprietary,
      which action or proceeding identifies the other Party such information without
      such Party’s consent.

    


    Article
      12. Remedies &
Disputes

    


    Section
      12.01Understanding and expectations.

    


    The
      remedies described in this Section
      are directed to HMO’s timely and responsive performance of the Services and
      production of Deliverables, and the creation of a flexible and responsive
      relationship between the Parties.  The HMO is expected to meet or
      exceed all HHSC objectives and standards, as set forth in the
      Contract.  All areas of responsibility and all Contract requirements
      will be subject to performance evaluation by HHSC.  Performance
      reviews may be conducted at the discretion of HHSC at any time and may relate
      to
      any responsibility and/or requirement.  Any and all responsibilities
      and/or requirements not fulfilled may be subject to remedies set forth in the
      Contract.

    


    Section
      12.02 Tailored
      remedies.

    


    (a)
      Understanding of the Parties.

    


    HMO
      agrees and understands that HHSC
      may pursue tailored contractual remedies for noncompliance with the
      Contract.  At any time and at its discretion, HHSC may impose or
      pursue one or

    more
      remedies for each item of noncompliance and will determine remedies on a
      case-by-case basis. HHSC’s
      pursuit or non-pursuit of a tailored remedy does not constitute a waiver of
      any
      other remedy that HHSC may have at law or equity.

    


    (b)
      Notice and opportunity to cure for non-material breach.

    


    (1)
      HHSC will notify HMO in writing of
      specific areas of HMO performance that fail to meet performance expectations,
      standards, or schedules set forth in the Contract, but that, in the
      determination of HHSC, do not result in a material deficiency or

    delay
      in
      the implementation or operation of the Services.

    


    (2)
      HMO will, within five (5) Business
      Days (or another date approved by HHSC) of receipt of written notice of a
      non-material deficiency, provide the HHSC Project Manager a written response
      that:

    


    (A)
      Explains the reasons for the deficiency, HMO’s plan to address or cure the
      deficiency, and the date and time by which the deficiency will be cured;
      or

    


    (B)
      If
      HMO disagrees with HHSC’s findings, its reasons for disagreeing with HHSC’s
      findings.

    


    (3)
      HMO’s proposed cure of a
      non-material deficiency is subject to the approval of HHSC. HMO’s repeated
      commission of non-material deficiencies or repeated failure to resolve any
      such
      deficiencies may be regarded by HHSC as a material deficiency and entitle HHSC
      to pursue any other remedy provided in the Contract or any other appropriate
      remedy HHSC may have at law or equity.

    


    (c)
      Corrective action plan.

    


    (1)
      At its option, HHSC may require HMO
      to submit to HHSC a written plan (the “Corrective Action Plan”) to correct or
      resolve a material breach of this Contract, as determined by HHSC.

    


    (2)
      The Corrective Action Plan must
      provide:

    


    (A)
      A
      detailed explanation of the reasons for the cited deficiency;

    


    (B)
      HMO’s
      assessment or diagnosis of the cause; and

    


    (C)
      A
      specific proposal to cure or resolve the deficiency.

    


    (3)
      The Corrective Action Plan must be
      submitted by the deadline set forth in HHSC’s request for a Corrective Action
      Plan.  The Corrective Action Plan is subject to approval by HHSC,
      which will not unreasonably be withheld.

    


    (4)
      HHSC will notify HMO in writing of
      HHSC’s final disposition of HHSC’s concerns.  If HHSC accepts HMO’s
      proposed Corrective Action Plan, HHSC may:

    


    (A)
      Condition such approval on completion of tasks in the order or priority that
      HHSC may reasonably prescribe;


    
      
        
        

      

      
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                Conditions

            	
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    (B)
      Disapprove portions of HMO’s proposed Corrective Action Plan; or

    


    (C)
      Require additional or different corrective action(s).

    


    Notwithstanding
      the submission and
      acceptance of a Corrective Action Plan, HMO remains responsible for achieving
      all written performance criteria.

    


    (5)
      HHSC’s acceptance of a Corrective
      Action Plan under this Section will not:

    


    (A)
      Excuse HMO’s prior substandard performance;

    


    (B)
      Relieve HMO of its duty to comply with performance standards; or

    


    (C)
      Prohibit HHSC from assessing additional tailored remedies or pursuing other
      appropriate remedies for continued substandard performance.

    


    (d)
      Administrative remedies.

    


    (1)
      At its discretion, HHSC may impose
      one or more of the following remedies for each item of material noncompliance
      and will determine the scope and severity of the remedy on a case-by-case
      basis:

    


    (A)
      Assess liquidated damages in accordance with Attachment B-5 to
      the HHSC Managed Care Contract, “Liquidated Damages
      Matrix;”

    


    (B)
      Conduct accelerated monitoring of the HMO. Accelerated monitoring includes
      more
      frequent or more extensive monitoring by HHSC or its agent;

    


    (C)
      Require additional, more detailed, financial and/or programmatic reports to
      be
      submitted by HMO;

    


    (D)
      Decline to renew or extend the Contract;

    


    (E)
      Appoint temporary management;

    


    (F)
      Initiate disenrollment of a Member or Members;

    


    (G)
      Suspend enrollment of Members;

    


    (H)
      Withhold or recoup payment to HMO;

    


    (I)
      Require forfeiture of all or part of the HMO’s bond; or

    


    (J)
      Terminate the Contract in accordance with Section 12.03,
      (“Termination by HHSC”).

    


    (2)
      For purposes of the Contract, an
      item of material noncompliance means a specific action of HMO that:

    


    (A)
      Violates a material provision of the Contract;

    


    (B)
      Fails
      to meet an agreed measure of performance; or

    


    (C)
      Represents a failure of HMO to be reasonably responsive to a reasonable request
      of HHSC relating to the Services for information, assistance, or support within
      the timeframe specified by HHSC.

    


    (3)
      HHSC will provide notice to HMO of
      the imposition of an administrative remedy in accordance with this Section,
      with
      the exception of accelerated monitoring, which may be
      unannounced.  HHSC may require HMO to file a written response in
      accordance with this Section.

    


    (4)
      The Parties agree that a State or
      Federal statute, rule, regulation, or Federal guideline will prevail over the
      provisions of this Section unless the statute, rule, regulation, or guidelines
      can be read together with this Section to give effect to both.

    


    (e)
      Damages.

    


    (1)
      HHSC will be entitled to actual and
      consequential damages resulting from the HMO’S failure to comply with any of the
      terms of the Contract.  In some cases, the actual damage to HHSC or
      State of Texas as a result of HMO’S failure to meet any aspect of the
      responsibilities ofthe Contract and/or to meet specific performance standards
      set forth in the Contract are difficult or impossible to determine with precise
      accuracy.  Therefore, liquidated damages will be assessed in writing
      against and paid by the HMO in accordance with and for failure to meet any
      aspect of the responsibilities of the Contract and/or to meet the specific
      performance standards identified by the HHSC in Attachment B-5 to the
      HHSC Managed Care Contract, “Deliverables/Liquidated Damages Matrix.”
Liquidated damages will be assessed if HHSC determines such failure
      is the fault
      of the HMO (including the HMO’S Subcontractors and/or consultants) and is not
      materially caused or contributed to by HHSC or its agents.  If at any
      time, HHSC determines the HMO has not met any aspect of the responsibilities
      of
      the Contract and/or the specific performance standards due to mitigating
      circumstances, HHSC reserves the right to waive all or part of the liquidated
      damages.  All such waivers must be in writing, contain the reasons for
      the waiver, and be signed by the appropriate executive of HHSC.

    


    (2)
      The liquidated damages prescribed
      in this Section are not intended to be in the nature of a penalty, but are
      intended to be reasonable estimates of HHSC’s projected financial loss and
      damage resulting from the HMO’s nonperformance, including financial loss as a
      result of project delays.  Accordingly, in the event HMO fails to
      perform in accordance with the Contract, HHSC may assess liquidated damages
      as
      provided in this Section.

    


    (3)
      If HMO fails to perform any of the
      Services described in the Contract, HHSC may assess


    
      
        
        

      

      
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                Conditions

            	
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    liquidated
      damages for each occurrence of a liquidated damages event, to the extent
      consistent with HHSC's tailored approach to remedies and Texas law.

    


    (4)
      HHSC may elect to collect
      liquidated damages:

    


    (A)
      Through direct assessment and demand for payment delivered to HMO;
      or

    


    (B)
      By
      deduction of amounts assessed as liquidated damages as set-off against payments
      then due to HMO or that become due at any time after assessment of the
      liquidated damages. HHSC will make deductions until the full amount payable
      by
      the HMO is received by HHSC.

    


    (f)
      Equitable Remedies

    


    (1)
      HMO acknowledges that, if HMO
      breaches (or attempts or threatens to breach) its material obligation under
      this
      Contract, HHSC may be irreparably harmed.  In such a circumstance,
      HHSC may proceed directly to court to pursue equitable remedies.

    


    (2)
      If a court of competent
      jurisdiction finds that HMO breached (or attempted or threatened to breach)
      any
      such obligations, HMO agrees that without any additional findings of irreparable
      injury or other conditions to injunctive relief, it will not oppose the entry
      of
      an appropriate order compelling performance by HMO and restraining it from
      any
      further breaches (or attempted or threatened breaches).

    


    (g)
      Suspension of Contract

    


    (1)
      HHSC may suspend performance of all
      or any part of the Contract if:

    


    (A)
      HHSC
      determines that HMO has committed a material breach of the
      Contract;

    


    (B)
      HHSC
      has reason to believe that HMO has committed, assisted in the commission of
      Fraud, Abuse, Waste, malfeasance, misfeasance, or nonfeasance by any party
      concerning the Contract;

    


    (C)
      HHSC
      determines that the HMO knew, or should have known of, Fraud, Abuse, Waste,
      malfeasance, or nonfeasance by any party concerning the Contract, and the HMO
      failed to take appropriate action; or

    


    (D)
      HHSC
      determines that suspension of the Contract in whole or in part is in the best
      interests of the State of Texas or the HHSC Programs.

    


    (2)
      HHSC will notify HMO in writing of
      its intention to suspend the Contract in whole or in part.  Such
      notice will:

    


    (A)
      Be
      delivered in writing to HMO;

    


    (B)
      Include a concise description of the facts or matter leading to HHSC’s decision;
      and

    


    (C)
      Unless HHSC is suspending the contract for convenience, request a Corrective
      Action Plan from HMO or describe actions that HMO may take to avoid the
      contemplated suspension of the Contract.

    


    Section
      12.03Termination by HHSC.

    


    This
      Contract will terminate upon the
      Expiration Date. In addition, prior to completion of the Contract Term, all
      or a
      part of this Contract may be terminated for any of the following
      reasons:

    


    (a)
      Termination in the best interest of HHSC.

    


    HHSC
      may terminate the Contract without
      cause at any time when, in its sole discretion, HHSC determines that termination
      is in the best interests of the State of Texas.  HHSC will provide
      reasonable advance written notice of the termination, as it deems appropriate
      under the circumstances.  The termination will be effective on the
      date specified in HHSC’s notice of termination.

    


    (b)
      Termination for cause.

    


    HHSC
      reserves the right to terminate this Contract, in whole or in part, upon the
      following conditions:

    


    (1)
      Assignment for the benefit of creditors, appointment of receiver, or inability
      to pay debts. HHSC may terminate this Contract at any time if HMO:

    


    (A)
      Makes
      an assignment for the benefit of its creditors;

    


    (B)
      Admits in writing its inability to pay its debts generally as they become due;
      or

    


    (C)
      Consents to the appointment of a receiver, trustee, or liquidator of HMO or
      of
      all or any part of its property.

    


    (2)
      Failure to adhere to laws, rules, ordinances, or orders.

    


    HHSC
      may
      terminate this Contract if a court of competent jurisdiction finds HMO failed
      to
      adhere to any laws, ordinances, rules, regulations or orders of any public
      authority having jurisdiction and such violation prevents or substantially
      impairs performance of HMO’s duties under this Contract.  HHSC will
      provide at least thirty (30) days advance written notice of such
      termination.

    


    (3)
      Breach of confidentiality.

    


    HHSC
      may
      terminate this Contract at any time if HMO breaches confidentiality laws
      with

    respect
      to the Services and Deliverables provided under this Contract.


    
      
        
        

      

      
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                Conditions

            	
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    (4)
      Failure to maintain adequate personnel or resources.

    


    HHSC
      may
      terminate this Contract if, after providing notice and an opportunity to
      correct, HHSC determines that HMO has failed to supply personnel or resources
      and such failure results in HMO’s inability to fulfill its duties under this
      Contract. HHSC will provide at least thirty (30) days advance written notice
      of
      such termination.

    


    (5)
      Termination for gifts and gratuities.

    


    (A)
      HHSC
      may terminate this Contract at any time following the determination by a
      competent judicial or quasi-judicial authority and HMO’s exhaustion of all legal
      remedies that HMO, its employees, agents or representatives have either offered
      or given any thing of value to an officer or employee of HHSC or the State
      of
      Texas in violation of state law.

    


    (B)
      HMO
      must include a similar provision in each of its Subcontracts and shall enforce
      this provision against a Subcontractor who has offered or given any thing of
      value to any of the persons or entities described in this Section, whether
      or
      not the offer or gift was in HMO’s behalf.

    


    (C)
      Termination of a Subcontract by HMO pursuant to this provision will not be
      a
      cause for termination of the Contract unless:

    


    (1)
      HMO
      fails to replace such terminated Subcontractor within a reasonable time;
      and

    


    (2)
      Such
      failure constitutes cause, as described in this Subsection
      12.03(b).

    


    (D)
      For
      purposes of this Section, a “thing of value” means any item of tangible or
      intangible property that has a monetary value of more than $50.00 and includes,
      but is not limited to, cash, food, lodging, entertainment, and charitable
      contributions.  The term does not include contributions to holders of
      public office or candidates for public office that are paid and reported in
      accordance with State and/or Federal law.

    


    (6)
      Termination for non-appropriation of funds.

    


    Notwithstanding
      any other provision of this Contract, if funds for the continued fulfillment
      of
      this Contract by HHSC are at any time not forthcoming or are insufficient,
      through failure of any entity to appropriate funds or otherwise, then HHSC
      will
      have the right to terminate this Contract at no additional cost and with no
      penalty whatsoever by giving prior written notice documenting the lack of
      funding.  HHSC will provide at least thirty (30) days advance written
      notice of such termination.  HHSC will use reasonable efforts to
      ensure appropriated funds are available.

    


    (7)
      Judgment and execution.

    


    (A)
      HHSC
      may terminate the Contract at any time if judgment for the payment of money
      in
      excess of $500,000.00 that is not covered by insurance, is rendered by any
      court
      or governmental body against HMO, and HMO does not:

    


    (1)
      Discharge the judgment or provide for its discharge in accordance with the
      terms
      of the judgment;

    


    (2)
      Procure a stay of execution of the judgment within thirty (30) days from the
      date of entry thereof; or

    


    (3)
      Perfect an appeal of such judgment and cause the execution of such judgment
      to
      be stayed during the appeal, providing such financial reserves as may be
      required under generally accepted accounting principles.

    


    (B)
      If a
      writ or warrant of attachment or any similar process is issued by any court
      against all or any material portion of the property of HMO, and such writ or
      warrant of attachment or any similar process is not released or bonded within
      thirty (30) days after its entry, HHSC may terminate the Contract in accordance
      with this Section.

    


    (8)
      Termination for insolvency.

    


    (A)
      HHSC
      may terminate the Contract at any time if HMO:

    


    (1)
      Files
      for bankruptcy;

    


    (2)
      Becomes or is declared insolvent, or is the subject of any proceedings related
      to its liquidation, insolvency, or the appointment of a receiver or similar
      officer for it;

    


    (3)
      Makes
      an assignment for the benefit of all or substantially all of its creditors;
      or

    


    (4)
      Enters into an Contract for the composition, extension, or readjustment of
      substantially all of its obligations.

    


    (B)
      HMO
      agrees to pay for all reasonable expenses of HHSC including the cost of counsel,
      incident to:

    


    (1)
      The
      enforcement of payment of all obligations of the HMO by any action or
      participation in, or in connection with a case or proceeding under Chapters
      7,
      11, or 13 of the United States Bankruptcy Code, or any successor
      statute;

    


    (2)
      A
      case or proceeding involving a receiver or other similar officer duly appointed
      to handle the HMO's business; or


    
      
        
        

      

      
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                Conditions

            	
              Version
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    (3)
      A
      case or proceeding in a State court initiated by HHSC when previous collection
      attempts have been unsuccessful.

    


    (9)
      Termination for HMO’S material breach of the Contract.

    


    HHSC
      will
      have the right to terminate the Contract in whole or in part if HHSC determines,
      at its sole discretion, that HMO has materially breached the
      Contract.  HHSC will provide at least thirty (30) days advance written
      notice of such termination.

    


    Section
      12.04Termination by HMO.

    


    (a)
      Failure to pay.

    


    HMO
      may terminate this Contract if HHSC
      fails to pay the HMO undisputed charges when due as required under this
      Contract.  Retaining premium, recoupment, sanctions, or penalties that
      are allowed under this Contract or that result from the HMO’s failure to perform
      or the HMO’s default under the terms of this Contract is not cause for
      termination.  Termination for failure to pay does not release HHSC
      from the obligation to pay undisputed charges for services provided prior to
      the
      termination date.

    


    If
      HHSC fails to pay undisputed charges
      when due, then the HMO may submit a notice of intent to terminate for failure
      to
      pay in accordance with the requirements of Subsection 12.04(d).
      If HHSC pays all undisputed amounts then due within thirty (30)-days after
      receiving the notice of intent to terminate,the HMO cannot proceed with
      termination of the Contract under this Article.

    


    (b)
      Change to HHSC Uniform Managed Care  Manual.

    


    HMO
      may terminate this agreement if the
      Parties are unable to resolve a dispute concerning a material and substantive
      change to the HHSC Uniform Managed Care Manual (a change that materially and
      substantively alters the HMO’s ability to fulfill its obligations under the
      Contract).  HMO must submit a notice of intent to terminate due to a
      material and substantive change in the HHSC Uniform Managed Care Manual no
      later
      than thirty (30) days after the effective date of the policy
      change.  HHSC will not enforce the policy change during the period of
      time between the receipt of the notice of intent to terminate and the effective
      date of termination.

    


    (c)
      Change to Capitation Rate.

    


    If
      HHSC
      proposes a modification to the Capitation Rate that is unacceptable to the
      HMO,
      the HMO may terminate the Contract.  HMO must submit a written notice
      of intent to terminate due to a change in the Capitation Rate no later than
      thirty (30) days after HHSC’s notice of the proposed change. HHSC will not
      enforce the rate change during the period of time between the receipt of the
      notice of intent to terminate and the effective date of
      termination.

    


    (d)
      Notice of intent to terminate.

    


    In
      order to terminate the Contract
      pursuant to this Section, HMO must give HHSC at least ninety

    (90)
      days
      written notice of intent to terminate.  The termination date will be
      calculated as the last day of the month following ninety (90) days from the
      date
      the notice of intent to terminate is received by HHSC.

    


    Section
      12.05Termination by mutual
      agreement.

    


    This
      Contract may be terminated by
      mutual written agreement of the Parties.

    


    Section
      12.06Effective date of
      termination.

    


    Except
      as otherwise provided in this
      Contract, termination will be effective as of the date specified in the notice
      of termination.

    


    Section
      12.07Extension of termination effective
      date.

    


    The
      Parties may extend the effective
      date of termination one or more times by mutual written agreement.

    


    Section
      12.08Payment and other provisions at Contract
      termination.

    


    (a)
      In the event of termination
      pursuant to this Article, HHSC will pay the Capitation Payment for Services
      and
      Deliverables rendered through the effective date of termination.  All
      pertinent provisions of the Contract will form the basis of
      settlement.

    


    (b)
      HMO must provide HHSC all
      reasonable access to records, facilities, and documentation as is required
      to
      efficiently and expeditiously close out the Services and Deliverables provided
      under this Contract.

    


    (c)
      HMO must prepare a Turnover Plan,
      which is acceptable to and approved by HHSC.  The Turnover Plan will
      be implemented during the time period between receipt of notice and the
      termination date.

    


    Section
      12.09Modification of Contract in the event of
      remedies.

    


    HHSC
      may propose a modification of this
      Contract in response to the imposition of a remedy under this Article. Any
      modifications under this Section must be reasonable, limited to the matters
      causing the exercise of a remedy, in writing, and executed in accordance with
      Article 8. HMO must negotiate such proposed modifications in good
      faith.

    


    Section
      12.10Turnover assistance.

    


    Upon
      receipt of notice of termination
      of the Contract by HHSC, HMO will provide any turnover assistance reasonably
      necessary to enable HHSC or its designee to effectively close out the Contract
      and move the work to another vendor or to perform the work
      itself.


    
      
        
        

      

      
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                Conditions

            	
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    Section
      12.11Rights upon termination or expiration of
      Contract.

    


    In
      the event that the Contract is
      terminated for any reason, or upon its expiration, HHSC will, at HHSC's
      discretion, retain ownership of any and all associated work products,
      Deliverables and/or documentation in whatever form that they exist.

    


    Section
      12.12HMO responsibility for associated
      costs.

    


    If
      HHSC terminates the Contract for
      Cause, the HMO will be responsible to HHSC for all reasonable costs incurred
      by
      HHSC, the State of Texas, or any of its administrative agencies to replace
      the
      HMO.  These costs include, but are not limited to, the costs of
      procuring a substitute vendor and the cost of any claim or litigation that
      is
      reasonably attributable to HMO’s failure to perform any Service in accordance
      with the terms of the Contract

    


    Section
      12.13 Dispute resolution.

    


    (a)
      General agreement of the Parties.

    


    The
      Parties mutually agree that the
      interests of fairness, efficiency, and good business practices are best served
      when the Parties employ all reasonable and informal means to resolve any dispute
      under this Contract. The Parties express their mutual commitment to using all
      reasonable and informal means of resolving disputes prior to invoking a remedy
      provided elsewhere in this Section.

    


    (b)
      Duty
      to negotiate in good faith.

    


    Any
      dispute that in the judgment of any
      Party to this Contract may materially or substantially affect the performance
      of
      any Party will be reduced to writing and delivered to the other Party. The
      Parties must then negotiate in good faith and use every reasonable effort to
      resolve such dispute and the Parties shall not resort to any formal proceedings
      unless they have reasonably determined that a negotiated resolution is not
      possible. The resolution of any dispute disposed of by Contract between the
      Parties shall be reduced to writing and delivered to all Parties within ten
      (10)
      Business Days.

    


    (c)
      Claims for breach of Contract.

    


    (1)
      General requirement. HMO’s claim
      for breach of this Contract will be resolved in accordance with the dispute
      resolution process established by HHSC in accordance with Chapter 2260, Texas
      Government Code.

    


    (2)
      Negotiation of claims. The Parties
      expressly agree that the HMO’s claim for breach of this Contract that the
      Parties cannot resolve in the ordinary course of business or through the use
      of
      all reasonable and informal means will be submitted to the negotiation process
      provided in Chapter 2260, Subchapter B, Texas Government Code.

    


    (A)
      To
      initiate the process, HMO must submit written notice to HHSC that specifically
      states that HMO invokes the provisions of Chapter 2260, Subchapter B, Texas
      Government Code.  The notice must comply with the requirements of
      Title 1, Chapter 392, Subchapter B of the Texas Administrative
      Code.

    


    (B)
      The
      Parties expressly agree that the HMO’s compliance with Chapter 2260, Subchapter
      B, Texas Government Code, will be a condition precedent to the filing of a
      contested case proceeding under Chapter 2260, Subchapter C, of the Texas
      Government Code.

    


    (3)
      Contested case proceedings. The contested case process provided in Chapter
      2260,
      Subchapter C, Texas Government Code, will be HMO’s sole and exclusive process
      for seeking a remedy for any and all alleged breaches of contract by HHSC if
      the
      Parties are unable to resolve their disputes under Subsection (c)(2) of this
      Section.

    


    The
      Parties expressly agree that
      compliance with the contested case process provided in Chapter 2260, Subchapter
      C, Texas Government Code, will be a condition precedent to seeking consent
      to
      sue from the Texas Legislature under Chapter 107, Civil Practices & Remedies
      Code. Neither the execution of this Contract by HHSC nor any other conduct
      of
      any representative of HHSC relating to this Contract shall be considered a
      waiver of HHSC’s sovereign immunity to suit.

    


    (4)
      HHSC rules. The submission,
      processing and resolution of HMO’s claim is governed by the rules adopted by
      HHSC pursuant to Chapter 2260, Texas Government Code, found at Title 1, Chapter
      392, Subchapter B of the Texas Administrative Code.

    


    (5)
      HMO’s duty to perform. Neither the
      occurrence of an event constituting an alleged breach of contract nor the
      pending status of any claim for breach of contract is grounds for the suspension
      of performance, in whole or in part, by HMO of any duty or obligation with
      respect to the performance of this Contract. Any changes to the Contract as
      a
      result of a dispute resolution will be implemented in accordance with
Article 8 (“Amendments and Modifications”).

    


    Section
      12.14 Liability of
      HMO.

    


    (a)
      HMO bears all risk of loss or
      damage to HHSC or the State due to:

    


    (1)
      Defects in Services or Deliverables;

    


    (2)
      Unfitness or obsolescence of Services or Deliverables; or

    


    (3)
      The
      negligence or intentional misconduct of HMO or its employees, agents,
      Subcontractors, or representatives.

    


    (b)
      HMO must, at the HMO’s own expense,
      defend with counsel approved by HHSC, indemnify, and hold harmless HHSC and
      State employees, officers, directors, contractors and agents from
      and


    
      
        
        

      

      
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    against
      any losses, liabilities, damages, penalties, costs, fees, including without
      limitation reasonable attorneys' fees, and expenses from any claim or action
      for
      property damage, bodily injury or death, to the extent caused by or arising
      from
      the negligence or intentional misconduct of the HMO and its employees, officers,
      agents, or Subcontractors.  HHSC will not unreasonably withhold
      approval of counsel selected by HMO.

    


    (c)
      HMO will not be liable to HHSC for
      any loss, damages or liabilities attributable to or arising from the failure
      of
      HHSC or any state agency to perform a service or activity in connection with
      this Contract.

    


    Article
      13. Assurances &
Certifications

    


    Section
      13.01Proposal certifications.

    


    HMO
      acknowledges its continuing
      obligation to comply with the requirements of the following certifications
      contained in its Proposal, and will immediately notify HHSC of any changes
      in
      circumstances affecting these certifications:

    


    (1)
      Federal lobbying;

    


    (2)
      Debarment and
      suspension;

    


    (3)
      Child support; and

    


    (4)
      Nondisclosure
      statement.

    


    Section
      13.02Conflicts of interest.

    


    (a)
      Representation.

    


    HMO
      agrees to comply with applicable
      state and federal laws, rules, and regulations regarding conflicts of interest
      in the performance of its duties under this Contract. HMO warrants that it
      has
      no interest and will not acquire any direct or indirect interest that would
      conflict in any manner or degree with its performance under this
      Contract.

    


    (b)
      General duty regarding conflicts of interest.

    


    HMO
      will establish safeguards to
      prohibit employees from using their positions for a purpose that constitutes
      or
      presents the appearance of personal or organizational conflict of interest,
      or
      personal gain. HMO will operate with complete independence and objectivity
      without actual, potential or apparent conflict of interest with respect to
      the
      activities conducted under this Contract with the State of Texas.

    


    Section
      13.03Organizational conflicts of
      interest.

    


    (a)
      Definition.

    


    An
      organizational conflict of interest
      is a set of facts or circumstances, a relationship, or other situation under
      which a HMO, or a Subcontractor has past, present, or currently planned personal
      or financial
      activities or interests that either directly or indirectly:

    


    (1)
      Impairs or diminishes the HMO’s, or Subcontractor’s ability to render impartial
      or objective assistance or advice to HHSC; or

    


    (2)
      Provides the HMO or Subcontractor an unfair competitive advantage in future
      HHSC
      procurements (excluding the award of this Contract).

    


    (b)
      Warranty.

    


    Except
      as otherwise disclosed and
      approved by HHSC prior to the Effective Date of the Contract, HMO warrants
      that,
      as of the Effective Date and to the best of its knowledge and belief, there
      are
      no relevant facts or circumstances that could give rise to an organizational
      conflict of interest affecting this Contract. HMO affirms that it has neither
      given, nor intends to give, at any time hereafter, any economic opportunity,
      future employment, gift, loan, gratuity, special discount, trip, favor, or
      service to a public servant or any employee or representative of same, at any
      time during the procurement process or in connection
      with the procurement process except as allowed under relevant state and federal
      law.

    


    (c)
      Continuing duty to disclose.

    


    (1)
      HMO
      agrees that, if after the Effective Date, HMO discovers or is made aware of
      an
      organizational conflict of interest, HMO will immediately and fully disclose
      such interest in writing to the HHSC project manager.  In addition,
      HMO must promptly disclose any relationship that might be perceived or
      represented as a conflict after its discovery by HMO or by HHSC as a potential
      conflict.  HHSC reserves the right to make a final determination
      regarding the existence of conflicts of interest, and HMO agrees to abide by
      HHSC’s decision.

    


    (2)
      The
      disclosure will include a description of the action(s) that HMO has taken or
      proposes to take to avoid or mitigate such conflicts.

    


    (d)
      Remedy.

    


    If
      HHSC determines that an
      organizational conflict of interest exists, HHSC may, at its discretion,
      terminate the Contract pursuant to Subsection 12.03(b)(9). If HHSC determines
      that HMO was aware of an organizational conflict of interest before the award
      of
      this Contract and did not disclose the conflict to the contracting officer,
      such
      nondisclosure will be considered a material breach of the
      Contract.  Furthermore, such breach may be submitted to the Office of
      the Attorney General, Texas Ethics Commission, or appropriate State or Federal
      law enforcement officials for further action.

    


    (e)
      Flow
      down obligation.

    


    HMO
      must include the provisions of this
      Section in all Subcontracts for work to be performed similar to the service
      provided by HMO, and the terms


    
      
        
        

      

      
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                Conditions

            	
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    "Contract,"
      "HMO," and "project manager" modified appropriately to preserve the State's
      rights.

    


    Section
      13.04HHSC personnel recruitment
      prohibition.

    


    HMO
      has not retained or promised to
      retain any person or company, or utilized or promised to utilize a consultant
      that participated in HHSC’s development of specific criteria of the RFP or who
      participated in the selection of the HMO for this Contract.

    


    Unless
      authorized in writing by HHSC,
      HMO will not recruit or employ any HHSC professional or technical personnel
      who
      have worked on projects relating to the subject matter of this Contract, or
      who
      have had any influence on decisions affecting the subject matter of this
      Contract, for two (2) years following the completion of this
      Contract.

    


    Section
      13.05Anti-kickback
      provision.

    


    HMO
      certifies that it will comply with
      the Anti-Kickback Act of 1986, 41 U.S.C. §51-58 and Federal Acquisition
      Regulation 52.203-7, to the extent applicable.

    


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

    


    In
      accordance with Section 403.055 of
      the Texas Government Code, HMO agrees that any payments due to HMO under the
      Contract will be first applied toward any debt and/or back taxes HMO owes State
      of Texas.  HMO further agrees that payments will be so applied until
      such debts and back taxes are paid in full.

    


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

    


    Article
      IX, Section 163 of the General
      Appropriations Act for the 1998/1999 state fiscal biennium prohibits an agency
      that receives an appropriation under either Article II or V of the General
      Appropriations Act from awarding a contract with the owner, operator, or
      administrator of a facility that has had a license, certificate, or permit
      revoked by another Article II or V agency. HMO certifies it is not ineligible
      for an award under this provision.

    


    Section
      13.08 Outstanding debts and
      judgments.

    


    HMO
      certifies that it is not presently
      indebted to the State of Texas, and that HMO is not subject to an outstanding
      judgment in a suit by State of Texas against HMO for collection of the balance.
      For purposes of this Section, an indebtedness is any amount sum of money that
      is
      due and owing to the State of Texas and is not currently under dispute. A false
      statement regarding HMO’s status will be treated as a material breach of this
      Contract and may be grounds for termination at the option of HHSC.

    


    Article
      14. Representations & Warranties

    


    Section
      14.01Authorization.

    


    (a)
      The execution, delivery and
      performance of this Contract has been duly authorized by HMO and no additional
      approval, authorization or consent of any governmental or regulatory agency
      is
      required to be obtained in order for HMO to enter into this Contract and perform
      its obligations under this Contract.

    


    (b)
      HMO has obtained all licenses,
      certifications, permits, and authorizations necessary to perform the Services
      under this Contract and currently is in good standing with all regulatory
      agencies that regulate any or all aspects of HMO’s performance of this Contract.
      HMO will maintain all required certifications, licenses, permits, and
      authorizations during the term of this Contract.

    


    Section
      14.02Ability to perform.

    


    HMO
      warrants that it has the financial
      resources to fund the capital expenditures required under the Contract without
      advances by HHSC or assignment of any payments by HHSC to a financing
      source.

    


    Section
      14.03Minimum Net Worth.

    


    The
      HMO has, and will maintain
      throughout the life of this Contract, minimum net worth to the greater of (a)
      $1,500,000; (b) an amount equal to the sum of twenty-five dollars ($25) times
      the number of all enrollees including Members; or (c) an amount that complies
      with standards adopted by TDI. Minimum net worth means the excess total admitted
      assets over total liabilities, excluding liability for subordinated debt issued
      in compliance with Chapter 843 of the Texas Insurance Code.

    Section
      14.04 Insurer solvency.

    


    (a)
      The HMO must be and remain in full
      compliance with all applicable state and federal solvency requirements for
      basic-service health maintenance organizations, including but not limited to,
      all reserve requirements, net worth standards, debt-to-equity ratios, or other
      debt limitations. In the event the HMO fails to maintain such compliance, HHSC,
      without limiting any other rights it may have by law or under the Contract,
      may
      terminate the Contract.

    


    (b)
      If the HMO becomes aware of any
      impending changes to its financial or business structure that could adversely
      impact its compliance with the requirements of the Contract or its ability
      to
      pay its debts as they come due, the HMO must notify HHSC immediately in
      writing.

    


    (c)
      The HMO must have a plan and take
      appropriate measures to ensure adequate provision against the risk of insolvency
      as required by TDI. Such provision must be adequate to provide for the following
      in the event of insolvency:


    
      
        
        

      

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

    


    (2)
      payments to unaffiliated health care providers and affiliated healthcare
      providers whose Contracts do not contain Member “hold harmless” clauses
      acceptable to the TDI;

    


    (3)
      continuation of Covered Services for the duration of the Contract Period for
      which a capitation has been paid for a Member;

    


    (4)
      provision against the risk of insolvency must be made by establishing adequate
      reserves, insurance or other guarantees in full compliance with all financial
      requirements of TDI and the Contract.

    


    Should
      TDI determine that there is an
      immediate risk of insolvency or the HMO is unable to provide Covered Services
      to
      its Members, HHSC, without limiting any other rights it may have by law, or
      under the Contract, may terminate the Contract.

    


    Section
      14.05Workmanship and performance.

    


    (a)
      All Services and Deliverables
      provided under this Contract will be provided in a manner consistent with the
      standards of quality and integrity as outlined in the Contract.

    


    (b)
      All Services and Deliverables must
      meet or exceed the required levels of performance specified in or pursuant
      to
      this Contract.

    


    (c)
      HMO will perform the Services and
      provide the Deliverables in a workmanlike manner, in accordance with best
      practices and high professional standards used in well-managed operations
      performing services similar to the services described in this
      Contract.

    


    Section
      14.06Warranty of
      deliverables.

    


    HMO
      warrants that Deliverables
      developed and delivered under this Contract will meet in all material respects
      the specifications as described in the Contract during the period following
      its
      acceptance by HHSC, through the term of the Contract, including any subsequently
      negotiated by HMO and HHSC. HMO will promptly repair or replace any such
      Deliverables not in compliance with this warranty at no charge to
      HHSC.

    


    Section
      14.07Compliance with
      Contract.

    


    HMO
      will not take any action
      substantially or materially inconsistent with any of the terms and conditions
      set forth in this Contract without the express written approval of
      HHSC.

    


    Section
      14.08Technology Access

    


    (a)
      HMO expressly acknowledges that
      State funds may not be expended in connection with the purchase of an automated
      information system unless that system meets certain statutory requirements
      relating to accessibility by persons with visual
      impairments.  Accordingly, HMO represents and warrants to HHSC that
      this technology is capable, either by virtue of features included within the
      technology or because it is readily adaptable by use with other technology,
      of:

    


    (1)
      Providing equivalent access for effective use by both visual and non-visual
      means;

    


    (2)
      Presenting information, including prompts used for interactive communications,
      in formats intended for non-visual use; and

    


    (3)
      Being
      integrated into networks for obtaining, retrieving, and disseminating
      information used by individuals who are not blind or visually
      impaired.

    


    (b)
      For purposes of this Section, the
      phrase "equivalent access" means a substantially similar ability to communicate
      with or make use of the technology, either directly by features incorporated
      within the technology or by other reasonable means such as assistive devices
      or
      services that would constitute reasonable accommodations under the Americans
      with Disabilities Act or similar State or Federal laws.  Examples of
      methods by which equivalent access may be provided include, but are not limited
      to, keyboard alternatives to mouse commands and other means of navigating
      graphical displays, and customizable display appearance.

    


    (c)
      In addition, all technological
      solutions offered by the HMO must comply with the requirements
      of  Texas Government Code §531.0162.  This includes, but is
      not limited to providing technological solutions that meet federal accessibility
      standards for persons with disabilities, as applicable.

    


    Article
      15. Intellectual
      Property

    


    Section
      15.01Infringement and
      misappropriation.

    


    (a)
      HMO warrants that all Deliverables
      provided by HMO will not infringe or misappropriate any right of, and will
      be
      free of any claim of, any third person or entity based on copyright, patent,
      trade secret, or other intellectual property rights.

    


    (b)
      HMO will, at its expense, defend
      with counsel approved by HHSC, indemnify, and hold harmless HHSC, its employees,
      officers, directors, contractors, and agents from and against any losses,
      liabilities, damages, penalties, costs, fees, including without limitation
      reasonable attorneys’ fees and expenses, from any claim or action against HHSC
      that is based on a claim of breach of the warranty set forth in the preceding
      paragraph.  HHSC will promptly notify HMO in writing of the claim,
      provide HMO a copy of all information received by HHSC with respect to the
      claim, and cooperate with HMO in defending or settling the
      claim.  HHSC will not unreasonably


    
      
        
        

      

      
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                Conditions

            	
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    withhold,
      delay or condition approval of counsel selected by the HMO.

    


    (c)
      In case the Deliverables, or any
      one or part thereof, is in such action held to constitute an infringement or
      misappropriation, or the use thereof is enjoined or restricted or if a
      proceeding appears to HMO to be likely to be brought, HMO will, at its own
      expense, either:

    


    (1)
      Procure for HHSC the right to continue using the Deliverables; or

    


    (2)
      Modify or replace the Deliverables to comply with the Specifications and to
      not
      violate any intellectual property rights.

    


    If
      neither of the alternatives set
      forth in (1) or (2) above are available to the HMO on commercially reasonable
      terms, HMO may require that HHSC return the allegedly infringing Deliverable(s)
      in which case HMO will refund all amounts paid for all such
      Deliverables.

    


    Section
      15.02Exceptions.

    


    HMO
      is not responsible for any claimed
      breaches of the warranties set forth in Section 15.01 to the extent caused
      by:

    


    (a)
      Modifications made to the item in
      question by anyone other than HMO or its Subcontractors, or modifications made
      by HHSC or its contractors working at HMO’s direction or in accordance with the
      specifications; or

    


    (b)
      The combination, operation, or use
      of the item with other items if HMO did not supply or approve for use with
      the
      item; or

    


    (c)
      HHSC’s failure to use any new or
      corrected versions of the item made available by HMO.

    


    Section
      15.03Ownership and Licenses

    


    (a)
      Definitions.

    


    For
      purposes of this Section 15.03, the following terms have the meanings set forth
      below:

    


    (1)  “Custom
      Software” means any software developed by the HMO:
      for HHSC; in connection with the Contract; and with funds received from
      HHSC.  The term does not include HMO Proprietary Software or Third
      Party Software.

    


    (2)  “HMO
      Proprietary Software” means software:(i) developed
      by the HMO prior to the Effective Date of the Contract, or (ii) software
      developed by the HMO after the Effective Date of the Contract that is not
      developed: for HHSC; in connection with the Contract; and with funds received
      from HHSC.

    


    (3)  “Third
      Party
      Software” means software that is: developed for
      general commercial use; available to the public; or not developed for
      HHSC.  Third Party Software includes without limitation: commercial
      off-the-shelf software; operating system software; and application software,
      tools, and utilities.

    


    (b)
      Deliverables.

    


    The
      Parties agree that any Deliverable, including without limitation the Custom
      Software, will be the exclusive property of HHSC.

    


    (c)
      Ownership rights.

    


    (1)
      HHSC will own all right, title, and
      interest in and to its Confidential Information and the Deliverables provided
      by
      the HMO, including without limitation the Custom Software and associated
      documentation.  For purposes of this Section 15.03, the Deliverables
      will not include HMO Proprietary Software or Third Party
      Software.  HMO will take all actions necessary and transfer ownership
      of the Deliverables to HHSC, including, without limitation, the Custom Software
      and associated documentation prior to Contract termination.

    


    (2)
      HMO will furnish such Deliverables,
      upon request of HHSC, in accordance with applicable State law. All Deliverables,
      in whole and in part, will be deemed works made for hire of HHSC for all
      purposes of copyright law, and copyright will belong solely to HHSC. To the
      extent that any such Deliverable does not qualify as a work for hire under
      applicable law, and to the extent that the Deliverable includes materials
      subject to copyright, patent, trade secret, or other proprietary right
      protection, HMO agrees to assign, and hereby assigns, all right, title, and
      interest in and to Deliverables, including without limitation all copyrights,
      inventions, patents, trade secrets, and other proprietary rights therein
      (including renewals thereof) to HHSC.

    


    (3)
      HMO will, at the expense of HHSC,
      assist HHSC or its nominees to obtain copyrights, trademarks, or patents for
      all
      such Deliverables in the United States and any other countries.  HMO
      agrees to execute all papers and to give all facts known to it necessary to
      secure United States or foreign country copyrights and patents, and to transfer
      or cause to transfer to HHSC all the right, title, and interest in and to such
      Deliverables. HMO also agrees not to assert any moral rights under applicable
      copyright law with regard to such Deliverables.

    


    (d)
      License Rights HHSC will have a
      royalty-free and non-exclusive license to access the HMO Proprietary Software
      and associated documentation during the term of the Contract. HHSC will also
      have ownership and unlimited rights to use, disclose, duplicate, or publish
      all
      information and data developed, derived, documented, or furnished by HMO under
      or resulting from the Contract.  Such data will include all results,
      technical information, and materials developed for and/or obtained by HHSC
      from
      HMO in the performance of the Services hereunder, including but not limited
      to
      all reports, surveys, plans, charts, recordings (video and/or sound), pictures,
      drawings, analyses, graphic representations computer,


    
      
        
        

      

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

            	
              Version
                1.7

            


    

    


    printouts,
      notes and memoranda, and documents whether finished or unfinished, which result
      from or are prepared in connection with the Services performed as a result
      of
      the Contract.

    


    (e)
      Proprietary Notices

    


    HMO
      will reproduce and include HHSC’s
      copyright and other proprietary notices and product identifications provided
      by
      HMO on such copies, in whole or in part, or on any form of the
      Deliverables.

    


    (f)
      State
      and Federal Governments

    


    In
      accordance with 45 C.F.R. §95.617,
      all appropriate State and Federal agencies will have a royalty-free,
      nonexclusive, and irrevocable license to reproduce, publish, translate, or
      otherwise use, and to authorize others to use for Federal Government purposes
      all materials, the Custom Software and modifications thereof, and associated
      documentation designed, developed, or installed with federal financial
      participation under the Contract, including but not limited to those materials
      covered by copyright, all software source and object code, instructions, files,
      and documentation.

    


    Article
      16.
      Liability

    


    Section
      16.01 Property
      damage.

    


    (a)
      HMO will protect HHSC’s real and
      personal property from damage arising from HMO’s, its agent’s, employees’ and
      Subcontractors’ performance of the Contract, and HMO will be responsible for any
      loss, destruction, or damage to  HHSC’s property that results from or
      is caused by HMO’s, its agents’, employees’ or Subcontractors’ negligent or
      wrongful acts or omissions.  Upon the loss of, destruction of, or
      damage to any property of HHSC, HMO will notify the HHSC Project Manager thereof
      and, subject to direction from the Project Manager or her or his designee,
      will
      take all reasonable steps to protect that property from further
      damage.

    


    (b)
      HMO agrees to observe and encourage
      its employees and agents to observe safety measures and proper operating
      procedures at HHSC sites at all times.

    


    (c)
      HMO will distribute a policy
      statement to all of its employees and agents that directs the employee or agent
      to promptly report to HHSC or to HMO any special defect or unsafe condition
      encountered while on HHSC premises.  HMO will promptly report to HHSC
      any special defect or an unsafe condition it encounters or otherwise learns
      about.

    


    Section
      16.02Risk of Loss.

    


    During
      the period Deliverables are in
      transit and in possession of HMO, its carriers or HHSC prior to being accepted
      by HHSC, HMO will bear the risk of loss or damage thereto, unless such loss
      or
      damage is caused by the negligence or intentional misconduct of HHSC. After
      HHSC
      accepts a Deliverable, the risk of loss or damage to the Deliverable will be
      borne by HHSC, except loss or damage attributable to the negligence or
      intentional misconduct of HMO’s agents, employees or
      Subcontractors.

    


    Section
      16.03Limitation of HHSC’s
      Liability.

    


    HHSC
      WILL NOT BE LIABLE FOR ANY
      INCIDENTAL, INDIRECT, SPECIAL, OR CONSEQUENTIAL DAMAGES UNDER CONTRACT, TORT
      (INCLUDING NEGLIGENCE), OR OTHER LEGAL THEORY.  THIS WILL APPLY
      REGARDLESS OF THE CAUSE OF ACTION AND EVEN IF HHSC HAS BEEN ADVISED OF THE
      POSSIBILITY OF SUCH DAMAGES.

    


    HHSC’S
      LIABILITY TO HMO UNDER THE
      CONTRACT WILL NOT EXCEED THE TOTAL CHARGES TO BE PAID BY HHSC TO HMO UNDER
      THE
      CONTRACT, INCLUDING CHANGE ORDER PRICES AGREED TO BY THE PARTIES OR OTHERWISE
      ADJUDICATED.

    


    HMO’s
      remedies are governed by the
      provisions in Article 12.

    


    Article
      17. Insurance &
Bonding

    


    Section
      17.01Insurance Coverage.

    


    (a)
      Statutory and General Coverage

    


    HMO
      will maintain the following
      insurance coverage.

    


    (1)
      Standard Worker's Compensation Insurance coverage;

    


    (2)
      Automobile Liability;

    


    (3)
      Comprehensive Liability Insurance including Bodily Injury coverage of
      $100,000.00 per each occurrence and Property Damage Coverage of $25,000.00
      per
      each occurrence; and

    


    (4)
      General Liability Insurance of at least $1,000,000.00 per occurrence and
      $5,000,000.00 in the aggregate.

    


    If
      HMO’s current Comprehensive General
      Liability insurance coverage does not meet the above stated requirements, HMO
      will obtain excess liability insurance to compensate for the difference in
      the
      coverage amounts.

    


    (b)
      Professional Liability Coverage.

    


    (1)
      HMO
      must maintain, or cause its Network Providers to maintain, Professional
      Liability Insurance for each Network Provider of $100,000.00 per occurrence
      and
      $300,000.00 in the aggregate, or the limits required by the hospital at which
      the Network Provider has admitting privileges.

    


    (2)
      HMO
      must maintain an Umbrella Professional Liability Insurance Policy for
      the


    
      
        
        

      

      
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                Conditions

            	
              Version
                1.7

            


    

    


    greater
      of $3,000,000.00 or an amount (rounded to the nearest $100,000.00) that
      represents the number of Members enrolled in the HMO in the first month of
      the
      applicable State Fiscal Year multiplied by $150.00, not to exceed
      $10,000,000.00.

    


    (c)
      General Requirements for All Insurance Coverage

    


    (1)
      Except as provided herein, all exceptions to the Contract’s insurance
      requirements must be approved in writing by HHSC. HHSC’s written approval is not
      required in the following situations:

    


    (A)
      An
      HMO or a Network Provider is not required to obtain the insurance coverage
      described in Section 17.01 if the HMO or Network Provider qualifies as a state
      governmental unit or municipality under the Texas Tort Claims Act, and is
      required to comply with, and subject to the provisions of, the Texas Tort Claims
      Act.

    


    (B)
      An
      HMO may waive the Professional Liability Insurance requirement described in
      Section 17.01(b)(1) for a Network Provider of Community-based Long Term Care
      Services.  An HMO may not waive this requirement if the Network
      Provider provides other Covered Services in addition to Community-based Long
      Term Care Services, or if a Texas licensing entity requires the Network Provider
      to carry such Professional Liability coverage.   An HMO that
      waives the Professional Liability Insurance requirement for a Network Provider
      pursuant to this provision is not required to obtain such coverage on behalf
      of
      the Network Provider.

    


    (2)
      HMO
      or the Network Provider is responsible for any and all deductibles stated in
      the
      insurance policies.

    


    (3)Insurance
      coverage must be issued by insurance companies authorized to conduct business
      in
      the State of Texas.

    


    (4)
      Insurance coverage must name HHSC as an additional insured with the following
      exceptions: Standard Workers’ Compensation Insurance maintained by the HMO, and
      Professional Liability Insurance maintained by Network Providers.

    


    (5)
      Insurance coverage kept by the HMO must be maintained throughout the Term of
      the
      Contract, and until HHSC’s final acceptance of all Services and Deliverables.
      Failure to maintain such insurance coverage will constitute a material breach
      of
      this Contract.

    


    (6)
      With
      the exception of Professional Liability Insurance maintained by Network
      Providers, the insurance policies described in this Section must have extended
      reporting periods of two years.  When policies are renewed or
      replaced, the policy retroactive date must coincide with, or precede, the
      Contract Effective Date.

    


    (7)
      With
      the exception of Professional Liability Insurance maintained by Network
      Providers, the insurance policies described in this Section must provide that
      prior written notice to be given to HHSC at least thirty (30) calendar days
      before coverage is substantially changed, canceled, or
      non-renewed.  HMO must submit a new coverage binder to HHSC to ensure
      no break in coverage.

    


    (8)
      The
      Parties expressly understand and agree that any insurance coverages and limits
      furnished by HMO will in no way expand or limit HMO’s liabilities and
      responsibilities specified within the Contract documents or by applicable
      law.

    


    (9)
      HMO
      expressly understands and agrees that any insurance maintained by HHSC will
      apply in excess of and not contribute to insurance provided by HMO under the
      Contract.

    


    (10)
      If
      HMO, or its Network Providers, desire additional coverage, higher limits of
      liability, or other modifications for its own protection, HMO or its Network
      Providers will be responsible for the acquisition and cost of such additional
      protection.  Such additional protection will not be an Allowable
      Expense under this Contract.

    


    (d)
      Proof
      of Insurance Coverage

    


    (1)
      Except as provided in Section 17.01(d)(2), the HMO must furnish the HHSC Project
      Manager original Certificates of Insurance evidencing the required insurance
      coverage on or before theEffective Date of the Contract.  If insurance
      coverage is renewed during the Term of the Contract, the HMO must furnish the
      HHSC Project Manager renewal certificates of insurance, or such similar
      evidence, within five (5) Business Days of renewal.  The failure of
      HHSC to obtain such evidence from HMO will not be deemed to be a waiver by
      HHSC
      and HMO will remain under continuing obligation to maintain and provide proof
      of
      insurance coverage.

    


    (2)
      The
      HMO is not required to furnish the HHSC Project Manager proof of Professional
      Liability Insurance maintained by Network Providers on or before the Effective
      Date of the Contract, but must provide such information upon HHSC’s request
      during the Term of the Contract.

    


    Section
      17.02 Performance Bond.

    


    (a)
      Beginning on the Operational Start Date of the Contract, and each year
      thereafter, the HMO must


    
      
        
        

      

      
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                Conditions

            	
              Version
                1.7

            


    

    


    obtain
      a
      performance bond with a one (1) year term.  The performance bond must
      continue to be in effect for one (1) year following the expiration of the one
      (1) year term.  HMO must obtain and maintain the annual performance
      bonds in the form prescribed by HHSC and approved by TDI, naming HHSC as
      Obligee, securing HMO’s faithful performance of the terms and conditions of this
      Contract. The annual performance bonds must comply with Chapter 843 of the
      Texas
      Insurance Code and 28 T.A.C. §11.1805.  The annual performance bond(s)
      must be issued in the amount of $100,000.00 for each applicable HMO Program
      within each Service Area that the HMO covers under this Contract. All
      performance bonds must be issued by a surety licensed by TDI, and specify cash
      payment as the sole remedy.  HMO must deliver the initial performance
      bond to HHSC prior to the Operational Start Date of the Contract, and each
      renewal performance bond prior to the first day of the State Fiscal
      Year.

    


    (b)
      Since the CHIP Perinatal Program is
      a sub-program of the CHIP Program, neither a separate performance bond for
      the
      CHIP Perinatal Program nor a combined performance bond for the CHIP and CHIP
      Perinatal Programs is required.  The same bond that the HMO obtains
      for its CHIP Program within a particular Service Area also will cover the HMO’s
      CHIP Perinatal Program, if applicable, in that same Service Area.

    


    Section
      17.03TDI Fidelity Bond

    


    The
      HMO will secure and maintain
      throughout the life of the Contract a fidelity bond in compliance with Chapter
      843 of the Texas Insurance Code and 28 T.A.C. §11.1805.  The HMO must
      promptly provide HHSC with copies of the bond and any amendments or renewals
      thereto.

    



    
      
        
        

      

      
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              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                6

            	 	
              Version
                1.7

            


    

    


    DOCUMENT
      HISTORY LOG

    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	
              Baseline

            	
              n/a

            	 	
              Initial
                version Attachment B-1, Section 6

            
	
              Revision

            	
              1.1

            	
              June
                30, 2006

            	
              Revised
                version of the Attachment B-1, Section 6, that includes provisions
                applicable to MCOs participating in the STAR+PLUS Program.

               

              Section
                6.3.2.1, Experience Rebate Reward, is modified to delete references
                to the
                selected performance indicators and the Quality Challenge
                Pool.

               

              Section
                6.3.2.2, Performance-Based Capitation Rate, is modified to include
                STAR+PLUS and to add Additional STAR+PLUS Performance Indicators.
                Section
                6.3.2.3, Quality Challenge Award, is modified to include STAR+PLUS.
                Section 6.3.2.5, STAR+PLUS Hospital Inpatient Performance Based Capitation
                Rate: Hospital Inpatient Stay Cost Incentives and Disincentives,
                is
                added.

               

              Section
                6.3.2.5.1, STAR+PLUS Hospital Inpatient Disincentive – Administrative Fee
                at Risk, is added.

               

              Section
                6.3.2.5.2, STAR+PLUS Hospital Inpatient Incentive – Shared Savings Award,
                is added.

            
	
              Revision

            	
              1.2

            	
              September
                1, 2006

            	
              Revised
                version of the Attachment B-1, Section 6, that includes provisions
                applicable to MCOs participating in the STAR and CHIP
                Programs.

               

              Section
                6.3.2.2, Performance-Based Capitation Rate, modifies the standard
                performance indicator for the Behavioral Health Hotline to change
                the
                maximum abandonment rate from 5% to 7% (except in the Dallas Core
                Service
                Area).

               

              Section
                6.3.2.3, Quality Challenge Award, is modified to reflect the new
                start
                date for the Quality Challenge Award, which will not be implemented
                until
                State Fiscal Year 2008.

            
	
              Revision

            	
              1.3

            	
              September
                1, 2006

            	
              Revised
                version of the Attachment B-1, Section 6 that includes provisions
                applicable to MCOs participating in the CHIP Perinatal
                Program.

               

              Section
                6.3.2.1 modified to clarify that the Experience Rebate Reward incentive
                may apply to the CHIP Perinatal Program at a later date.

               

              Section
                6.3.2.2 modified to clarify that the Performance-based Capitation
                Rate
                will not apply for the CHIP Perinatal Program in SFY
                2007.

            
	
              Revision

            	
              1.4

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-1 Section 6 – Premium Payment,
                Incentives, and Disincentives

            


    

    


    6-1

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                6

            	 	
              Version
                1.7

            


    

    


    
      	
              Revision

            	
              1.5

            	
              January
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-1 Section 6 – Premium Payment,
                Incentives, and Disincentives

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

            	
              Revised
                version of the Attachment B-1, Section 6, that

              includes
                provisions applicable to MCOs participating in the STAR+PLUS
                Program.

               

              Section
                6.3.2.5 is modified to clarify the months included in Rate Period
                1.

            
	
              Revision

            	
              1.7

            	
              July
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-1 Section 6 – Premium Payment,
                Incentives, and Disincentives

            
	
              1
Status
                should be represented as “Baseline” for initial issuances, “Revision” for
                changes to the Baseline version, and “Cancellation” for withdrawn
                versions

              2
Revisions
                should be
                numbered in accordance according to the version of the issuance and
                sequential numbering of the revision—e.g., “1.2” refers to the first
                version of the document and the second revision.

              3
Brief
                description of the
                changes to the document made in the
                revision.

            


    

    


    6-2

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
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                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                6

            	 	
              Version
                1.7

            


    

    


    
      	
              6.

            	
              Premium
                Payment, Incentives, and
                Disincentives

            


    

    


    This
      section documents how the Capitation Rates are developed and describes
      performance incentives and disincentives related to HHSC’s value-based
      purchasing approach. For further information, HMOs should refer to the HHSC
      Uniform Managed Care Contract Terms and
      Conditions.

    


    Under
      the
      HMO Contracts, health care coverage for Members will be provided on a fully
      insured basis. The HMO must provide the Services and Deliverables, including
      Covered Services to enrolled Members in order for monthly Capitation Payments
      to
      be paid by HHSC. Attachment B- 1, Section 8 includes the HMO’s
      financial responsibilities regarding out-of-network Emergency Services and
      Medically Necessary Covered Services not available through Network
      Providers.

    


    
      	
              6.1

            	
              Capitation
                Rate Development

            


    

    


    Refer
      to
Attachment A, HHSC Uniform Managed Care Contract Terms
& Conditions, Article 10, “Terms & Conditions of Payment,” for
      information concerning Capitation Rate development.

    


    
      	
              6.2

            	
              Financial
                Payment Structure and
                Provisions

            


    

    


    HHSC
      will
      pay the HMO monthly Capitation Payments based on the number of eligible and
      enrolled Members. HHSC will calculate the monthly Capitation Payments by
      multiplying the number of Member Months times the applicable monthly Capitation
      Rate by Member Rate Cell. The HMO must provide the Services and Deliverables,
      including Covered Services to Members, described in the Contract for monthly
      Capitation Payments to be paid by HHSC.

    


    The
      HMO
      must understand and expressly assume the risks associated with the performance
      of the duties and responsibilities under the Contract, including the failure,
      termination, or suspension of funding to HHSC, delays or denials of required
      approvals, cost of claims incorrectly paid by the HMO, and cost overruns not
      reasonably attributable to HHSC. The HMO must further agree that no other
      charges for tasks, functions, or activities that are incidental or ancillary
      to
      the delivery of the Services and Deliverables will be sought from HHSC or any
      other state agency, nor will the failure of HHSC or any other party to pay
      for
      such incidental or ancillary services entitle the HMO to withhold Services
      or
      Deliverables due under the Contract.

    


    
      	
              6.2.1

            	
              Capitation
                Payments

            


    

    


    The
      HMO
      must refer to the HHSC Uniform Managed Care Contract Terms &
Conditions for information and Contract requirements on
      the:

    


    6-3

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
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              Responsible
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              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                6

            	 	
              Version
                1.7

            


    

    


    1)
      Time
      and Manner of Payment,

    2)
      Adjustments to Capitation Payments,

    3)
      Delivery Supplemental Payment, and

    4)
      Experience Rebate.

    


    
      	
              6.3

            	
              Performance
                Incentives and
                Disincentives

            


    

    


    HHSC
      introduces several financial and non-financial performance incentives and
      disincentives through this Contract. These incentives and disincentives are
      subject to change by HHSC over the course of the Contract Period. The
      methodologies required to implement these strategies will be refined by HHSC
      after collaboration with contracting HMOs through a new incentives workgroup
      to
      be established by HHSC.

    


    
      	
              6.3.1

            	
              Non-financial
                Incentives

            


    

    


    
      	
              6.3.1.1

            	
              Performance
                Profiling

            


    

    


    HHSC
      intends to distribute information on key performance indicators to HMOs on
      a
      regular basis, identifying an HMO’s performance, and comparing that performance
      to other HMOs, and HHSC standards and/or external Benchmarks. HHSC will
      recognize HMOs that attain superior performance and/or improvement by
      publicizing their achievements. For example, HHSC may post information
      concerning exceptional performance on its website, where it will be available
      to
      both stakeholders and members of the public.

    


    
      	
              6.3.1.2

            	
              Auto-assignment
                Methodology for Medicaid
                HMOs

            


    

    


    HHSC
      may
      also revise its auto-assignment methodology during the Contract Period for
      new
      Medicaid Members who do not select an HMO (Default Members). The new assignment
      methodology would reward those HMOs that demonstrate superior performance and/or
      improvement on one or more key dimensions of performance. In establishing the
      assignment methodology, HHSC will employ a subset of the performance indicators
      contained within the Performance Indicator Dashboard. At
      present, HHSC intends to recognize those HMOs that exceed the minimum geographic
      access standards defined within Attachment B-1, Section 8 and the
      Performance Indicator Dashboard. HHSC may also use its assessment of
      HMO performance on annual quality improvement goals (described in
Attachment B-1, Section 8) in developing the assignment
      methodology. The methodology would disproportionately assign Default Members
      to
      the HMO(s) in a given Service Area that performed comparably favorably on the
      selected performance indicators.

    


    HHSC
      anticipates that it will not implement a performance-based auto-assignment
      algorithm before September 1, 2007. HHSC will invite HMO comments on potential
      approaches prior to implementation of the new performance-based auto-assignment
      algorithm.

    


    6-4

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                6

            	 	
              Version
                1.7

            


    

    


    
      	
              6.3.2

            	
              Financial
                Incentives and
                Disincentives

            


    

    


    
      	
              6.3.2.1

            	
              Experience
                Rebate Reward

            


    

    


    HHSC
      historically has required HMOs to provide HHSC with an Experience Rebate (see
      the Uniform Managed Care Contract Terms and Conditions, Article 10.11)
      when there has been an aggregate excess of Revenues over Allowable
      Expenses. During the Contract Period, should the HMO experience an aggregate
      excess of Revenues over Allowable Expenses across STAR and CHIP HMO Programs
      and
      Service Areas, HHSC will allow the HMO to retain that portion of the aggregate
      excess of Revenues over Allowable Expenses that is equal to or less than 3.5%
      of
      the total Revenue for the period should the HMO demonstrate superior performance
      on selected performance indicators. The retention of 3.5% of revenue exceeds
      the
      retention of 3.0% of revenue that would otherwise be afforded to a HMO without
      demonstrated superior performance on these performance indicators relative
      to
      other HMOs. HHSC will develop the methodology for determining the level of
      performance necessary for an HMO to retain the additional 0.5% of revenue after
      consultation with HMOs. The finalized methodology will be added to the
Uniform Managed Care Manual.

    


    HHSC
      will
      calculate the Experience Rebate Reward after it has calculated the HMO’s at-risk
      Capitation Rate payment, as described below in Section 6.3.2.2.
      HHSC will calculate whether a HMO is eligible for the Experience Rebate Reward
      prior to the 90-day Financial Statistical Report (FSR) filing.

    


    HHSC
      anticipates that it will not implement the incentive for Rate Period 1 of the
      Contract. HHSC will invite HMO comments on potential approaches prior to
      implementation of the new performance-based Experience Rebate Reward. HHSC
      may
      also implement this incentive option for the STAR+PLUS and CHIP Perinatal
      programs in the future.

    


    
      	
              6.3.2.2

            	
              Performance-Based
                Capitation Rate

            


    

    


    Beginning
      in State Fiscal Year 2007 of the Contract, HHSC will place each STAR and CHIP
      HMO at risk for 1% of the Capitation Rate(s). Beginning in State Fiscal Year
      2008 of the Contract, HHSC will also place each STAR+PLUS HMO at risk for 1%
      of
      the Capitation Rate(s). HHSC retains the right to vary the percentage of the
      Capitation Rate placed at risk in a given RatePeriod. HHSC will not place CHIP
      Perinatal HMOs at risk for 1% of the Capitation Rate(s) in State Fiscal Year
      2007, but reserves this right in subsequent State Fiscal Years.

    


    As
      noted
      in Section 6.2, HHSC will pay the HMO monthly Capitation Payments based on
      the
      number of eligible and enrolled Members. HHSC will calculate the monthly
      Capitation Payments by multiplying the number of Member months times the
      applicable monthly Capitation Rate by Member rate cell. At the end of each
      Rate
      Period, HHSC will evaluate if the HMO has demonstrated that it has fully met
      the
      performance expectations for which the HMO is at risk. Should the HMO fall
      short
      on some or all of the performance expectations, HHSC will adjust a future
      monthly Capitation Payment by an appropriate portion of the 1% at-risk amount.
      HMOs will be able to earn variable percentages up to 100% of the 1% at-risk
      Capitation Rate. HHSC’s objective is that all HMOs achieve performance levels
      that enable them to receive the full at-risk amount.

    


    6-5

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                6

            	 	
              Version
                1.7

            


    

    


    HHSC
      will
      determine the extent to which the HMO has met the performance expectations
      by
      assessing the HMO’s performance for each applicable HMO Program relative to
      performance targets for the rate period. HHSC will conduct separate accounting
      for each HMO Program’s at-risk Capitation Rate amount.

    


    HHSC
      will
      identify no more than 10 performance indicators for each HMO Program. Some
      of
      the

    performance
      indicators will be standard across the HMO Programs while others may apply
      to

    only
      one
      of the HMO Programs.

    


    HHSC’s
      performance indicators may include some or all of the following measures. The
      specific performance indicators, periods of data collection, and associated
      points are detailed in the HHSC Uniform Managed Care Manual.
The minimum percentage targets identified in this section
      were
      developed based, in part, on the HHSC HMO Program objective of ensuring access
      to care and quality of care, past performance of the HHSC HMOs, and performance
      of Medicaid and CHIP HMOs nationally on HEDIS and CAHPS measures of plan
      performance. The Performance Indicator Dashboard includes a
      more detailed explanation.

    


    Standard
      Performance Indicators:

    


    
      	
               

            	
              1.

            	
              98%
                of Clean Claims are properly Adjudicated within 30 calendar
                days.

            


    

    
      	
               

            	
              2.

            	
              The
                Member Services Hotline abandonment rate does not exceed
                7%.

            


    

    
      	
               

            	
              3.

            	
              The
                Behavioral Health Hotline
                abandonment rate does not exceed
                7%.1

            


    

    
      	
               

            	
              4.

            	
              The
                Provider Services Hotline abandonment rate does not exceed
                7%.

            


    

    


    Additional
      STAR Performance Indicators

    


    
      	
               

            	
              1.

            	
              90%
                of child Members have access to at least one child-appropriate PCP
                with an
                Open Panel within 30 miles travel
                distance.

            


    

    
      	
               

            	
              2.

            	
              90%
                of adult Members have access to at least one adult-appropriate PCP
                with an
                Open Panel within 30 miles travel
                distance.

            


    

    
      	
               

            	
              3.

            	
              36%
                of age-qualified child Members receive six or more well-child visits
                (in
                the first 15 months of life.

            


    

    
      	
               

            	
              4.

            	
              56%
                of age-qualified child Members receive at least one well-child visit
                in
                the 3rd, 4th, 5th, or 6th year of
                life.

            


    

    
      	
               

            	
              5.

            	
              72%
                of pregnant women Members receive a prenatal care visit in the first
                trimester or within 42 days of
                enrollment.

            


    

    


    Additional
      CHIP Performance Indicators

    


    
      	
               

            	
              1.

            	
              90%
                of child Members have access to at least one child-appropriate PCP
                with an
                Open Panel within 30 miles travel
                distance.

            


    

    
      	
               

            	
              2.

            	
              90%
                of child Members have access to at least one otolaryngologist (ENT)
                within
                75 miles travel distance.

            


    

    _______________________

    


    1Will
      not apply in
      the Dallas Core Service Area. Points will be allocated proportionately over
      the
      remaining standard performance indicators.

    


    6-6

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                6

            	 	
              Version
                1.7

            


    

    


    
      	
               

            	
              3.

            	
              56%
                of age-qualified child Members receive at least one well-child visit
                in
                the 3rd, 4th, 5th, or 6th year of
                life

            


    

    
      	
               

            	
              4.

            	
              38%
                of adolescents receive an annual well
                visit.

            


    

    


    Additional
      STAR+PLUS Performance Indicators

    


    
      	
               

            	
              1.

            	
              57%
                of adult Members report no problem with delays in getting approval
                from
                the HMO

            


    

    
      	
               

            	
              2.

            	
              90%
                of adult Members have access to at least one adult-appropriate PCP
                with an
                Open Panel within 30 miles travel
                distance

            


    

    
      	
               

            	
              3.

            	
              62%
                of adult Members report no problem in getting a referral to a Specialty
                Physician

            


    

    
      	
               

            	
              4.

            	
              47%
                of adult Members report no problem getting needed Special Therapy
                (physical therapy, occupational therapy, and speech therapy) from
                the
                HMO

            


    

    
      	
               

            	
              5.

            	
              57%
                of adult Members report no problem getting needed Behavioral Health
                Services from the HMO

            


    

    


    Failure
      to timely provide HHSC with necessary data related to the calculation of the
      performance indicators will result in HHSC’s assignment of a zero percent
      performance rate for each related performance indicator.

    


    Should
      Member survey-based indicators yield response rates deemed by HHSC to be too
      low
      to yield credible data, HHSC will reapportion points across the remaining
      measures.

    


    Actual
      plan rates will be rounded to the nearest whole number. HHSC will calculate
      performance assessment for the at-risk portion of the capitation payments by
      summing all earned points and converting them to a percentage. For example,
      an
      HMO that earns 92 points will earn 92% of the at-risk Capitation Rate. HHSC
      will
      apply the premium assessment of 8% of the at-risk Capitation Rate as a reduction
      to the monthly Capitation Payment ninety days after the end of the contract
      period.

    


    HMOs
      will
      report actual Capitation Payments received on the Financial Statistical Report
      (FSR). Actual Capitation Payments received include all of the at-risk Capitation
      Payment paid to the HMO. Any performance assessment based on performance for
      a
      contract period will appear on the second final (334-day) FSR for that contract
      period.

    


    HHSC
      will
      evaluate the performance-based Capitation Rate methodology annually in
      consultation with HMOs. HHSC may then modify the methodology it deems necessary
      and appropriate to motivate, recognize, and reward HMOs for performance. The
      methodologies for Rate Periods 1 and 2 will be included in the HHSC
      Uniform Managed Care Manual.

    


    
      	
              6.3.2.3

            	
              Quality
                Challenge Award

            


    

    


    Data
      collection for the Quality Challenge Award will begin on September 1, 2006;
      however, the Quality Challenge Award will not be implemented until State Fiscal
      Year 2008. Should one or more HMOs be unable to earn the full amount of the
      performance-based at-risk portion of the Capitation Rate, HHSC will reallocate
      the funds through the HMO Program’s Quality Challenge Award. HHSC will use these
      funds to reward HMOs that demonstrate superior clinical quality. HHSC will
      determine the number of HMOs that will receive Quality Challenge Award funds
      annually based on the amount of the funds to be reallocated. Separate Quality
      Challenge Award

    


    6-7

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                6

            	 	
              Version
                1.7

            


    

    


    payments
      will be made for each of the HMO programs. As with the performance-based
      Capitation Rate, each HMO will be evaluated separately for each HMO Program.
      HHSC intends to evaluate HMO performance annually on some combination of the
      following performance indicators in order to determine which HMOs demonstrate
      superior clinical quality. In no event will a distribution from the Quality
      Challenge Award, plus any other incentive payments made in accordance with
      the
      HMO Contract, when combined with the Capitation Rate payments, exceed 105%
      of
      the Capitation Rate payments to an HMO.

    


    Information
      about the data collection period to be used for each indicator is found in
      the
HHSC

    Uniform
      Managed Care Manual.

    


    
      	
              6.3.2.4

            	
              Remedies
                and Liquidated Damages

            


    

    


    All
      areas
      of responsibility and all requirements in the Contract will be subject to
      performance evaluation by HHSC. Any and all responsibilities or requirements
      not
      fulfilled may have remedies and HHSC will assess either actual or liquidated
      damages. Refer to Attachment A, HHSC Uniform Managed Care Contract Terms
      and Conditions and Attachment B-5 for performance
      standards that carry liquidated damage values.

    


    
      	
              6.3.2.5

            	
              STAR+PLUS
                Hospital Inpatient Performance-Based Capitation Rate: Hospital Inpatient
                Stay Cost Incentives &
                Disincentives

            


    

    


    


    Effective
      as of the STAR+PLUS Operational Start Date, HHSC will place at-risk a portion
      of
      the HMO’s Medicaid-Only Capitation Rate. Settlements for Inpatient Stay costs
      will be calculated by the State after the end of each State Fiscal Year (SFY)
      using three (3) months of completed Hospital paid data for the preliminary
      settlement and 11 months of completed data for the final settlement. The SFY
      2006 Fee-for-Service (FFS) Inpatient Hospital per-member-per-month (PMPM) rate
      will be projected for Rate Period 1 (February 1, 2007 through August 31, 2007)
      for the first settlement. Adjustments for the projection will include trending
      and risk adjustment. The base and final inpatient hospital PMPM rate will be
      calculated separately for each HMO, Service Area, and Rate Cell. Harris County
      is excluded from the Harris Service Area calculations.

    


    
      	
              6.3.2.5.1

            	
              STAR+PLUS
                Hospital Inpatient Disincentive - Administrative Fee at
                Risk

            


    

    


    HHSC
      has
      assumed that STAR+PLUS HMOs will achieve a 22% reduction in projected FFS
      Hospital Inpatient Stay costs, for the Medicaid-Only population, through the
      implementation of the STAR+PLUS model. HMOs achieving savings beyond 22% will
      be
      eligible for the STAR+PLUS Shared Savings Award described in Section
      6.3.2.5.2. The HMO will be at-risk for savings less than
      22%.

    


    The
      maximum risk to the HMO will be equal to 50% of the difference between 15%
      Hospital inpatient savings and 22% Hospital inpatient savings. The disincentive
      for savings above 15%, but still less than 22% will be equal to 50% of the
      difference between the level of achieved savings and 22%. HHSC retains the
      right
      to vary the disincentive percentage in a given Rate Period by Contract
      amendment.

    


    6-8

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                6

            	 	
              Version
                1.7

            


    

    


    
      	
              6.3.2.5.2

            	
              STAR+PLUS
                Hospital Inpatient Incentive – Shared Savings
                Award

            


    

    


    HMOs
      that
      exceed the 22% reduction in Inpatient Stay costs incurred by STAR+PLUS Members
      specified in Section 6.3.2.5.1 will be eligible to obtain a 20%
      share of the savings achieved beyond the 22% target. HHSC will determine the
      extent to which the HMO has met and exceeded the performance expectation in
      the
      manner described within Section 6.3.2.5. Should HHSC determine
      that the HMO exceeded the 22% target, HHSC will adjust a future monthly
      Capitation Payment upward by 20% of the calculated savings. This shared savings
      award is limited to 5% of the HMO’s capitation in accordance with Federal
      Balance Budget Act requirements and is calculated off of total of STAR+PLUS
      Capitation Payment. An HMO will be subject to contractual remedies and
      determined ineligible for the award, if a HHSC audit reveals that the HMO has
      inappropriately averted Medically Necessary Inpatient Stay admissions and
      potentially endangered Member safety.

    


    6-9

    
       

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                  7

              	
                Version
                  1.7

              


      

       

      DOCUMENT
        HISTORY LOG

      
        	
                STATUS1

              	
                DOCUMENT

                REVISION2

              	
                EFFECTIVE

                DATE

              	
                DESCRIPTION3

              
	
                 

                Baseline

                 

              	
                 

                n/a

                 

              	 	
                 

                Initial
                  version Attachment B-1, Section 7

                 

              
	
                 

                Revision

              	
                 

                1.1

              	
                 

                June
                  30, 2006

              	
                 

                Revised
                  version of the Attachment B-1, Section 7, that

                includes
                  provisions applicable to MCOs participating in the

                STAR+PLUS
                  Program.

                 

                Sections
                  7.1 to 7.3 modified to include STAR+PLUS.

                 

              
	
                 

                Revision

              	
                 

                1.2

              	
                 

                September
                  1, 2006

              	
                 

                Revised
                  version of the Attachment B-1, Section 7, that

                includes
                  provisions applicable to MCOs participating in the

                STAR
                  and CHIP Programs.

                 

                Section
                  7.3.1.7, Operations Readiness, changes reference

                from
                  “Operational Date” to “Effective Date.”

              
	
                 

                Revision

              	
                 

                1.3

              	
                 

                September
                  1, 2006

              	
                 

                Revised
                  version of the Attachment B-1, Section 7, that

                includes
                  provisions applicable to MCOs participating in the

                CHIP
                  Perinatal Program.

                Sections
                  7.2, 7.3, and 7.3.1.2 through 7.3.1.7 modified to

                include
                  the CHIP Perinatal Program.

              
	
                 

                Revision

              	
                 

                1.4

              	
                 

                September
                  1, 2006

              	
                 

                Contract
                  amendment did not revise Attachment B-1

                Section
                  7 – Transition Phase Requirements

              
	
                 

                Revision

              	
                 

                1.5

              	
                 

                January
                  1, 2007

              	
                 

                Contract
                  amendment did not revise Attachment B-1

                Section
                  7 – Transition Phase Requirements

              
	
                 

                Revision

              	
                 

                1.6

              	
                 

                February
                  1, 2007

              	
                 

                Contract
                  amendment did not revise Attachment B-1

                Section
                  7 – Transition Phase Requirements

              
	
                 

                Revision

              	
                 

                1.7

              	
                 

                July
                  1, 2007

              	
                 

                Section
                  7.3.1.9 is modified to add a cross-reference to

                Attachment
                  B-1, Sections 8.1.1.2 and 8.1.18.

              
	
                1Status
                  should be represented as “Baseline” for initial issuances, “Revision” for
                  changes to the Baseline version, and

                “Cancellation”
                  for withdrawn versions

                2 Revisions
                  should be
                  numbered in accordance according to the version of the issuance
                  and
                  sequential numbering of the

                revision—e.g.,
                  “1.2” refers to the first version of the document and the second
                  revision.

                3 Brief
                  description of
                  the changes to the document made in the revision.

                 

              


      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                  7

              	
                Version
                  1.7

              


      

      


      
        	
                7.

              	
                Transition
                  Phase Requirements

              


      

      


      
        	
                7.1

              	
                Introduction

              


      

      


      This
        Section presents the scope of work for the Transition Phase of the Contract,
        which includes those activities that must take place between the time of
        Contract award and the Operational Start Date.

      


      The
        Transition Phase will include a Readiness Review of each HMO, which must
        be
        completed successfully prior to a HMO’s Operational Start Date for each
        applicable HMO Program. HHSC may, at its discretion, postpone the Operational
        Start Date of the Contract for any such HMO that fails to satisfy all Transition
        Phase requirements.

      


      If
        for
        any reason, a HMO does not fully meet the Readiness Review prior to the
        Operational Start Date, and HHSC has not approved a delay in the Operational
        Start Date or approved a delay in the HMO’s compliance with the applicable
        Readiness Review requirement, then HHSC shall impose remedies and either
        actual
        or liquidated damages. If the HMO is a current HMO Contractor, HHSC may also
        freeze enrollment into the HMO’s plan for any of its HMO Programs. Refer to the
HHSC Uniform Managed Care Contract Terms and Conditions (Attachment
        A)
and the Liquidated Damages Matrix (Attachment B-5) for
        additional information.

      


      
        	
                7.2

              	
                Transition
                  Phase Scope for HMOs

              


      

      


      STAR,
        STAR+PLUS and CHIP HMOs must meet the Readiness Review requirements established
        by HHSC no later than 90 days prior to the Operational Start Date for each
        applicable HMO Program. CHIP Perinatal HMOS must meet the Readiness Review
        requirements established by HHSC not later than 60 days prior to the Operational
        Start Date for the CHIP Perinatal Program. HMO agrees to provide all materials
        required to complete the readiness review by the dates established by HHSC
        and
        its Contracted Readiness Review Vendor.

      


      
        	
                7.3

              	
                Transition
                  Phase Schedule and Tasks

              


      

      


      The
        Transition Phase will begin after both Parties sign the Contract. The start
        date
        for the STAR and CHIP Transition Phase is November 15, 2005. The start date
        for
        the STAR+PLUS Transition Phase is June 30, 2006. The start date for the CHIP
        Perinate Transition Phase is September 1, 2006.

      


      The
        Transition Phase must be completed no later than the agreed upon Operational
        Start Date(s) for each HMO Program and Service Area. The HMO may be subject
        to
        liquidated damages for failure to meet the agreed upon Operational Start
        Date
        (see Attachment B-5).

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                  7

              	
                Version
                  1.7

              


      

      


      
        	
                7.3.1

              	
                Transition
                  Phase Tasks

              


      

      


      The
        HMO
        has overall responsibility for the timely and successful completion of each
        of
        the Transition Phase tasks. The HMO is responsible for clearly specifying
        and
        requesting information needed from HHSC, other HHSC contractors, and Providers
        in a manner that does not delay the schedule or work to be
        performed.

      


      
        	
                7.3.1.1

              	
                Contract
                  Start-Up and Planning

              


      

      


      HHSC
        and
        the HMO will work together during the initial Contract start-up phase
        to:

      


      
        	
                 

              	
                •

              	
                define
                  project management and reporting
                  standards;

              


      

      


      
        	
                 

              	
                •

              	
                establish
                  communication protocols between HHSC and the
                  HMO;

              


      

      


      
        	
                 

              	
                •

              	
                establish
                  contacts with other HHSC
                  contractors;

              


      

      


      
        	
                 

              	
                •

              	
                establish
                  a schedule for key activities and milestones;
                  and

              


      

      


      
        	
                 

              	
                •

              	
                clarify
                  expectations for the content and format of Contract
                  Deliverables.

              


      

      


      The
        HMO
        will be responsible for developing a written work plan, referred to as the
        Transition/Implementation Plan, which will be used to monitor progress
        throughout the Transition Phase. An updated and detailed Transition
        /Implementation Plan will be due to HHSC.

      


      
        	
                7.3.1.2

              	
                Administration
                  and Key HMO Personnel

              


      

      


      No
        later
        than the Effective Date of the Contract, the HMO must designate and identify
        Key
        HMO Personnel that meet the requirements in HHSC Uniform Managed Care
        Contract Terms & Conditions, Article 4. The HMO will supply HHSC
        with resumes of each Key HMO Personnel as well as organizational information
        that has changed relative to the HMO’s Proposal, such as updated job
        descriptions and updated organizational charts, (including updated Management
        Information System (MIS) job descriptions and an updated MIS staff
        organizational chart), if applicable. If the HMO is using a Material
        Subcontractor(s), the HMO must also provide the organizational chart for
        such
        Material Subcontractor(s).

      


      No
        later
        than the Contract execution date, STAR+PLUS HMOs must update the information
        above and provide any additional information as it relates to the STAR+PLUS
        Program.

      


      No
        later
        than the Contract execution date, CHIP Perinatal HMOs must update the
        information above and provide any additional information as it relates to
        the
        CHIP Perinatal Program.

      


      
        	
                7.3.1.3

              	
                Financial
                  Readiness Review

              


      

      


      In
        order
        to complete a Financial Readiness Review, HHSC will require that HMOs update
        information submitted in their proposals. Note: STAR+PLUS and/or CHIP Perinatal
        HMOs who have already submitted proposal updates for HHSC’s review for STAR
        and/or CHIP, must either verify that the information has not changed and
        that it
        applies to STAR+PLUS and/or the CHIP

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                  7

              	
                Version
                  1.7

              


      

      


      Perinatal
        Program or provide updated information for STAR+PLUS by July 10, 2006 and
        for
        the CHIP Perinatal Program by September 1, 2006. This information will include
        the following:

      


      Contractor
        Identification and Information

      


      
        	
                1.

              	
                The
                  Contractor’s legal name, trade name, or any other name under which the
                  Contractor does business, if any.

              


      

      
        	
                2.

              	
                The
                  address and telephone number of the Contractor’s headquarters
                  office.

              


      

      
        	
                3.

              	
                A
                  copy of its current Texas Department of Insurance Certificate of
                  Authority
                  to provide HMO or ANHC services in the applicable Service Area(s).
                  The
                  Certificate of Authority must include all counties in the Service
                  Area(s)
                  for which the Contractor is proposing to serve HMO
                  Members.

              


      

      
        	
                4.

              	
                Indicate
                  with a “Yes-HMO”, “Yes-ANHC” or “No” in the applicable cell(s) of the
                  Column B of the following chart whether the Contractor is currently
                  certified by TDI as an HMO or ANHC in allcounties
                  in each of the CSAs in which the Contractor proposes to participate
                  in one
                  or more of the HHSC HMO Programs. If the Contractor is not proposing
                  to
                  serve a CSA for a particular HMO Program, the Contractor should
                  leave the
                  applicable cells in the table
                  empty.

              


      

      


      Table
        2: TDI Certificate of Authority in Proposed HMO Program
        CSAs

      


      
        	
                Column
                  A

              	
                Column
                  B

              	
                Column
                  C

              
	
                Core
                  Service

                Area
                  (CSA)

              	
                TDI
                  Certificate of Authority

                 

              	
                Counties/Partial
                  Counties without a

                TDI
                  Certificate of Authority

              
	
                Bexar

              	 	 
	
                Dallas

              	 	 
	
                El
                  Paso

              	 	 
	
                Harris

              	 	 
	
                Lubbock

              	 	 
	
                Nueces

              	 	 
	
                Tarrant

              	 	 
	
                Travis

              	 	 
	
                Webb

              	 	 


      

      


      If
        the
        Contractor is not currently certified by TDI as an HMO
        or ANHC in any one or more counties in a proposed CSA, the Contractor must
        identify such entire counties in Column C for each CSA. For each county listed
        in Column C, the Contractor must document that it applied to TDI for such
        certification of authority prior to the submission of a Proposal for this
        RFP.
        The Contractor shall indicate the date that it applied for such certification
        and the status of its application to get TDI certification in the relevant
        counties in this section of its submission to HHSC.

      


      
        	
                5.

              	
                For
                  Contractors serving any CHIP and CHIP Perinatal OSAs, indicate
                  with a
                  “Yes-HMO”, “Yes-ANHC” or “No” in the applicable cell(s) of the Column C of
                  the following chart whether the Contractor is currently certified
                  by TDI
                  as an HMO or ANHC in the entire county in the OSA. If the Contractor
                  is
                  not proposing to serve an OSA, the Contractor should leave the
                  applicable
                  cells in the table empty.

              


      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                  7

              	
                Version
                  1.7

              


      

      


      Table
        3: TDI Certificate of Authority in Proposed HMO Program
        OSAs

      


      
        	
                CHIP
                  Program

              
	
                Column
                  A

              	
                Column
                  B

              	
                Column
                  C

              
	
                Core
                  Service Area

                (CSA)

              	
                Affiliated
                  CHIP OSA

              	
                TDI
                  Certificate of Authority

              
	
                Bexar

              	 	 
	
                El
                  Paso

              	 	 
	
                Harris

              	 	 
	
                Lubbock

              	 	 
	
                Nueces

              	 	 
	
                Travis

              	 	 


      

      


      


      
        	
                CHIP
                  Perinatal Program

              
	
                Column
                  A

              	
                Column
                  B

              	
                Column
                  C

              
	
                Core
                  Service Area

                (CSA)

              	
                Affiliated
                  CHIP OSA

              	
                TDI
                  Certificate of Authority

              
	
                Bexar

              	 	 
	
                El
                  Paso

              	 	 
	
                Harris

              	 	 
	
                Lubbock

              	 	 
	
                Nueces

              	 	 
	
                Travis

              	 	 


      

      


      For
        each
        county listed in Column C, the Contractor must document that it applied to
        TDI
        for such certification of authority prior to the submission of a Proposal
        for
        this RFP. The Contractor shall indicate the date that it applied for such
        certification and the status of its application to get TDI certification
        in the
        relevant counties in this section of its submission to HHSC.

      


      
        	
                6.

              	
                 

              	
                If
                  the Contractor proposes to participate in STAR or STAR+PLUS and
                  seeks to
                  be considered as an organization meeting the requirements of Section
                  §533.004(a) or (e) of the Texas Government Code, describe how the
                  Contractor meets the requirements of §§533.004(a)(1), (a)(2), (a)(3), or
                  (e) for each proposed Service
                  Areas.

              


      

      
        	
                7.

              	
                 

              	
                The
                  type of ownership (proprietary, partnership,
                  corporation).

              


      

      
        	
                8.

              	
                 

              	
                The
                  type of incorporation (for profit, not-for-profit, or non-profit)
                  and
                  whether the Contractor is publicly or privately
                  owned.

              


      

      
        	
                9.

              	
                 

              	
                If
                  the Contractor is an Affiliate or Subsidiary, identify the parent
                  organization.

              


      

      
        	
                10.

              	
                If
                  any change of ownership of the Contractor’s company is anticipated during
                  the 12 months following the Proposal due date, the Contractor must
                  describe the circumstances of such change and indicate when the
                  change is
                  likely to occur.

              


      

      
        	
                11.

              	
                The
                  name and address of any sponsoring corporation or others who provide
                  financial support to the Contractor and type of support, e.g.,
                  guarantees,
                  letters of credit, etc. Indicate if there are maximum limits of
                  the
                  additional financial support.

              


      

      
        	
                12.

              	
                The
                  name and address of any health professional that has at least a
                  five
                  percent financial interest in the Contractor and the type of financial
                  interest.

              


      

      
        	
                13.

              	
                The
                  names of officers and directors.

              


      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                  7

              	
                Version
                  1.7

              


      

      


      
        	
                14.

              	
                The
                  state in which the Contractor is incorporated and the state(s)
                  in which
                  the Contractor is licensed to do business as an HMO. The Contractor
                  must
                  also indicate the state where it is commercially domiciled, if
                  applicable.

              


      

      
        	
                15.

              	
                The
                  Contractor’s federal taxpayer identification
                  number.

              


      

      
        	
                16.

              	
                The
                  Contractor’s Texas Provider Identifier (TPI) number if the Contractor is
                  Medicaidenrolled in Texas.

              


      

      
        	
                17.

              	
                Whether
                  the Contractor had a contract terminated or not renewed for
                  non-performance or poor performance within the past five years.
                  In such
                  instance, the Contractor must describe the issues and the parties
                  involved, and provide the address and telephone number of the principal
                  terminating party. The Contractor must also describe any corrective
                  action
                  taken to prevent any future occurrence of the problem leading to
                  the
                  termination.

              


      

      
        	
                18.

              	
                A
                  current Certificate of Good Standing issued by the Texas Comptroller
                  of
                  Public Accounts, or an explanation for why this form is not applicable
                  to
                  the Contractor.

              


      

      
        	
                19.

              	
                Whether
                  the Contractor has ever sought, or is currently seeking, National
                  Committee for Quality Assurance (NCQA) or American Accreditation
                  HealthCare Commission (URAC) accreditation status, and if it has
                  or is,
                  indicate:

              


      

      
        	
                 

              	
                •

              	
                its
                  current NCQA or URAC accreditation
                  status;

              


      

      
        	
                 

              	
                •

              	
                if
                  NCQA or URAC accredited, its accreditation term effective dates;
                  and

              


      

      
        	
                 

              	
                •

              	
                if
                  not accredited, a statement describing whether and when NCQA or
                  URAC
                  accreditation status was ever denied the
                  Contractor.

              


      

      


      Material
        Subcontractor Information

      


      A
        Material Subcontractor means any entity retained by the HMO to provide all
        or
        part of the HMO Administrative Services where the value of the subcontracted
        HMO
        Administrative Service(s) exceeds $100,000 per fiscal year. HMO Administrative
        Services are those services or functions other than the direct delivery of
        Covered Services necessary to manage the delivery of and payment for Covered
        Services. HMO Administrative Services include but are not limited to Network,
        utilization, clinical and/or quality management, service authorization, claims
        processing, Management Information System (MIS) operation and reporting.
        The
        term Material Subcontractor does not include Providers in the HMO’s Provider
        Network.

      


      Contractors
        must submit the following for each proposed Material Subcontractor, if
        any:

      


      
        	
                1.

              	
                A
                  signed letter of commitment from each Material Subcontractor that
                  states
                  the Material Subcontractor’s willingness to enter into a Subcontractor
                  agreement with the Contractor and a statement of work for activities
                  to be
                  subcontracted. Letters of Commitment must be provided on the Material
                  Subcontractor’s official company letterhead and signed by an official with
                  the authority to bind the company for the subcontracted work. The
                  Letter
                  of Commitment must state, if applicable, the company’s certified HUB
                  status.

              


      

      
        	
                2.

              	
                The
                  Material Subcontractor’s legal name, trade name, or any other name under
                  which the Material Subcontractor does business, if
                  any.

              


      

      
        	
                3.

              	
                The
                  address and telephone number of the Material Subcontractor’s headquarters
                  office.

              


      

      
        	
                4.

              	
                The
                  type of ownership (e.g., proprietary, partnership,
                  corporation).

              


      

      
        	
                5.

              	
                The
                  type of incorporation (i.e., for profit, not-for-profit, or non-profit)
                  and whether the Material Subcontractor is publicly or privately
                  owned.

              


      

      
        	
                6.

              	
                If
                  a Subsidiary or Affiliate, the identification of the parent
                  organization.

              


      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                  7

              	
                Version
                  1.7

              


      

      


      
        	
                7.

              	
                 

              	
                The
                  name and address of any sponsoring corporation or others who provide
                  financial support to the Material Subcontractor and type of support,
                  e.g.,
                  guarantees, letters of credit, etc. Indicate if there are maximum
                  limits
                  of the additional financial
                  support.

              


      

      
        	
                8.

              	
                 

              	
                The
                  name and address of any health professional that has at least a
                  five
                  percent (5%) financial interest in the Material Subcontractor and
                  the type
                  of financial interest.

              


      

      
        	9.	
                 

              	
                The
                  state in which the Material Subcontractor is incorporated, commercially
                  domiciled, and the state(s) in which the organization is licensed
                  to do
                  business.

              


      

      
        	
                10.

              	
                The
                  Material Subcontractor’s Texas Provider Identifier if Medicaid-enrolled in
                  Texas.

              


      

      
        	
                11.

              	
                The
                  Material Subcontractor’s federal taxpayer identification
                  number.

              


      

      
        	
                12.

              	
                Whether
                  the Material Subcontractor had a contract terminated or not renewed
                  for
                  nonperformance or poor performance within the past five years.
                  In such
                  instance, the Contractor must describe the issues and the parties
                  involved, and provide the address and telephone number of the principal
                  terminating party. The Contractor must also describe any corrective
                  action
                  taken to prevent any future occurrence of the problem leading to
                  the
                  termination.

              


      

      
        	
                13.

              	
                Whether
                  the Material Subcontractor has ever sought, or is currently seeking,
                  National Committee for Quality Assurance (NCQA) or American Accreditation
                  HealthCare Commission (URAC) accreditation or certification status,
                  and if
                  it has or is, indicate:

              


      

      


      
        	
                 

              	
                •its
                  current NCQA or
                  URAC accreditation or certification
                  status;

              


      

      
        	
                 

              	
                •if
                  NCQA or URAC
                  accredited or certified, its accreditation or certification term
                  effective
                  dates; and

              


      

      
        	
                 

              	
                •if
                  not accredited,
                  a statement describing whether and when NCQA or URAC accreditation
                  status
                  was ever denied the Material
                  Subcontractor.

              


      

      


      Organizational
        Overview

      


      
        	
                1.

              	
                Submit
                  an organizational chart (labeled Chart A), showing the corporate
                  structure
                  and lines of responsibility and authority in the administration
                  of the
                  Bidder’s business as a health plan.

              


      

      
        	
                2.

              	
                Submit
                  an organizational chart (labeled Chart B) showing the Texas organizational
                  structure and how it relates to the proposed Service Area(s), including
                  staffing and functions performed at the local level. If Chart A
                  represents
                  the entire organizational structure, label the submission as Charts
                  A and
                  B.

              


      

      
        	
                3.

              	
                Submit
                  an organizational chart (labeled Chart C) showing the Management
                  Information System (MIS) staff organizational structure and how
                  it relates
                  to the proposed Service Area(s) including staffing and functions
                  performed
                  at the local level.

              


      

      
        	
                4.

              	
                If
                  the Bidder is proposing to use a Material Subcontractor(s), the
                  Bidder
                  shall include an organizational chart demonstrating how the Material
                  Subcontractor(s) will be managed within the Bidder’s Texas organizational
                  structure, including the primary individuals at the Bidder’s organization
                  and at each Material Subcontractor organization responsible for
                  overseeing
                  such Material Subcontract. This information may be included in
                  Chart B, or
                  in a separate organizational
                  chart(s).

              


      

      
        	
                5.

              	
                Submit
                  a brief narrative explaining the organizational charts submitted,
                  and
                  highlighting the key functional responsibilities and reporting
                  requirements of each organizational unit relating to the Bidder’s proposed
                  management of the HMO Program(s), including its management of any
                  proposed
                  Material Subcontractors.

              


      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                  7

              	
                Version
                  1.7

              


      

      


      Other
        Information

      


      
        	
                1.

              	
                Briefly
                  describe any regulatory action, sanctions, and/or fines imposed
                  by any
                  federal or Texas regulatory entity or a regulatory entity in another
                  state
                  within the last 3 years, including a description of any letters
                  of
                  deficiencies, corrective actions, findings of noncompliance, and/or
                  sanctions. Please indicate which of these actions or fines, if
                  any, were
                  related to Medicaid or CHIP programs. HHSC may, at its option,
                  contact
                  these clients or regulatory agencies and any other individual or
                  organization whether or not identified by the
                  Contractor.

              


      

      


      
        	
                2.

              	
                No
                  later than ten (10) days after the Contract Effective Date, submit
                  documentation that demonstrates that the HMO has secured the required
                  insurance and bonds in accordance with TDI requirements and Attachment
                  B-1, Section 8.

              


      

      


      
        	
                3.

              	
                Submit
                  annual audited financial statement for fiscal years 2004 and 2005
                  (2005 to
                  be submitted no later than six months after the close of the fiscal
                  year).

              


      

      


      
        	
                4.

              	
                Submit
                  an Affiliate Report containing a list of all Affiliates and for
                  HHSC’s
                  prior review and approval, a schedule of all transactions with
                  Affiliates
                  that, under the provisions of the Contract, will be allowable as
                  expenses
                  in the FSR Report for services provided to the HMO by the Affiliate.
                  Those
                  should include financial terms, a detailed description of the services
                  to
                  be provided, and an estimated amount that will be incurred by the
                  HMO for
                  such services during the Contract
                  Period.

              


      

      


      
        	
                7.3.1.4

              	
                System
                  Testing and Transfer of
                  Data

              


      

      


      The
        HMO
        must have hardware, software, network and communications systems with the
        capability and capacity to handle and operate all MIS systems and subsystems
        identified in Attachment B-1, Section 8.1.18. For example, the
        HMO’s MIS system must comply with the Health Insurance Portability and
        Accountability Act of 1996 (HIPAA) as indicated in
Section

      8.1.18.4.

      


      During
        this Readiness Review task, the HMO will accept into its system any and all
        necessary data files and information available from HHSC or its contractors.
        The
        HMO will install and test all hardware, software, and telecommunications
        required to support the Contract. The HMO will define and test modifications
        to
        the HMO’s system(s) required to support the business functions of the
        Contract.

      


      The
        HMO
        will produce data extracts and receive all electronic data transfers and
        transmissions. STAR and CHIP HMOs must be able to demonstrate the ability
        to
        produce an EQRO (currently, Institute for Child Health Policy (ICHP)) encounter
        file by April 1, 2006, and the 837-encounter file by August 1, 2006. STAR+PLUS
        HMOs must be able to demonstrate the ability to produce the STAR+PLUS encounter
        file by the STAR+PLUS Operational Start Date and the 837- encounter file
        by
        September 1, 2007. CHIP Perinatal HMOs who have already demonstrated the
        ability
        to produce an EQRO encounter file and 837-encounter file for the CHIP Program
        are not required to produce separate files for the CHIP Perinatal
        Program.

      


      If
        any
        errors or deficiencies are evident, the HMO will develop resolution procedures
        to address problems identified. The HMO will provide HHSC, or a designated
        vendor, with test data files for systems and interface testing for all external
        interfaces. This includes testing of the required

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                  7

              	
                Version
                  1.7

              


      

      


      telephone
        lines for Providers and Members and any necessary connections to the HHSC
        Administrative Services Contractor and the External Quality Review Organization.
        The HHSC Administrative Services Contractor will provide enrollment test
        files
        to new HMOs that do not have previous HHSC enrollment files. The HMO will
        demonstrate its system capabilities and adherence to Contract specifications
        during readiness review.

      


      
        	
                7.3.1.5

              	
                System
                  Readiness Review

              


      

      


      The
        HMO
        must assure that systems services are not disrupted or interrupted during
        the
        Operations Phase of the Contract. The HMO must coordinate with HHSC and other
        contractors to ensure the business and systems continuity for the processing
        of
        all health care claims and data as required under this contract.

      


      The
        HMO
        must submit to HHSC, descriptions of interface and data and process flow
        for
        each key business processes described in Section 8.1.18.3,
        System-wide Functions.

      


      The
        HMO
        must clearly define and document the policies and procedures that will be
        followed to support day-to-day systems activities. The HMO must develop,
        and
        submit for State review and approval, the following information by December
        14,
        2005 for STAR and CHIP, by July 31, 2006 for STAR+PLUS:

      


      
        	
                 

              	
                1.

              	
                Joint
                  Interface Plan.

              


      

      


      
        	
                 

              	
                2.

              	
                Disaster
                  Recovery Plan

              


      

      


      
        	
                 

              	
                3.

              	
                Business
                  Continuity Plan

              


      

      


      
        	
                 

              	
                4.

              	
                Risk
                  Management Plan, and

              


      

      


      
        	
                 

              	
                5.

              	
                Systems
                  Quality Assurance Plan.

              


      

      


      Separate
        plans are not required for CHIP Perinatal HMOs.

      


      
        	
                7.3.1.6

              	
                Demonstration
                  and Assessment of System
                  Readiness

              


      

      


      The
        HMO
        must provide documentation on systems and facility security and provide evidence
        or demonstrate that it is compliant with HIPAA. The HMO shall also provide
        HHSC
        with a summary of all recent external audit reports, including findings and
        corrective actions, relating to the HMO’s proposed systems, including any SAS70
        audits that have been conducted in the past three years. The HMO shall promptly
        make additional information on the detail of such system audits available
        to
        HHSC upon request.

      


      In
        addition, HHSC will provide to the HMO a test plan that will outline the
        activities that need to be performed by the HMO prior to the Operational
        Start
        Date of the Contract. The HMO must be prepared to assure and demonstrate
        system
        readiness. The HMO must execute system readiness test cycles to include all
        external data interfaces, including those with Material
        Subcontractors.

      


      HHSC,
        or
        its agents, may independently test whether the HMO’s MIS has the capacity to
        administer the STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO business,
        as
        applicable to the HMO. This Readiness Review of a HMO’s MIS may include a desk
        review and/or an

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                  7

              	
                Version
                  1.7

              


      

      


      onsite
        review. HHSC may request from the HMO additional documentation to support
        the
        provision of STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO Services, as
        applicable to the HMO. Based in part on the HMO’s assurances of systems
        readiness, information contained in the Proposal, additional documentation
        submitted by the HMO, and any review conducted by HHSC or its agents, HHSC
        will
        assess the HMO’s understanding of its responsibilities and the HMO’s capability
        to assume the MIS functions required under the Contract.

      


      The
        HMO
        is required to provide a Corrective Action Plan in response to any Readiness
        Review deficiency no later than ten (10) calendar days after notification
        of any
        such deficiency by HHSC. If the HMO documents to HHSC’s satisfaction that the
        deficiency has been corrected within ten (10) calendar days of such deficiency
        notification by HHSC, no Corrective Action Plan is required.

      


      
        	
                7.3.1.7

              	
                Operations
                  Readiness

              


      

      


      The
        HMO
        must clearly define and document the policies and procedures that will be
        followed to support day-to-day business activities related to the provision
        of
        STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO Services, including
        coordination with contractors. The HMO will be responsible for developing
        and
        documenting its approach to quality assurance.

      


      Readiness
        Review. Includes all plans to be implemented in one or more Service
        Areas on the anticipated Operational Start Date. At a minimum, the HMO shall,
        for each HMO Program:

      


      
        	
                 

              	
                1.

              	
                Develop
                  new, or revise existing, operations procedures and associated
                  documentation to support the HMO’s proposed approach to conducting
                  operations activities in compliance with the contracted scope of
                  work.

              


      

      


      
        	
                 

              	
                2.

              	
                Submit
                  to HHSC, a listing of all contracted and credentialed Providers,
                  in a HHSC
                  approved format including a description of additional contracting
                  and
                  credentialing activities scheduled to be completed before the Operational
                  Start Date.

              


      

      


      
        	
                 

              	
                3.

              	
                Prepare
                  and implement a Member Services staff training curriculum and a
                  Provider
                  training curriculum.

              


      

      


      
        	
                 

              	
                4.

              	
                Prepare
                  a Coordination Plan documenting how the HMO will coordinate its
                  business
                  activities with those activities performed by HHSC contractors
                  and the
                  HMO’s Material Subcontractors, if any. The Coordination Plan will include
                  identification of coordinated activities and protocols for the
                  Transition
                  Phase.

              


      

      


      
        	
                 

              	
                5.

              	
                Develop
                  and submit to HHSC the draft Member Handbook, draft Provider Manual,
                  draft
                  Provider Directory, and draft Member Identification Card for HHSC’s review
                  and approval. The materials must at a minimum meet the requirements
                  specified in Section 8.1.5 and include the Critical
                  Elements to be defined in the HHSC Uniform Managed Care
                  Manual.

              


      

      


      
        	
                 

              	
                6.

              	
                Develop
                  and submit to HHSC the HMO’s proposed Member complaint and appeals
                  processes for Medicaid, CHIP, and CHIP Perinatal as applicable
                  to the
                  HMO’s Program participation.

              


      

      


      
        	
                 

              	
                7.

              	
                Provide
                  sufficient copies of the final Provider Directory to the HHSC
                  Administrative Services Contractor in sufficient time to meet the
                  enrollment schedule.

              


      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                  7

              	
                Version
                  1.7

              


      

      


      
        	
                 

              	
                8.

              	
                Demonstrate
                  toll-free telephone systems and reporting capabilities for the
                  Member
                  Services Hotline, the Behavioral Health Hotline, and the Provider
                  Services
                  Hotline.

              


      

      


      
        	
                 

              	
                9.

              	
                Submit
                  a written Fraud and Abuse Compliance Plan to HHSC for approval
                  no later
                  than 30 days after the Contract Effective Date. See Section
                  8.1.19, Fraud and Abuse, for the requirements of the plan,
                  including new requirements for special investigation units. As
                  part of the
                  Fraud and Abuse Compliance Plan, the HMO
                  shall:

              


      

      


      
        	
                 

              	
                •

              	
                designate
                  executive and essential personnel to attend mandatory training
                  in fraud
                  and abuse detection, prevention and reporting. Executive and essential
                  fraud and abuse personnel means HMO staff persons who supervise
                  staff in
                  the following areas: data collection, provider enrollment or
                  disenrollment, encounter data, claims processing, utilization review,
                  appeals or grievances, quality assurance and marketing, and who
                  are
                  directly involved in the decision-making and administration of
                  the fraud
                  and abuse detection program within the HMO. The training will be
                  conducted
                  by the Office of Inspector General, Health and Human Services Commission,
                  and will be provided free of charge. The HMO must schedule and
                  complete
                  training no later than 90 days after the Effective
                  Date.

              


      

      


      
        	
                 

              	
                •

              	
                designate
                  an officer or director within the organization responsible for
                  carrying
                  out the provisions of the Fraud and Abuse Compliance
                  Plan.

              


      

      


      
        	
                 

              	
                •

              	
                The
                  HMO is held to the same requirements and must ensure that, if this
                  function is subcontracted to another entity, the subcontractor
                  also meets
                  all the requirements in this section and the Fraud and Abuse section
                  as
                  stated in Attachment B-1, Section
                  8.

              


      

      


      
        	
                 

              	
                •

              	
                Note:
                  STAR+PLUS HMOs who have already submitted and received HHSC’s approval for
                  their Fraud and Abuse Compliance Plans must submit acknowledgement
                  that
                  the HMO’s approved Fraud and Abuse Compliance Plan also applies to the
                  STAR+PLUS program, or submit a revised Fraud and Abuse Compliance
                  Plan for
                  HHSC’s approval, with an explanation of changes to be made to incorporate
                  the STAR+PLUS program into the plan, by July 10,
                  2006.

              


      

      


      
        	
                 

              	
                •

              	
                CHIP
                  Perinatal HMOs who have already submitted and received HHSC’s approval for
                  their Fraud and Abuse Compliance Plans must submit acknowledgement
                  that
                  the HMO’s approved Fraud and Abuse Compliance Plan also applies to the
                  CHIP Perinatal Program, or submit a revised Fraud and Abuse Compliance
                  Plan for HHSC’s approval, with an explanation of changes to be made to
                  incorporate the CHIP Perinatal program into the plan, by September
                  15,
                  2006.

              


      

      


      
        	
                 

              	
                •

              	
                Complete
                  hiring and training of STAR+PLUS Service Coordination staff, no
                  later than
                  45 days prior to the STAR+PLUS Operational Start
                  Date.

              


      

      


      During
        the Readiness Review, HHSC may
        request from the HMO certain operating procedures and updates to documentation
        to support the provision of STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal
        HMO
        Services. HHSC will assess the HMO’s understanding of its responsibilities and
        the HMO’s capability to assume the functions required under the Contract, based
        in part on the HMO’s assurances of operational readiness, information contained
        in the Proposal, and in Transition Phase documentation submitted by the
        HMO. 

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                  7

              	
                Version
                  1.7

              


      

      


      The
        HMO
        is required to promptly provide a Corrective Action Plan and/or Risk Mitigation
        Plan as requested by HHSC in response to Operational Readiness Review
        deficiencies identified by the HMO or by HHSC or its agent. The HMO must
        promptly alert HHSC of deficiencies, and must correct a deficiency or provide
        a
        Corrective Action Plan and/or Risk Mitigation Plan no later than ten (10)
        calendar days after HHSC’s notification of deficiencies. If the Contractor
        documents to HHSC’s satisfaction that the deficiency has been corrected within
        ten (10) calendar days of such deficiency notification by HHSC, no Corrective
        Action Plan is required.

      


      
        	
                7.3.1.8

              	
                Assurance
                  of System and Operational
                  Readiness

              


      

      


      In
        addition to successfully providing the Deliverables described in Section
        7.3.1, the HMO must assure HHSC that all processes, MIS systems, and
        staffed functions are ready and able to successfully assume responsibilities
        for
        operations prior to the Operational Start Date. In particular, the HMO must
        assure that Key HMO Personnel, Member Services staff, Provider Services staff,
        and MIS staff are hired and trained, MIS systems and interfaces are in place
        and
        functioning properly, communications procedures are in place, Provider Manuals
        have been distributed, and that Provider training sessions have occurred
        according to the schedule approved by HHSC.

      


      
        	
                7.3.1.9

              	
                Post-Transition

              


      

      


      The
        HMO
        will work with HHSC, Providers, and Members to promptly identify and resolve
        problems identified after the Operational Start Date and to communicate to HHSC,
        Providers, and Members, as applicable, the steps the HMO is taking to resolve
        the problems.

      


      If
        a HMO
        makes assurances to HHSC of its readiness to meet Contract requirements,
        including MIS and operational requirements, but fails to satisfy requirements
        set forth in this Section, or as otherwise required pursuant to the Contract,
        HHSC may, at its discretion do any of the following in accordance with the
        severity of the non-compliance and the potential impact on Members and
        Providers:

      


      
        	
                 

              	
                1.

              	
                freeze
                  enrollment into the HMO’s plan for the affected HMO Program(s) and Service
                  Area(s);

              


      

      


      
        	
                 

              	
                2.

              	
                freeze
                  enrollment into the HMO’s plan for all HMO Programs or for all Service
                  Areas of an affected HMO Program;

              


      

      


      
        	
                 

              	
                3.

              	
                impose
                  contractual remedies, including liquidated damages;
                  or

              


      

      


      
        	
                 

              	
                4.

              	
                pursue
                  other equitable, injunctive, or regulatory
                  relief.

              


      

      


      Refer
        to
Attachment B-1, Sections 8.1.1.2 and 8.1.18
for additional information regarding
        HMO Readiness Reviews during the
        Operations Phase.

      





    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    DOCUMENT
      HISTORY LOG

    


    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	
              Baseline

            	
              n/a

            	 	
              Initial
                version Attachment B-1, Section 8

            
	 	 	 	 
	
              Revision

            	
              1.1

            	
              June
                30, 2006

            	
              Revised
                version of the Attachment B-1, Section 8, that includes provisions
                applicable to MCOs participating in the STAR+PLUS Program.

               

              Section
                8.1.1.1, Performance Evaluation, is modified to include STAR+PLUS
                Performance Improvement Goals.

               

              Section
                8.1.2, Covered Services, is modified to include Functionally Necessary
                Community Long-term Care Services for STAR+PLUS.

               

              Section
                8.1.2.1 Value-Added Services, is modified to add language allowing
                for the
                HMO to distinguish between the Dual Eligible and non-Dual Eligible
                populations.

               

              Section
                8.1.2.2 Case-by-Case Added Services, is modified to clarify for STAR+Plus
                members it is based on functionality.

               

              Section
                8.1.3, Access to Care, is modified to include STAR+PLUS Functional
                Necessity and 1915(c) Nursing Facility Waiver clarifications.

               

              Section
                8.1.4, Provider Network, is modified to include STAR+PLUS.

               

              Section
                8.1.4.2, Primary Care Providers, is modified to include
                STAR+PLUS

               

              Section
                8.1.4.8, Provider Reimbursement, is modified to include Functionally
                Necessary Long-term care services for STAR+PLUS.

               

              Section
                8.1.7.7, Provider Profiling, is modified to include
                STAR+PLUS.

               

              Sections
                8.1.12 and 8.1.12.2, Services for People with Special Health Care
                Needs,
                are modified to include STAR+PLUS.

               

              Section
                8.1.13, Service Management for Certain Populations, is modified to
                include
                STAR+PLUS.

               

              Section
                8.1.14, Disease Management, is modified to include STAR+PLUS.

               

              Section
                8.2, Additional Medicaid HMO Scope of Work, is modified to include
                STAR+PLUS.

               

              Section
                8.3, Additional STAR+PLUS Scope of Work, is added.

               

            
	
              Revision

            	
              1.2

            	
              September
                1, 2006

            	
              Revised
                version of Attachment B-1, Section 8, that includes provisions applicable
                to MCOs participating in the STAR and CHIP Programs.

               

              Section
                8.1.1.1, Performance Evaluation, is modified to clarify that the
                HMOs
                goals are Service Area and Program specific; when the percentages
                for
                Goals 1 and 2 are to be negotiated; and when Goal 3 is to be
                negotiated.

               

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	 	 	 	
              Section
                8.1.2.1, Value-Added Services, is modified to add language allowing
                for
                the addition of two Value-added Services during the Transition Phase
                of
                the Contract and to clarify the effective dates for Value Added Services
                for the Transition Phase and the Operation Phase of the
                Contract.

               

              Section
                8.1.3.2, Access to Network Providers, is modified to delete references
                to
                Open Panels.

               

              Section
                8.1.4, Provider Network, is modified to clarify that “Out-of- Network
                reimbursement arrangements” with certain providers must be in
                writing.

               

              Section
                8.1.5.1, Member Materials, is modified to clarify the date that the
                member
                ID card and the member handbook are to be sent to members.

               

              Section
                8.1.5.6, Member Hotline, is modified to clarify the hotline performance
                requirements.

               

              Section
                8.1.17.2, Financial Reporting Requirements, is modified to clarify
                that
                the Bonus Incentive Plan refers to the Employee Bonus Incentive Plan.
                It
                has also been modified to clarify the reports and deliverable due
                dates
                and to change the name of the Claims Summary Lag Report and clarify
                that
                the report format has been moved to the Uniform Managed Care
                Manual.

               

              Section
                8.1.18.5, Claims Processing Requirements, is modified to revise the
                claims
                processing requirements and move many of the specifics to the Uniform
                Managed Care Manual.

               

              Section
                8.1.20, Reporting Requirements, is modified to clarify the reports
                and
                deliverable due dates.

               

              Section
                8.1.20.2, Reports, is modified to delete the Claims Data Specifications
                Report, amend the All Claims Summary Report, and add two new
                provider-related reports to the contract.

               

              Section
                8.2.2.10, Cooperation with Immunization Registry, is added to comply
                with
                legislation, SB 1188 sec. 6(e)(1), 79th Legislature,
                Regular
                Session, 2005.

               

              Section
                8.2.2.11, Case Management for Children and Pregnant Women, is
                added.

               

              Section
                8.2.5.1, Provider Complaints, is modified to include the 30- day
                resolution requirement.

               

              Section
                8.2.10.2, Non-Reimbursed Arrangements with Local Public Health Entities,
                is modified to update the requirements and delete the requirement
                for an
                MOU.

               

              Section
                8.2.11, Coordination with Other State Health and Human Services (HHS)
                Programs, is modified to update the requirements and delete the
                requirement for an MOU.

               

              Section
                8.4.2, CHIP Provider Complaint and Appeals, is modified to include
                the
                30-day resolution requirement.

               

            
	
              Revision

            	
              1.3

            	
              September
                1, 2006

            	
              Revised
                version of Attachment B-1, Section 8, that includes provisions applicable
                to MCOs participating in the CHIP Perinatal
                Program.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	 	 	 	
              Section
                8.1.1.1, Performance Evaluation, is modified to clarify that HHSC
                will
                negotiate and implement Performance Improvement Goals for the first
                full
                State Fiscal Year following the CHIP Perinatal Operational Start
                Date

               

              Section
                8.1.2, Covered Services is amended to: (a) clarify that Fee For Service
                will pay the Hospital costs for CHIP Perinate Newborns; (b) add a
                reference to new Attachment B-2.2 concerning covered services; (c)
                add
                CHIP Perinate references where appropriate.

               

              Section
                8.1.2.2 Case-by-Case Added Services, is modified to clarify that
                this does
                not apply to the CHIP Perinatal Program.

               

              Section
                8.1.3, Access to Care, is amended to include emergency services
                limitations.

               

              Section
                8.1.3.2, Access to Network Providers, is amended to include the Provider
                access standards for the CHIP Perinatal Program.

               

              Section
                8.1.4.2 Primary Care Providers, is modified to clarify the development
                of
                the PCP networks between the CHIP Perinates and the CHIP Perinate
                Newborns.

               

              Section
                8.1.4.6 Provider Manual, Materials and Training, modified to include
                the
                CHIP Perinatal Program

               

              Section
                8.1.4.9 Termination of Provider Contracts modified to include the
                CHIP
                Perinatal Program.

               

              Section
                8.1.5.2 Member Identification (ID) Card, modified to include the
                CHIP
                Perinatal Program.

               

              Section
                8.1.5.3 Member Handbook, modified to include the CHIP Perinatal
                Program.

               

              Section
                8.1.5.4 Provider Directory, modified to include the CHIP Perinatal
                Program.

               

              Section
                8.1.5.6 Member Hotline, modified to include the CHIP Perinatal
                Program.

               

              Section
                8.1.5.7 Member Education, modified to include the CHIP Perinatal
                Program.

               

              Section
                8.1.5.9 Member Complaint and Appeal Process, modified to include
                the CHIP
                Perinatal Program.

               

              Section
                8.1.7.7, Provider Profiling, is modified to include the CHIP Perinatal
                Program.

               

              Section
                8.1.12, Services for People with Special Health Care Needs, modified
                to
                clarify between CHIP Perinatal Program and CHIP Perinatal
                Newborn.

               

              Section
                8.1.13, Service Management for Certain Populations, modified to clarify
                the CHIP Perinatal Program.

               

              Section
                8.1.15, Behavioral Health (BH) Network and Services, modified to
                clarify
                between CHIP Perinatal and Perinate members.

               

              Section
                8.1.17.2, Financial Reporting Requirements, modified to include the
                CHIP
                Perinatal Program.

               

              Section
                8.1.18.3, System-wide Functions, modified to include the CHIP Perinatal
                Program.

               

              Section
                8.1.18.5, Claims Processing Requirements, modified to include the
                CHIP
                Perinatal Program.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	 	 	 	
              Section
                8.1.19, Fraud and Abuse, modified to include the CHIP Perinatal
                Program

               

              Section
                8.1.20.2, Provider Termination Report and Provider Network Capacity
                Report, is modified to include the CHIP Perinatal Program.

               

              Section
                8.5, Additional Scope of Work for CHIP Perinatal Program HMOs, is
                added to
                Attachment B-1

               

            
	
              Revision

            	
              1.4

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-1, Section 8- Operations Phase
                Requirements.

               

            
	
              Revision

            	
              1.5

            	
              January
                1, 2007

            	
              Revised
                version of the Attachment B-1, Section 8, that includes provisions
                applicable to MCOs participating in the STAR and STAR+PLUS
                Program.

               

              Section
                8.1.2 is modified to include a reference to STAR and STAR+PLUS covered
                services.

               

              Section
                8.1.20.2 is modified to update the references to the Uniform Managed
                Care
                Manual for the “Summary Report of Member Complaints and Appeals” and the
                “Summary Report of Provider Complaints.”

               

              Section
                8.2.2.5 is modified to require the Provider to coordinate with the
                Regional Health Authority.

               

              Section
                8.2.4 is amended to clarify cost settlements and encounter rates
                for
                Federally Qualified Health Centers (FQHCs) and Rural Health Clinics
                (RHCs)
                for STAR and STAR+PLUS service areas.

               

              Section
                8.3.2.4 is amended to clarify the timeframe for initial STAR+PLUS
                assessments.

               

              Section
                8.3.3 is amended to: (1) clarify the use of the DHS Form 2060; (2)
                require
                the HMO to complete the Individual Service Plan (ISP), Form 3671
                for each
                Member receiving 1915(c) Nursing Facility Waiver Services; (3) require
                HMOs to complete Form 3652 and Form 3671annually at reassessment;
                (4)
                allow the HMOs to administer the Minimum Data Set for Home Care (MDS-HC)
                instrument for nonwaiver 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

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	 	 	 	
              contains
                the HMO’s methodology for implementing and paying the enhanced
                payments.

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

            	
               

              Revised
                version of the Attachment B-1, Section 8, that includes provisions
                applicable to MCOs participating in the STAR+PLUS and CHIP Perinatal
                Programs.

               

              Section
                8.1 is modified to clarify the Operational Start Date of the STAR+PLUS
                Program.

               

              Section
                8.1.3.2 is modified to allow exceptions to hospital access standards
                on a
                case-by-case basis only for HMOs participating in the CHIP Perinatal
                Program.

               

              Section
                8.3.3 is modified to clarify when the 12-month period begins for
                the
                STAR+PLUS HMOs to complete the MDS-HC instruments for non-1915(c)
                Nursing
                Facility Waiver Members who are receiving Community-based Long-term
                Care
                Services.

               

            
	
              Revision

            	
              1.7

            	
              July
                1, 2007

            	
              New
                Section 8.1.1.2 is added to require the HMOs to pay for any additional
                readiness reviews beyond the original ones conducted before the
                Operational Start Date.

               

              Section
                8.1.5.5 is modified to add a requirement that all HMOs must list
                Home
                Health Ancillary providers on their websites, with an indicator for
                Pediatric services.

               

              Section
                8.1.17.2 is modified to remove the requirement that the Claims Lag
                Report
                separate claims by service categories.

               

              Section
                8.1.18 is modified to update the cross-references to sections of
                the
                contract addressing remedies and damages and to add crossreferences
                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.

            
	
              1Status
                should be represented as “Baseline” for initial issuances, “Revision” for
                changes to the Baseline version, and “Cancellation” for withdrawn
                versions

              2Revisions
                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.

              3Brief
                description of the changes to the document made in the
                revision.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.

            	
              OPERATIONS
                PHASE REQUIREMENTS

            


    

    


    This
      Section is designed to provide HMOs with sufficient information to understand
      the HMOs' responsibilities. This Section describes scope of work requirements
      for the Operations Phase of the Contract.

    


    Section
      8.1 includes the general scope of work that applies to the STAR,
      STAR+PLUS, CHIP, and CHIP Perinatal HMO Programs.

    


    Section
      8.2 includes the additional Medicaid scope of work that applies only to
      the STAR and STAR+PLUS HMOs.

    


    Section
      8.3 includes the additional scope of work that applies only to
      STAR+PLUS HMOs.

    


    Section
      8.4 includes the additional scope of work that applies only to CHIP
      HMOs.

    


    Section
      8.5 includes the additional scope of work that applies only to CHIP
      Perinatal HMOs. 

     

    The
      Section does not include detailed information on the STAR, STAR+PLUS, CHIP,
      and
      CHIP Perinatal HMO Program requirements, such as the time frame and format
      for
      all reporting requirements. HHSC has included this information in the
Uniform Managed Care Contract Terms and Conditions
(Attachment A) and the Uniform Managed Care
      Manual. HHSC reserves the right to modify these documents as it deems
      necessary using the procedures set forth in the Uniform Managed Care
      Contract Terms and Conditions.

    


    
      	
              8.1

            	
              General
                Scope of Work

            


    

    


    In
      each
      HMO Program Service Area, HHSC will select HMOs for each HMO Program to provide
      health care services to Members. The HMO must be licensed by the Texas
      Department of Insurance (TDI) as an HMO or an ANHC in all zip codes in the
      respective Service Area(s).

    


    Coverage
      for benefits will be available to enrolled Members effective on the Operational
      Start Date. The Operational Start Date is September 1, 2006 for STAR and CHIP
      HMOs, January 1, 2007 for CHIP Perinatal HMOs, and February 1, 2007 for the
      STAR+PLUS HMOs.

    


    
      	
              8.1.1

            	
              Administration
                and Contract Management

            


    

    


    The
      HMO
      must comply, to the satisfaction of HHSC, with (1) all provisions set forth
      in
      this Contract, and (2) all applicable provisions of state and federal laws,
      rules, regulations, and waivers.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.1.1.1

            	
              Performance
                Evaluation

            


    

    


    The
      HMO
      must identify and propose to HHSC, in writing, no later than May 1st of each
      State Fiscal Year (SFY) after the Operational Start Date, annual HMO Performance
      Improvement Goals for the next fiscal year, as well as measures and time frames
      for demonstrating that such goals are being met. Performance Improvement Goals
      must be based on HHSC priorities and identified opportunities for improvement
      (see Attachment B-4, Performance Improvement Goals). The
      Parties will negotiate such Performance Improvement Goals, the measures that
      will be used to assess goal achievement, and the time frames for completion,
      which will be incorporated into the Contract. If HHSC and the HMO cannot agree
      on the Performance Improvement Goals, measures, or time frames, HHSC will set
      the goals, measures, or time frames.

    


    For
      State
      Fiscal Year 2007, HHSC has established three overarching goals for each Program.
      These overarching goals are as follows:

    


    
      	
              Goal
                1

            	
              (STAR
                and CHIP) Improve Access to Primary Care Services for
                Members

            


    

    


    
      	
              Goal
                2

            	
              (STAR
                and CHIP) Improve Access to Behavioral Health Services for
                Members,

            


    

    


    
      	
              Goal
                3

            	
              (STAR
                Only) Improve Access to Clinically Appropriate Alternatives to Emergency
                Room Services Outside of Regular Office Hours (CHIP Only) Improve
                Current
                Member Understanding About the CHIP Benefit Renewal
                Processes

            


    

    


    Note:
      The HMO is required to propose customized sub-goals specific to the
      HMO’s Service Areas and Programs for all overarching goals. The sub-goals must
      be approved by HHSC as part of the negotiation process.

    


    The
      specific percentages of expected achievement for each sub-goal will be
      negotiated by HHSC

    and
      the
      HMO before the Operational Start Date.

    


    For
      STAR+PLUS HMOs, HHSC will negotiate and implement Performance Improvement Goals
      for the first full fiscal year following the STAR+PLUS Operational Start Date.
      One standard STAR+PLUS goal will relate to Consumer-Directed Services. STAR+PLUS
      improvement goals for SFY2008 will be included in Attachment
      B-4.1.

    


    For
      CHIP
      Perinatal HMOs, HHSC will negotiate and implement Performance Improvement Goals
      for the first full State Fiscal Year following the CHIP Perinatal Operational
      Start Date.

    


    The
      HMO
      must participate in semi-annual Contract Status Meetings (CSMs) with HHSC for
      the primary purpose of reviewing progress toward the achievement of annual
      Performance Improvement Goals and Contract requirements. HHSC may request
      additional CSMs, as it deems necessary to address areas of noncompliance. HHSC
      will provide the HMO with reasonable advance notice of additional CSMs,
      generally at least five (5) business days.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      must provide to HHSC, no later than 14 business days prior to each semi-annual
      CSM, one electronic copy of a written update, detailing and documenting the
      HMO’s progress toward meeting the annual Performance Improvement Goals or other
      areas of noncompliance.

    


    HHSC
      will
      track HMO performance on Performance Improvement Goals. It will also track
      other
      key facets of HMO performance through the use of a Performance Indicator
      Dashboard (see HHSC’s Uniform Managed Care Manual). HHSC will compile
      the Performance Indicator Dashboard based on HMO submissions, data from the
      External Quality Review Organization (EQRO), and other data available to HHSC.
      HHSC will share the Performance Indicator Dashboard with the HMO on a quarterly
      basis.

    


    
      	
              8.1.1.2

            	
              Additional
                HMO Readiness Reviews

            


    

    


    During
      the Operations Phase, a HMO that chooses to make a change to any operational
      system or undergo any major transition may be subject to an additional Readiness
      Review(s). HHSC will determine whether the proposed changes will require a
      desk
      review and/or an onsite review. The HMO is responsible for all costs incurred
      by
      HHSC or its authorized agent to conduct an onsite Readiness Review.

    


    Refer
      to
Attachment B-1, Section 7 and Attachment B-1, Section
      8.1.18 for additional information regarding HMO Readiness Reviews.
      Refer to Attachment A, Section 4.08(c) for information
      regarding Readiness Reviews of the HMO’s Material Subcontractors.

    


    
      	
              8.1.2

            	
              Covered
                Services

            


    

    


    The
      HMO
      is responsible for authorizing, arranging, coordinating, and providing Covered
      Services in accordance with the requirements of the Contract. The HMO must
      provide Medically Necessary Covered Services to all Members beginning on the
      Member’s date of enrollment regardless of pre-existing conditions, prior
      diagnosis and/or receipt of any prior health care services. STAR+PLUS HMOs
      must
      also provide Functionally Necessary Community Long-term Care Services to all
      Members beginning on the Member’s date of enrollment regardless of preexisting
      conditions, prior diagnosis and/or receipt of any prior health care services.
      The HMO must not impose any pre-existing condition limitations or exclusions
      or
      require Evidence of Insurability to provide coverage to any Member.

    


    The
      HMO
      must provide full coverage for Medically Necessary Covered Services to all
      Members and, for STAR+PLUS Members, Functionally Necessary Community Long-term
      Care Services, without regard to the Member’s:

    


    
      	
               

            	
              1.

            	
              previous
                coverage, if any, or the reason for termination of such
                coverage;

            


    

    
      	
               

            	
              2.

            	
              health
                status;

            


    

    
      	
               

            	
              3.

            	
              confinement
                in a health care facility; or

            


    

    
      	
               

            	
              4.

            	
              for
                any other reason.

            


    

    


    Please
      Note:

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    (STAR
      HMOs): A Member cannot change from one STAR HMO to another STAR HMO during
      an
      inpatient hospital stay. The STAR HMO responsible for the hospital charges
      for
      STAR Members at the start of an Inpatient Stay remains responsible for hospital
      charges until the time of discharge or until such time that there is a loss
      of
      Medicaid eligibility. STAR HMOs are responsible for professional charges during
      every month for which the HMO receives a full capitation for a
      Member.

    


    (STAR+PLUS
      HMOs): A Member cannot change from one STAR+PLUS HMO to another STAR+PLUS HMO
      during an inpatient hospital stay. The STAR+PLUS HMO is responsible for
      authorization and management of the inpatient hospital stay until the time
      of
      discharge, or until such time that there is a loss of Medicaid eligibility.
      STAR+PLUS HMOs are responsible for professional charges during every month
      for
      which the HMO receives a full capitation for a Member.

    


    A
      Member
      cannot change from one STAR+PLUS HMO to another STAR+PLUS HMO during a nursing
      facility stay.

    


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

    


    (CHIP
      Perinatal HMOs): If a CHIP Perinate’s Effective Date of Coverage occurs while
      the CHIP Perinate is confined in a Hospital, HMO is responsible for the CHIP
      Perinate’s costs of Covered Services beginning on the Effective Date of
      Coverage. If a CHIP Perinate is disenrolled while the CHIP Perinate is confined
      in a Hospital, HMO’s responsibility for the CHIP Perinate’s costs of Covered
      Services terminates on the Date of Disenrollment.

    


    The
      HMO
      must not practice discriminatory selection, or encourage segregation among
      the
      total group of eligible Members by excluding, seeking to exclude, or otherwise
      discriminating against any group or class of individuals.

    


    Covered
      Services for all Medicaid HMO Members are listed in Attachments B-2 and
      B-2.1 of the Contract (STAR and STAR+PLUS Covered Services). As noted
      in Attachments B-2 and B-2.1, all Medicaid HMOs must provide
      Covered Services described in the most recent Texas Medicaid Provider
      Procedures Manual (Provider Procedures Manual), the THSteps
      Manual (a supplement to the Provider Procedures Manual), and in all
Texas Medicaid Bulletins, which update the Provider Procedures
      Manual except for those services identified in Section 8.2.2.8
as non-capitated services. A description of CHIP Covered
      Services and
      exclusions is provided in Attachment B-2 of the Contract. A
      description of CHIP Perinatal Program Covered Services and exclusions is
      provided in Attachment B-2.2 of the Contract. Covered Services
      are subject to change due to changes in federal and state law, changes in
      Medicaid, CHIP or CHIP Perinatal Program policy, and changes in medical
      practice, clinical protocols, or technology.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.1.2.1

            	
              Value-added
                Services

            


    

    


    HMOs
      may
      propose additional services for coverage. These are referred to as “Value-added
      Services.” Value-added Services must be actual health care services or benefits
      rather than gifts, incentives, educational classes or health assessments.
      Temporary phones, cell phones, additional transportation benefits, and extra
      home health services may be Value-added Services, if approved by HHSC. Best
      practice approaches to delivering Covered Services are not considered
      Value-added Services.

    


    If
      offered, Value-added Services must be offered to all mandatory STAR, and CHIP
      and CHIP Perinatal HMO Members within the applicable HMO Program and Service
      Area. For STAR+PLUS Acute Care services, the HMO may distinguish between the
      Dual Eligible and non-Dual Eligible populations. Value-added Services do not
      need to be consistent across more than one HMO Program or across more than
      one
      Service Area. Value-added Services that are approved by HHSC during the
      contracting process will be included in the Contract’s scope of
      services.

    


    The
      HMO
      must provide Value-added Services at no additional cost to HHSC. The HMO must
      not pass on the cost of the Value-added Services to Providers. The HMO must
      specify the conditions and parameters regarding the delivery of the Value-added
      Services in the HMO’s Marketing Materials and Member Handbook, and must clearly
      describe any limitations or conditions specific to the Value-added
      Services.

    


    Transition
      Phase. During the Transition Phase, HHSC will offer a one-time
      opportunity for the HMO to propose two additional Value-added Services to its
      list of current, approved Value-added Services. (See Attachment B-3,
      Value-Added Services). HHSC will establish the requirements and the
      timeframes for submitting the two additional proposed Value-added
      Services.

    


    During
      this HHSC-designated opportunity, the HMO may propose either to add new
      Value-added Services or to enhance its current, approved Value-added Services.
      The HMO may propose two additional Value-added Services per HMO Program, and
      the
      services do not have to be the same for each HMO Program. HHSC will review
      the
      proposed additional services and, if appropriate, will approve the additional
      Value-added Services, which will be effective on the Operational Start Date.
      The
      HMO’s Contract will be amended to reflect the additional, approved Value-added
      Services.

    


    The
      HMO
      does not have to add Value-added Services during the HHSC-designated
      opportunity, but this will be the only time during the Transition Phase for
      the
      HMO to add Value-added Services. At no time during the Transition Phase will
      the
      HMO be allowed to delete, limit or restrict any of its current, approved
      Value-added Services.

    


    Operations
      Phase. During the Operations Phase, Value-added Services can be added
      or removed only by written amendment of the Contract one time per fiscal year
      to
      be effective September 1 of the fiscal year, except when services are amended
      by
      HHSC during the fiscal year. This will allow HHSC to coordinate with annual
      revisions to HHSC’s HMO Comparison Charts for Members. A HMO’s request to add or
      delete a Value-added Service must be submitted to HHSC by May 1 of each year
      to
      be effective September 1 for the following contract period. (For STAR and CHIP,
      see Attachment B-3, Value-Added Services. For STAR+PLUS,
      see

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    Attachment
      B-3.1, STAR+PLUS Value-Added Services. For CHIP Perinatal, see
Attachment B-3.2, CHIP Perinatal Value-Added
      Services.)

    


    A
      HMO’s
      request to add a Value-added Service must:

    


    
      	
               

            	
              a.

            	
              Define
                and describe the proposed Value-added
                Service;

            


    

    
      	
               

            	
              b.

            	
              Specify
                the Service Areas and HMO Programs for the proposed Value-added
                Service;

            


    

    
      	
               

            	
              c.

            	
              Identify
                the category or group of mandatory Members eligible to receive the
                Value-added Service if it is a type of service that is not appropriate
                for
                all mandatory Members;

            


    

    
      	
               

            	
              d.

            	
              Note
                any limits or restrictions that apply to the Value-added
                Service;

            


    

    
      	
               

            	
              e.

            	
              Identify
                the Providers responsible for providing the Value-added
                Service;

            


    

    
      	
               

            	
              f.

            	
              Describe
                how the HMO will identify the Value-added Service in administrative
                (Encounter) data;

            


    

    
      	
               

            	
              g.

            	
              Propose
                how and when the HMO will notify Providers and mandatory Members
                about the
                availability of such Value-added
                Service;

            


    

    
      	
               

            	
              h.

            	
              Describe
                how a Member may obtain or access the Value-added Service;
                and

            


    

    
      	
               

            	
              i.

            	
              Include
                a statement that the HMO will provide such Value-added Service for
                at
                least 12 months from the September 1 effective
                date.

            


    

    


    A
      HMO
      cannot include a Value-added Service in any material distributed to mandatory
      Members or prospective mandatory Members until the Parties have amended the
      Contract to include that Value-added Service. If a Value-added Service is
      deleted by amendment, the HMO must notify each mandatory Member that the service
      is no longer available through the HMO. The HMO must also revise all materials
      distributed to prospective mandatory Members to reflect the change in
      Value-added Services.

    


    
      	
              8.1.2.2

            	
              Case-by-Case
                Added Services

            


    

    


    Except
      as
      provided below, the HMO may offer additional benefits that are outside the
      scope
      of services to individual Members on a case-by-case basis, based on Medical
      Necessity, cost-effectiveness, the wishes of the Member/Member’s family, the
      potential for improved health status of the Member, and for STAR+PLUS Members
      based on functional necessity.

    


    Section
      8.1.2.2, Case-by-Case Added Services, does not apply to the CHIP Perinatal
      Program.

    


    
      	
              8.1.3

            	
              Access
                to Care

            


    

    


    All
      Covered Services must be available to Members on a timely basis in accordance
      with medically appropriate guidelines, and consistent with generally accepted
      practice parameters, requirements in this Contract. The HMO must comply with
      the
      access requirements as established by the Texas Department of Insurance (TDI)
      for all HMOs doing business in Texas, except as otherwise required by this
      Contract. Medicaid HMOs must be responsive to the possibility of increased
      Members due to the phase-out of the PCCM model in Service Areas where adequate
      HMO coverage exists.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      must provide coverage for Emergency Services to Members 24 hours a day and
      7
      days a week, without regard to prior authorization or the Emergency Service
      provider’s contractual relationship with the HMO. The HMO’s policy and
      procedures, Covered Services, claims adjudication methodology, and reimbursement
      performance for Emergency Services must comply with all applicable state and
      federal laws and regulations, whether the provider is in-network or
      Out-of-Network. A HMO is not responsible for payment for unauthorized
      non-emergency services provided to a Member by Out-of-Network
      providers.

    


    The
      HMO
      must also have an emergency and crisis Behavioral Health Services Hotline
      available 24 hours a day, 7 days a week, toll-free throughout the Service Area.
      The Behavioral Health Services Hotline must meet the requirements described
      in
Section 8.1.15. For Medicaid Members, a HMO must provide
      coverage for Emergency Services in compliance with 42 C.F.R. §438.114, and as
      described in more detail in Section 8.2.2.1. The HMO may
      arrange Emergency Services and crisis Behavioral Health Services through mobile
      crisis teams.

    


    For
      CHIP
      Members, Emergency Services, including emergency Behavioral Health Services,
      must be provided in accordance with the Texas Insurance Code and TDI
      regulations.

    


    For
      the
      CHIP Perinatal Program, refer to Attachment B-2.2 for description of emergency
      services for CHIP Perinates and CHIP Perinate Newborns.

    


    For
      the
      STAR, STAR+PLUS, and CHIP Programs, and for CHIP Perinate Newborns, HMO must
      require, and make best efforts to ensure, that PCPs are accessible to Members
      24
      hours a day, 7 days a week and that its Network Primary Care Providers (PCPs)
      have after-hours telephone availability that is consistent with, Section
      8.1.4. CHIP Perinatal HMOs are not required to establish PCP Networks
      for CHIP Perinates.

    


    The
      HMO
      must provide that if Medically Necessary Covered Services are not available
      through Network physicians or other Providers, the HMO must, upon the request
      of
      a Network physician or other Provider, within the time appropriate to the
      circumstances relating to the delivery of the services and the condition of
      the
      patient, but in no event to exceed five business days after receipt of
      reasonably requested documentation, allow a referral to a non-network physician
      or provider. The HMO must fully reimburse the non-network provider in accordance
      with the Out-of-Network methodology for Medicaid as defined by HHSC, and for
      CHIP, at the usual and customary rate defined by TDI in 28 T.A.C. Section
      11.506.

    


    The
      Member will not be responsible for any payment for Medically Necessary Covered
      Services, including Functionally Necessary Covered Services, other
      than:

    


    
      	
              (1)

            	
              HHSC-specified
                co-payments for CHIP Members, where applicable;
                and

            


    

    


    (2)              STAR+PLUS
      Members who qualify for 1915(c) Nursing Facility Waiver services and enter
      a
      24-hour setting will be required to pay the provider of care room and board
      costs and any income in excess of the personal needs allowance, as established
      by HHSC. If the HMO provides Members who do not qualify for the 1915(c) Nursing
      Facility Waiver services in a 24-hour setting as an alternative to nursing
      facility or hospitalization, the Member will be required to pay the provider
      of
      care room and board costs and any income in excess of the personal needs
      allowance, as established by HHSC.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.1.3.1

            	
              Waiting
                Times for Appointments

            


    

    


    Through
      its Provider Network composition and management, the HMO must ensure that
      appointments for the following types of Covered Services are provided within
      the
      time frames specified below. In all cases below, “day” is defined as a calendar
      day.

    


    
      	
               

            	
              1.

            	
              Emergency
                Services must be provided upon Member presentation at the service
                delivery
                site, including at non-network and out-of-area
                facilities;

            


    

    
      	
               

            	
              2.

            	
              Urgent
                care, including urgent specialty care, must be provided within 24
                hours of
                request.

            


    

    
      	
               

            	
              3.

            	
              Routine
                primary care must be provided within 14 days of
                request;

            


    

    
      	
               

            	
              4.

            	
              Initial
                outpatient behavioral health visits must be provided within 14 days
                of
                request;

            


    

    
      	
               

            	
              5.

            	
              Routine
                specialty care referrals must be provided within 30 days of
                request;

            


    

    
      	
               

            	
              6.

            	
              Pre-natal
                care must be provided within 14 days of request, except for high-risk
                pregnancies or new Members in the third trimester, for whom an appointment
                must be offered within five days, or immediately, if an emergency
                exists;

            


    

    
      	
               

            	
              7.

            	
              Preventive
                health services for adults must be offered to a Member within 90
                days of
                request; and

            


    

    
      	
               

            	
              8.

            	
              Preventive
                health services for children, including well-child check-ups should
                be
                offered to Members in accordance with the American Academy of Pediatrics
                (AAP) periodicity schedule. Please note that for Medicaid Members,
                HMOs
                should use the THSteps Program modifications to the AAP periodicity
                schedule. For newly enrolled Members under age 21, overdue or upcoming
                well-child checkups, including THSteps medical checkups, should be
                offered
                as soon as practicable, but in no case later than 14 days of enrollment
                for newborns, and no later than 60 days of enrollment for all other
                eligible child Members.

            


    

    


    
      	
              8.1.3.2

            	
              Access
                to Network Providers

            


    

    


    The
      HMO’s
      Network shall have within its Network, PCPs in sufficient numbers, and with
      sufficient capacity, to provide timely access to regular and preventive
      pediatric care and THSteps services to all child Members in accordance with
      the
      waiting times for appointments in Section 8.1.3.1.

    


    PCP
      Access: At a minimum, the HMO must ensure that all Members have access
      to an age-appropriate PCP in the Provider Network with an Open Panel within
      30
      miles of the Member’s residence. For the purposes of assessing compliance with
      this requirement, an internist who provides primary care to adults only is
      not
      considered an age-appropriate PCP choice for a Member under age 21, and a
      pediatrician is not considered an age-appropriate choice for a Member age 21
      and
      over. Note: This provision does not apply to CHIP Perinates, but it does apply
      to CHIP Perinate Newborns.

    


    OB/GYN
      Access and CHIP Perinatal Program Provider Access: STAR, STAR+PLUS and
      CHIP Program Network: at a minimum, STAR, STAR+PLUS and CHIP HMOs must ensure
      that all female Members have access to an OB/GYN in the Provider Network within
      75 miles of the Member’s residence. (If the OB/GYN is acting as the Member’s
      PCP, the HMO must follow the access requirements for the PCP.) The HMO must
      allow female Members to select an OB/GYN within its Provider Network. A female
      Member who selects an OB/GYN must be allowed direct access to the OB/GYN’s
      health care services without a referral from the Member’s PCP or a
      prior

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    authorization.
      A pregnant Member with 12 weeks or less remaining before the expected delivery
      date must be allowed to remain under the Member’s current OB/GYN care though the
      Member’s post-partum checkup, even if the OB/GYN provider is, or becomes,
      Out-of-Network.

    


    CHIP
      Perinatal Program Network: At a minimum, CHIP Perinatal HMOs must ensure that
      CHIP Perinates have access to a Provider of perinate services within 75 miles
      of
      the Member’s residence if the Member resides in an urban area and within 125
      miles of the Member’s residence if the Member resides in a rural
      area.

    


    Outpatient
      Behavioral Health Service Provider Access: At a minimum, the HMO must
      ensure that all Members except CHIP Perinates have access to an outpatient
      Behavioral Health Service Provider in the Network within 75 miles of the
      Member’s residence. Outpatient Behavioral Health Service Providers must include
      Masters and Doctorate-level trained practitioners practicing independently
      or at
      community mental health centers, other clinics or at outpatient hospital
      departments. A Qualified Mental Health Provider (QMHP), as defined and
      credentialed by the Texas Department of State Health Services standards (T.A.C.
      Title 25, Part I, Chapter 412), is an acceptable outpatient behavioral health
      provider as long as the QMHP is working under the authority of an MHMR entity
      and is supervised by a licensed mental health professional or
      physician.

    


    Other
      Specialist Physician Access: At a minimum, the HMO must ensure that all
      Members except CHIP Perinates have access to a Network specialist physician
      within 75 miles of the Member’s residence for common medical specialties. For
      adult Members, common medical specialties shall include general surgery,
      cardiology, orthopedics, urology, and ophthalmology. For child Members, common
      medical specialties shall include orthopedics and otolaryngology.

    


    Hospital
      Access: The HMO must ensure that all Members have access to an Acute
      Care hospital in the Provider Network within 30 miles of the Member’s residence.
      For HMOs participating in the CHIP Perinatal Program, exceptions to this access
      standard may be requested on a case-by-case basis and must have HHSC
      approval.

    


    All
      other Covered Services, except for services provided in the Member’s
      residence: At a minimum, the HMO must ensure that all Members have
      access to at least one Network Provider for each of the remaining Covered
      Services described in Attachment B-2, within 75 miles of the
      Member’s residence. This access requirement includes, but is not limited to,
      specialists, specialty hospitals, psychiatric hospitals, diagnostic and
      therapeutic services, and single or limited service health care physicians
      or
      Providers, as applicable to the HMO Program.

    


    The
      HMO
      is not precluded from making arrangements with physicians or providers outside
      the HMO’s Service Area for Members to receive a higher level of skill or
      specialty than the level available within the Service Area, including but not
      limited to, treatment of cancer, burns, and cardiac diseases. HHSC may consider
      exceptions to the above access-related requirements when an HMO has established,
      through utilization data provided to HHSC, that a normal pattern for securing
      health care services within an area does not meet these standards, or when
      an
      HMO is providing care of a higher skill level or specialty than the level which
      is available within the Service Area such as, but not limited to, treatment
      of
      cancer, burns, and cardiac diseases.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.1.3.3

            	
              Monitoring
                Access

            


    

    


    The
      HMO
      is required to systematically and regularly verify that Covered Services
      furnished by Network Providers are available and accessible to Members in
      compliance with the standards described in Sections 8.1.3.1 and
      8.1.3.2, and for Covered Services furnished by PCPs, the standards
      described in Section 8.1.4.2.

    


    The
      HMO
      must enforce access and other Network standards required by the Contract and
      take appropriate action with Providers whose performance is determined by the
      HMO to be out of compliance.

    


    
      	
              8.1.4

            	
              Provider
                Network

            


    

    


    The
      HMO
      must enter into written contracts with properly credentialed Providers as
      described in this Section. The Provider contracts must comply with the
Uniform Managed Care Manual’s requirements.

    


    The
      HMO
      must maintain a Provider Network sufficient to provide all Members with access
      to the full range of Covered Services required under the Contract. The HMO
      must
      ensure its Providers and subcontractors meet all current and future state and
      federal eligibility criteria, reporting requirements, and any other applicable
      rules and/or regulations related to the Contract.

    


    The
      Provider Network must be responsive to the linguistic, cultural, and other
      unique needs of any minority, elderly, or disabled individuals, or other special
      population in the Service Areas and HMO Programs served by the HMO, including
      the capacity to communicate with Members in languages other than English, when
      necessary, as well as with those who are deaf or hearing impaired.

    


    The
      HMO
      must seek to obtain the participation in its Provider Network of qualified
      providers currently serving the Medicaid and CHIP Members in the HMO’s proposed
      Service Area(s).

    


    NOTE:
      The following Provider descriptions do not require STAR+PLUS HMOs to contract
      with Hospital providers for Inpatient Stay services. STAR+PLUS HMOs are
      required, however, to contract with Hospitals for Outpatient Hospital
      Services.

    


    All
      Providers: All Providers must be licensed in the State of Texas to
      provide the Covered Services for which the HMO is contracting with the Provider,
      and not be under sanction or exclusion from the Medicaid program. All Acute
      Care
      Providers serving Medicaid Members must be enrolled as Medicaid providers and
      have a Texas Provider Identification Number (TPIN). Long-term Care Providers
      are
      not required to have a TPIN but must have a LTC Provider number. Providers
      must
      also have a National Provider Identifier (NPI) in accordance with the timelines
      established in 45 C.F.R. Part 162, Subpart D (for most Providers, the NPI must
      be in place by May 23, 2007.)

    


    Inpatient
      hospital and medical services: The HMO must ensure that Acute Care
      hospitals and specialty hospitals are available and accessible 24 hours per
      day,
      seven days per week, within the HMO’s Network to provide Covered Services to
      Members throughout the Service Area.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    Children’s
      Hospitals/hospitals with specialized pediatric services: The HMO must
      ensure Members access to hospitals designated as Children’s Hospitals by
      Medicare and hospitals with specialized pediatric services, such as teaching
      hospitals and hospitals with designated children’s wings, so that these services
      are available and accessible 24 hours per day, seven days per week, to provide
      Covered Services to Members throughout the Service Area. The HMO must make
      Out-of-Network reimbursement arrangements with a designated Children’s Hospital
      and/or hospital with specialized pediatric services in proximity to the Member’s
      residence, and such arrangements must be in writing, if the HMO does not include
      such hospitals in its Provider Network. Provider Directories, Member materials,
      and Marketing materials must clearly distinguish between hospitals designated
      as
      Children’s Hospitals and hospitals that have designated children’s
      units.

    


    Trauma:
      The HMO must ensure Members access to Texas Department of State Health
      Services (TDSHS) designated Level I and Level II trauma centers within the
      State
      or hospitals meeting the equivalent level of trauma care in the HMO’s Service
      Area, or in close proximity to such Service Area. The HMO must make
      Out-of-Network reimbursement arrangements with the DSHS-designated Level I
      and
      Level II trauma centers or hospitals meeting equivalent levels of trauma care,
      and such arrangements must be in writing, if the HMO does not include such
      a
      trauma center in its Provider Network.

    


    Transplant
      centers: The HMO must ensure Member access to HHSC-designated
      transplant centers or centers meeting equivalent levels of care. A list of
      HHSC-designated transplant centers can be found in the Procurement Library
      in
      Attachment H. The HMO must make Out-of-Network reimbursement arrangements with
      a
      designated transplant center or center meeting equivalent levels of care in
      proximity to the Member’s residence, and such arrangements must be in writing,
      if the HMO does not include such a center in its Provider Network.

    


    Hemophilia
      centers: The HMO must ensure Member access to hemophilia centers
      supported by the Centers for Disease Control (CDC). A list of these hemophilia
      centers can be found at http://www.cdc.gov/ncbddd/hbd/htc_list.htm. The HMO
      must
      make Out-of-Network reimbursement arrangements with a CDC-supported hemophilia
      center, and such arrangements must be in writing, if the HMO does not include
      such a center in its Provider Network.

    


    Physician
      services: The HMO must ensure that Primary Care Providers are available
      and accessible 24 hours per day, seven days per week, within the Provider
      Network. The HMO must contract with a sufficient number of participating
      physicians and specialists within each Service Area to comply with the access
      requirements throughout Section 8.1.3 and meet the needs of
      Members for all Covered Services.

    


    The
      HMO
      must ensure that an adequate number of participating physicians have admitting
      privileges at one or more participating Acute Care hospitals in the Provider
      Network to ensure that necessary admissions are made. In no case may there
      be
      less than one in-network PCP with admitting privileges available and accessible
      24 hours per day, seven days per week for each Acute Care hospital in the
      Provider Network.

    


    The
      HMO
      must ensure that an adequate number of participating specialty physicians have
      admitting privileges at one or more participating hospitals in the HMO’s
      Provider Network to

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    ensure
      necessary admissions are made. The HMO shall require that all physicians who
      admit to hospitals maintain hospital access for their patients through
      appropriate call coverage.

    


    Laboratory
      services: The HMO must ensure that in-network reference laboratory
      services must be of sufficient size and scope to meet the non-emergency and
      emergency needs of the enrolled population and the access requirements in
Section 8.1.3. Reference laboratory specimen procurement
      services must facilitate the provision of clinical diagnostic services for
      physicians, Providers and Members through the use of convenient reference
      satellite labs in each Service Area, strategically located specimen collection
      areas in each Service Area, and the use of a courier system under the management
      of the reference lab. For Medicaid Members, THSteps requires that laboratory
      specimens obtained as part of a THSteps medical checkup visit must be sent
      to
      the TDSHS Laboratory.

    


    Diagnostic
      imaging: The HMO must ensure that diagnostic imaging services are
      available and accessible to all Members in each Service Area in accordance
      with
      the access standards in Section 8.1.3. The HMO must ensure that
      diagnostic imaging procedures that require the injection or ingestion of
      radiopaque chemicals are performed only under the direction of physicians
      qualified to perform those procedures.

    


    Home
      health services: The HMO must have a contract(s) with a home health
      Provider so that all Members living within the HMO’s Service Area will have
      access to at least one such Provider for home health Covered Services. (These
      services are provided as part of the Acute Care Covered Services, not the
      Community Long-term Care Services.)

    


    Community
      Long-term Care services: STAR+PLUS HMOs must have contracts with
      Community Long-term Care service Providers, so that all Members living within
      the Contractor’s Service Area will have access to Medically Necessary and
      Functionally Necessary Covered Services.

    


    
      	
              8.1.4.1

            	
              Provider
                Contract Requirements

            


    

    


    The
      HMO
      is prohibited from requiring a provider or provider group to enter into an
      exclusive contracting arrangement with the HMO as a condition for participation
      in its Provider Network. 

     

    The
      HMO’s
      contract with health care Providers must be in writing, must be in compliance
      with applicable federal and state laws and regulations, and must include minimum
      requirements specified in the Uniform Managed Care Contract Terms and
      Conditions (Attachment A) and HHSC’s Uniform Managed Care
      Manual.

    


    The
      HMO
      must submit model Provider contracts to HHSC for review during Readiness Review.
      HHSC retains the right to reject or require changes to any model Provider
      contract that does not comply with HMO Program requirements or the HHSC-HMO
      Contract.

    


    
      	
              8.1.4.2

            	
              Primary
                Care Providers

            


    

    


    The
      HMO’s
      PCP Network may include Providers from any of the following practice areas:
      General Practice; Family Practice; Internal Medicine; Pediatrics;
      Obstetrics/Gynecology

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    (OB/GYN);
      Certified Nurse Midwives (CNM) and Physician Assistants (PAs) practicing under
      the supervision of a physician; Federally Qualified Health Centers (FQHCs),
      Rural Health Clinics (RHCs), and similar community clinics; and specialist
      physicians who are willing to provide a Medical Home to selected Members with
      special needs and conditions. Section 533.005(a)(13), Government Code, requires
      the HMO to use Pediatric and Family Advanced Practice Nurses practicing under
      the supervision of a physician as PCPs in its Provider Network for STAR and
      STAR+PLUS.

    


    CHIP
      Perinatal HMOs are not required to develop PCP Networks for CHIP Perinates.
      CHIP
      Perinatal HMOs may use the same PCP Network for CHIP Members and CHIP Perinatal
      Newborns.

    


    An
      internist or other Provider who provides primary care to adults only is not
      considered an age-appropriate PCP choice for a Member under age 21. An internist
      or other Provider who provides primary care to adults and children may be a
      PCP
      for children if:

    


    
      	
               

            	
              1.

            	
              the
                Provider assumes all HMO PCP responsibilities for such Members in
                a
                specific age group under age 21,

            


    

    
      	
               

            	
              2.

            	
              the
                Provider has a history of practicing as a PCP for the specified age
                group
                as evidenced by the Provider’s primary care practice including an
                established patient population under age 20 and within the specified
                age
                range, and

            


    

    
      	
               

            	
              3.

            	
              the
                Provider has admitting privileges to a local hospital that includes
                admissions to pediatric units.

            


    

    


    A
      pediatrician is not considered an age-appropriate choice for a Member age 21
      and
      over.

    


    The
      PCP
      for a Member with disabilities, Special Health Care Needs, or Chronic or Complex
      Conditions may be a specialist physician who agrees to provide PCP services
      to
      the Member. The specialty physician must agree to perform all PCP duties
      required in the Contract and PCP duties must be within the scope of the
      specialist’s license. Any interested person may initiate the request through the
      HMO for a specialist to serve as a PCP for a Member with disabilities, Special
      Health Care Needs, or Chronic or Complex Conditions. The HMO shall handle such
      requests in accordance with 28 T.A.C. Part 1, Chapter 11, Subchapter
      J.

    


    PCPs
      who
      provide Covered Services for STAR, CHIP, and CHIP Perinatal Newborns must either
      have admitting privileges at a Hospital that is part of the HMO’s Provider
      Network or make referral arrangements with a Provider who has admitting
      privileges to a Network Hospital. STAR+PLUS PCPs must either have admitting
      privileges at a Medicaid Hospital or make referral arrangements with a Provider
      who has admitting privileges to a Medicaid Hospital.

    


    The
      HMO
      must require, through contract provisions, that PCPs are accessible to Members
      24 hours a day, 7 days a week. The HMO is encouraged to include in its Network
      sites that offer primary care services during evening and weekend hours. The
      following are acceptable and unacceptable telephone arrangements for contacting
      PCPs after their normal business hours.

    


    Acceptable
      after-hours coverage:

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
               

            	
              1.

            	
              The
                office telephone is answered after-hours by an answering service,
                which
                meets language requirements of the Major Population Groups and which
                can
                contact the PCP or another designated medical practitioner. All calls
                answered by an answering service must be returned within 30
                minutes;

            


    

    
      	
               

            	
              2.

            	
              The
                office telephone is answered after normal business hours by a recording
                in
                the language of each of the Major Population Groups served, directing
                the
                patient to call another number to reach the PCP or another provider
                designated by the PCP. Someone must be available to answer the designated
                provider’s telephone. Another recording is not acceptable;
                and

            


    

    
      	
               

            	
              3.

            	
              The
                office telephone is transferred after office hours to another location
                where someone will answer the telephone and be able to contact the
                PCP or
                another designated medical practitioner, who can return the call
                within 30
                minutes.

            


    

    


    Unacceptable
      after-hours coverage:

    


    
      	
               

            	
              1.

            	
              The
                office telephone is only answered during office
                hours;

            


    

    
      	
               

            	
              2.

            	
              The
                office telephone is answered after-hours by a recording that tells
                patients to leave a message;

            


    

    
      	
               

            	
              3.

            	
              The
                office telephone is answered after-hours by a recording that directs
                patients to go to an Emergency Room for any services needed;
                and

            


    

    
      	
               

            	
              4.

            	
              Returning
                after-hours calls outside of 30
                minutes.

            


    

    


    The
      HMO
      must require PCPs, through contract provisions or Provider Manual, to provide
      children under the age of 21 with preventive services in accordance with the
      AAP
      recommendations for CHIP Members and CHIP Perinate Newborns, and the THSteps
      periodicity schedule published in the THSteps Manual for Medicaid Members.
      The
      HMO must require PCPs, through contract provisions or Provider Manual, to
      provide adults with preventive services in accordance with the U.S. Preventive
      Services Task Force requirements. The HMO must make best efforts to ensure
      that
      PCPs follow these periodicity requirements for children and adult Members.
      Best
      efforts must include, but not be limited to, Provider education, Provider
      profiling, monitoring, and feedback activities.

    


    The
      HMO
      must require PCPs, through contract provisions or Provider Manual, to assess
      the
      medical needs of Members for referral to specialty care providers and provide
      referrals as needed. PCPs must coordinate Members’ care with specialty care
      providers after referral. The HMO must make best efforts to ensure that PCPs
      assess Member needs for referrals and make such referrals. Best efforts must
      include, but not be limited to, Provider education activities and review of
      Provider referral patterns.

    


    
      	
              8.1.4.3

            	
              PCP
                Notification

            


    

    


    The
      HMO
      must furnish each PCP with a current list of enrolled Members enrolled or
      assigned to that Provider no later than five (5) working days after the HMO
      receives the Enrollment File from the HHSC Administrative Services Contractor
      each month. The HMO may offer and provide such enrollment information in
      alternative formats, such as through access to a secure Internet site, when
      such
      format is acceptable to the PCP.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.1.4.4

            	
              Provider
                Credentialing and
                Re-credentialing

            


    

    


    The
      HMO
      must review, approve and periodically recertify the credentials of all
      participating physician Providers and all other licensed Providers who
      participate in the HMO’s Provider Network. The HMO may subcontract with another
      entity to which it delegates such credentialing activities if such delegated
      credentialing is maintained in accordance with the National Committee for
      Quality Assurance (NCQA) delegated credentialing requirements and any comparable
      requirements defined by HHSC.

    


    At
      a
      minimum, the scope and structure of a HMO’s credentialing and re-credentialing
      processes must be consistent with recognized HMO industry standards such as
      those provided by NCQA and relevant state and federal regulations including
      28
      T.A.C. §11.1902, relating to credentialing of providers in HMOs, and as an
      additional requirement for Medicaid HMOs, 42 C.F.R. §438.214(b). The initial
      credentialing process, including application, verification of information,
      and a
      site visit (if applicable), must be completed before the effective date of
      the
      initial contract with the physician or Provider. The re-credentialing process
      must occur at least every three years.

    


    The
      re-credentialing process must take into consideration Provider performance
      data
      including, but not be limited to, Member Complaints and Appeals, quality of
      care, and utilization management.

    


    
      	
              8.1.4.5

            	
              Board
                Certification Status

            


    

    


    The
      HMO
      must maintain a policy with respect to Board Certification for PCPs and
      specialty physicians that encourage participation of board certified PCPs and
      specialty physicians in the Provider Network. The HMO must make information
      on
      the percentage of Board-certified PCPs in the Provider Network and the
      percentage of Board-certified specialty physicians, by specialty, available
      to
      HHSC upon request.

    


    
      	
              8.1.4.6

            	
              Provider
                Manual, Materials and
                Training

            


    

    


    The
      HMO
      must prepare and issue a Provider Manual(s), including any necessary specialty
      manuals (e.g., behavioral health) to all existing Network Providers. For newly
      contracted Providers, the HMO must issue copies of the Provider Manual(s) within
      five (5) working days from inclusion of the Provider into the Network. The
      Provider Manual must contain sections relating to special requirements of the
      HMO Program(s) and the enrolled populations in compliance with the requirements
      of this Contract.

    


    HHSC
      or
      its designee must approve the Provider Manual, and any substantive revisions
      to
      the Provider Manual, prior to publication and distribution to Providers. The
      Provider Manual must contain the critical elements defined in the
Uniform Managed Care Manual. HHSC’s initial review of the
      Provider Manual is part of the Operational Readiness Review described in
Attachment B-1, Section 7.

    


    The
      HMO
      must provide training to all Providers and their staff regarding the
      requirements of the Contract and special needs of Members. The HMO’s Medicaid,
      CHIP and/or CHIP Perinatal Program training must be completed within 30 days
      of
      placing a newly contracted Provider on active status. The HMO must provide
      on-going training to new and existing Providers as required

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    by
      the
      HMO or HHSC to comply with the Contract. The HMO must maintain and make
      available upon request enrollment or attendance rosters dated and signed by
      each
      attendee or other written evidence of training of each Provider and their
      staff.

    


    The
      HMO
      must establish ongoing Provider training that includes, but is not limited
      to,
      the following issues:

    


    
      	
               

            	
              1.

            	
              Covered
                Services and the Provider’s responsibilities for providing and/or
                coordinating such services. Special emphasis must be placed on areas
                that
                vary from commercial coverage rules (e.g., Early Intervention services,
                therapies and DME/Medical Supplies); and for Medicaid, making referrals
                and coordination with Non-capitated
                Services;

            


    

    
      	
               

            	
              2.

            	
              Relevant
                requirements of the Contract;

            


    

    
      	
               

            	
              3.

            	
              The
                HMO’s quality assurance and performance improvement program and the
                Provider’s role in such a program;
                and

            


    

    
      	
               

            	
              4.

            	
              The
                HMO’s policies and procedures, especially regarding in-network and Out-of-
                Network referrals.

            


    

    


    Provider
      Materials produced by the HMO, relating to Medicaid Managed Care, the CHIP
      Program, and/or the CHIP Perinatal Program must be in compliance with State
      and
      Federal laws and requirements of the HHSC Uniform Managed Care Contract
      Terms and Conditions. HMO must make available any provider materials to
      HHSC upon request.

    


    
      	
              8.1.4.7

            	
              Provider
                Hotline

            


    

    


    The
      HMO
      must operate a toll-free telephone line for Provider inquiries from 8 a.m.
      to 5
      p.m. local time for the Service Area, Monday through Friday, except for
      State-approved holidays. The Provider Hotline must be staffed with personnel
      who
      are knowledgeable about Covered Services and each applicable HMO Program, and
      for Medicaid, about Non-capitated Services.

    


    The
      HMO
      must ensure that after regular business hours the line is answered by an
      automated system with the capability to provide callers with operating hours
      information and instructions on how to verify enrollment for a Member with
      an
      Urgent Condition or an Emergency Medical Condition. The HMO must have a process
      in place to handle after-hours inquiries from Providers seeking to verify
      enrollment for a Member with an Urgent Condition or an Emergency Medical
      Condition, provided, however, that the HMO and its Providers must not require
      such verification prior to providing Emergency Services.

    


    The
      HMO
      must ensure that the Provider Hotline meets the following minimum performance
      requirements for all HMO Programs and Service Areas:

    


    
      	
               

            	
              1.

            	
              99%
                of calls are answered by the fourth ring or an automated call pick-up
                system is used;

            


    

    
      	
               

            	
              2.

            	
              no
                more than one percent of incoming calls receive a busy
                signal;

            


    

    
      	
               

            	
              3.

            	
              the
                average hold time is 2 minutes or less;
                and

            


    

    
      	
               

            	
              4.

            	
              the
                call abandonment rate is 7% or
                less.

            


    

    


    The
      HMO
      must conduct ongoing call quality assurance to ensure these standards are met.
      The Provider Hotline may serve multiple HMO Programs if Hotline staff is
      knowledgeable about all of the HMO’s Programs. The Provider Hotline may serve
      multiple Service Areas if the Hotline

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    staff
      is
      knowledgeable about all such Service Areas, including the Provider Network
      in
      such Service Areas.

    


    The
      HMO
      must monitor its performance regarding Provider Hotline standards and submit
      performance reports summarizing call center performance for the Hotline as
      indicated in Section 8.1.20. If the HMO subcontracts with a
      Behavioral Health Organization (BHO) that is responsible for Provider Hotline
      functions related to Behavioral Health Services, the BHO’s Provider Hotline must
      meet the requirements in Section 8.1.4.7.

    


    
      	
              8.1.4.8

            	
              Provider
                Reimbursement

            


    

    


    The
      HMO
      must make payment for all Medically Necessary Covered Services provided to
      all
      Members for whom the HMO is paid a capitation. A STAR+PLUS HMO must also make
      payment for all Functionally Necessary Covered Services provided to all Members
      for whom the HMO is paid a capitation. The HMO must ensure that claims payment
      is timely and accurate as described in Section 8.1.18.5. The
      HMO must require tax identification numbers from all participating Providers.
      The HMO is required to do back-up withholding from all payments to Providers
      who
      fail to give tax identification numbers or who give incorrect
      numbers.

    


    
      	
              8.1.4.9

            	
              Termination
                of Provider Contracts

            


    

    


    Unless
      prohibited or limited by applicable law, at least 15 days prior to the effective
      date of the HMO’s termination of contract of any participating Provider the HMO
      must notify the HHSC Administrative Services Contractor and notify affected
      current Members in writing. Affected Members include all Members in a PCP’s
      panel and all Members who have been receiving ongoing care from the terminated
      Provider, where ongoing care is defined as two or more visits for home-based
      or
      office-based care in the past 12 months.

    


    For
      the
      CHIP and CHIP Perinatal Programs, the HMO’s process for terminating Provider
      contracts must comply with the Texas Insurance Code and TDI
      regulations.

    


    
      	
              8.1.5

            	
              Member
                Services

            


    

    


    The
      HMO
      must maintain a Member Services Department to assist Members and Members’ family
      members or guardians in obtaining Covered Services for Members. The HMO must
      maintain employment standards and requirements (e.g., education, training,
      and
      experience) for Member Services Department staff and provide a sufficient number
      of staff for the Member Services Department to meet the requirements of this
      Section, including Member Hotline response times, and Linguistic Access
      capabilities, see 8.1.5.6 Member Hotline Requirements.

    


    
      	
              8.1.5.1

            	
              Member
                Materials

            


    

    


    The
      HMO
      must design, print and distribute Member identification (ID) cards and a Member
      Handbook to Members. Within five business days following the receipt of an
      Enrollment File from the HHSC Administrative Services Contractor, the HMO must
      mail a Member’s ID card and Member Handbook to the Case Head or Account Name for
      each new Member. When the Case Head or Account Name is on behalf of two or
      more
      new Members, the HMO is only

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    required
      to send one Member Handbook. The HMO is responsible for mailing materials only
      to those Members for whom valid address data are contained in the Enrollment
      File.

    


    The
      HMO
      must design, print and distribute a Provider Directory to the HHSC
      Administrative Services Contractor as described in Section
      8.1.5.4.

    


    Member
      materials must be at or below a 6th grade reading level as measured by the
      appropriate score on the Flesch reading ease test. Member materials must be
      available in English, Spanish, and the languages of other Major Population
      Groups making up 10% or more of the managed care eligible population in the
      HMO’s Service Area, as specified by HHSC. HHSC will provide the HMO with
      reasonable notice when the enrolled population reaches 10% within the HMO’s
      Service Area. All Member materials must be available in a format accessible
      to
      the visually impaired, which may include large print, Braille, and
      audiotapes.

    


    The
      HMO
      must submit member materials to HHSC for approval prior to use or mailing.
      HHSC
      will identify any required changes to the Member materials within 15 business
      days. If HHSC has not responded to the Contractor by the fifteenth day, the
      Contractor may proceed to use the submitted materials. HHSC reserves the right
      to require discontinuation of any Member materials that violate the terms of
      the
Uniform Managed Care Terms and Conditions, including but not
      limited to “Marketing Policies and Procedures” as described in the
Uniform Managed Care Manual.

    


    
      	
              8.1.5.2

            	
              Member
                Identification (ID) Card

            


    

    


    All
      Member ID cards must, at a minimum, include the following
      information:

    


    
      	
               

            	
              1.

            	
              the
                Member’s name;

            


    

    
      	
               

            	
              2.

            	
              the
                Member’s Medicaid, CHIP or CHIP Perinatal Program
                number;

            


    

    
      	
               

            	
              3.

            	
              the
                effective date of the PCP assignment (excluding CHIP
                Perinates);

            


    

    
      	
               

            	
              4.

            	
              the
                PCP’s name, address (optional for all products), and telephone number
                (excluding CHIP Perinates);

            


    

    
      	
               

            	
              5.

            	
              the
                name of the HMO;

            


    

    
      	
               

            	
              6.

            	
              the
                24-hour, seven (7) day a week toll-free Member services telephone
                number
                and BH Hotline number operated by the HMO;
                and

            


    

    
      	
               

            	
              7.

            	
              any
                other critical elements identified in the Uniform Managed Care
                Manual.

            


    

    


    The
      HMO
      must reissue the Member ID card if a Member reports a lost card, there is a
      Member name change, if the Member requests a new PCP, or for any other reason
      that results in a change to the information disclosed on the ID card. CHIP
      Perinatal HMOs must issue Member ID cards to both CHIP Perinates and CHIP
      Perinate Newborns.

    


    
      	
              8.1.5.3

            	
              Member
                Handbook

            


    

    


    HHSC
      must
      approve the Member Handbook, and any substantive revisions, prior to publication
      and distribution. As described in Attachment B-1, Section 7,
      the HMO must develop and submit to HHSC the draft Member Handbook for approval
      during the Readiness Review and must submit a final Member Handbook
      incorporating changes required by HHSC prior to the Operational Start
      Date.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      Member Handbook for each applicable HMO Program must, at a minimum, meet the
      Member materials requirements specified by Section 8.1.5.1
above and must include critical elements in the Uniform Managed
      Care Manual. CHIP Perinatal HMOs must issue Member Handbooks to both
      CHIP Perinates and CHIP Perinate Newborns. The Member Handbook for CHIP Perinate
      Newborns may be the same as that used for CHIP.

    


    The
      HMO
      must produce a revised Member Handbook, or an insert informing Members of
      changes to Covered Services upon HHSC notification and at least 30 days prior
      to
      the effective date of such change in Covered Services. In addition to modifying
      the Member materials for new Members, the HMO must notify all existing Members
      of the Covered Services change during the time frame specified in this
      subsection.

    


    
      	
              8.1.5.4

            	
              Provider
                Directory

            


    

    


    The
      Provider Directory for each applicable HMO Program, and any substantive
      revisions, must be approved by HHSC prior to publication and distribution.
      The
      HMO is responsible for submitting draft Provider directory updates to HHSC
      for
      prior review and approval if changes other than PCP information or clerical
      corrections are incorporated into the Provider Directory.

    


    As
      described in Attachment B-1, Section 7, during the Readiness
      Review, the HMO must develop and submit to HHSC the draft Provider Directory
      template for approval and must submit a final Provider Directory incorporating
      changes required by HHSC prior to the Operational Start Date. Such draft and
      final Provider Directories must be submitted according to the deadlines
      established in Attachment B-1, Section 7.

    


    The
      Provider Directory for each applicable HMO Program must, at a minimum, meet
      the
      Member Materials requirements specified by Section 8.1.5.1
above and must include critical elements in the Uniform Managed
      Care Manual. The Provider Directory must include only Network Providers
      credentialed by the HMO in accordance with Section 8.1.4.4. If
      the HMO contracts with limited Provider Networks, the Provider Directory must
      comply with the requirements of 28 T.A.C. §11.1600(b)(11), relating to the
      disclosure and notice of limited Provider Networks.

    


    CHIP
      Perinatal HMOs must develop Provider Directories for both CHIP Perinates and
      CHIP Perinate Newborns. The Provider Directory for CHIP Perinate Newborns may
      be
      the same as that used for the CHIP Program.

    


    The
      HMO
      must update the Provider Directory on a quarterly basis. The HMO must make
      such
      update available to existing Members on request, and must provide such update
      to
      the HHSC Administrative Services Contractor at the beginning of each state
      fiscal quarter. HHSC will consult with the HMOs and the HHSC Administrative
      Services Contractors to discuss methods for reducing the HMO’s administrative
      costs of producing new Provider Directories, including considering submission
      of
      new Provider Directories on a semi-annual rather than a quarterly basis if
      a HMO
      has not made major changes in its Provider Network, as determined by HHSC.
      HHSC
      will establish weight limits for the Provider Directories. Weight limits may
      vary by Service Area. HHSC will require HMOs that exceed the weight limits
      to
      compensate HHSC for postage fees in excess of the weight limits.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      must send the most recent Provider Directory, including any updates, to
      Members

    upon
      request. The HMO must, at least annually, include written and verbal offers
      of
      such

    Provider
      Directory in its Member outreach and education materials.

    


    
      	
              8.1.5.5

            	
              Internet
                Website

            


    

    


    The
      HMO
      must develop and maintain, consistent with HHSC standards and Section 843.2015
      of

    the
      Texas
      Insurance Code and other applicable state laws, a website to provide
      general

    information
      about the HMO’s Program(s), its Provider Network, its customer services, and
      its

    Complaints
      and Appeals process. The HMO may develop a page within its existing website
      to

    meet
      the
      requirements of this section. The HMO must maintain a Provider Directory for
      its
      HMO

    Program(s)
      on the HMO’s website with designation of open versus closed panels. All
      HMOs

    must
      list
      Home Health Ancillary providers on their websites, with an indicator for
      Pediatric

    services
      if provided. The HMO’s website must comply with the Marketing Policies
      and

    Procedures
      for each applicable HHSC HMO Program.

    


    The
      website’s HMO Program content must be:

    


    
      	
               

            	
              1.

            	
              Written
                in Major Population Group languages (which under this contract include
                only English and Spanish);

            


    

    
      	
               

            	
              2.

            	
              Culturally
                appropriate;

            


    

    
      	
               

            	
              3.

            	
              Written
                for understanding at the 6th grade reading level;
                and

            


    

    
      	
               

            	
              4.

            	
              Be
                geared to the health needs of the enrolled HMO Program
                population.

            


    

    


    To
      minimize download and “wait times,” the website must avoid tools or techniques
      that require

    significant
      memory or disk resources or require special intervention on the customer side
      to

    install
      plug-ins or additional software. Use of proprietary items that would require
      a
      specific

    browser
      are not allowed. HHSC strongly encourages the use of tools that take advantage
      of

    efficient
      data access methods and reduce the load on the server or bandwidth.

    


    
      	
              8.1.5.6

            	
              Member
                Hotline

            


    

    


    The
      HMO
      must operate a toll-free hotline that Members can call 24 hours a day, seven
      (7)
      days a

    week.
      The
      Member Hotline must be staffed with personnel who are knowledgeable about
      its

    HMO
      Program(s) and Covered Services, between the hours of 8:00 a.m. to 5:00 p.m.
      local time

    for
      the
      Service Area, Monday through Friday, excluding state-approved
      holidays.

    


    The
      HMO
      must ensure that after hours, on weekends, and on holidays the Member
      Services

    Hotline
      is answered by an automated system with the capability to provide callers with
      operating

    hours
      and
      instructions on what to do in cases of emergency. All recordings must be in
      English

    and
      in
      Spanish. A voice mailbox must be available after hours for callers to leave
      messages. The

    HMO’s
      Member Services representatives must return member calls received by the
      automated

    system
      on
      the next working day.

    


    If
      the
      Member Hotline does not have a voice-activated menu system, the HMO must have
      a
      menu

    system
      that will accommodate Members who cannot access the system through other
      physical

    means,
      such as pushing a button.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      must ensure that its Member Service representatives treat all callers with
      dignity and respect the callers’ need for privacy. At a minimum, the HMO’s
      Member Service representatives must be:

    


    
      	
               

            	
              1.

            	
              Knowledgeable
                about Covered Services;

            


    

    
      	
               

            	
              2.

            	
              Able
                to answer non-technical questions pertaining to the role of the PCP,
                as
                applicable;

            


    

    
      	
               

            	
              3.

            	
              Able
                to answer non-clinical questions pertaining to referrals or the process
                for receiving authorization for procedures or
                services;

            


    

    
      	
               

            	
              4.

            	
              Able
                to give information about Providers in a particular
                area;

            


    

    
      	
               

            	
              5.

            	
              Knowledgeable
                about Fraud, Abuse, and Waste and the requirements to report any
                conduct
                that, if substantiated, may constitute Fraud, Abuse, or Waste in
                the HMO
                Program;

            


    

    
      	
               

            	
              6.

            	
              Trained
                regarding Cultural Competency;

            


    

    
      	
               

            	
              7.

            	
              Trained
                regarding the process used to confirm the status of persons with
                Special
                Health Care Needs;

            


    

    
      	
               

            	
              8.

            	
              For
                Medicaid members, able to answer non-clinical questions pertaining
                to
                accessing Non-capitated Services;
                and

            


    

    
      	
               

            	
              9.

            	
              For
                CHIP Members, able to give correct cost-sharing information relating
                to
                premiums, co-pays or deductibles, as applicable. (Cost-sharing does
                not
                apply to CHIP Perinates or CHIP Perinate
                Newborns.)

            


    

    


    Hotline
      services must meet Cultural Competency requirements and must appropriately
      handle calls from non-English speaking (and particularly, Spanish-speaking)
      callers, as well as calls from individuals who are deaf or hard-of-hearing.
      To
      meet these requirements, the HMO must employ bilingual Spanish-speaking Member
      Services representatives and must secure the services of other contractors
      as
      necessary to meet these requirements.

    


    The
      HMO
      must process all incoming Member correspondence and telephone inquiries in a
      timely and responsive manner. The HMO cannot impose maximum call duration limits
      but must allow calls to be of sufficient length to ensure adequate information
      is provided to the Member. The HMO must ensure that the toll-free Member Hotline
      meets the following minimum performance requirements for all HMO Programs and
      Service Areas:

    


    
      	
               

            	
              1.

            	
              99%
                of calls are answered by the fourth ring or an automated call pick-up
                system;

            


    

    
      	
               

            	
              2.

            	
              no
                more than one percent (1%) of incoming calls receive a busy
                signal;

            


    

    
      	
               

            	
              3.

            	
              at
                least 80% of calls must be answered by toll-free line staff within
                30
                seconds measured from the time the call is placed in queue after
                selecting
                an option; and

            


    

    
      	
               

            	
              4.

            	
              the
                call abandonment rate is 7% or
                less.

            


    

    


    The
      HMO
      must conduct ongoing quality assurance to ensure these standards are
      met.

    


    The
      Member Services Hotline may serve multiple HMO Programs if Hotline staff is
      knowledgeable about all of the HMO’s Medicaid and/or CHIP Programs. The Member
      Services Hotline may serve multiple Service Areas if the Hotline staff is
      knowledgeable about all such Service Areas, including the Provider Network
      in
      each Service Area.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      must monitor its performance regarding HHSC Member Hotline standards and submit
      performance reports summarizing call center performance for the Member Hotline
      as indicated in Section 8.1.20 and the Uniform Managed
      Care Manual.

    


    
      	
              8.1.5.7

            	
              Member
                Education

            


    

    


    The
      HMO
      must, at a minimum, develop and implement health education initiatives that
      educate Members about:

    


    
      	
               

            	
              1.

            	
              How
                the HMO system operates, including the role of the
                PCP;

            


    

    
      	
               

            	
              2.

            	
              Covered
                Services, limitations and any Value-added Services offered by the
                HMO;

            


    

    
      	
               

            	
              3.

            	
              The
                value of screening and preventive care,
                and

            


    

    
      	
               

            	
              4.

            	
              How
                to obtain Covered Services,
                including:

            


    

    
      	
               

            	
              a.

            	
              Emergency
                Services;

            


    

    
      	
               

            	
              b.

            	
              Accessing
                OB/GYN and specialty care;

            


    

    
      	
               

            	
              c.

            	
              Behavioral
                Health Services;

            


    

    
      	
               

            	
              d.

            	
              Disease
                Management programs;

            


    

    
      	
               

            	
              e.

            	
              Service
                Coordination, treatment for pregnant women, Members with Special
                Health
                Care Needs, including Children with Special Health Care Needs; and
                other
                special populations;

            


    

    
      	
               

            	
              f.

            	
              Early
                Childhood Intervention (ECI)
                Services;

            


    

    
      	
               

            	
              g.

            	
              Screening
                and preventive services, including well-child care (THSteps medical
                checkups for Medicaid Members);

            


    

    
      	
               

            	
              h.

            	
              For
                CHIP Members, Member co-payments

            


    

    
      	
               

            	
              i.

            	
              Suicide
                prevention; and

            


    

    
      	
               

            	
              j.

            	
              Identification
                and health education related to
                Obesity.

            


    

    


    The
      HMO
      must provide a range of health promotion and wellness information and activities
      for Members in formats that meet the needs of all Members. The HMO must propose,
      implement, and assess innovative Member education strategies for wellness care
      and immunization, as well as general health promotion and prevention. The HMO
      must conduct wellness promotion programs to improve the health status of its
      Members. The HMO may cooperatively conduct health education classes for all
      enrolled Members with one or more HMOs also contracting with HHSC in the Service
      Area. The HMO must work with its Providers to integrate health education,
      wellness and prevention training into the care of each Member.

    


    The
      HMO
      also must provide condition and disease-specific information and educational
      materials to Members, including information on its Service Management and
      Disease Management programs described in Section 8.1.13 and Section 8.1.
Condition- and disease-specific information must be oriented
      to various
      groups within the managed care eligible population, such as children, the
      elderly, persons with disabilities and non-English speaking Members, as
      appropriate to the HMO’s Medicaid, CHIP and/or CHIP Perinatal
      Program(s).

    


    
      	
              8.1.5.8

            	
              Cultural
                Competency Plan

            


    

    


    The
      HMO
      must have a comprehensive written Cultural Competency Plan describing how the
      HMO will ensure culturally competent services, and provide Linguistic Access
      and
      Disability-related Access. The Cultural Competency Plan must describe how the
      individuals and systems

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    within
      the HMO will effectively provide services to people of all cultures, races,
      ethnic backgrounds, and religions as well as those with disabilities in a manner
      that recognizes, values, affirms, and respects the worth of the individuals
      and
      protects and preserves the dignity of each. The HMO must submit the Cultural
      Competency Plan to HHSC for Readiness Review. Modifications and amendments
      to
      the plan must be submitted to HHSC no later than 30 days prior to
      implementation. The Plan must also be made available to the HMO’s Network of
      Providers.

    


    
      	
              8.1.5.9

            	
              Member
                Complaint and Appeal
                Process

            


    

    


    The
      HMO
      must develop, implement and maintain a system for tracking, resolving, and
      reporting Member Complaints regarding its services, processes, procedures,
      and
      staff. The HMO must ensure that Member Complaints are resolved within 30
      calendar days after receipt. The HMO is subject to remedies, including
      liquidated damages, if at least 98 percent of Member Complaints are not resolved
      within 30 days of receipt of the Complaint by the HMO. Please see the
Uniform Managed Care Contract Terms & Conditions and
Attachment B-5, Deliverables/Liquidated Damages
      Matrix.

    


    The
      HMO
      must develop, implement and maintain a system for tracking, resolving, and
      reporting Member Appeals regarding the denial or limited authorization of a
      requested service, including the type or level of service and the denial, in
      whole or in part, of payment for service. Within this process, the HMO must
      respond fully and completely to each Appeal and establish a tracking mechanism
      to document the status and final disposition of each Appeal.

    


    The
      HMO
      must ensure that Member Appeals are resolved within 30 calendar days, unless
      the
      HMO can document that the Member requested an extension or the HMO shows there
      is a need for additional information and the delay is in the Member's interest.
      The HMO is subject to liquidated damages if at least 98 percent of Member
      Appeals are not resolved within 30 days of receipt of the Appeal by the HMO.
      Please see the Uniform Managed Care Contract Terms & Conditions
and Attachment B-5, Deliverables/Liquidated Damages
      Matrix.

    


    Medicaid
      HMOs must follow the Member Complaint and Appeal Process described in
Section 8.2.6. CHIP and CHIP Perinatal HMOs must comply with
      the CHIP Complaint and Appeal Process described in Sections 8.4.2
and 8.5.2, respectively.

    


    
      	
              8.1.6

            	
              Marketing
                and Prohibited Practices

            


    

    


    The
      HMO
      and its Subcontractors must adhere to the Marketing Policies and Procedures
      as
      set forth by HHSC in the Contract, and the HHSC Uniform Managed Care
      Manual.

    


    
      	
              8.1.7

            	
              Quality
                Assessment and Performance
                Improvement

            


    

    


    The
      HMO
      must provide for the delivery of quality care with the primary goal of improving
      the health status of Members and, where the Member’s condition is not amenable
      to improvement, maintain the Member’s current health status by implementing
      measures to prevent any further decline in condition or deterioration of health
      status. The HMO must work in collaboration with Providers to actively improve
      the quality of care provided to Members, consistent with the

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    Quality
      Improvement Goals and all other requirements of the Contract. The HMO must
      provide mechanisms for Members and Providers to offer input into the HMO’s
      quality improvement activities.

    


    
      	
              8.1.7.1

            	
              QAPI
                Program Overview

            


    

    


    The
      HMO
      must develop, maintain, and operate a quality assessment and performance
      improvement (QAPI) Program consistent with the Contract, and TDI requirements,
      including 28 T.A.C. §11.1901(a)(5) and §11.1902. Medicaid HMOs must also meet
      the requirements of 42 C.F.R. §438.240.

    


    The
      HMO
      must have on file with HHSC an approved plan describing its QAPI Program,
      including how the HMO will accomplish the activities required by this section.
      The HMO must submit a QAPI Program Annual Summary in a format and timeframe
      specified by HHSC or its designee. The HMO must keep participating physicians
      and other Network Providers informed about the QAPI Program and related
      activities. The HMO must include in Provider contracts a requirement securing
      cooperation with the QAPI.

    


    The
      HMO
      must approach all clinical and non-clinical aspects of quality assessment and
      performance improvement based on principles of Continuous Quality Improvement
      (CQI)/Total Quality Management (TQM) and must:

    


    
      	
               

            	
              1.

            	
              Evaluate
                performance using objective quality
                indicators;

            


    

    
      	
               

            	
              2.

            	
              Foster
                data-driven decision-making;

            


    

    
      	
               

            	
              3.

            	
              Recognize
                that opportunities for improvement are
                unlimited;

            


    

    
      	
               

            	
              4.

            	
              Solicit
                Member and Provider input on performance and QAPI
                activities;

            


    

    
      	
               

            	
              5.

            	
              Support
                continuous ongoing measurement of clinical and non-clinical effectiveness
                and Member satisfaction;

            


    

    
      	
               

            	
              6.

            	
              Support
                programmatic improvements of clinical and non-clinical processes
                based on
                findings from on-going measurements;
                and

            


    

    
      	
               

            	
              7.

            	
              Support
                re-measurement of effectiveness and Member satisfaction, and continued
                development and implementation of improvement interventions as
                appropriate.

            


    

    


    
      	
              8.1.7.2

            	
              QAPI
                Program Structure

            


    

    


    The
      HMO
      must maintain a well-defined QAPI structure that includes a planned systematic
      approach to improving clinical and non-clinical processes and outcomes. The
      HMO
      must designate a senior executive responsible for the QAPI Program and the
      Medical Director must have substantial involvement in QAPI Program activities.
      At a minimum, the HMO must ensure that the QAPI Program structure:

    


    
      	
               

            	
              1.

            	
              Is
                organization-wide, with clear lines of accountability within the
                organization;

            


    

    
      	
               

            	
              2.

            	
              Includes
                a set of functions, roles, and responsibilities for the oversight
                of QAPI
                activities that are clearly defined and assigned to appropriate
                individuals, including physicians, other clinicians, and
                non-clinicians;

            


    

    
      	
               

            	
              3.

            	
              Includes
                annual objectives and/or goals for planned projects or activities
                including clinical and non-clinical programs or initiatives and
                measurement activities; and

            


    

    
      	
               

            	
              4.

            	
              Evaluates
                the effectiveness of clinical and non-clinical
                initiatives.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.1.7.3

            	
              Clinical
                Indicators

            


    

    


    The
      HMO
      must engage in the collection of clinical indicator data. The HMO must use
      such
      clinical indicator data in the development, assessment, and modification of
      its
      QAPI Program.

    


    
      	
              8.1.7.4

            	
              QAPI
                Program Subcontracting

            


    

    


    If
      the
      HMO subcontracts any of the essential functions or reporting requirements
      contained within the QAPI Program to another entity, the HMO must maintain
      a
      file of the subcontractors. The file must be available for review by HHSC or
      its
      designee upon request.

    


    
      	
              8.1.7.5

            	
              Behavioral
                Health Integration into QAPI
                Program

            


    

    


    If
      the
      HMO provides Behavioral Health Services within the Covered Services as defined
      in Attachments B-2, B-2.1, and B-2.2, it must integrate
      behavioral health into its QAPI Program and include a systematic and on-going
      process for monitoring, evaluating, and improving the quality and
      appropriateness of Behavioral Health Services provided to Members. The HMO
      must
      collect data, and monitor and evaluate for improvements to physical health
      outcomes resulting from behavioral health integration into the Member’s overall
      care.

    


    
      	
              8.1.7.6

            	
              Clinical
                Practice Guidelines

            


    

    


    The
      HMO
      must adopt not less than two evidence-based clinical practice guidelines for
      each applicable HMO Program. Such practice guidelines must be based on valid
      and
      reliable clinical evidence, consider the needs of the HMO’s Members, be adopted
      in consultation with contracting health care professionals, and be reviewed
      and
      updated periodically, as appropriate. The HMO must develop practice guidelines
      based on the health needs and opportunities for improvement identified as part
      of the QAPI Program.

    


    The
      HMO
      may coordinate the development of clinical practice guidelines with other HHSC
      HMOs to avoid providers in a Service Area receiving conflicting practice
      guidelines from different HMOs.

    


    The
      HMO
      must disseminate the practice guidelines to all affected Providers and, upon
      request, to Members and potential Members.

    


    The
      HMO
      must take steps to encourage adoption of the guidelines, and to measure
      compliance with the guidelines, until such point that 90% or more of the
      Providers are consistently in compliance, based on HMO measurement findings.
      The
      HMO must employ substantive Provider motivational incentive strategies, such
      as
      financial and non-financial incentives, to improve Provider compliance with
      clinical practice guidelines. The HMO’s decisions regarding utilization
      management, Member education, coverage of services, and other areas included
      in
      the practice guidelines must be consistent with the HMO’s clinical practice
      guidelines.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.1.7.7

            	
              Provider
                Profiling

            


    

    


    The
      HMO
      must conduct PCP and other Provider profiling activities at least annually.
      As
      part of its QAPI Program, the HMO must describe the methodology it uses to
      identify which and how many Providers to profile and to identify measures to
      use
      for profiling such Providers.

    


    Provider
      profiling activities must include, but not be limited to:

    


    
      	
               

            	
              1.

            	
              Developing
                PCP and Provider-specific reports that include a multi-dimensional
                assessment of a PCP or Provider’s performance using clinical,
                administrative, and Member satisfaction indicators of care that are
                accurate, measurable, and relevant to the enrolled
                population;

            


    

    
      	
               

            	
              2.

            	
              Establishing
                PCP, Provider, group, Service Area or regional Benchmarks for areas
                profiled, where applicable, including STAR, STAR+PLUS, CHIP and CHIP
                Perinatal Program-specific Benchmarks, where appropriate;
                and

            


    

    
      	
               

            	
              3.

            	
              Providing
                feedback to individual PCPs and Providers regarding the results of
                their
                performance and the overall performance of the Provider
                Network.

            


    

    


    
      	
              8.1.7.8

            	
              Network
                Management

            


    

    


    The
      HMO
      must:

    


    
      	
               

            	
              1.

            	
              Use
                the results of its Provider profiling activities to identify areas
                of
                improvement for individual PCPs and Providers, and/or groups of
                Providers;

            


    

    
      	
               

            	
              2.

            	
              Establish
                Provider-specific quality improvement goals for priority areas in
                which a
                Provider or Providers do not meet established HMO standards or improvement
                goals;

            


    

    
      	
               

            	
              3.

            	
              Develop
                and implement incentives, which may include financial and non-financial
                incentives, to motivate Providers to improve performance on profiled
                measures; and

            


    

    
      	
               

            	
              4.

            	
              At
                least annually, measure and report to HHSC on the Provider Network
                and
                individual Providers’ progress, or lack of progress, towards such
                improvement goals.

            


    

    


    
      	
              8.1.7.9

            	
              Collaboration
                with the EQRO

            


    

    


    The
      HMO
      will collaborate with HHSC’s external quality review organization (EQRO) to
      develop studies, surveys, or other analytical approaches that will be carried
      out by the EQRO. The purpose of the studies, surveys, or other analytical
      approaches is to assess the quality of care and service provided to Members
      and
      to identify opportunities for HMO improvement. To facilitate this process,
      the
      HMO will supply claims data to the EQRO in a format identified by HHSC in
      consultation with HMOs, and will supply medical records for focused clinical
      reviews conducted by the EQRO. The HMO must also work collaboratively with
      HHSC
      and the EQRO to annually measure selected HEDIS measures that require chart
      reviews. During the first year of operations, HHSC anticipates that the selected
      measures will include, at a minimum, well-child visits and immunizations,
      appropriate use of asthma medications, measures related to Members with
      diabetes, and control of high blood pressure.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.1.8

            	
              Utilization
                Management

            


    

    


    The
      HMO
      must have a written utilization management (UM) program description, which
      includes, at a minimum:

    


    
      	
               

            	
              1.

            	
              Procedures
                to evaluate the need for Medically Necessary Covered
                Services;

            


    

    
      	
               

            	
              2.

            	
              The
                clinical review criteria used, the information sources, the process
                used
                to review and approve the provision of Covered
                Services;

            


    

    
      	
               

            	
              3.

            	
              The
                method for periodically reviewing and amending the UM clinical review
                criteria; and

            


    

    
      	
               

            	
              4.

            	
              The
                staff position functionally responsible for the day-to-day management
                of
                the UM function.

            


    

    


    The
      HMO
      must make best efforts to obtain all necessary information, including pertinent
      clinical information, and consult with the treating physician as appropriate
      in
      making UM determinations.

    


    The
      HMO
      must issue coverage determinations, including adverse determinations, according
      to the following timelines:

    


    
      	
               

            	
              •

            	
              Within
                three (3) business days after receipt of the request for authorization
                of
                services;

            


    

    
      	
               

            	
              •

            	
              Within
                one (1) business day for concurrent hospitalization decisions;
                and

            


    

    
      	
               

            	
              •

            	
              Within
                one (1) hour for post-stabilization or life-threatening conditions,
                except
                that for Emergency Medical Conditions and Emergency Behavioral Health
                Conditions, the HMO must not require prior
                authorization.

            


    

    


    The
      HMO’s
      UM Program must include written policies and procedures to ensure:

    


    
      	
               

            	
              1.

            	
              Consistent
                application of review criteria that are compatible with Members’ needs and
                situations;

            


    

    
      	
               

            	
              2.

            	
              Determinations
                to deny or limit services are made by physicians under the direction
                of
                the Medical Director;

            


    

    
      	
               

            	
              3.

            	
              Appropriate
                personnel are available to respond to utilization review inquiries
                8:00
                a.m. to 5:00 p.m., Monday through Friday, with a telephone system
                capable
                of accepting utilization review inquiries after normal business hours.
                The
                HMO must respond to calls within one business
                day;

            


    

    
      	
               

            	
              4.

            	
              Confidentiality
                of clinical information; and

            


    

    
      	
               

            	
              5.

            	
              Quality
                is not adversely impacted by financial and reimbursement-related
                processes
                and decisions.

            


    

    


    For
      HMOs
      with preauthorization or concurrent review programs, qualified medical
      professionals must supervise preauthorization and concurrent review
      decisions.

    


    The
      HMO
      UM Program must include polices and procedures to:

    


    
      	
               

            	
              1.

            	
              Routinely
                assess the effectiveness and the efficiency of the UM
                Program;

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
               

            	
              2.

            	
              Evaluate
                the appropriate use of medical technologies, including medical
                procedures, drugs and devices;

            


    

    
      	
               

            	
              3.

            	
              target
                areas of suspected inappropriate service
                utilization;

            


    

    
      	
               

            	
              4.

            	
              Detect
                over- and under-utilization;

            


    

    
      	
               

            	
              5.

            	
              Routinely
                generate Provider profiles regarding utilization patterns and compliance
                with utilization review criteria and
                policies;

            


    

    
      	
               

            	
              6.

            	
              Compare
                Member and Provider utilization with norms for comparable
                individuals;

            


    

    
      	
               

            	
              7.

            	
              Routinely
                monitor inpatient admissions, emergency room use, ancillary, and
                out-of-area services;

            


    

    
      	
               

            	
              8.

            	
              Ensure
                that when Members are receiving Behavioral Health Services from the
                local mental health authority that the HMO is using the same UM
                guidelines as those prescribed for use by Local Mental Health
                Authorities by MHMR which are published
                at: http://www.mhmr.state.tx.us/centraloffice/behavioralhealthservices/RDMClinGuide.html ;
                and

            


    

    
      	
               

            	
              9.

            	
              Refer
                suspected cases of provider or Member Fraud, Abuse, or Waste to the
                Office
                of Inspector General (OIG) as required by Section
                8.1.19.

            


    

    


    
      	
              8.1.9

            	
              Early
                Childhood Intervention
                (ECI)

            


    

    


    The
      HMO
      must ensure that Network Providers are educated regarding their responsibility
      under federal laws (e.g., 20 U.S.C. §1435 (a)(5); 34 C.F.R. §303.321(d)) to
      identify and refer any Member age three (3) or under suspected of having a
      developmental disability or delay, or who is at risk of delay, to the
      designated ECI program for screening and assessment within two (2) working
      days from the day the Provider identifies the Member. The HMO must use
      written educational materials developed or approved by the Department of
      Assistive and Rehabilitative Services – Division for Early Childhood
      Intervention Services for these “child find” activities. Eligibility for
      ECI services will be determined by the local ECI program using the
      criteria contained in 40 T.A.C. §108.25.

    


    The
      HMO
      must contract with qualified ECI Providers to provide ECI services to Members
      under age three who have been determined eligible for ECI services. The HMO
      must permit Members to self refer to local ECI Service Providers without
      requiring a referral from the Member’s PCP. The HMO’s policies and
      procedures, including its Provider Manual, must include written
      policies and procedures for allowing such self-referral to ECI
      providers.

    


    The
      HMO
      must coordinate and cooperate with local ECI programs in the development
      and implementation of the Individual Family Service Plan (IFSP), including
      on-going case management and other non-capitated services required by the
      Member’s IFSP. The IFSP is an agreement developed by the interdisciplinary
      team that consists of the ECI Case Manager/Service Coordinator, the
      Member/family, and other professionals who participated in the
      Member’s evaluation or are providing direct services to the Member, and may
      include the Member’s Primary Care Physician (PCP) with parental consent.
      The IFSP identifies the Member’s present level of development based on
      assessment, describes the services to be provided to the child to meet the
      needs of the child and the family, and identifies the person or persons
      responsible for each service required by the plan. The IFSP shall be
      transmitted by the ECI Provider to the HMO and the PCP with parental
      consent to enhance coordination of the plan of care. The IFSP may
      be included in the Member’s medical record.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    Cooperation
      with the ECI program includes covering medical diagnostic procedures and
      providing medical records required to perform developmental assessments and
      developing the IFSP within the 45-day timeline established in federal rule
      (34
      C.F.R. §303.342(a)). The HMO must require compliance with these requirements
      through Provider contract provisions. The HMO must not withhold authorization
      for the provision of such medical diagnostic procedures. The HMO must promptly
      provide to the ECI program, relevant medical records available to the
      HMO.

    


    The
      interdisciplinary team will determine Medical Necessity for health and
      Behavioral Health Services as approved by the Member’s PCP. The HMO must
      require, through contract provisions, that all Medically Necessary health and
      Behavioral Health Services contained in the Member’s IFSP are provided to the
      Member in the amount, duration, scope and service setting established by the
      IFSP. The HMO must allow services to be provided by a non-network provider
      if a
      Network Provider is not available to provide the services in the amount,
      duration, scope and service setting as required by the IFSP. The HMO cannot
      modify the plan of care or alter the amount, duration, scope, or service setting
      required by the Member’s IFSP. The HMO cannot create unnecessary barriers for
      the Member to obtain IFSP services, including requiring prior authorization
      for
      the ECI assessment or establishing insufficient authorization periods for prior
      authorized services.

    


    
      	
              8.1.10

            	
              Special
                Supplemental Nutrition Program for Women, Infants, and Children (WIC)
                -
                Specific Requirements

            


    

    


    The
      HMO
      must, by contract, require its Providers to coordinate with the Special
      Supplemental Nutrition Program for Women, Infants, and Children (WIC) to provide
      medical information necessary for WIC eligibility determinations, such as
      height, weight, hematocrit or hemoglobin. The HMO must make referrals to WIC
      for
      Members potentially eligible for WIC. The HMO may use the nutrition education
      provided by WIC to satisfy certain health education requirements of the
      Contract.

    


    
      	
              8.1.11

            	
              Coordination
                with Texas Department of Family and Protective
                Services

            


    

    


    The
      HMO
      must cooperate and coordinate with the Texas Department of Family and Protective
      Services (TDFPS) (formerly the Department of Protective and Regulatory Services)
      for the care of a child who is receiving services from or has been placed in
      the
      conservatorship of TDFPS.

    


    The
      HMO
      must comply with all provisions related to Covered Services, including
      Behavioral Health Services, in the following documents:

    


    
      	
               

            	
              •

            	
              A
                court order (Order) entered by a Court of Continuing Jurisdiction
                placing
                a child under the protective custody of
                TDFPS.

            


    

    
      	
               

            	
              •

            	
              A
                TDFPS Service Plan entered by a Court of Continuing Jurisdiction
                placing a
                child under the protective custody of
                TDFPS.

            


    

    
      	
               

            	
              •

            	
              A
                TDFPS Service Plan voluntarily entered into by the parents or person
                having legal custody of a Member and
                TDFPS.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      cannot deny, reduce, or controvert the Medical Necessity of any health or
      Behavioral Health Services included in an Order. The HMO may participate in
      the
      preparation of the medical and behavioral care plan prior to TDFPS submitting
      the health care plan to the Court. Any modification or termination of
      court-ordered services must be presented and approved by the court having
      jurisdiction over the matter.

    


    A
      Member
      or the parent or guardian whose rights are subject to an Order or Service Plan
      cannot use the HMO’s Complaint or Appeal processes, or the HHSC Fair Hearing
      process to Appeal the necessity of the Covered Services.

    


    The
      HMO
      must include information in its Provider Manuals and training materials
      regarding:

    


    
      	
               

            	
              1.

            	
              Providing
                medical records to TDFPS;

            


    

    
      	
               

            	
              2.

            	
              Scheduling
                medical and Behavioral Health Services appointments within 14 days
                unless
                requested earlier by TDFPS; and

            


    

    
      	
               

            	
              3.

            	
              Recognition
                of abuse and neglect, and appropriate referral to
                TDFPS.

            


    

    


    The
      HMO
      must continue to provide all Covered Services to a Member receiving services
      from, or in the protective custody of, TDFPS until the Member has been
      disenrolled from the HMO due to loss of Medicaid managed care eligibility or
      placed into foster care.

    


    
      	
              8.1.12

            	
              Services
                for People with Special Health Care
                Needs

            


    

    


    This
      section applies to STAR, STAR+PLUS, CHIP HMOs. It applies to CHIP Perinatal
      HMOs
      with respect to their Perinate Newborn Members only.

    


    
      	
              8.1.12.1

            	
              Identification

            


    

    


    The
      HMO
      must develop and maintain a system and procedures for identifying Members with
      Special Health Care Needs (MSHCN), including people with disabilities or chronic
      or complex medical and behavioral health conditions and Children with Special
      Health Care Needs (CSHCN)1.

    


    The
      HMO
      must contact Members pre-screened by the HHSC Administrative Services Contractor
      as MSHCN to determine whether they meet the HMO’s MSHCN assessment criteria, and
      to determine whether the Member requires special services described in this
      section. The HMO must provide information to the HHSC Administrative Services
      Contractor that identifies Members who the HMO has assessed to be MSHCN,
      including any Members pre-screened by the HHSC Administrative Services
      Contractor and confirmed by the HMO as a MSHCN. The information must be
      provided, in a format and on a timeline to be specified by HHSC in the
Uniform

    


    ________________

    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.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    Managed
      Care Manual, and updated with newly identified MSHCN by the 10th day of
      each month. In the event that a MSHCN changes HMOs, the HMO must provide the
      receiving contractor information concerning the results of the HMO’s
      identification and assessment of that Member’s needs, to prevent duplication of
      those activities.

    


    
      	
              8.1.12.2

            	
              Access
                to Care and Service
                Management

            


    

    


    Once
      identified, the HMO must have effective systems to ensure the provision of
      Covered Services to meet the special preventive, primary Acute Care, and
      specialty health care needs appropriate for treatment of the individual Member’s
      condition(s). All STAR+PLUS Members are considered to be MSHCN.

    


    The
      HMO
      must provide access to identified PCPs and specialty care Providers with
      experience serving MSHCN. Such Providers must be board-qualified or
      board-eligible in their specialty. The HMO may request exceptions from HHSC
      for
      approval of traditional providers who are not board-qualified or board-eligible
      but who otherwise meet the HMO’s credentialing requirements.

    


    For
      services to CSHCN, the HMO must have Network PCPs and specialty care Providers
      that have demonstrated experience with CSHCN in pediatric specialty centers
      such
      as children’s hospitals, teaching hospitals, and tertiary care
      centers.

    


    The
      HMO
      is responsible for working with MSHCN, their families and legal guardians if
      applicable, and their health care providers to develop a seamless package of
      care in which primary, Acute Care, and specialty service needs are met through
      a
      Service Plan that is understandable to the Member, or, when applicable, the
      Member’s legal guardian.

    


    The
      HMO
      is responsible for providing Service Management to develop a Service Plan and
      ensure MSHCN, including CSHCN, have access to treatment by a multidisciplinary
      team when the Member’s PCP determines the treatment is Medically Necessary, or
      to avoid separate and fragmented evaluations and service plans. The team must
      include both physician and nonphysician providers determined to be necessary
      by
      the Member’s PCP for the comprehensive treatment of the Member. The team
      must:

    


    
      	
               

            	
              1.

            	
              Participate
                in hospital discharge planning;

            


    

    
      	
               

            	
              2.

            	
              Participate
                in pre-admission hospital planning for non-emergency
                hospitalizations;

            


    

    
      	
               

            	
              3.

            	
              Develop
                specialty care and support service recommendations to be incorporated
                into
                the Service Plan; and

            


    

    
      	
               

            	
              4.

            	
              Provide
                information to the Member, or when applicable, the Member’s legal guardian
                concerning the specialty care
                recommendations.

            


    

    


    MSHCN,
      their families, or their health providers may request Service Management from
      the HMO. The HMO must make an assessment of whether Service Management is needed
      and furnish Service Management when appropriate. The HMO may also recommend
      to a
      MSHCN, or to a CSHCN’s family, that Service Management be furnished if the HMO
      determines that Service Management would benefit the Member.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      must provide information and education in its Member Handbook and Provider
      Manual about the care and treatment available in the HMO’s plan for Members with
      Special Health Care Needs, including the availability of Service
      Management.

    


    The
      HMO
      must have a mechanism in place to allow Members with Special Health Care Needs
      to have direct access to a specialist as appropriate for the Member’s condition
      and identified needs, such as a standing referral to a specialty physician.
      The
      HMO must also provide MSHCN with access to non-primary care physician
      specialists as PCPs, as required by 28 T.A.C. §11.900 and Section
      8.1.

    


    The
      HMO
      must implement a systematic process to coordinate Non-capitated Services, and
      enlist the involvement of community organizations that may not be providing
      Covered Services but are otherwise important to the health and wellbeing of
      Members. The HMO also must make a best effort to establish relationships with
      State and local programs and community organizations, such as those listed
      below, in order to make referrals for MSHCN and other Members who need community
      services:

    


    
      	
               

            	
              •

            	
              Community
                Resource Coordination Groups
                (CRCGs);

            


    

    
      	
               

            	
              •

            	
              Early
                Childhood Intervention (ECI)
                Program;

            


    

    
      	
               

            	
              •

            	
              Local
                school districts (Special
                Education);

            


    

    
      	
               

            	
              •

            	
              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

            


    

    


    The
      HMO
      must have service management programs and procedures for the following
      populations, as applicable to the HMO’s Medicaid and/or CHIP Program(s) (See
      CHIP Perinatal Program Covered Services, Attachment B-2.2, for
      the applicability of these services to the CHIP Perinatal Program):

    


    
      	
              1.

            	
              High-cost
                catastrophic cases;

            


    

    
      	
              2.

            	
              Women
                with high-risk pregnancies (STAR and STAR+PLUS Programs only);
                and

            


    

    
      	
              3.

            	
              Individuals
                with mental illness and co-occurring substance
                abuse.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.1.14

            	
              Disease
                Management (DM)

            


    

    


    The
      HMO
      must provide, or arrange to have provided to Members, comprehensive disease
      management services consistent with state statutes and regulations. Such DM
      services must be part of person-based approach to DM and holistically address
      the needs of persons with multiple chronic conditions. The HMO must develop
      and
      implement DM services that relate to chronic conditions that are prevalent
      in
      HMO Program Members. In the first year of operations, STAR, STAR+PLUS and CHIP
      HMOs must have DM Programs that address Members with chronic conditions to
      be
      identified by HHSC and included within the Uniform Managed Care
      Manual. HHSC will not identify the Members with chronic conditions. The
      HMO must implement policies and procedures to ensure that Members that require
      DM services are identified and enrolled in a program to provide such DM
      services. The HMO must develop and maintain screening and evaluation procedures
      for the early detection, prevention, treatment, or referral of participants
      at
      risk for or diagnosed with chronic conditions identified by HHSC and included
      within the Uniform Managed Care Manual. The HMO must ensure
      that all Members identified for DM are enrolled into a DM Program with the
      opportunity to opt out of these services within 30 days while still maintaining
      access to all other Covered Services.

    


    The
      DM
      Program(s) must include:

    


    
      	
              1.

            	
              Patient
                self-management education;

            


    

    
      	
              2.

            	
              Provider
                education;

            


    

    
      	
              3.

            	
              Evidence-based
                models and minimum standards of
                care;

            


    

    
      	
              4.

            	
              Standardized
                protocols and participation
                criteria;

            


    

    
      	
              5.

            	
              Physician-directed
                or physician-supervised care;

            


    

    
      	
              6.

            	
              Implementation
                of interventions that address the continuum of
                care;

            


    

    
      	
              7.

            	
              Mechanisms
                to modify or change interventions that are not proven effective;
                and

            


    

    
      	
              8.

            	
              Mechanisms
                to monitor the impact of the DM Program over time, including both
                the
                clinical and the financial impact.

            


    

    


    The
      HMO
      must maintain a system to track and monitor all DM participants for clinical,
      utilization, and cost measures.

    


    The
      HMO
      must provide designated staff to implement and maintain DM Programs and to
      assist participating Members in accessing DM services. The HMO must educate
      Members and Providers about the HMO’s DM Programs and activities. Additional
      requirements related to the HMO’s Disease Management Programs and activities are
      found in the HHSC Uniform Managed Care Manual.

    


    
      	
              8.1.14.1

            	
              DM
                Services and Participating
                Providers

            


    

    


    At
      a
      minimum, the HMO must:

    


    
      	
              1.

            	
              Implement
                a system for Providers to request specific DM
                interventions;

            


    

    
      	
              2.

            	
              Give
                Providers information, including differences between recommended
                prevention and treatment and actual care received by Members enrolled
                in a
                DM Program, and information concerning such Members’ adherence to a
                service plan; and

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              3.

            	
              For
                Members enrolled in a DM Program, provide reports on changes in a
                Member’s
                health status to their PCP.

            


    

    


    
      	
              8.1.14.2

            	
              HMO
                DM Evaluation

            


    

    


    HHSC
      or
      its EQRO will evaluate the HMO’s DM Program.

    


    
      	
              8.1.15

            	
              Behavioral
                Health (BH) Network and
                Services

            


    

    


    The
      requirements in this sub-section pertain to all HMOs except: (1) the STAR HMOs
      in the Dallas CSA, whose Members receive Behavioral Health Services through
      the
      NorthSTAR Program, and (2) the CHIP Perinatal Program HMOs with respect to
      their
      Perinate Members.

    


    The
      HMO
      must provide, or arrange to have provided, to Members all Medically Necessary
      Behavioral Health (BH) Services as described in Attachments B-2, B-2.1,
      and B-2.2. All BH Services must be provided in conformance with the
      access standards included in Section 8.1.3. For Medicaid HMOs,
      BH Services are described in more detail in the Texas Medicaid Provider
      Procedures Manual and the Texas Medicaid Bulletins.
      When assessing Members for BH Services, the HMO and its Network Behavioral
      Health Service Providers must use the DSM-IV multi-axial classification. HHSC
      may require use of other assessment instrument/outcome measures in addition
      to
      the DSM-IV. Providers must document DSM-IV and assessment/outcome information
      in
      the Member’s medical record.

    


    
      	
              8.1.15.1

            	
              BH
                Provider Network

            


    

    


    The
      HMO
      must maintain a Behavioral Health Services Provider Network that includes
      psychiatrists, psychologists, and other Behavioral Health Service Providers.
      The
      Provider Network must include Behavioral Health Service Providers with
      experience serving special populations among the HMO Program(s)’ enrolled
      population, including, as applicable, children and adolescents, persons with
      disabilities, the elderly, and cultural or linguistic minorities, to ensure
      accessibility and availability of qualified Providers to all Members in the
      Service Area.

    


    
      	
              8.1.15.2

            	
              Member
                Education and Self-referral for Behavioral Health
                Services

            


    

    


    The
      HMO
      must maintain a Member education process to help Members know where and how
      to
      obtain Behavioral Health Services.

    


    The
      HMO
      must permit Members to self refer to any in-network Behavioral Health Services
      Provider without a referral from the Member’s PCP. The HMOs’ policies and
      procedures, including its Provider Manual, must include written policies and
      procedures for allowing such self- referral to BH services.

    


    The
      HMO
      must permit Members to participate in the selection of the appropriate
      behavioral health individual practitioner(s) who will serve them and must
      provide the Member with information on accessible in-network Providers with
      relevant experience.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.1.15.3

            	
              Behavioral
                Health Services Hotline

            


    

    


    This
      Section includes Hotline functions pertaining to Members. Requirements for
      Provider Hotlines are found in Section 8.1.4.7. The HMO must
      have an emergency and crisis Behavioral Health Services Hotline staffed by
      trained personnel 24 hours a day, 7 days a week, toll-free throughout the
      Service Area. Crisis hotline staff must include or have access to qualified
      Behavioral Health Services professionals to assess behavioral health
      emergencies. Emergency and crisis Behavioral Health Services may be arranged
      through mobile crisis teams. It is not acceptable for an emergency intake line
      to be answered by an answering machine.

    


    The
      HMO
      must operate a toll-free hotline as described in Section 8.1.5.6
to handle Behavioral Health-related calls. The HMO may operate
      one
      hotline to handle emergency and crisis calls and routine Member calls. The
      HMO
      cannot impose maximum call duration limits and must allow calls to be of
      sufficient length to ensure adequate information is provided to the Member.
      Hotline services must meet Cultural Competency requirements and provide
      linguistic access to all Members, including the interpretive services required
      for effective communication.

    


    The
      Behavioral Health Services Hotline may serve multiple HMO Programs Hotline
      staff
      is knowledgeable about all of the HMO Programs. The Behavioral Health Services
      Hotline may serve multiple Service Areas if the Hotline staff is knowledgeable
      about all such Service Areas, including the Behavioral Health Provider Network
      in each Service Area. The HMO must ensure that the toll-free Behavioral Health
      Services Hotline meets the following minimum performance requirements for all
      HMO Programs and Service Areas:

    


    
      	
               

            	
              1.

            	
              99%
                of calls are answered by the fourth ring or an automated call pick-up
                system;

            


    

    
      	
               

            	
              2.

            	
              No
                incoming calls receive a busy
                signal;

            


    

    
      	
               

            	
              3.

            	
              At
                least 80% of calls must be answered by toll-free line staff within
                30
                seconds measured from the time the call is placed in queue after
                selecting
                an option; and

            


    

    
      	
               

            	
              4.

            	
              The
                call abandonment rate is 7% or
                less.

            


    

    


    The
      HMO
      must conduct on-going quality assurance to ensure these standards are
      met.

    


    The
      HMO
      must monitor the HMO’s performance against the Behavioral Health Services
      Hotline standards and submit performance reports summarizing call center
      performance as indicated in Section 8.1.20 and the
Uniform Managed Care Manual.

    


    
      	
              8.1.15.4

            	
              Coordination
                between the BH Provider and the
                PCP

            


    

    


    The
      HMO
      must require, through contract provisions, that PCPs have screening and
      evaluation procedures for the detection and treatment of, or referral for,
      any
      known or suspected behavioral health problems and disorders. PCPs may provide
      any clinically appropriate Behavioral Health Services within the scope of their
      practice.

    


    The
      HMO
      must provide training to network PCPs on how to screen for and identify
      behavioral health disorders, the HMO’s referral process for Behavioral Health
      Services and clinical coordination requirements for such services. The HMO
      must
      include training on coordination and quality of care such as behavioral health
      screening techniques for PCPs and new models of

    behavioral
      health interventions.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      shall develop and disseminate policies regarding clinical coordination between
      Behavioral Health Service Providers and PCPs. The HMO must require that
      Behavioral Health Service Providers refer Members with known or suspected and
      untreated physical health problems or disorders to their PCP for examination
      and
      treatment, with the Member’s or the Member’s legal guardian’s consent.
      Behavioral Health Providers may only provide physical health care services
      if
      they are licensed to do so. This requirement must be specified in all Provider
      Manuals.

    


    The
      HMO
      must require that behavioral health Providers send initial and quarterly (or
      more frequently if clinically indicated) summary reports of a Members’
behavioral health status to the PCP, with the Member’s or the Member’s legal
      guardian’s consent. This requirement must be specified in all Provider
      Manuals.

    


    
      	
              8.1.15.5

            	
              Follow-up
                after Hospitalization for Behavioral Health
                Services

            


    

    


    The
      HMO
      must require, through Provider contract provisions, that all Members receiving
      inpatient psychiatric services are scheduled for outpatient follow-up and/or
      continuing treatment prior to discharge. The outpatient treatment must occur
      within seven (7) days from the date of discharge. The HMO must ensure that
      Behavioral Health Service Providers contact Members who have missed appointments
      within 24 hours to reschedule appointments.

    


    
      	
              8.1.15.6

            	
              Chemical
                Dependency

            


    

    


    The
      HMO
      must comply with 28 T.A.C. §3.8001 et seq., regarding utilization
      review for Chemical Dependency Treatment. Chemical Dependency Treatment must
      conform to the standards set forth in 28 T.A.C. Part 1, Chapter 3, Subchapter
      HH.

    


    
      	
              8.1.15.7

            	
              Court-Ordered
                Services

            


    

    


    “Court-Ordered
      Commitment” means a commitment of a Member to a psychiatric facility for
      treatment that is ordered by a court of law pursuant to the Texas Health and
      Safety Code, Title VII, Subtitle C.

    


    The
      HMO
      must provide inpatient psychiatric services to Members under the age of 21,
      up
      to the annual limit, who have been ordered to receive the services by a court
      of
      competent jurisdiction under the provisions of Chapters 573 and 574 of the
      Texas
      Health and Safety Code, relating to Court-Ordered Commitments to psychiatric
      facilities. The HMO is not obligated to cover placements as a condition of
      probation, authorized by the Texas Family Code.

    


    The
      HMO
      cannot deny, reduce or controvert the Medical Necessity of inpatient psychiatric
      services provided pursuant to a Court-ordered Commitment for Members under
      age
      21. Any modification or termination of services must be presented to the court
      with jurisdiction over the matter for determination.

    


    A
      Member
      who has been ordered to receive treatment under the provisions of Chapter 573
      or
      574 of the Texas Health and Safety Code can only Appeal the commitment through
      the court system.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.1.15.8

            	
              Local
                Mental Health Authority
                (LMHA)

            


    

    


    The
      HMO
      must coordinate with the Local Mental Health Authority (LMHA) and state
      psychiatric facility regarding admission and discharge planning, treatment
      objectives and projected length of stay for Members committed by a court of
      law
      to the state psychiatric facility.

    


    Medicaid
      HMOs are required to comply with additional Behavioral Health Services
      requirements relating to coordination with the LMHA and care for special
      populations. These Medicaid HMO requirements are described in Section
      8.2.8.

    


    
      	
              8.1.16

            	
              Financial
                Requirements for Covered
                Services

            


    

    


    The
      HMO
      must pay for or reimburse Providers for all Medically Necessary Covered Services
      provided to all Members. The HMO is not liable for cost incurred in connection
      with health care rendered prior to the date of the Member’s Effective Date of
      Coverage in that HMO. A Member may receive collateral health benefits under
      a
      different type of insurance such as workers compensation or personal injury
      protection under an automobile policy. If a Member is entitled to coverage
      for
      specific services payable under another insurance plan and the HMO paid for
      such
      Covered Services, the HMO may obtain reimbursement from the responsible
      insurance entity not to exceed 100% of the value of Covered Services
      paid.

    


    
      	
              8.1.17

            	
              Accounting
                and Financial Reporting
                Requirements

            


    

    


    The
      HMO’s
      accounting records and supporting information related to all aspects of the
      Contract must be accumulated in accordance with Generally Accepted Accounting
      Principles (GAAP) and the cost principles contained in the Cost Principles
      Document in the Uniform Managed Care Manual. The State will not
      recognize or pay services that cannot be properly substantiated by the HMO
      and
      verified by HHSC.

    


    The
      HMO
      must:

    


    
      	
               

            	
              1.

            	
              Maintain
                accounting records for each applicable HMO Program separate and apart
                from
                other corporate accounting records;

            


    

    
      	
               

            	
              2.

            	
              Maintain
                records for all claims payments, refunds and adjustment payments
                to
                providers, capitation payments, interest income and payments for
                administrative services or functions and must maintain separate records
                for medical and administrative fees, charges, and
                payments;

            


    

    
      	
               

            	
              3.

            	
              Maintain
                an accounting system that provides an audit trail containing sufficient
                financial documentation to allow for the reconciliation of billings,
                reports, and financial statements with all general ledger accounts;
                and

            


    

    
      	
               

            	
              4.

            	
              Within
                60 days after Contract execution, submit an accounting policy manual
                that
                includes all proposed policies and procedures the HMO will follow
                during
                the duration of the Contract. Substantive modifications to the accounting
                policy manual must be approved by
                HHSC.

            


    

    


    The
      HMO
      agrees to pay for all reasonable costs incurred by HHSC to perform an
      examination, review or audit of the HMO’s books pertaining to the
      Contract.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.1.17.1

            	
              General
                Access to Accounting
                Records

            


    

    


    The
      HMO
      must provide authorized representatives of the Texas and federal government
      full
      access to all financial and accounting records related to the performance of
      the
      Contract.

    


    The
      HMO
      must:

    


    
      	
               

            	
              1.

            	
              Cooperate
                with the State and federal governments in their evaluation, inspection,
                audit, and/or review of accounting records and any necessary supporting
                information;

            


    

    
      	
               

            	
              2.

            	
              Permit
                authorized representatives of the State and federal governments full
                access, during normal business hours, to the accounting records that
                the
                State and the Federal government determine are relevant to the Contract.
                Such access is guaranteed at all times during the performance and
                retention period of the Contract, and will include both announced
                and
                unannounced inspections, on-site audits, and the review, analysis,
                and
                reproduction of reports produced by the
                HMO;

            


    

    
      	
               

            	
              3.

            	
              Make
                copies of any accounting records or supporting documentation relevant
                to
                the Contract available to HHSC or its agents within ten (10) business
                days
                of receiving a written request from HHSC for specified records or
                information. If such documentation is not made available as requested,
                the
                HMO agrees to reimburse HHSC for all costs, including, but not limited
                to,
                transportation, lodging, and subsistence for all State and federal
                representatives, or their agents, to carry out their inspection,
                audit,
                review, analysis, and reproduction functions at the location(s) of
                such
                accounting records; and

            


    

    
      	
               

            	
              4.

            	
              Pay
                any and all additional costs incurred by the State and federal government
                that are the result of the HMO’s failure to provide the requested
                accounting records or financial information within ten (10) business
                days
                of receiving a written request from the State or federal
                government.

            


    

    


    
      	
              8.1.17.2

            	
              Financial
                Reporting Requirements

            


    

    


    HHSC
      will
      require the HMO to provide financial reports by HMO Program and by Service
      Area
      to support Contract monitoring as well as State and Federal reporting
      requirements. HHSC will consult with HMOs regarding the format and frequency
      of
      such reporting. All financial information and reports that are not
      Member-specific are property of HHSC and will be public record. Any deliverable
      or report in Section 8.1.17.2 without a specified due date is due quarterly
      on
      the last day of the month. Where the due date states 30 days, the HMO is to
      provide the deliverable by the last day of the month following the end of the
      reporting period. Where the due date states 45 days, the HMO is to provide
      the
      deliverable by the 15th day of the second month following the end of the
      reporting period.

    


    CHIP
      Perinatal Program data must be reported, and the data will be integrated into
      existing CHIP Program financial reports. Except for the Financial Statistical
      Report, no separate CHIP Perinatal Program reports are required. For all other
      CHIP financial reports, where appropriate, HHSC will designate specific
      attributes within the CHIP Program financial reports that the CHIP Perinatal
      HMOs must complete to allow HHSC to extract financial data particular to the
      CHIP Perinatal Program.

    


    HHSC’s
      Uniform Managed Care Manual will govern the timing, format and
      content for the following reports.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    Audited
      Financial Statement –The HMO must provide the annual audited financial
      statement, for each year covered under the Contract, no later than June 30.
      The
      HMO must provide the most recent annual financial statements, as required by
      the
      Texas Department of Insurance for each year covered under the Contract, no
      later
      than March 1.

    


    Affiliate
      Report – The HMO must submit an Affiliate Report to HHSC if this
      information has changed since the last report submission. The report must
      contain the following:

    


    
      	
               

            	
              1.

            	
              A
                list of all Affiliates, and

            


    

    
      	
               

            	
              2.

            	
              For
                HHSC’s prior review and approval, a schedule of all transactions with
                Affiliates that, under the provisions of the Contract, will be allowable
                as expenses in the FSR Report for services provided to the HMO by
                the
                Affiliate. Those should include financial terms, a detailed description
                of
                the services to be provided, and an estimated amount that will be
                incurred
                by the HMO for such services during the Contract
                Period.

            


    

    


    Employee
      Bonus and/or Incentive Payment Plan – If a HMO intends to include
      Employee Bonus or Incentive Payments as allowable administrative expenses,
      the
      HMO must furnish a written Employee Bonus and/or Incentive Payments Plan to
      HHSC
      so it may determine whether such payments are allowable administrative expenses
      in accordance with Cost Principles Document in the Uniform Managed Care
      Manual. The written plan must include a description of the HMO’s
      criteria for establishing bonus and/or incentive payments, the methodology
      to
      calculate bonus and/or incentive payments, and the timing of bonus and/or
      incentive payments. The Bonus and/or Incentive Payment Plan and description
      must
      be submitted to HHSC for approval no later than 30 days after the Effective
      Date
      of the Contract and any Contract renewal. If the HMO substantively revises
      the
      Employee Bonus and/or Incentive Payment Plan, the HMO must submit the revised
      plan to HHSC for prior review and approval.

    


    Claims
      Lag Report - The HMO must submit Claims Lag Report as a Contract
      year-to-date report. The report must be submitted quarterly by the last day
      of
      the month following the reporting period. The report must be submitted to HHSC
      in a format specified by HHSC. The report format is contained in the
Uniform Managed Care Manual Chapter 5, Section 5.6.2. The
      report must disclose the amount of incurred claims each month and the amount
      paid each month.

    


    DSP
      Report - The HMO must submit a monthly Delivery Supplemental Payment
      (DSP) Report that includes the data elements specified by HHSC in the format
      specified by HHSC. HHSC will consult with contracted HMOs prior to revising
      the
      DSP Report data elements and requirements. The DSP Report must include only
      unduplicated deliveries and only deliveries for which the HMO has made a
      payment, to either a hospital or other provider.

    


    Form
      CMS-1513 - The HMO must file an original Form CMS-1513 prior to
      beginning operations regarding the HMO’s control, ownership, or affiliations. An
      updated Form CMS-1513 must also be filed no later than 30 days after any change
      in control, ownership, or affiliations.

    


    FSR
      Reports – The HMO must file quarterly and annual Financial-Statistical
      Reports (FSR) in the format and timeframe specified by HHSC. HHSC will include
      FSR format and directions in the Uniform Managed Care Manual.
      The HMO must incorporate financial and statistical data of delegated networks
      (e.g., IPAs, ANHCs, Limited Provider Networks), if any, in its FSR Reports.
      Administrative expenses reported in the FSRs must be reported in accordance
      with
      the

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    Cost
      Principles Document in the Uniform Managed Care Manual.
      Quarterly FSR reports are due no later than 30 days after the end of the quarter
      and must provide information for the current quarter and year-to-date
      information through the current quarter. The first annual FSR report must
      reflect expenses incurred through the 90th day after the end of the fiscal
      year.
      The first annual report must be filed on or before the 120th day after the
      end
      of each fiscal year and accompanied by an actuarial opinion by a qualified
      actuary who is in good standing with the American Academy of Actuaries.
      Subsequent annual reports must reflect data completed through the 334th day after
      the end
      of each fiscal year and must be filed on or before the 365th day following
      the
      end of each fiscal year.

    


    CHIP
      Perinatal HMOs are required to submit separate FSRs for the CHIP Perinatal
      Program following the instructions outlined above and in the Uniform
      Managed Care Manual.

    


    Out-of-Network
      Utilization Reports – The HMO must file quarterly Out-of Network
      Utilization Reports in the format and timeframe specified by HHSC. HHSC will
      include the report format and directions in the Uniform Managed Care
      Manual. Quarterly reports are due 30 days after the end of each
      quarter.

    


    HUB
      Reports – Upon contract award, the HMO must attend a post award meeting
      in Austin, Texas, at a time specified by HHSC, to discuss the development and
      submission of a Client Services HUB Subcontracting Plan for inclusion and the
      HMO’s good faith efforts to notify HUBs of subcontracting opportunities. The HMO
      must maintain its HUB Subcontracting Plan and submit monthly reports documenting
      the HMO’s Historically Underutilized Business (HUB) program efforts and
      accomplishments to the HHSC HUB Office. The report must include a narrative
      description of the HMO’s program efforts and a financial report reflecting
      payments made to HUBs. HMOs must use the formats included in HHSC’s
Uniform Managed Care Manual for the HUB monthly reports. The
      HMO must comply with HHSC’s standard Client Services HUB Subcontracting Plan
      requirements for all subcontractors.

    


    IBNR
      Plan - The HMO must furnish a written IBNR Plan to manage
      incurred-but-not-reported (IBNR) expenses, and a description of the method
      of
      insuring against insolvency, including information on all existing or proposed
      insurance policies. The Plan must include the methodology for estimating IBNR.
      The plan and description must be submitted to HHSC no later than 60 days after
      the Effective Date of the Contract. Substantive changes to a HMO’s IBNR plan and
      description must be submitted to HHSC no later than 30 days before the HMO
      implements changes to the IBNR plan.

    


    Medicaid
      Disproportionate Share Hospital (DSH) Reports – Medicaid HMOs must file
      preliminary and final Medicaid DSH reports, required by HHSC to identify and
      reimburse hospitals that qualify for Medicaid DSH funds. The preliminary and
      final DSH reports must include the data elements and be submitted in the form
      and format specified by HHSC in the Uniform Managed Care
      Manual. The preliminary DSH reports are due on or before June 1 of the
      year following the state fiscal reporting year. The final DSH reports are due
      no
      later than July 15 of the year following the state fiscal reporting year. This
      reporting requirement does not apply to CHIP or CHIP Perinatal Program HMOs.
      For
      STAR+PLUS, HMOs will include only outpatient services in the DSH
      report.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    TDI
      Examination Report - The HMO must furnish a copy of any TDI Examination
      Report, including the financial, market conduct, target exam, quality of care
      components, and corrective action plans and responses, no later than 10 days
      after receipt of the final report from TDI.

    


    TDI
      Filings – The HMO must submit annual figures for controlled risk-based
      capital, as well as its quarterly financial statements, both as required by
      TDI.

    


    Registration
      Statement (also known as the “Form B”) - If the HMO is a part of an
      insurance holding company system, the HMO must submit to HHSC a complete
      registration statement, also known as Form B, and all amendments to this form,
      and any other information filed by such insurer with the insurance regulatory
      authority of its domiciliary jurisdiction.

    


    Section
      1318 Financial Disclosure Report - The HMO must file an original CMS
      Public Health Service (PHS) Section 1318 Financial Disclosure Report prior
      to
      the start of Operations and an updated CMS PHS Section 1318 Financial Disclosure
      Report no later than 30 days after the end of each Contract Year and no later
      than 30 days after entering into, renewing, or terminating a relationship with
      an affiliated party.

    


    Third
      Party Recovery (TPR) Reports - The HMO must file TPR Reports in
      accordance with the format developed by HHSC in the Uniform Managed Care
      Manual. HHSC will require the HMO to submit TPR reports no more often
      than quarterly. TPR reports must include total dollars recovered from third
      party payers for each HMO Program for services to the HMO’s Members, and the
      total dollars recovered through coordination of benefits, subrogation, and
      worker’s compensation. For CHIP HMOs, the TPR Reports only apply if the HMO
      chooses to engage in TPR activities.

    


    
      	
              8.1.18

            	
              Management
                Information System
                Requirements

            


    

    


    The
      HMO
      must maintain a Management Information System (MIS) that supports all functions
      of the HMO’s processes and procedures for the flow and use of HMO data. The HMO
      must have hardware, software, and a network and communications system with
      the
      capability and capacity to handle and operate all MIS subsystems for the
      following operational and administrative areas:

    


    
      	
               

            	
              1.

            	
              Enrollment/Eligibility
                Subsystem;

            


    

    
      	
               

            	
              2.

            	
              Provider
                Subsystem;

            


    

    
      	
               

            	
              3.

            	
              Encounter/Claims
                Processing Subsystem;

            


    

    
      	
               

            	
              4.

            	
              Financial
                Subsystem;

            


    

    
      	
               

            	
              5.

            	
              Utilization/Quality
                Improvement Subsystem;

            


    

    
      	
               

            	
              6.

            	
              Reporting
                Subsystem;

            


    

    
      	
               

            	
              7.

            	
              Interface
                Subsystem; and

            


    

    
      	
               

            	
              8.

            	
              TPR
                Subsystem, as applicable to each HMO
                Program.

            


    

    


    The
      MIS
      must enable the HMO to meet the Contract requirements, including all applicable
      state and federal laws, rules, and regulations. The MIS must have the capacity
      and capability to capture and utilize various data elements required for HMO
      administration.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    HHSC
      will
      provide the HMO with pharmacy data on the HMO’s Members on a weekly basis
      through the HHSC Vendor Drug Program, or should these services be outsourced,
      through the Pharmacy Benefit Manager. HHSC will provide a sample format of
      pharmacy data to contract awardees.

    


    The
      HMO
      must have a system that can be adapted to changes in Business Practices/Policies
      within the timeframes negotiated by the Parties. The HMO is expected to cover
      the cost of such systems modifications over the life of the
      Contract.

    


    The
      HMO
      is required to participate in the HHSC Systems Work Group.

    


    The
      HMO
      must provide HHSC prior written notice of major systems changes, generally
      within 90 days, and implementations, including any changes relating to Material
      Subcontractors, in accordance with the requirements of this Contract and the
      Uniform Managed Care Terms and Conditions.

    


    The
      HMO
      must provide HHSC any updates to the HMO’s organizational chart relating to MIS
      and the description of MIS responsibilities at least 30 days prior to the
      effective date of the change. The HMO must provide HHSC official points of
      contact for MIS issues on an on-going basis.

    


    HHSC,
      or
      its agent, may conduct a Systems Readiness Review to validate the HMO’s ability
      to meet the MIS requirements as described in Attachment B-1, Section
      7. The System Readiness Review may include a desk review and/or an
      onsite review and must be conducted for the following events:

    


    
      	
               

            	
              1.

            	
              A
                new plan is brought into the HMO
                Program;

            


    

    
      	
               

            	
              2.

            	
              An
                existing plan begins business in a new Service
                Area;

            


    

    
      	
               

            	
              3.

            	
              An
                existing plan changes location;

            


    

    
      	
               

            	
              4.

            	
              An
                existing plan changes its processing system, including changes in
                Material
                Subcontractors performing MIS or claims processing functions;
                and

            


    

    
      	
               

            	
              5.

            	
              An
                existing plan in one or two HHSC HMO Programs is initiating a Contract
                to
                participate in any additional HMO
                Programs.

            


    

    


    If
      for
      any reason, a HMO does not fully meet the MIS requirements, then the HMO must,
      upon request by HHSC, either correct such deficiency or submit to HHSC a
      Corrective Action Plan and Risk Mitigation Plan to address such deficiency
      as
      requested by HHSC. Immediately upon identifying a deficiency, HHSC may impose
      remedies and either actual or liquidated damages according to the severity
      of
      the deficiency. HHSC may also freeze enrollment into the HMO’s plan for any of
      its HMO Programs until such deficiency is corrected. Refer to Attachment
      A, Article 12 and Attachment B-5 for additional
      information regarding remedies and damages. Refer to Attachment B-1,
      Section 7 and Attachment B-1, Section 8.1.1.2 for
      additional information regarding HMO Readiness Reviews. Refer to
Attachment A, Section 4.08(c) for information regarding
      Readiness Reviews of the HMO’s Material Subcontractors.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.1.18.1

            	
              Encounter
                Data

            


    

    


    The
      HMO
      must provide complete Encounter Data for all Covered Services, including Value
      added Services. Encounter Data must follow the format, and data elements as
      described in the HIPAA-compliant 837 format. HHSC will specify the method of
      transmission, and the submission schedule, in the Uniform Managed Care
      Manual. The HMO must submit monthly Encounter Data transmissions, and
      include all Encounter Data and Encounter Data adjustments processed by the
      HMO.
      Encounter Data quality validation must incorporate assessment standards
      developed jointly by the HMO and HHSC. The HMO must make original records
      available for inspection by HHSC for validation purposes. Encounter Data that
      do
      not meet quality standards must be corrected and returned within a time period
      specified by HHSC.

    


    In
      addition to providing Encounter Data in the 837 format described above, HMOs
      must submit an Encounter Data file to HHSC's EQRO, in the format provided in
      the
Uniform Managed Care Manual. This additional submission
      requirement is time-limited and may not be required for the entire term of
      the
      Contract.

    


    For
      reporting Encounters and fee-for-service claims to HHSC, the HMO must use the
      procedure codes, diagnosis codes, and other codes as directed by HHSC. Any
      exceptions will be considered on a code-by-code basis after HHSC receives
      written notice from the HMO requesting an exception. The HMO must also use
      the
      provider numbers as directed by HHSC for both Encounter and fee-for-service
      claims submissions, as applicable.

    


    
      	
              8.1.18.2

            	
              HMO
                Deliverables related to MIS
                Requirements

            


    

    


    At
      the
      beginning of each state fiscal year, the HMO must submit for HHSC’s review and
      approval any modifications to the following documents:

    


    
      	
               

            	
              1.

            	
              Joint
                Interface Plan;

            


    

    
      	
               

            	
              2.

            	
              Disaster
                Recovery Plan;

            


    

    
      	
               

            	
              3.

            	
              Business
                Continuity Plan;

            


    

    
      	
               

            	
              4.

            	
              Risk
                Management Plan; and

            


    

    
      	
               

            	
              5.

            	
              Systems
                Quality Assurance Plan.

            


    

    


    The
      HMO
      must submit such modifications to HHSC according to the format and schedule
      identified the HHSC Uniform Managed Care Manual.

    


    
      	
              8.1.18.3

            	
              System-wide
                Functions

            


    

    


    The
      HMO’s
      MIS system must include key business processing functions and/or features,
      which
      must apply across all subsystems as follows:

    


    
      	
               

            	
              1.

            	
              Process
                electronic data transmission or media to add, delete or modify membership
                records with accurate begin and end
                dates;

            


    

    
      	
               

            	
              2.

            	
              Track
                Covered Services received by Members through the system, and accurately
                and fully maintain those Covered Services as HIPAA-compliant Encounter
                transactions;

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              3.

            	
               

            	
              Transmit
                or transfer Encounter Data transactions on electronic media in the
                HIPAA
                format to the contractor designated by HHSC to receive the Encounter
                Data;

            


    

    
      	
              4.

            	
               

            	
              Maintain
                a history of changes and adjustments and audit trails for current
                and
                retroactive data;

            


    

    
      	
              5.

            	
               

            	
              Maintain
                procedures and processes for accumulating, archiving, and restoring
                data
                in the event of a system or subsystem
                failure;

            


    

    
      	
              6.

            	
               

            	
              Employ
                industry standard medical billing taxonomies (procedure codes, diagnosis
                codes) to describe services delivered and Encounter transactions
                produced;

            


    

    
      	
              7.

            	
               

            	
              Accommodate
                the coordination of benefits;

            


    

    
      	
              8.

            	
               

            	
              Produce
                standard Explanation of Benefits
                (EOBs);

            


    

    
      	
              9.

            	
               

            	
              Pay financial transactions to Providers in compliance
                with
                federal and state laws, rules and
                regulations;

            


    

    
      	
              10.

            	
              Ensure
                that all financial transactions are auditable according to GAAP
                guidelines.

            


    

    
      	
              11.

            	
              Relate
                and extract data elements to produce report formats (provided within
                the
                Uniform Managed Care Manual) or otherwise required by
                HHSC;

            


    

    
      	
              12.

            	
              Ensure
                that written process and procedures manuals document and describe
                all
                manual and automated system procedures and processes for the
                MIS;

            


    

    
      	
              13.

            	
              Maintain
                and cross-reference all Member-related information with the most
                current
                Medicaid, CHIP or CHIP Perinatal Program Provider number;
                and

            


    

    
      	
              14.

            	
              Ensure
                that the MIS is able to integrate pharmacy data from HHSC’s Drug Vendor
                file (available through the Virtual Private Network (VPN)) into the
                HMO’s
                Member data.

            


    

    


    
      	
              8.1.18.4

            	
              Health
                Insurance Portability and Accountability Act (HIPAA)
                Compliance

            


    

    


    The
      HMO’s
      MIS system must comply with applicable certificate of coverage and data
      specification and reporting requirements promulgated pursuant to the Health
      Insurance Portability and Accountability Act (HIPAA) of 1996, P.L. 104-191
      (August 21, 1996), as amended or modified. The HMO must comply with HIPAA EDI
      requirements. HMO’s enrollment files must be in the 834 HIPAA-compliant format.
      Eligibility inquiries must be in the 270/271 format and all claims and
      remittance transactions in the 837/835 format.

    


    The
      HMO
      must provide its Members with a privacy notice as required by HIPAA. The HMO
      must provide HHSC with a copy of its privacy notice for filing.

    


    
      	
              8.1.18.5

            	
              Claims
                Processing Requirements

            


    

    


    The
      HMO
      must process and adjudicate all provider claims for Medically Necessary Covered
      Services that are filed within the time frames specified in the Uniform
      Managed Care Manual. The HMO is subject to remedies, including
      liquidated damages and interest, if the HMO does not process and adjudicate
      claims within the timeframes listed in the Uniform Managed Care
      Manual.

    


    The
      HMO
      must administer an effective, accurate, and efficient claims payment process
      in
      compliance with federal laws and regulations, applicable state laws and rules,
      the Contract, and the Uniform Managed Care Manual. In addition,
      a Medicaid HMO must be able to accept and process provider claims in compliance
      with the Medicaid Provider Procedures Manual and The Texas Medicaid
      Bulletin.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      must maintain an automated claims processing system that registers the date
      a
      claim is received by the MCO, the detail of each claim transaction (or action)
      at the time the transaction occurs, and has the capability to report each claim
      transaction by date and type to include interest payments. The claims system
      must maintain information at the claim and line detail level. The claims system
      must maintain adequate audit trails and report accurate claims performance
      measures to HHSC.

    


    The
      HMO’s
      claims system must maintain online and archived files. The HMO must keep online
      automated claims payment history for the most current 18 months. The HMO must
      retain other financial information and records, including all original claims
      forms, for the time period established in Attachment A, Section
      9.01. All claims data must be easily sorted and produced in formats as
      requested by HHSC.

    


    The
      HMO
      must offer its Providers/Subcontractors the option of submitting and receiving
      claims information through electronic data interchange (EDI) that allows for
      automated processing and adjudication of claims. EDI processing must be offered
      as an alternative to the filing of paper claims. Electronic claims must use
      HIPAA-compliant electronic formats.

    


    The
      HMO
      must make an electronic funds transfer (EFT) payment process (for direct
      deposit) available to in-network providers when processing claims for Medically
      Necessary covered STAR+PLUS services.

    


    The
      HMO
      may deny a claim submitted by a provider for failure to file in a timely manner
      as provided for in the Uniform Managed Care Manual. The HMO
      must not pay any claim submitted by a provider excluded or suspended from the
      Medicare, Medicaid, CHIP or CHIP Perinatal programs for Fraud, Abuse, or Waste.
      The HMO must not pay any claim submitted by a Provider that is on payment hold
      under the authority of HHSC or its authorized agent(s), or who has pending
      accounts receivable with HHSC.

    


    The
      HMO
      is subject to the requirements related to coordination of benefits for secondary
      payors in the Texas Insurance Code Section 843.349 (e) and (f).

    


    The
      HMO
      must notify HHSC of major claim system changes in writing no later than 90
      days
      prior to implementation. The HMO must provide an implementation plan and
      schedule of proposed changes. HHSC reserves the right to require a desk or
      on-site readiness review of the changes.

    


    The
      HMO
      must inform all Network Providers about the information required to submit
      a
      claim at least 30 days prior to the Operational Start Date and as a provision
      within the HMO/Provider contract. The HMO must make available to Providers
      claims coding and processing guidelines for the applicable provider type.
      Providers must receive 90 days notice prior to the HMO’s implementation of
      changes to claims guidelines.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.1.19

            	
              Fraud
                and Abuse

            


    

    


    A
      HMO is
      subject to all state and federal laws and regulations relating to Fraud, Abuse,
      and Waste in health care and the Medicaid and CHIP programs. The HMO must
      cooperate and assist HHSC and any state or federal agency charged with the
      duty
      of identifying, investigating, sanctioning or prosecuting suspected Fraud,
      Abuse
      or Waste. The HMO must provide originals and/or copies of all records and
      information requested and allow access to premises and provide records to the
      Inspector General for the Texas Health and Human Services System, HHSC or its
      authorized agent(s), the Centers for Medicare and Medicaid Services (CMS),
      the
      U.S. Department of Health and Human Services (DHHS), Federal Bureau of
      Investigation, TDI, or other units of state government. The HMO must provide
      all
      copies of records free of charge.

    


    The
      HMO
      must submit a written Fraud and Abuse compliance plan to the Office of Inspector
      General at HHSC for approval (See Attachment B-1, Section 7 for
      requirements regarding timeframes for submitting the original plan.) The plan
      must ensure that all officers, directors, managers and employees know and
      understand the provisions of the HMO’s Fraud and Abuse compliance plan. The plan
      must include the name, address, telephone number, electronic mail address,
      and
      fax number of the individual(s) responsible for carrying out the
      plan.

    


    The
      written Fraud and Abuse compliance plan must:

    


    
      	
               

            	
              1.

            	
              Contain
                procedures designed to prevent and detect potential or suspected
                Abuse,
                Fraud and Waste in the administration and delivery of services under
                the
                Contract;

            


    

    
      	
               

            	
              2.

            	
              Contain
                a description of the HMO’s procedures for educating and training personnel
                to prevent Fraud, Abuse, or Waste;

            


    

    
      	
               

            	
              3.

            	
              Include
                provisions for the confidential reporting of plan violations to the
                designated person within the HMO’s organization and ensure that the
                identity of an individual reporting violations is protected from
                retaliation;

            


    

    
      	
               

            	
              4.

            	
              Include
                provisions for maintaining the confidentiality of any patient information
                relevant to an investigation of Fraud, Abuse, or
                Waste;

            


    

    
      	
               

            	
              5.

            	
              Provide
                for the investigation and follow-up of any allegations of Fraud,
                Abuse, or
                Waste and contain specific and detailed internal procedures for officers,
                directors, managers and employees for detecting, reporting, and
                investigating Fraud and Abuse compliance plan
                violations;

            


    

    
      	
               

            	
              6.

            	
              Require
                that confirmed violations be reported to the Office of Inspector
                General
                (OIG); and

            


    

    
      	
               

            	
              7.

            	
              Require
                any confirmed violations or confirmed or suspected Fraud, Abuse,
                or Waste
                under state or federal law be reported to
                OIG.

            


    

    


    If
      the
      HMO contracts for the investigation of allegations of Fraud, Abuse, or Waste
      and
      other types of program abuse by Members or Providers, the plan must include
      a
      copy of the subcontract; the names, addresses, telephone numbers, electronic
      mail addresses, and fax numbers of the principals of the subcontracted entity;
      and a description of the qualifications of the subcontracted entity. Such
      subcontractors must be held to the requirements stated in this
      Section.

    


    The
      HMO
      must designate executive and essential personnel to attend mandatory training
      in
      Fraud and Abuse detection, prevention and reporting. Designated executive and
      essential personnel

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    means
      the
      HMO staff persons who supervise staff in the following areas: data collection,
      provider enrollment or disenrollment, encounter data, claims processing,
      utilization review, appeals or grievances, quality assurance and marketing,
      and
      who are directly involved in the decision-making and administration of the
      Fraud
      and Abuse detection program within the HMO. The training will be conducted
      by
      the OIG free of charge. The HMO must schedule and complete training no later
      than 90 days after the Effective Date of the Contract. If the HMO updates or
      modifies its written Fraud and Abuse compliance plan, the HMO must train its
      executive and essential personnel on these updates or modifications no later
      than 90 days after the effective date of the updates or
      modifications.

    


    The
      HMO
      must designate an officer or director in its organization with responsibility
      and authority to carry out the provisions of the Fraud and Abuse compliance
      plan. A HMO’s failure to report potential or suspected Fraud or Abuse may result
      in sanctions, cancellation of the Contract, and/or exclusion from participation
      in the Medicaid, CHIP or CHIP Perinatal HMO Programs. The HMO must allow the
      OIG, HHSC, its agents, or other governmental units to conduct private interviews
      of the HMO’s personnel, subcontractors and their personnel, witnesses, and
      Members with regard to a confirmed violation. The HMO’s personnel and it
      subcontractors must reasonably cooperate, to the satisfaction of HHSC, by being
      available in person for interviews, consultation, grand jury proceedings,
      pre-trial conferences, hearings, trials and in any other process, including
      investigations, at the HMO’s and subcontractors’ own expense.

    


    Additional
      Requirements for STAR and STAR+PLUS HMOs:

    


    In
      accordance with Section 1902(a)(68) of the Social Security Act, STAR and
      STAR+PLUS HMOs that receive or make annual Medicaid payments of at least $5
      million must:

    


    
      	
               

            	
              1.

            	
              Establish
                written policies for all employees, managers, officers, contractors,
                subcontractors, and agents of the HMO, which provide detailed information
                about the False Claims Act, administrative remedies for false claims
                and
                statements, any state laws pertaining to civil or criminal penalties
                for
                false claims, and whistleblower protections under such laws, as described
                in Section 1902(a)(68)(A).

            


    

    
      	
               

            	
              2.

            	
              Include
                as part of such written policies, detailed provisions regarding the
                HMO’s
                policies and procedures for detecting and preventing fraud, waste,
                and
                abuse.

            


    

    
      	
               

            	
              3.

            	
              Include
                in any employee handbook a specific discussion of the laws described
                in
                Section 1902(a)(68)(A), the rights of employees to be protected as
                whistleblowers, and the HMO’s policies and procedures for detecting and
                preventing fraud, waste, and abuse.

            


    

    


    
      	
              8.1.20

            	
              Reporting
                Requirements

            


    

    


    The
      HMO
      must provide and must require its subcontractors to provide:

    


    
      	
               

            	
              1.

            	
              All
                information required under the Contract, including but not limited
                to, the
                reporting requirements or other information related to the performance
                of
                its responsibilities hereunder as reasonably requested by the HHSC;
                and

            


    

    
      	
               

            	
              2.

            	
              Any
                information in its possession sufficient to permit HHSC to comply
                with the
                Federal Balanced Budget Act of 1997 or other Federal or state laws,
                rules,
                and regulations. All information must be provided in accordance with
                the
                timelines, definitions, formats and

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    instructions
      as specified by HHSC. Where practicable, HHSC may consult with HMOs to establish
      time frames and formats reasonably acceptable to both parties.

    


    Any
      deliverable or report in Section 8.1.20 without a specified due date is due
      quarterly on the last day of the month following the end of the reporting
      period. Where the due date states 30 days, the HMO is to provide the deliverable
      by the last day of the month following the end of the reporting period. Where
      the due date states 45 days, the HMO is to provide the deliverable by the 15th
      day of the second month following the end of the reporting period.

    


    The
      HMO’s
      Chief Executive and Chief Financial Officers, or persons in equivalent
      positions, must certify that financial data, Encounter Data and other
      measurement data has been reviewed by the HMO and is true and accurate to the
      best of their knowledge after reasonable inquiry.

    


    
      	
              8.1.20.1

            	
              HEDIS
                and Other Statistical Performance
                Measures

            


    

    


    The
      HMO
      must provide to HHSC or its designee all information necessary to analyze the
      HMO’s provision of quality care to Members using measures to be determined by
      HHSC in consultation with the HMO. Such measures must be consistent with HEDIS
      or other externally based measures or measurement sets, and involve collection
      of information beyond that present in Encounter Data. The Performance
      Indicator Dashboard, found in the Uniform Managed Care Manual
provides additional information on the role of the
      HMO and the EQRO in
      the collection and calculation of HEDIS, CAHPS, and other performance
      measures.

    


    
      	
              8.1.20.2

            	
              Reports

            


    

    


    The
      HMO
      must provide the following reports, in addition to the Financial Reports
      described in Section 8.1.17 and those reporting requirements
      listed elsewhere in the Contract. The HHSC Uniform Managed Care Manual
will include a list of all required reports, and a description
      of the
      format, content, file layout and submission deadlines for each
      report.

    


    For
      the
      following reports, CHIP Perinatal Program data will be integrated into existing
      CHIP Program reports. Generally, no separate CHIP Perinatal Program reports
      are
      required. Where appropriate, HHSC will designate specific attributes within
      the
      CHIP Program reports that the CHIP Perinatal HMOs must complete to allow HHSC
      to
      extract data particular to the CHIP Perinatal Program.

    


    Claims
      Summary Report - The HMO must submit quarterly Claims Summary Reports
      to HHSC by HMO Program, Service Area and claim type by the 30th day following
      the end of the reporting period unless otherwise specified. Claim Types include
      facility and/or professional services for Acute Care, Behavioral Health, Vision,
      and Long Term Services and Supports. Within each claim type, claims data must
      be
      reported separately on the UB and CMS 1500 claim forms. The format for the
      Claims Summary Report is contained in Chapter 5, Section 5.6.1 of the
Uniform Managed Care Manual.

    


    QAPI
      Program Annual Summary Report - The HMO must submit a QAPI Program
      Annual Summary in a format and timeframe as specified in the Uniform Managed
      Care Manual.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    Fraudulent
      Practices Report - Utilizing the HHSC-Office of Inspector General (OIG)
      fraud referral form, the HMO’s assigned officer or director must report and
      refer all possible acts of waste, abuse or fraud to the HHSC-OIG within 30
      working days of receiving the reports of possible acts of waste, abuse or fraud
      from the HMO’s Special Investigative Unit (SIU). The report and referral must
      include: an investigative report identifying the allegation,
      statutes/regulations violated or considered, and the results of the
      investigation; copies of program rules and regulations violated for the time
      period in question; the estimated overpayment identified; a summary of the
      interviews conducted; the encounter data submitted by the provider for the
      time
      period in question; and all supporting documentation obtained as the result
      of
      the investigation. This requirement applies to all reports of possible acts
      of
      waste, abuse and fraud.

    


    Additional
      reports required by the Office of the Inspector General relating to waste,
      abuse
      or fraud are listed in the HHSC Uniform Managed Care
      Manual.

    


    Provider
      Termination Report: (CHIP (including integrated CHIP Perinatal Program data),
      STAR, and STAR+PLUS)

    


    MCO
      must
      submit a quarterly report that identifies any providers who cease to participate
      in MCO's provider network, either voluntarily or involuntarily. The report
      must
      be submitted to HHSC in the format specified by HHSC, no later than 30 days
      after the end of the reporting period.

    


    PCP
      Network & Capacity Report: (CHIP only (including integrated CHIP Perinatal
      Program data))

    


    For
      the
      CHIP Program, MCO must submit a quarterly report listing all unduplicated PCPs
      in the MCO's Provider Network. For the CHIP Perinatal Program, the Perinatal
      Newborns are assigned PCPs that are part of the CHIP PCP Network. The report
      must be submitted to HHSC in the format specified by HHSC, no later than 30
      days
      after the end of the reporting quarter.

    


    Summary
      Report of Member Complaints and Appeals - The HMO must submit quarterly
      Member Complaints and Appeals reports. The HMO must include in its reports
      Complaints and Appeals submitted to its subcontracted risk groups (e.g., IPAs)
      and any other subcontractor that provides Member services. The HMO must submit
      the Complaint and Appeals reports electronically on or before 45 days following
      the end of the state fiscal quarter, using the format specified by HHSC in
      the
HHSC Uniform Managed Care Manual, Chapter 5.4.2.

    


    HHSC
      may
      direct the CHIP Perinatal HMOs to provide segregated Member Complaints and
      Appeals reports on an as-needed basis.

    


    Summary
      Report of Provider Complaints - The HMO must submit Provider complaints
      reports on a quarterly basis. The HMO must include in its reports complaints
      submitted by providers to its subcontracted risk groups (e.g., IPAs) and any
      other subcontractor that provides Provider services. The complaint reports
      must
      be submitted electronically on or before 45 days following the end of the state
      fiscal quarter, using the format specified by HHSC in the HHSC Uniform
      Managed Care Manual, Chapter 5.4.2.

    


    HHSC
      may
      direct the CHIP Perinatal HMOs to provide segregated Provider Complaints and
      Appeals reports on an as-needed basis.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    Hotline
      Reports - The HMO must submit, on a quarterly basis, a status report
      for the Member Hotline, the Behavioral Health Services Hotline, and the Provider
      Hotline in comparison with the performance standards set out in Sections
      8.1.5.6, 8.1.14.3, and 8.1.4.7. The HMO shall submit such reports using
      a format to be prescribed by HHSC in consultation with the HMOs.

    


    If
      the
      HMO is not meeting a hotline performance standard, HHSC may require the HMO
      to
      submit monthly hotline performance reports and implement corrective actions
      until the hotline performance standards are met. If a HMO has a single hotline
      serving multiple Service Areas, multiple HMO Programs, or multiple hotline
      functions, (i.e. Member, Provider, Behavioral Health Services hotlines), HHSC
      may request on an annual basis that the HMO submit certain hotline response
      information by HMO Program, by Service Area, and by hotline function, as
      applicable to the HMO. HHSC may also request this type of hotline information
      if
      a HMO is not meeting a hotline performance standard.

    


    The
      HMO
      must follow all applicable Joint Interface Plans (JIPs) and all required file
      submissions for HHSC’s Administrative Services Contractor, External Quality
      Review Organization (EQRO) and HHSC Medicaid Claims Administrator. The JIPs
      can
      be accessed through the Uniform Managed Care Manual.

    


    
      	
              8.2

            	
              Additional
                Medicaid HMO Scope of Work

            


    

    


    The
      following provisions apply to any HMO participating in the STAR or STAR+PLUS
      HMO
      Program.

    


    
      	
              8.2.1

            	
              Continuity
                of Care and Out-of-Network
                Providers

            


    

    


    The
      HMO
      must ensure that the care of newly enrolled Members is not disrupted or
      interrupted. The HMO must take special care to provide continuity in the care
      of
      newly enrolled Members whose health or behavioral health condition has been
      treated by specialty care providers or whose health could be placed in jeopardy
      if Medically Necessary Covered Services are disrupted or
      interrupted.

    


    The
      HMO
      must allow pregnant Members with 12 weeks or less remaining before the expected
      delivery date to remain under the care of the Member’s current OB/GYN through
      the Member’s postpartum checkup, even if the provider is Out-of-Network. If a
      Member wants to change her OB/GYN to one who is in the Network, she must be
      allowed to do so if the Provider to whom she wishes to transfer agrees to accept
      her in the last trimester of pregnancy.

    


    The
      HMO
      must pay a Member’s existing Out-of-Network providers for Medically Necessary
      Covered Services until the Member’s records, clinical information and care can
      be transferred to a Network Provider, or until such time as the Member is no
      longer enrolled in that HMO, whichever is shorter. Payment to Out-of-Network
      providers must be made within the time period required for Network Providers.
      The HMO must comply with out-of-network provider reimbursement rules as adopted
      by HHSC.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    This
      Article does not extend the obligation of the HMO to reimburse the Member’s
      existing Out-of- Network providers for on-going care for:

    


    
      	
               

            	
              1.

            	
              More
                than 90 days after a Member enrolls in the HMO’s Program,
                or

            


    

    
      	
               

            	
              2.

            	
              For
                more than nine (9) months in the case of a Member who, at the time
                of
                enrollment in the HMO, has been diagnosed with and receiving treatment
                for
                a terminal illness and remains enrolled in the
                HMO.

            


    

    


    The
      HMO’s
      obligation to reimburse the Member’s existing Out-of-Network provider for
      services provided to a pregnant Member with 12 weeks or less remaining before
      the expected delivery date extends through delivery of the child, immediate
      postpartum care, and the follow-up checkup within the first six weeks of
      delivery.

    


    The
      HMO
      must provide or pay Out-of-Network providers who provide Medically Necessary
      Covered Services to Members who move out of the Service Area through the end
      of
      the period for which capitation has been paid for the Member.

    


    The
      HMO
      must provide Members with timely and adequate access to Out-of-Network services
      for as long as those services are necessary and covered benefits not available
      within the network, in accordance with 42 C.F.R. §438.206(b)(4). The HMO will
      not be obligated to provide a Member with access to Out-of-Network services
      if
      such services become available from a Network Provider.

    


    The
      HMO
      must ensure that each Member has access to a second opinion regarding the use
      of
      any Medically Necessary Covered Service. A Member must be allowed access to
      a
      second opinion from a Network Provider or Out-of-Network provider if a Network
      Provider is not available, at no cost to the Member, in accordance with 42
      C.F.R. §438.206(b)(3).

    


    
      	
              8.2.2

            	
              Provisions
                Related to Covered Services for Medicaid
                Members

            


    

    


    
      	
              8.2.2.1

            	
              Emergency
                Services

            


    

    


    HMO
      policy and procedures, Covered Services, claims adjudication methodology, and
      reimbursement performance for Emergency Services must comply with all applicable
      state and federal laws, rules, and regulations including 42 C.F.R. §438.114,
      whether the provider is in-network or Out-of-Network. HMO policies and
      procedures must be consistent with the prudent layperson definition of an
      Emergency Medical Condition and the claims adjudication processes required
      under
      the Contract and 42 C.F.R. §438.114.

    


    The
      HMO
      must pay for the professional, facility, and ancillary services that are
      Medically Necessary to perform the medical screening examination and
      stabilization of a Member presenting with an Emergency Medical Condition or
      an
      Emergency Behavioral Health Condition to the hospital emergency department,
      24
      hours a day, 7 days a week, rendered by either the HMO's Network or
      Out-of-Network providers.

    


    The
      HMO
      cannot require prior authorization as a condition for payment for an Emergency
      Medical Condition, an Emergency Behavioral Health Condition, or labor and
      delivery. The HMO

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    cannot
      limit what constitutes an Emergency Medical Condition on the basis of lists
      of
      diagnoses or symptoms. The HMO cannot refuse to cover Emergency Services based
      on the emergency room provider, hospital, or fiscal agent not notifying the
      Member’s PCP or the HMO of the Member’s screening and treatment within 10
      calendar days of presentation for Emergency Services. The HMO may not hold
      the
      Member who has an Emergency Medical Condition liable for payment of subsequent
      screening and treatment needed to diagnose the specific condition or stabilize
      the patient. The HMO must accept the emergency physician or provider’s
      determination of when the Member is sufficiently stabilized for transfer or
      discharge.

    


    A
      medical
      screening examination needed to diagnose an Emergency Medical Condition must
      be
      provided in a hospital based emergency department that meets the requirements
      of
      the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 C.F.R.
§§489.20, 489.24 and 438.114(b)&(c)). The HMO must pay for the emergency
      medical screening examination, as required by 42 U.S.C. §1395dd. The HMO must
      reimburse for both the physician's services and the hospital's Emergency
      Services, including the emergency room and its ancillary services.

    


    When
      the
      medical screening examination determines that an Emergency Medical Condition
      exists, the HMO must pay for Emergency Services performed to stabilize the
      Member. The emergency physician must document these services in the Member's
      medical record. The HMO must reimburse for both the physician's and hospital's
      emergency stabilization services including the emergency room and its ancillary
      services.

    


    The
      HMO
      must cover and pay for Post-Stabilization Care Services in the amount, duration,
      and scope necessary to comply with 42 C.F.R. §438.114(b)&(e) and 42 C.F.R.
§422.113(c)(iii). The HMO is financially responsible for post-stabilization
      care
      services obtained within or outside the Network that are not pre-approved by
      a
      Provider or other HMO representative, but administered to maintain, improve,
      or
      resolve the Member’s stabilized condition if:

    


    
      	
               

            	
              1.

            	
              The
                HMO does not respond to a request for pre-approval within 1
                hour;

            


    

    
      	
               

            	
              2.

            	
              The
                HMO cannot be contacted; or

            


    

    
      	
               

            	
              3.

            	
              The
                HMO representative and the treating physician cannot reach an agreement
                concerning the Member’s care and a Network physician is not available for
                consultation. In this situation, the HMO must give the treating physician
                the opportunity to consult with a Network physician and the treating
                physician may continue with care of the patient until an HMO physician
                is
                reached. The HMO’s financial responsibility ends as follows: the HMO
                physician with privileges at the treating hospital assumes responsibility
                for the Member’s care; the HMO physician assumes responsibility for the
                Member’s care through transfer; the HMO representative and the treating
                physician reach an agreement concerning the Member’s care; or the Member
                is discharged.

            


    

    


    
      	
              8.2.2.2

            	
              Family
                Planning - Specific
                Requirements

            


    

    


    The
      HMO
      must require, through Provider contract provisions, that Members requesting
      contraceptive services or family planning services are also provided counseling
      and education about the family planning and family planning services available
      to Members. The HMO must develop outreach programs to increase community support
      for family planning and encourage Members to use available family planning
      services.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      must ensure that Members have the right to choose any Medicaid participating
      family planning provider, whether the provider chosen by the Member is in or
      outside the Provider Network. The HMO must provide Members access to information
      about available providers of family planning services and the Member’s right to
      choose any Medicaid family planning provider. The HMO must provide access to
      confidential family planning services.

    


    The
      HMO
      must provide, at minimum, the full scope of services available under the Texas
      Medicaid program for family planning services. The HMO will reimburse family
      planning agencies the Medicaid fee-for service amounts for family planning
      services, including Medically Necessary medications, contraceptives, and
      supplies not covered by the Vendor Drug Program and will reimburse
      Out-of-Network family planning providers in accordance with HHSC’s
      administrative rules.

    


    The
      HMO
      must provide medically approved methods of contraception to Members, provided
      that the methods of contraception are Covered Services. Contraceptive methods
      must be accompanied by verbal and written instructions on their correct use.
      The
      HMO must establish mechanisms to ensure all medically approved methods of
      contraception are made available to the Member, either directly or by referral
      to a subcontractor.

    


    The
      HMO
      must develop, implement, monitor, and maintain standards, policies and
      procedures for providing information regarding family planning to Providers
      and
      Members, specifically regarding State and federal laws governing Member
      confidentiality (including minors). Providers and family planning agencies
      cannot require parental consent for minors to receive family planning services.
      The HMO must require, through contractual provisions, that subcontractors have
      mechanisms in place to ensure Member’s (including minor’s) confidentiality for
      family planning services.

    


    
      	
              8.2.2.3

            	
              Texas
                Health Steps (EPSDT)

            


    

    


    The
      HMO
      must develop effective methods to ensure that children under the age of 21
      receive THSteps services when due and according to the recommendations
      established by the AAP and the THSteps periodicity schedule for children. The
      HMO must arrange for THSteps services for all eligible Members except when
      a
      Member knowingly and voluntarily declines or refuses services after receiving
      sufficient information to make an informed decision.

    


    HMO
      must
      have mechanisms in place to ensure that all newly enrolled newborns receive
      an
      appointment for a THSteps checkup within 14 days of enrollment and all other
      eligible child Members receive a THSteps checkup within 60 days of enrollment,
      if one is due according to the AAP periodicity schedule.

    


    The
      HMO
      must ensure that Members are provided information and educational materials
      about the services available through the THSteps Program, and how and when
      they
      may obtain the services. The information should tell the Member how they can
      obtain dental benefits, transportation services through the Texas Department
      of
      Transportation’s Medical Transportation Program, and advocacy assistance from
      the HMO.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      must provide appropriate training to all Network Providers and Provider staff
      in
      the Providers’ area of practice regarding the scope of benefits available and
      the THSteps Program. Training must include:

    


    
      	
               

            	
              1.

            	
              THSteps
                benefits,

            


    

    
      	
               

            	
              2.

            	
              The
                periodicity schedule for THSteps medical checkups and
                immunizations,

            


    

    
      	
               

            	
              3.

            	
              The
                required elements of THSteps medical
                checkups,

            


    

    
      	
               

            	
              4.

            	
              Providing
                or arranging for all required lab screening tests (including lead
                screening), and Comprehensive Care Program (CCP) services available
                under
                the THSteps program to Members under age 21
                years.

            


    

    


    HMO
      must
      also educate and train Providers regarding the requirements imposed on HHSC
      and
      contracting HMOs under the Consent Decree entered in Frew v. Hawkins, et. al.,
      Civil Action No. 3:93CV65, in the United States District Court for the Eastern
      District of Texas, Paris Division. Providers should be educated and trained
      to
      treat each THSteps visit as an opportunity for a comprehensive assessment of
      the
      Member.

    


    The
      HMO
      must provide outreach to Members to ensure they receive prompt services and
      are
      effectively informed about available THSteps services. Each month, the HMO
      must
      retrieve from the HHSC Administrative Services Contractor Bulletin Board System
      a list of Members who are due and overdue THSteps services. Using these lists
      and its own internally generated list, the HMO will contact such Members to
      obtain the service as soon as possible. The HMO outreach staff must coordinate
      with DSHS THSteps outreach staff to ensure that Members have access to the
      Medical Transportation Program, and that any coordination with other agencies
      is
      maintained.

    


    The
      HMO
      must cooperate and coordinate with the State, outreach programs and THSteps
      regional program staff and agents to ensure prompt delivery of services to
      children of migrant farm workers and other migrant populations who may
      transition into and out of the HMO’s Program more rapidly and/or unpredictably
      than the general population.

    


    The
      HMO
      must have mechanisms in place to ensure that all newborn Members have an initial
      newborn checkup before discharge from the hospital and again within two weeks
      from the time of birth. The HMO must require Providers to send all THSteps
      newborn screens to the DSHS Bureau of Laboratories or a DSHS certified
      laboratory. Providers must include detailed identifying information for all
      screened newborn Members and the Member’s mother to allow DSHS to link the
      screens performed at the hospital with screens performed at the two-week
      follow-up.

    


    All
      laboratory specimens collected as a required component of a THSteps checkup
      (see
      Medicaid Provider Procedures Manual for age-specific requirements) must be
      submitted to the DSHS Laboratory for analysis. The HMO must educate Providers
      about THSteps Program requirements for submitting laboratory tests to the DSHS
      Bureau of Laboratories.

    


    The
      HMO
      must make an effort to coordinate and cooperate with existing community and
      school-based health and education programs that offer services to school-aged
      children in a location that is both familiar and convenient to the Members.
      The
      HMO must make a good faith effort to comply with Head Start’s requirement that
      Members participating in Head Start receive their THSteps checkup no later
      than
      45 days after enrolling into either program.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      must educate Providers on the Immunization Standard Requirements set forth
      in
      Chapter 161, Health and Safety Code; the standards in the ACIP Immunization
      Schedule; the AAP Periodicity Schedule for CHIP Members; and the DSHS
      Periodicity Schedule for Medicaid Members. The HMO shall educate Providers
      that
      Medicaid Members under age 21 must be immunized during the THSteps checkup
      according to the DSHS routine immunization schedule. The HMO shall also educate
      Providers that the screening provider is responsible for administration of
      the
      immunization and should not refer children to Local Health Departments to
      receive immunizations.

    


    The
      HMO
      must educate Providers about, and require Providers to comply with, the
      requirements of Chapter 161, Health and Safety Code, relating to the Texas
      Immunization Registry (ImmTrac), to include parental consent on the Vaccine
      Information Statement.

    


    The
      HMO
      must require all THSteps Providers to submit claims for services paid (either
      on
      a capitated or fee-for service basis) on the HCFA 1500 claim form and use the
      HIPAA compliant code set required by HHSC.

    


    Encounter
      Data will be validated by chart review of a random sample of THSteps eligible
      enrollees against monthly Encounter Data reported by the HMO. HHSC or its
      designee will conduct chart reviews to validate that all screens are performed
      when due and as reported, and that reported data is accurate and timely.
      Substantial deviation between reported and charted Encounter Data could result
      in the HMO and/or Network Providers being investigated for potential Fraud,
      Abuse, or Waste without notice to the HMO or the Provider.

    


    
      	
              8.2.2.4

            	
              Perinatal
                Services

            


    

    


    The
      HMO’s
      perinatal health care services must ensure appropriate care is provided to
      women
      and infant Members of the HMO from the preconception period through the infant’s
      first year of life. The HMO’s perinatal health care system must comply with the
      requirements of the Texas Health and Safety Code, Chapter 32 (the Maternal
      and
      Infant Health Improvement Act) and administrative rules codified at 25 T.A.C.
      Chapter 37, Subchapter M.

    


    The
      HMO
      must have a perinatal health care system in place that, at a minimum, provides
      the following services:

    


    
      	
               

            	
              1.

            	
              Pregnancy
                planning and perinatal health promotion and education for reproductive-
                age women;

            


    

    
      	
               

            	
              2.

            	
              Perinatal
                risk assessment of non-pregnant women, pregnant and postpartum women,
                and
                infants up to one year of age;

            


    

    
      	
               

            	
              3.

            	
              Access
                to appropriate levels of care based on risk assessment, including
                emergency care;

            


    

    
      	
               

            	
              4.

            	
              Transfer
                and care of pregnant women, newborns, and infants to tertiary care
                facilities when necessary;

            


    

    
      	
               

            	
              5.

            	
              Availability
                and accessibility of OB/GYNs, anesthesiologists, and neonatologists
                capable of dealing with complicated perinatal problems;
                and

            


    

    
      	
               

            	
              6.

            	
              Availability
                and accessibility of appropriate outpatient and inpatient facilities
                capable of dealing with complicated perinatal
                problems.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      must have a process to expedite scheduling a prenatal appointment for an
      obstetrical exam for a TP40 Member no later than two weeks after receiving
      the
      daily Enrollment File verifying the Member’s enrollment into the
      HMO.

    


    The
      HMO
      must have procedures in place to contact and assist a pregnant/delivering Member
      in selecting a PCP for her baby either before the birth or as soon as the baby
      is born.

    


    The
      HMO
      must provide inpatient care and professional services relating to labor and
      delivery for its pregnant/delivering Members, and neonatal care for its newborn
      Members at the time of delivery and for up to 48 hours following an
      uncomplicated vaginal delivery and 96 hours following an uncomplicated Caesarian
      delivery.

    


    The
      HMO
      must Adjudicate provider claims for services provided to a newborn Member in
      accordance with HHSC’s claims processing requirements using the proxy ID number
      or Stateissued Medicaid ID number. The HMO cannot deny claims based on a
      provider’s non-use of State-issued Medicaid ID number for a newborn Member. The
      HMO must accept provider claims for newborn services based on mother’s name
      and/or Medicaid ID number with accommodations for multiple births, as specified
      by the HMO.

    


    The
      HMO
      must notify providers involved in the care of pregnant/delivering women and
      newborns (including Out-of-Network providers and hospitals) of the HMO’s prior
      authorization requirements. The HMO cannot require a prior authorization for
      services provided to a pregnant/delivering Member or newborn Member for a
      medical condition that requires Emergency Services, regardless of when the
      emergency condition arises.

    


    
      	
              8.2.2.5

            	
              Sexually
                Transmitted Diseases (STDs) and Human Immunodeficiency Virus
                (HIV)

            


    

    


    The
      HMO
      must provide STD services that include STD/HIV prevention, screening,
      counseling, diagnosis, and treatment. The HMO is responsible for implementing
      procedures to ensure that Members have prompt access to appropriate services
      for
      STDs, including HIV. The HMO must allow Members access to STD services and
      HIV
      diagnosis services without prior authorization or referral by a
      PCP.

    


    The
      HMO
      must comply with Texas Family Code Section 32.003, relating to consent to
      treatment by a child. The HMO must provide all Covered Services required to
      form
      the basis for a diagnosis by the Provider as well as the STD/HIV treatment
      plan.

    


    The
      HMO
      must make education available to Providers and Members on the prevention,
      detection and effective treatment of STDs, including HIV.

    


    The
      HMO
      must require Providers to report all confirmed cases of STDs, including HIV,
      to
      the local or regional health authority according to 25 T.A.C. §§97.131 - 97.134,
      using the required forms and procedures for reporting STDs. The HMO must require
      the Providers to coordinate with the HHSC regional health authority to ensure
      that Members with confirmed cases of syphilis, chancroid, gonorrhea, chlamydia
      and HIV receive risk reduction and partner elicitation/notification
      counseling.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      must have established procedures to make Member records available to public
      health agencies with authority to conduct disease investigation, receive
      confidential Member information, and provide follow up activities.

    


    The
      HMO
      must require that Providers have procedures in place to protect the
      confidentiality of Members provided STD/HIV services. These procedures must
      include, but are not limited to, the manner in which medical records are to
      be
      safeguarded, how employees are to protect medical information, and under what
      conditions information can be shared. The HMO must inform and require its
      Providers who provide STD/HIV services to comply with all state laws relating
      to
      communicable disease reporting requirements. The HMO must implement policies
      and
      procedures to monitor Provider compliance with confidentiality
      requirements.

    


    The
      HMO
      must have policies and procedures in place regarding obtaining informed consent
      and counseling Members provided STD/HIV services.

    


    
      	
              8.2.2.6

            	
              Tuberculosis
                (TB)

            


    

    


    The
      HMO
      must provide Members and Providers with education on the prevention, detection
      and effective treatment of tuberculosis (TB). The HMO must establish mechanisms
      to ensure all procedures required to screen at-risk Members and to form the
      basis for a diagnosis and proper prophylaxis and management of TB are available
      to all Members, except services referenced in Section 8.2.2.8
as Non-Capitated Services. The HMO must develop policies
      and procedures
      to ensure that Members who may be or are at risk for exposure to TB are screened
      for TB. An at-risk Member means a person who is susceptible to TB because of
      the
      association with certain risk factors, behaviors, drug resistance, or
      environmental conditions. The HMO must consult with the local TB control program
      to ensure that all services and treatments are in compliance with the guidelines
      recommended by the American Thoracic Society (ATS), the Centers for Disease
      Control and Prevention (CDC), and DSHS policies and standards.

    


    The
      HMO
      must implement policies and procedures requiring Providers to report all
      confirmed or suspected cases of TB to the local TB control program within one
      working day of identification, using the most recent DSHS forms and procedures
      for reporting TB. The HMO must provide access to Member medical records to
      DSHS
      and the local TB control program for all confirmed and suspected TB cases upon
      request.

    


    The
      HMO
      must coordinate with the local TB control program to ensure that all Members
      with confirmed or suspected TB have a contact investigation and receive Directly
      Observed Therapy (DOT). The HMO must require, through contract provisions,
      that
      Providers report to DSHS or the local TB control program any Member who is
      non-compliant, drug resistant, or who is or may be posing a public health
      threat. The HMO must cooperate with the local TB control program in enforcing
      the control measures and quarantine procedures contained in Chapter 81 of the
      Texas Health and Safety Code.

    


    The
      HMO
      must have a mechanism for coordinating a post-discharge plan for follow-up
      DOT
      with the local TB program. The HMO must coordinate with the DSHS South Texas
      Hospital and Texas Center for Infectious Disease for voluntary and court-ordered
      admission, discharge plans, treatment objectives and projected length of stay
      for Members with multi-drug resistant TB.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.2.2.7

            	
              Objection
                to Provide Certain
                Services

            


    

    


    In
      accordance with 42 C.F.R. §438.102, the HMO may file an objection to providing,
      reimbursing for, or providing coverage of, a counseling or referral service
      for
      a Covered Service based on moral or religious grounds. The HMO must work with
      HHSC to develop a work plan to complete the necessary tasks and determine an
      appropriate date for implementation of the requested changes to the requirements
      related to Covered Services. The work plan will include timeframes for
      completing the necessary Contract and waiver amendments, adjustments to
      Capitation Rates, identification of the HMO and enrollment materials needing
      revision, and notifications to Members.

    


    In
      order
      to meet the requirements of this section, the HMO must notify HHSC of grounds
      for and provide detail concerning its moral or religious objections and the
      specific services covered under the objection, no less than 120 days prior
      to
      the proposed effective date of the policy change.

    


    
      	
              8.2.2.8

            	
              Medicaid
                Non-capitated Services

            


    

    


    The
      following Texas Medicaid programs and services have been excluded from HMO
      Covered Services. Medicaid Members are eligible to receive these Non-capitated
      Services on a Fee-for- Service basis from Texas Medicaid providers. HMOs should
      refer to relevant chapters in the Provider Procedures Manual
and the Texas Medicaid Bulletins for more
      information.

    


    
      	
               

            	
              1.

            	
              THSteps
                dental (including orthodontia);

            


    

    
      	
               

            	
              2.

            	
              Early
                Childhood Intervention (ECI) case management/service
                coordination;

            


    

    
      	
               

            	
              3.

            	
              DSHS
                targeted case management;

            


    

    
      	
               

            	
              4.

            	
              DSHS
                mental health rehabilitation;

            


    

    
      	
               

            	
              5.

            	
              DSHS
                case management for Children and Pregnant
                Women;

            


    

    
      	
               

            	
              6.

            	
              Texas
                School Health and Related Services
                (SHARS);

            


    

    
      	
               

            	
              7.

            	
              Department
                of Assistive and Rehabilitative Services Blind Children’s Vocational
                Discovery and Development Program;

            


    

    
      	
               

            	
              8.

            	
              Tuberculosis
                services provided by DSHS-approved providers (directly observed therapy
                and contact investigation);

            


    

    
      	
               

            	
              9.

            	
              Vendor
                Drug Program (out-of-office drugs);

            


    

    
      	
              10.

            	
              Texas
                Department of Transportation Medical
                Transportation;

            


    

    
      	
              11.

            	
              DADS
                hospice services (all Members are disenrolled from their health plan
                upon
                enrollment into hospice except STAR+PLUS members receiving 1915(c)
                Nursing
                Facility Waiver services that are not covered by the Hospice
                Program);

            


    

    
      	
              12.

            	
              Audiology
                services and hearing aids for children (under age 21) (hearing screening
                services are provided through the THSteps Program and are capitated)
                through PACT (Program for Amplification for Children of
                Texas).

            


    

    
      	
              13.

            	
              For
                STAR+PLUS, Inpatient Stays are Non-capitated
                Services.

            


    

    


    
      	
              8.2.2.9

            	
              Referrals
                for Non-capitated Services

            


    

    


    Although
      Medicaid HMOs are not responsible for paying or reimbursing for Non-capitated
      Services, HMOs are responsible for educating Members about the availability
      of
      Non-capitated Services, and for providing appropriate referrals for Members
      to
      obtain or access these services.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      is responsible for informing Providers that bills for all Non-capitated Services
      must be submitted to HHSC’s Claims Administrator for
      reimbursement.

    


    
      	
              8.2.2.10

            	
              Cooperation
                with Immunization Registry

            


    

    


    The
      HMO
      must work with HHSC and health care providers to improve the immunization rate
      of Medicaid clients and the reporting of immunization information for
      inclusion in the Texas Immunization Registry, called
“ImmTrac.”

    


    
      	
              8.2.2.11

            	
              Case
                Management for Children and Pregnant
                Women

            


    

    


    The
      HMO
      must educate Members and Providers on the services available through
      Case Management for Children and Pregnant Women (CPW) as described on the
      program’s website
      at http://www.dshs.state.tx.us/caseman/default.shtm. An HMO may
      provide information about CPW’s website and basic information about CPW
      services in order to meet this requirement. CPW information and materials
      must be included in the HMO’s Provider Manual, Member Handbook and Provider
      orientations. The information and materials must also inform Providers that
      the disclosure of medical records or information between Providers, HMO’s and
      CPW case managers does not require a medical release form from the
      Member.

    


    The
      HMO
      must coordinate services with CPW regarding a Member’s health care needs that
      are identified by CPW and referred to the HMO. Upon receipt of a referral
      or assessment from a CPW case manager, the HMO’s designated staff are
      required to review the assessment and determine, based on the HMO’s
      policies, the appropriate level of health care and services. The HMO’s
      staff must also coordinate with the Member’s family, Member’s Primary Care
      Provider (PCP), in and Out-of-Network Providers, agencies, and the HMO’s
      utilization management staff to ensure that the health care and services
      identified are properly referred, authorized, scheduled and provided within
      a timely manner.

    


    The
      HMO
      must ensure that access to medically necessary health care needed by the Member
      is available within the standards established by HHSC for respective care.
      HMOs are not required to arrange or provide for any covered or non-covered
      services identified in the CPW assessment. The decision whether to
      authorize these services is made by the HMO. Within five (5) business days
      of identifying any non-covered health care services or other services that
      the
      Member may need, the HMO’s staff must report to the CPW case manager which
      items/services will not be performed by the HMO. Additionally, within ten
      (10) business days after all of the authorized services have been provided,
      the HMO’s staff must follow-up with CPW case manager to report the
      provision of services. The HMO’s staff must ensure that all services provided to
      a Member by an HMO Provider are reported to the Member’s PCP.

    


    The
      CPW
      program requires its contracted case managers to coordinate with the HMO and
      the HMO’s PCPs. The HMO should report problems regarding CPW referrals,
      assessments or coordination activities to HHSC for follow-up with CPW
      program staff.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.2.3

            	
              Medicaid
                Significant Traditional
                Providers

            


    

    


    In
      the
      first three (3) years of a Medicaid HMO Program operating in a Service Area,
      the
      HMO must seek participation in its Network from all Medicaid Significant
      Traditional Providers (STPs) defined by HHSC in the applicable Service Area
      for
      the applicable HMO Program. For STAR HMOs, the Medicaid STP requirements only
      apply in the Nueces Service Area. For STAR+PLUS HMOs, the Medicaid STP
      requirements apply to all Service Areas, except Harris County within the Harris
      Service Area.

    


    Medicaid
      STPs are defined as PCPs and, for STAR+PLUS, Community-based Long Term Care
      providers in a county, that, when listed by provider type by county in
      descending order by unduplicated number of clients, served the top 80% of
      unduplicated clients. Hospitals receiving Disproportionate Share Hospital (DSH)
      funds are also considered STPs in the Service Area in which they are located.
      Note that STAR+PLUS HMOs are not required to contract with Hospitals for
      Inpatient Stays, but are required to contract with Hospitals for Outpatient
      Hospital Services. The HHSC website includes a list of Medicaid STPs by Service
      Area.

    


    Because
      the STP lists were produced in FY2005, HHSC has developed an updated list for
      Long Term Care Providers. The list will be provided to HMOs and posted on HHSC’s
      website.

    


    The
      STP
      requirement will be in place for three years after the program has been
      implemented. During that time, providers who believe they meet the STP
      requirements may contact HHSC request HHSC’s consideration for STP status.
      STAR+PLUS HMOs will be notified when Providers are added to the list of STPs
      for
      a Service Area.

    


    The
      HMO
      must give STPs the opportunity to participate in its Network for at least three
      (3) years commencing on the implementation date of Medicaid managed care in
      the
      Service Area. However, the STP provider must:

    


    
      	
               

            	
              1.

            	
              Agree
                to accept the HMO’s Provider reimbursement rate for the provider type;
                and

            


    

    
      	
               

            	
              2.

            	
              Meet
                the standard credentialing requirements of the HMO, provided that
                lack of
                board certification or accreditation by the Joint Commission on
                Accreditation of Health Care Organizations (JCAHO) is not the sole
                grounds
                for exclusion from the Provider
                Network.

            


    

    


    
      	
              8.2.4

            	
              Federally
                Qualified Health Centers (FQHCs) and Rural Health Clinics
                (RHCs)

            


    

    


    The
      HMO
      must make reasonable efforts to include FQHCs and RHCs (freestanding and
      hospital-based) in its Provider Network. The HMO must reimburse FQHCs and RHCs
      for health care services provided outside of regular business hours, as defined
      by HHSC in rules, including weekend days or holidays, at a rate that is equal
      to
      the allowable rate for those services as determined under Section 32.028, Human
      Resources Code, if the Member does not have a referral from their PCP. FQHCs
      or
      RHCs will receive a cost settlement from HHSC and must agree to accept initial
      payments from the HMO in an amount that is equal to or greater than the HMO’s
      payment terms for other Providers providing the same or similar services. Cost
      settlements will not be applicable to the Nueces Service Area and the STAR+PLUS
      Service Areas. The HMOs serving those Areas will pay the full encounter rates
      to
      the FQHCs and RHCs when claims payments are made.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      must submit monthly FQHC and RHC encounter and payment reports to all contracted
      FQHCs and RHCs, and FQHCs and RHCs with which there have been encounters, not
      later than 21 days from the end of the month for which the report is submitted.
      The format will be developed by HHSC and provided in the Uniform Managed
      Care Manual. The FQHC and RHC must validate the encounter and payment
      information contained in the report(s). The HMO and the FQHC/RHC must both
      sign
      the report(s) after each party agrees that it accurately reflects encounters
      and
      payments for the month reported. The HMO must submit the signed FQHC and RHC
      encounter and payment reports to HHSC not later than 45 days from the end of
      the
      reported month. Encounter and payment reports will not be necessary for the
      Nueces Service Area and the STAR+PLUS Service Areas since the HMOs in those
      Areas will be paying the full encounter rates to the FQHCs and
      RHCs.

    


    
      	
              8.2.5

            	
              Provider
                Complaints and Appeals

            


    

    


    
      	
              8.2.5.1

            	
              Provider
                Complaints

            


    

    


    Medicaid
      HMOs must develop, implement, and maintain a system for tracking and resolving
      all Medicaid Provider complaints. Within this process, the HMO must respond
      fully and completely to each complaint and establish a tracking mechanism to
      document the status and final disposition of each Provider complaint. The HMO
      must resolve Provider Complaints within 30 days from the date the Complaint
      is
      received.

    


    
      	
              8.2.5.2

            	
              Appeal
                of Provider Claims

            


    

    


    Medicaid
      HMOs must develop, implement, and maintain a system for tracking and resolving
      all Medicaid Provider appeals related to claims payment. Within this process,
      the Provider must respond fully and completely to each Medicaid Provider’s
      claims payment appeal and establish a tracking mechanism to document the status
      and final disposition of each Medicaid Provider’s claims payment
      appeal.

    


    Medicaid
      HMOs must contract with physicians who are not Network Providers to resolve
      claims disputes related to denial on the basis of medical necessity that remain
      unresolved subsequent to a Provider appeal. The determination of the physician
      resolving the dispute must be binding on the HMO and the Provider. The physician
      resolving the dispute must hold the same specialty or a related specialty as
      the
      appealing Provider. HHSC reserves the right to amend this process to include
      an
      independent review process established by HHSC for final determination on these
      disputes.

    


    
      	
              8.2.6

            	
              Member
                Rights and
                Responsibilities

            


    

    


    In
      accordance with 42 C.F.R. §438.100, all Medicaid HMOs must maintain written
      policies and procedures for informing Members of their rights and
      responsibilities, and must notify their Members of their right to request a
      copy
      of these rights and responsibilities. The Member Handbook must include
      notification of Member rights and responsibilities.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.2.7

            	
              Medicaid
                Member Complaint and Appeal
                System

            


    

    


    The
      HMO
      must develop, implement, and maintain a Member Complaint and Appeal system
      that
      complies with the requirements in applicable federal and state laws and
      regulations, including 42 C.F.R. §431.200, 42 C.F.R. Part 438, Subpart F,
“Grievance System,” and the provisions of 1 T.A.C. Chapter 357 relating to
      Medicaid managed care organizations.

    


    The
      Complaint and Appeal system must include a Complaint process, an Appeal process,
      and access to HHSC’s Fair Hearing System. The procedures must be the same for
      all Members and must be reviewed and approved in writing by HHSC or its
      designee. Modifications and amendments to the Member Complaint and Appeal system
      must be submitted for HHSC’s approval at least 30 days prior to the
      implementation.

    


    
      	
              8.2.7.1

            	
              Member
                Complaint Process

            


    

    


    The
      HMO
      must have written policies and procedures for receiving, tracking, responding
      to, reviewing, reporting and resolving Complaints by Members or their authorized
      representatives. For purposes of this Section 8.2.7, an
“authorized representative” is any person or entity acting on behalf of the
      Member and with the Member’s written consent. A Provider may be an authorized
      representative.

    


    The
      HMO
      must resolve Complaints within 30 days from the date the Complaint is received.
      The HMO is subject to remedies, including liquidated damages, if at least 98
      percent of Member Complaints are not resolved within 30 days of receipt of
      the
      Complaint by the HMO. Please see the Uniform Managed Care Contract Terms
& Conditions and Attachment B-5, Deliverables/Liquidated
      Damages Matrix. The Complaint procedure must be the same for all
      Members under the Contract. The Member or Member’s authorized representative may
      file a Complaint either orally or in writing. The HMO must also inform Members
      how to file a Complaint directly with HHSC, once the Member has exhausted the
      HMO’s complaint process.

    


    The
      HMO
      must designate an officer of the HMO who has primary responsibility for ensuring
      that Complaints are resolved in compliance with written policy and within the
      required timeframe. For purposes of Section 8.2.7.2, an
“officer” of the HMO means a president, vice president, secretary,
      treasurer, or
      chairperson of the board for a corporation, the sole proprietor, the managing
      general partner of a partnership, or a person having similar executive authority
      in the organization.

    


    The
      HMO
      must have a routine process to detect patterns of Complaints. Management,
      supervisory, and quality improvement staff must be involved in developing policy
      and procedure improvements to address the Complaints.

    


    The
      HMO’s
      Complaint procedures must be provided to Members in writing and through oral
      interpretive services. A written description of the HMO’s Complaint procedures
      must be available in prevalent non-English languages for Major Population Groups
      identified by HHSC, at no more than a 6th grade reading level.

    


    The
      HMO
      must include a written description of the Complaint process in the Member
      Handbook. The HMO must maintain and publish in the Member Handbook, at least
      one
      local and one toll-

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    free
      telephone number with TeleTypewriter/Telecommunications Device for the Deaf
      (TTY/TDD) and interpreter capabilities for making Complaints.

    


    The
      HMO’s
      process must require that every Complaint received in person, by telephone,
      or
      in writing must be acknowledged and recorded in a written record and logged
      with
      the following details:

    


    
      	
               

            	
              1.

            	
              Date;

            


    

    
      	
               

            	
              2.

            	
              Identification
                of the individual filing the
                Complaint;

            


    

    
      	
               

            	
              3.

            	
              Identification
                of the individual recording the
                Complaint;

            


    

    
      	
               

            	
              4.

            	
              Nature
                of the Complaint;

            


    

    
      	
               

            	
              5.

            	
              Disposition
                of the Complaint (i.e., how the HMO resolved the
                Complaint);

            


    

    
      	
               

            	
              6.

            	
              Corrective
                action required; and

            


    

    
      	
               

            	
              7.

            	
              Date
                resolved.

            


    

    


    The
      HMO
      is prohibited from discriminating or taking punitive action against a Member
      or
      his or her representative for making a Complaint.

    


    If
      the
      Member makes a request for disenrollment, the HMO must give the Member
      information on the disenrollment process and direct the Member to the HHSC
      Administrative Services Contractor. If the request for disenrollment includes
      a
      Complaint by the Member, the Complaint will be processed separately from the
      disenrollment request, through the Complaint process.

    


    The
      HMO
      will cooperate with the HHSC’s Administrative Services Contractor and HHSC or
      its designee to resolve all Member Complaints. Such cooperation may include,
      but
      is not limited to, providing information or assistance to internal Complaint
      committees.

    


    The
      HMO
      must provide designated Member Advocates to assist Members in understanding
      and
      using the HMO’s Complaint system as described in Section
      8.2.7.9. The HMO’s Member Advocates must assist Members in writing or
      filing a Complaint and monitoring the Complaint through the HMO’s Complaint
      process until the issue is resolved.

    


    
      	
              8.2.7.2

            	
              Medicaid
                Standard Member Appeal
                Process

            


    

    


    The
      HMO
      must develop, implement and maintain an Appeal procedure that complies with
      state and federal laws and regulations, including 42 C.F.R.§ 431.200 and 42
      C.F.R. Part 438, Subpart F, “Grievance System.” An Appeal is a disagreement with
      an HMO Action as defined in HHSC’s Uniform Contract Terms and
      Conditions. The Appeal procedure must be the same for all Members. When
      a Member or his or her authorized representative expresses orally or in writing
      any dissatisfaction or disagreement with an Action, the HMO must regard the
      expression of dissatisfaction as a request to Appeal an Action.

    


    A
      Member
      must file a request for an Appeal with the HMO within 30 days from receipt
      of
      the notice of the Action. The HMO is subject to remedies, including liquidated
      damages, if at least 98 percent of Member Appeals are not resolved within 30
      days of receipt of the Appeal by the HMO. Please see the Uniform Managed
      Care Contract Terms & Conditions and Attachment B-5, Deliverables/Liquidated
      Damages Matrix. To ensure continuation of currently authorized
      services, however, the Member must file the Appeal on or before the later of
      10
      days following

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    the
      HMO’s
      mailing of the notice of the Action, or the intended effective date of the
      proposed Action. The HMO must designate an officer who has primary
      responsibility for ensuring that Appeals are resolved in compliance with written
      policy and within the 30-day time limit.

    


    The
      provisions of Article 21.58A, Texas Insurance Code, (to be recodified as Texas
      Insurance Code, Title 14, Chapter 4201), relating to a Member’s right to Appeal
      an Adverse Determination made by the HMO or a utilization review agent to an
      independent review organization, do not apply to a Medicaid recipient. Article
      21.58A is pre-empted by federal Fair Hearings requirements.

    


    The
      HMO
      must have policies and procedures in place outlining the Medical Director’s role
      in an Appeal of an Action. The Medical Director must have a significant role
      in
      monitoring, investigating and hearing Appeals. In accordance with 42 C.F.R.§
438.406, the HMO’s policies and procedures must require that individuals who
      make decisions on Appeals are not involved in any previous level of review
      or
      decision-making, and are health care professionals who have the appropriate
      clinical expertise in treating the Member’s condition or disease.

    


    The
      HMO
      must provide designated Member Advocates, as described in Section
      8.2.7.9, to assist Members in understanding and using the Appeal
      process. The HMO’s Member Advocates must assist Members in writing or filing an
      Appeal and monitoring the Appeal through the HMO’s Appeal process until the
      issue is resolved.

    


    The
      HMO
      must have a routine process to detect patterns of Appeals. Management,
      supervisory, and quality improvement staff must be involved in developing policy
      and procedure improvements to address the Appeals.

    


    The
      HMO’s
      Appeal procedures must be provided to Members in writing and through oral
      interpretive services. A written description of the Appeal procedures must
      be
      available in prevalent non-English languages identified by HHSC, at no more
      than
      a 6th grade reading level. The HMO must include a written description of the
      Appeals process in the Member Handbook. The HMO must maintain and publish in
      the
      Member Handbook at least one local and one toll-free telephone number with
      TTY/TDD and interpreter capabilities for requesting an Appeal of an
      Action.

    


    The
      HMO’s
      process must require that every oral Appeal received must be confirmed by a
      written, signed Appeal by the Member or his or her representative, unless the
      Member or his or her representative requests an expedited resolution. All
      Appeals must be recorded in a written record and logged with the following
      details:

    


    
      	
               

            	
              1)

            	
              Date
                notice is sent;

            


    

    
      	
               

            	
              2)

            	
              Effective
                date of the Action;

            


    

    
      	
               

            	
              3)

            	
              Date
                the Member or his or her representative requested the
                Appeal;

            


    

    
      	
               

            	
              4)

            	
              Date
                the Appeal was followed up in
                writing;

            


    

    
      	
               

            	
              5)

            	
              Identification
                of the individual filing;

            


    

    
      	
               

            	
              6)

            	
              Nature
                of the Appeal; and

            


    

    
      	
               

            	
              7)

            	
              Disposition
                of the Appeal, and notice of disposition to
                Member.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      must send a letter to the Member within five (5) business days acknowledging
      receipt of the Appeal request. Except for the resolution of an Expedited Appeal
      as provided in Section 8.2.7.3, the HMO must complete the
      entire standard Appeal process within 30 calendar days after receipt of the
      initial written or oral request for Appeal. The timeframe for a standard Appeal
      may be extended up to 14 calendar days if the Member or his or her
      representative requests an extension; or the HMO shows that there is a need
      for
      additional information and how the delay is in the Member’s interest. If the
      timeframe is extended, the HMO must give the Member written notice of the reason
      for delay if the Member had not requested the delay. The HMO must designate
      an
      officer who has primary responsibility for ensuring that Appeals are resolved
      within these timeframes and in accordance with the HMO’s written
      policies.

    


    During
      the Appeal process, the HMO must provide the Member a reasonable opportunity
      to
      present evidence and any allegations of fact or law in person as well as in
      writing. The HMO must inform the Member of the time available for providing
      this
      information and that, in the case of an expedited resolution, limited time
      will
      be available. 

     

    The
      HMO
      must provide the Member and his or her representative opportunity, before and
      during the
      Appeal process, to examine the Member’s case file, including medical records and
      any other documents considered during the Appeal process. The HMO must include,
      as parties to the Appeal, the Member and his or her representative or the legal
      representative of a deceased Member’s estate.

    


    In
      accordance with 42 C.F.R.§ 438.420, the HMO must continue the Member’s benefits
      currently being received by the Member, including the benefit that is the
      subject of the Appeal, if all of the following criteria are met:

    


    
      	
               

            	
              1.

            	
              The
                Member or his or her representative files the Appeal timely as defined
                in
                this Contract:

            


    

    
      	
               

            	
              2.

            	
              The
                Appeal involves the termination, suspension, or reduction of a previously
                authorized course of treatment;

            


    

    
      	
               

            	
              3.

            	
              The
                services were ordered by an authorized
                provider;

            


    

    
      	
               

            	
              4.

            	
              The
                original period covered by the original authorization has not expired;
                and

            


    

    
      	
               

            	
              5.

            	
              The
                Member requests an extension of the
                benefits.

            


    

    


    If,
      at
      the Member’s request, the HMO continues or reinstates the Member’s benefits
      while the Appeal is pending, the benefits must be continued until one of the
      following occurs:

    


    
      	
               

            	
              1.

            	
              The
                Member withdraws the Appeal;

            


    

    


    
      	
               

            	
              2.

            	
              Ten
                (10) days pass after the HMO mails the notice resolving the Appeal
                against
                the Member, unless the Member, within the 10-day timeframe, has requested
                a Fair Hearing with continuation of benefits until a Fair Hearing
                decision
                can be reached; or

            


    

    


    
      	
               

            	
              3.

            	
              A
                state Fair Hearing officer issues a hearing decision adverse to the
                Member
                or the time period or service limits of a previously authorized service
                has been met.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    In
      accordance with 42 C.F.R.§ 438.420(d), if the final resolution of the Appeal is
      adverse to the Member and upholds the HMO’s Action, then to the extent that the
      services were furnished to comply with the Contract, the HMO may recover such
      costs from the Member.

    


    If
      the
      HMO or State Fair Hearing Officer reverses a decision to deny, limit, or delay
      services that were not furnished while the Appeal was pending, the HMO must
      authorize or provide the disputed services promptly and as expeditiously as
      the
      Member’s health condition requires.

    


    If
      the
      HMO or State Fair Hearing Officer reverses a decision to deny authorization
      of
      services and the Member received the disputed services while the Appeal was
      pending, the HMO is responsible for the payment of services.

    


    The
      HMO
      is prohibited from discriminating or taking punitive action against a Member
      or
      his or her representative for making an Appeal.

    


    
      	
              8.2.7.3

            	
              Expedited
                Medicaid HMO Appeals

            


    

    


    In
      accordance with 42 C.F.R. §438.410, the HMO must establish and maintain an
      expedited review process for Appeals, when the HMO determines (for a request
      from a Member) or the provider indicates (in making the request on the Member’s
      behalf or supporting the Member’s request) that taking the time for a standard
      resolution could seriously jeopardize the Member’s life or health. The HMO must
      follow all Appeal requirements for standard Member Appeals as set forth in
      Section 8.2.7.2), except where differences are specifically
      noted. The HMO must accept oral or written requests for Expedited
      Appeals.

    


    Members
      must exhaust the HMO’s Expedited Appeal process before making a request for an
      expedited Fair Hearing. After the HMO receives the request for an Expedited
      Appeal, it must hear an approved request for a Member to have an Expedited
      Appeal and notify the Member of the outcome of the Expedited Appeal within
      3
      business days, except that the HMO must complete investigation and resolution
      of
      an Appeal relating to an ongoing emergency or denial of continued
      hospitalization: (1) in accordance with the medical or dental immediacy of
      the
      case; and (2) not later than one (1) business day after receiving the Member’s
      request for Expedited Appeal is received.

    


    Except
      for an Appeal relating to an ongoing emergency or denial of continued
      hospitalization, the timeframe for notifying the Member of the outcome of the
      Expedited Appeal may be extended up to 14 calendar days if the Member requests
      an extension or the HMO shows (to the satisfaction of HHSC, upon HHSC’s request)
      that there is a need for additional information and how the delay is in the
      Member’s interest. If the timeframe is extended, the HMO must give the Member
      written notice of the reason for delay if the Member had not requested the
      delay.

    


    If
      the
      decision is adverse to the Member, the HMO must follow the procedures relating
      to the notice in Section 8.2.7.5. The HMO is responsible for
      notifying the Member of his or her right to access an expedited Fair Hearing
      from HHSC. The HMO will be responsible for providing documentation to the State
      and the Member, indicating how the decision was made, prior to HHSC’s expedited
      Fair Hearing.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      is prohibited from discriminating or taking punitive action against a Member
      or
      his or her representative for requesting an Expedited Appeal. The HMO must
      ensure that punitive action is neither taken against a provider who requests
      an
      expedited resolution or supports a Member’s request.

    


    If
      the
      HMO denies a request for expedited resolution of an Appeal, it
      must:

    


    
      	
              (1)

            	
              Transfer
                the Appeal to the timeframe for standard resolution,
                and

            


    

    
      	
              (2)

            	
              Make
                a reasonable effort to give the Member prompt oral notice of the
                denial,
                and follow up within two (2) calendar days with a written
                notice.

            


    

    


    
      	
              8.2.7.4

            	
              Access
                to Fair Hearing for Medicaid
                Members

            


    

    


    The
      HMO
      must inform Members that they have the right to access the Fair Hearing process
      at any time during the Appeal system provided by the HMO. In the case of an
      expedited Fair Hearing process, the HMO must inform the Member that he or she
      must first exhaust the HMO’s internal Expedited Appeal process prior to filing
      an Expedited Fair Hearing. The HMO must notify Members that they may be
      represented by an authorized representative in the Fair Hearing
      process.

    


    
      	
              8.2.7.5

            	
              Notices
                of Action and Disposition of Appeals for Medicaid
                Members

            


    

    


    The
      HMO
      must notify the Member, in accordance with 1 T.A.C. Chapter 357, whenever the
      HMO takes an Action. The notice must, at a minimum, include any information
      required by 1 T.A.C. Chapter 357 that relates to a managed care organization’s
      notice of Action and any information required by 42 C.F.R. §438.404 as directed
      by HHSC, including but not limited to:

    


    
      	
               

            	
              1.

            	
              The
                dates, types and amount of service
                requested;

            


    

    


    
      	
               

            	
              2.

            	
              The
                Action the HMO has taken or intends to
                take;

            


    

    


    
      	
               

            	
              3.

            	
              The
                reasons for the Action (If the Action taken is based upon a determination
                that the requested service is not medically necessary, the HMO must
                provide an explanation of the medical basis for the decision, application
                of policy or accepted standards of medical practice to the individuals
                medical circumstances, in it’s notice to the
                member.);

            


    

    


    
      	
               

            	
              4.

            	
              The
                Member’s right to access the HMO’s Appeal
                process.

            


    

    


    
      	
               

            	
              5.

            	
              The
                procedures by which the Member may Appeal the HMO’s
                Action;

            


    

    


    
      	
               

            	
              6.

            	
              The
                circumstances under which expedited resolution is available and how
                to
                request it;

            


    

    


    
      	
               

            	
              7.

            	
              The
                circumstances under which a Member may continue to receive benefits
                pending resolution of the Appeal, how to request that benefits be
                continued, and the circumstances under which the Member may be required
                to
                pay the costs of these services;

            


    

    


    
      	
               

            	
              8.

            	
              The
                date the Action will be taken;

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              9.

            	
               

            	
              A
                reference to the HMO policies and procedures supporting the HMO’s
                Action;

            


    

    


    
      	
              10.

            	
              An
                address where written requests may be sent and a toll-free number
                that the
                Member can call to request the assistance of a Member representative,
                file
                an Appeal, or request a Fair
                Hearing;

            


    

    


    
      	
              11.

            	
              An
                explanation that Members may represent themselves, or be represented
                by a
                provider, a friend, a relative, legal counsel or another
                spokesperson;

            


    

    


    
      	
              12.

            	
              A
                statement that if the Member wants a Fair Hearing on the Action,
                the
                Member must make the request for a Fair Hearing within 90 days of
                the date
                on the notice or the right to request a hearing is
                waived;

            


    

    


    
      	
              13.

            	
              A
                statement explaining that the HMO must make its decision within 30
                days
                from the date the Appeal is received by the HMO, or 3 business days
                in the
                case of an Expedited Appeal; and

            


    

    


    
      	
              14.

            	
              A
                statement explaining that the hearing officer must make a final decision
                within 90 days from the date a Fair Hearing is
                requested.

            


    

    


    
      	
              8.2.7.6

            	
              Timeframe
                for Notice of Action

            


    

    


    In
      accordance with 42 C.F.R.§ 438.404(c), the HMO must mail a notice of Action
      within the following timeframes:

    


    
      	
               

            	
              1.

            	
              For
                termination, suspension, or reduction of previously authorized
                Medicaid-covered services, within the timeframes specified in 42
                C.F.R.§§
                431.211, 431.213, and 431.214;

            


    

    
      	
               

            	
              2.

            	
              For
                denial of payment, at the time of any Action affecting the
                claim;

            


    

    
      	
               

            	
              3.

            	
              For
                standard service authorization decisions that deny or limit services,
                within the timeframe specified in 42 C.F.R.§
                438.210(d)(1);

            


    

    
      	
               

            	
              4.

            	
              If
                the HMO extends the timeframe in accordance with 42 C.F.R. §438.210(d)(1),
                it must:

            


    

    
      	
               

            	
              5.

            	
              give
                the Member written notice of the reason for the decision to extend
                the
                timeframe and inform the Member of the right to file an Appeal if
                he or
                she disagrees with that decision;
                and

            


    

    
      	
               

            	
              6.

            	
              issue
                and carry out its determination as expeditiously as the Member’s health
                condition requires and no later than the date the extension
                expires;

            


    

    
      	
               

            	
              7.

            	
              For
                service authorization decisions not reached within the timeframes
                specified in 42 C.F.R.§ 438.210(d) (which constitutes a denial and is thus
                an adverse Action), on the date that the timeframes expire;
                and

            


    

    
      	
               

            	
              8.

            	
              For
                expedited service authorization decisions, within the timeframes
                specified
                in 42 C.F.R. 438.210(d).

            


    

    


    
      	
              8.2.7.7

            	
              Notice
                of Disposition of Appeal

            


    

    


    In
      accordance with 42 C.F.R.§ 438.408(e), the HMO must provide written notice of
      disposition of all Appeals including Expedited Appeals. The written resolution
      notice must include the results

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    and
      date
      of the Appeal resolution. For decisions not wholly in the Member’s favor, the
      notice must contain:

    


    
      	
               

            	
              1.

            	
              The
                right to request a Fair Hearing;

            


    

    
      	
               

            	
              2.

            	
              How
                to request a Fair Hearing;

            


    

    
      	
               

            	
              3.

            	
              The
                circumstances under which the Member may continue to receive benefits
                pending a Fair Hearing;

            


    

    
      	
               

            	
              4.

            	
              How
                to request the continuation of
                benefits;

            


    

    
      	
               

            	
              5.

            	
              If
                the HMO’s Action is upheld in a Fair Hearing, the Member may be liable for
                the cost of any services furnished to the Member while the Appeal
                is
                pending; and

            


    

    
      	
               

            	
              6.

            	
              Any
                other information required by 1 T.A.C. Chapter 357 that relates to
                a
                managed care organization’s notice of disposition of an
                Appeal.

            


    

    


    
      	
              8.2.7.8

            	
              Timeframe
                for Notice of Resolution of
                Appeals

            


    

    


    In
      accordance with 42 C.F.R.§ 438.408, the HMO must provide written notice of
      resolution of Appeals, including Expedited Appeals, as expeditiously as the
      Member’s health condition requires, but the notice must not exceed the timelines
      as provided in this Section for Standard or Expedited Appeals. For expedited
      resolution of Appeals, the HMO must make reasonable efforts to give the Member
      prompt oral notice of resolution of the Appeal, and follow up with a written
      notice within the timeframes set forth in this Section for Expedited Appeals.
      If
      the HMO denies a request for expedited resolution of an Appeal, the HMO must
      transfer the Appeal to the timeframe for standard resolution as provided in
      this
      Section, and make reasonable efforts to give the Member prompt oral notice
      of
      the denial, and follow up within two calendar days with a written
      notice.

    


    
      	
              8.2.7.9

            	
              Medicaid
                Member Advocates

            


    

    


    The
      HMO
      must provide Member Advocates to assist Members. Member Advocates must be
      physically located within the Service Area unless an exception is approved
      by
      HHSC. Member Advocates must inform Members of the following:

    


    
      	
               

            	
              1.

            	
              Their
                rights and responsibilities,

            


    

    
      	
               

            	
              2.

            	
              The
                Complaint process,

            


    

    
      	
               

            	
              3.

            	
              The
                Appeal process,

            


    

    
      	
               

            	
              4.

            	
              Covered
                Services available to them, including preventive services,
                and

            


    

    
      	
               

            	
              5.

            	
              Non-capitated
                Services available to them.

            


    

    


    Member
      Advocates must assist Members in writing Complaints and are responsible for
      monitoring the Complaint through the HMO’s Complaint process.

    


    Member
      Advocates are responsible for making recommendations to management on any
      changes needed to improve either the care provided or the way care is delivered.
      Member Advocates are also responsible for helping or referring Members to
      community resources available to meet Member needs that are not available from
      the HMO as Medicaid Covered Services.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.2.8

            	
              Additional
                Medicaid Behavioral Health
                Provisions

            


    

    


    
      	
              8.2.8.1

            	
              Local
                Mental Health Authority
                (LMHA)

            


    

    


    Assessment
      to determine eligibility for rehabilitative and targeted DSHS case
      management services is a function of the LMHA. Covered Services must be
      provided to Members with severe and persistent mental illness (SPMI) and
      severe emotional disturbance (SED), when Medically Necessary, whether or
      not they are also receiving targeted case management or
      rehabilitation services through the LMHA.

    


    The
      HMO
      must enter into written agreements with all LMHAs in the Service Area that
      describe the process(es) that the HMO and LMHAs will use to coordinate
      services for Medicaid Members with SPMI or SED. The agreements
      will:

    


    
      	
               

            	
              1.

            	
              Describe
                the Behavioral Health Services indicated in detail in the Provider
                Procedures Manual and in
                the Texas Medicaid Bulletin, include the amount,
                duration, and scope of basic and Value-added Services, and the HMO’s
                responsibility to provide these
                services;

            


    

    
      	
               

            	
              2.

            	
              Describe
                criteria, protocols, procedures and instrumentation for referral
                of
                Medicaid Members from and to the HMO and the
                LMHA;

            


    

    
      	
               

            	
              3.

            	
              Describe
                processes and procedures for referring Members with SPMI or SED to
                the LMHA for assessment and determination of eligibility for
                rehabilitation or targeted case management
                services;

            


    

    
      	
               

            	
              4.

            	
              Describe
                how the LMHA and the HMO will coordinate providing Behavioral
                Health Services to Members with SPMI or
                SED;

            


    

    
      	
               

            	
              5.

            	
              Establish
                clinical consultation procedures between the HMO and LMHA
                including consultation to effect referrals and on-going consultation
                regarding the
                Member’s progress;

            


    

    
      	
               

            	
              6.

            	
              Establish
                procedures to authorize release and exchange of clinical treatment
                records;

            


    

    
      	
               

            	
              7.

            	
              Establish
                procedures for coordination of assessment, intake/triage,
                utilization review/utilization management and care for persons with
                SPMI or SED;

            


    

    
      	
               

            	
              8.

            	
              Establish
                procedures for coordination of inpatient psychiatric services (including
                Court-ordered Commitment of Members under 21) in state psychiatric
                facilities within the LMHA’s catchment
                area;

            


    

    
      	
               

            	
              9.

            	
              Establish
                procedures for coordination of emergency and urgent services to
                Members;

            


    

    
      	
            	
                     
                10.

            	
              Establish
                procedures for coordination of care and transition of care for new
                Members who are receiving treatment through the LMHA;
                and

            


    

    
      	
                         
                11.

            	
              Establish
                that when Members are receiving Behavioral Health Services from the
                Local Mental Health Authority that the HMO is using the same UM
                guidelines as those prescribed for use by local mental health
                authorities by DSHS which are published
                at: http://www.mhmr.state.tx.us/centraloffice/behavioralhealthservices/RDMClinGuide.html.

            


    

    


    The
      HMO
      must offer licensed practitioners of the healing arts (defined in 25 T.A.C.,
      Part 2, Chapter 419, Subchapter L), who are part of the Member’s treatment
      team for rehabilitation services, the opportunity to participate in the
      HMO’s Network. The practitioner must agree to accept the HMO’s Provider
      reimbursement rate, meet the credentialing requirements, and comply with
      all the terms and conditions of the HMO’s standard Provider
      contract.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    HMOs
      must
      allow Members receiving rehabilitation services to choose the licensed
      practitioners of the healing arts who are currently a part of the Member’s
      treatment team for rehabilitation services to provide Covered Services. If
      the
      Member chooses to receive these services from licensed practitioners of the
      healing arts who are part of the Member’s rehabilitation services treatment team
      but are not part of the HMO’s Network, the HMO must reimburse the Local Mental
      Health Authority through Out-of-Network reimbursement arrangements.

    


    Nothing
      in this section diminishes the potential for the Local Mental Health Authority
      to seek best value for rehabilitative services by providing these services
      under
      arrangement, where possible, as specified is 25 T.A.C. §419.455.

    


    
      	
              8.2.9

            	
              Third
                Party Liability and
                Recovery

            


    

    


    Medicaid
      HMOs are responsible for establishing a plan and process for recovering costs
      for services that should have been paid through a third party in accordance
      with
      State and Federal law and regulations. To recognize this requirement, capitation
      payments to the HMOs are reduced by the projected amount of TPR that the HMO
      is
      expected to recover.

    


    The
      HMOs
      must provide required reports as stated in Section 8.1.17.2,
Financial Reporting Requirements.

    


    After
      120-days from the date of service on any claim, encounter, or other Medicaid
      related payment by the HMO subject to Third Party Recovery, HHSC may attempt
      recovery independent of any HMO action. HHSC will retain, in full, all funds
      received as a result of the state initiated recovery or subrogation
      action.

    


    HMOs
      shall provide a Member quarterly file, which contains the following information
      if available to the HMO: the Member name, address, claim submission address,
      group number, employer's mailing address, social security number, and date
      of
      birth for each subscriber or policyholder and each dependent of the subscriber
      or policyholder covered by the insurer. The file shall be used for the purpose
      of matching the Texas Medicaid eligibility file against the HMO Member file
      to
      identify Medicaid clients enrolled in the HMO, which may not be known the
      Medicaid Program.

    


    
      	
              8.2.10

            	
              Coordination
                With Public Health
                Entities

            


    

    


    
      	
              8.2.10.1

            	
              Reimbursed
                Arrangements with Public Health
                Entities

            


    

    


    The
      HMO
      must make a good faith effort to enter into a subcontract for Covered Services
      with Public Health Entities. Possible Covered Services that could be provided
      by
      Public Health Entities include, but are not limited to, the following
      services:

    


    
      	
               

            	
              1.

            	
              Sexually
                Transmitted Diseases (STDs)
                services;

            


    

    
      	
               

            	
              2.

            	
              Confidential
                HIV testing;

            


    

    
      	
               

            	
              3.

            	
              Immunizations;

            


    

    
      	
               

            	
              4.

            	
              Tuberculosis
                (TB) care;

            


    

    
      	
               

            	
              5.

            	
              Family
                Planning services;

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
               

            	
              6.

            	
              THSteps
                medical checkups, and

            


    

    
      	
               

            	
              7.

            	
              Prenatal
                services.

            


    

    


    These
      subcontracts must be available for review by HHSC or its designated agent(s)
      on
      the same basis as all other subcontracts. If the HMO is unable to enter into
      a
      contract with Public Health Entities, the HMO must document efforts to contract
      with Public Health Entities, and make such documentation available to HHSC
      upon
      request.

    


    HMO
      Contracts with Public Health Entities must specify the scope of responsibilities
      of both parties, the methodology and agreements regarding billing and
      reimbursements, reporting responsibilities, Member and Provider educational
      responsibilities, and the methodology and agreements regarding sharing of
      confidential medical record information between the Public Health Entity and
      the
      HMO or PCP.

    


    The
      HMO
      must:

    


    
      	
               

            	
              1.

            	
              Identify
                care managers who will be available to assist public health providers
                and
                PCPs in efficiently referring Members to the public health providers,
                specialists, and health-related service providers either within or
                outside
                the HMO’s Network; and

            


    

    
      	
               

            	
              2.

            	
              Inform
                Members that confidential healthcare information will be provided
                to the
                PCP, and educate Members on how to better utilize their PCPs, public
                health providers, emergency departments, specialists, and health-related
                service providers.

            


    

    


    
      	
              8.2.10.2

            	
              Non-Reimbursed
                Arrangements with Local Public Health
                Entities

            


    

    


    The
      HMO
      must coordinate with Public Health Entities in each Service Area regarding
      the
      provision of essential public health care services. In addition to the
      requirements listed above in Section 8.2.2, or otherwise required under state
      law or this contract, the HMO must meet the following requirements:

    


    
      	
               

            	
              1.

            	
              Report
                to public health entities regarding communicable diseases and/or
                diseases
                that are preventable by immunization as defined by state
                law;

            


    

    
      	
               

            	
              2.

            	
              Notify
                the local Public Health Entity, as defined by state law, of communicable
                disease outbreaks involving
                Members;

            


    

    
      	
               

            	
              3.

            	
              Educate
                Members and Providers regarding WIC services available to Members;
                and

            


    

    
      	
               

            	
              4.

            	
              Coordinate
                with local public health entities that have a child lead program,
                or with
                DSHS regional staff when the local public health entity does not
                have a
                child lead program, for follow-up of suspected or confirmed cases
                of
                childhood lead exposure.

            


    

    


    
      	
              8.2.11

            	
              Coordination
                with Other State Health and Human Services (HHS)
                Programs

            


    

    


    The
      HMO
      must coordinate with other state HHS Programs in each Service Area regarding
      the
      provision of essential public health care services. In addition to the
      requirements listed above in Section 8.2.2. or otherwise required under state
      law or this contract, the HMO must meet the following requirements:

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
               

            	
              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; and

            


    

    
      	
               

            	
              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.

            


    

    


    
      	
              8.2.12

            	
              Advance
                Directives

            


    

    


    Federal
      and state law require HMOs and providers to maintain written policies and
      procedures for informing all adult Members 18 years of age and older about
      their
      rights to refuse, withhold or withdraw medical treatment and mental health
      treatment through advance directives (see Social Security Act §1902(a)(57) and
§1903(m)(1)(A)). The HMO’s policies and procedures must include written
      notification to Members and comply with provisions contained in 42 C.F.R.
§434.28 and 42 C.F.R. § 489, Subpart I, relating to advance directives for all
      hospitals, critical access hospitals, skilled nursing facilities, home health
      agencies, providers of home health care, providers of personal care services
      and
      hospices, as well as the following state laws and rules:

    


    
      	
               

            	
              1.

            	
              A
                Member’s right to self-determination in making health care
                decisions;

            


    

    
      	
               

            	
              2.

            	
              The
                Advance Directives Act, Chapter 166, Texas Health and Safety Code,
                which
                includes:

            


    

    
      	
               

            	
              a.

            	
              A
                Member’s right to execute an advance written directive to physicians and
                family or surrogates, or to make a non-written directive to administer,
                withhold or withdraw life-sustaining treatment in the event of a
                terminal
                or irreversible condition;

            


    

    
      	
               

            	
              b.

            	
              A
                Member’s right to make written and non-written out-of-hospital
                do-not-resuscitate (DNR) orders;

            


    

    
      	
               

            	
              c.

            	
              A
                Member’s right to execute a Medical Power of Attorney to appoint an agent
                to make health care decisions on the Member’s behalf if the Member becomes
                incompetent; and

            


    

    
      	
               

            	
              3.

            	
              The
                Declaration for Mental Health Treatment, Chapter 137, Texas Civil
                Practice
                and Remedies Code, which includes: a Member’s right to execute a
                Declaration for Mental Health Treatment in a document making a declaration
                of preferences or instructions regarding mental health
                treatment.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      must maintain written policies for implementing a Member’s advance directive.
      Those policies must include a clear and precise statement of limitation if
      the
      HMO or a Provider cannot or will not implement a Member’s advance
      directive.

    


    The
      HMO
      cannot require a Member to execute or issue an advance directive as a condition
      of receiving health care services. The HMO cannot discriminate against a Member
      based on whether or not the Member has executed or issued an advance
      directive.

    


    The
      HMO’s
      policies and procedures must require the HMO and subcontractors to comply with
      the requirements of state and federal law relating to advance directives. The
      HMO must provide education and training to employees and Members on issues
      concerning advance directives.

    


    All
      materials provided to Members regarding advance directives must be written
      at a
      7th - 8th grade
      reading comprehension level, except where a provision is required by state
      or
      federal law and the provision cannot be reduced or modified to a 7th - 8th
      grade
      reading level because it is a reference to the law or is required to be included
      “as written” in the state or federal law.

    


    The
      HMO
      must notify Members of any changes in state or federal laws relating to advance
      directives within 90 days from the effective date of the change, unless the
      law
      or regulation contains a specific time requirement for
      notification.

    


    
      	
              8.3

            	
              Additional
                STAR+PLUS Scope of Work

            


    

    


    
      	
              8.3.1

            	
              Covered
                Community-Based Long-Term Care
                Services

            


    

    


    The
      HMO
      must ensure that STAR+PLUS Members needing Community Long-term Care Services
      are
      identified and that services are referred and authorized in a timely manner.
      The
      HMO must ensure that Providers of Community Long-term Care Services are licensed
      to deliver the service they provide. The inclusion of Community Long-term Care
      Services in a managed care model presents challenges, opportunities and
      responsibilities.

    


    Community
      Long-term Care Services may be necessary as a preventative service to avoid
      more
      expensive hospitalizations, emergency room visits, or institutionalization.
      Community Long-term Care Services should also be made available to Members
      to
      assure maintenance of the highest level of functioning possible in the least
      restrictive setting. A Member’s need for Community Long-term Care Services to
      assist with the activities of daily living must be considered as important
      as
      needs related to a medical condition. HMOs must provide Functionally Necessary
      Covered Services to Community Long-term Care Service Members.

    


    
      	
              8.3.1.1

            	
              Community
                Based Long-Term Care Services Available to All
                Members

            


    

    


    The
      HMO
      shall enter into written contracts with Providers of Personal Assistance
      Services and Day Activity and Health Services (DAHS) to make them available
      to
      all STAR+PLUS Members. These Providers must at a minimum, meet all of the
      following state licensure and certification requirements for providing the
      services in Attachment B-2.1, Covered Services.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              Community
                Long-Term Care Services Available to All
                Members

            
	
              Service

            	
              Licensure
                and Certification Requirements

            
	
              Personal
                Attendant Services

            	
              The
                Provider must be licensed by the Texas Department of Human Services
                as a
                Home and Community Support Services Agency. The level of licensure
                required depends on the type of service delivered.

              NOTE:
                For primary home care and client managed attendant care, the agency
                may
                have only the Personal Assistance Services level of
                licensure.

            
	
              Day
                Activity and Health Services (DAHS)

            	
              The
                Provider must be licensed by the Texas Department of Human Services,
                Long
                Term Care Regulatory Division, as an adult day care provider. To
                provide
                DAHS, the Provider must provide the range of services required for
                DAHS.

            


    

    


    
      	
              8.3.1.2

            	
              1915(c)
                Nursing Facility Waiver Services Available to Members Who Qualify
                for 1915
                (c) Nursing Facility Waiver
                Services

            


    

    


    The
      1915(c) Nursing Facility Waiver provides Community Long-term Care Services
      to
      Medicaid Eligibles who are elderly and to adults with disabilities as a
      cost-effective alternative to living in a nursing facility. These Members must
      be age 21 or older, be a Medicaid recipient or be otherwise financially eligible
      for waiver services. To be eligible for 1915(c) Nursing Facility Waiver
      Services, a Member must meet income and resource requirements for Medicaid
      nursing facility care, and receive a determination from HHSC on the medical
      necessity of the nursing facility care. The HMO must make available to STAR+PLUS
      Members who meet the eligibility requirements the array of services allowable
      through HHSC’s CMS-approved 1915(c) Nursing Facility Waiver (see
Appendix B-2.1, STAR+PLUS Covered Services).

    


    
      	
              Community
                Long-Term Care Services Under the 1915(c) Nursing Facility
                Waiver

            
	
              Service

            	
              Licensure
                and Certification Requirements

            
	
              Personal
                Attendant Services

            	
              The
                Provider must be licensed by the Texas Department of Human Services
                as a
                Home and Community Support Services Agency. The level of licensure
                required depends on the type of service delivered. For Primary Home
                Care
                and Client Managed Attendant Care, the agency may have only the Personal
                Assistance Services level of licensure.

            
	
              Assisted
                Living

            	
              The
                Provider must be licensed by the Texas Department of Aging and Disability
                Services, Long Term Care Regulatory Division. The type of licensure
                determines what services may be provided.

            
	
              Emergency
                Response Service Provider

            	
              Texas
                Department of Aging and Disability Services (DADS) Standards for
                Emergency
                Response Services at 40 T.A.C. §52.201(a), and be licensed by the Texas
                Board of Private Investigators and Private Security Agencies, unless
                exempt from licensure.

            
	
              Adult
                Foster Home

            	
              TDSHS
                Provider standards for Adult Foster Care and TDSHS Rules at 40 T.A.C.
                §48.6032. Four bed homes also licensed under
                TDSHS

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              Community
                Long-Term Care Services Under the 1915(c) Nursing Facility
                Waiver

            
	
              Service

            	
              Licensure
                and Certification Requirements

            
	 	
              Rules
                at 40 T.A.C. §481.8906.

               

              DFPS
                licensure in accordance with 24-hour Care Licensing requirements
                found in
                T.A.C., Title 40, Part 19, Chapter 720.

            
	
              Home
                Delivered Meals

            	
              T.A.C.,
                Title 40, Part 1, Chapter 55.

            
	
              Physical
                Therapy

            	
              Licensed
                Physical Therapist through the Texas Board of Physical Therapy Examiners,
                Chapter 453.

            
	
              Occupational
                Therapy

            	
              Licensed
                Occupational Therapist through the Texas Board of Occupational Therapy
                Examiners, Chapter 454.

            
	
              Speech
                Therapy

            	
              Licensed
                Speech Therapist Through the Department of State Health
                Services.

            
	
              Consumer
                Directed Services

            	
              Home
                and Community Support Services Agency (HCSSA)

            
	
              Transition
                Assistance Services

            	
              No
                licensure or certification requirements.

            
	
              Minor
                Home Modification

            	
              No
                licensure or certification requirements.

            
	
              Adaptive
                Aids and Medicaid Equipment

            	
              No
                licensure or certification requirements.

            
	
              Medical
                supplies

            	
              No
                licensure or certification
                requirements.

            


    

    


    
      	
              8.3.2

            	
              Service
                Coordination

            


    

    


    The
      HMO
      must furnish a Service Coordinator to all STAR+PLUS Members who request one.
      The
      HMO should also furnish a Service Coordinator to a STAR+PLUS Member when the
      HMO
      determines one is required through an assessment of the Member’s health and
      support needs. The HMO must ensure that each STAR+PLUS Member has a qualified
      PCP who is responsible for overall clinical direction and, in conjunction with
      the Service Coordinator, serves as a central point of integration and
      coordination of Covered Services, including primary, Acute Care, long-term
      care
      and Behavioral Health Services.

    


    The
      Service Coordinator must work as a team with the PCP, and coordinate all
      STAR+PLUS Covered Services and any applicable Non-capitated Services with the
      PCP. This requirement applies whether or not the PCP is in the HMO’s Network, as
      some STAR+PLUS Members dually eligible for Medicare may have a PCP that is
      not
      in the HMO’s Provider Network. In order to integrate the Member’s Acute Care and
      primary care, and stay abreast of the Member’s needs and condition, the Service
      Coordinator must also actively involve and coordinate with the Member’s primary
      and specialty care providers, including Behavioral Health Service providers,
      and
      providers of Non-capitated Services.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    STAR+PLUS
      Members dually eligible for Medicare will receive most prescription drug
      services through Medicare rather than Medicaid. The Texas Vendor Drug Program
      will pay for a limited number of medications not covered by
      Medicare.

    


    The
      HMO
      must identify and train Members or their families to coordinate their own care,
      to the extent of the Member’s or the family’s capability and willingness to
      coordinate care.

    


    
      	
              8.3.2.1

            	
              Service
                Coordinators

            


    

    


    The
      HMO
      must employ as Service Coordinators persons experienced in meeting the needs
      of
      vulnerable populations who have Chronic or Complex Conditions. Such Service
      Coordinators are Key HMO Personnel as described in Attachment
      A, HHSC’s Uniform Managed Care Contract Terms and Conditions,
      Section 4.02, and must meet the requirements set forth in
Section 4.04.1 of HHSC’s Uniform Managed Care Contract
      Terms and Conditions.

    


    
      	
              8.3.2.2

            	
              Referral
                to Community Organizations

            


    

    


    The
      HMO
      must provide information about and referral to community organizations that
      may
      not be providing STAR+PLUS Covered Services, but are otherwise important to
      the
      health and well being of Members. These organizations include, but are not
      limited to:

    


    
      	
               

            	
              1.

            	
              State/federal
                agencies (e.g., those agencies with jurisdiction over aging, public
                health, substance abuse, mental health/retardation, rehabilitation,
                developmental disabilities, income support, nutritional assistance,
                family
                support agencies, etc.);

            


    

    
      	
               

            	
              2.

            	
              social
                service agencies (e.g., Area Agencies on Aging, residential support
                agencies, independent living centers, supported employment agencies,
                etc.);

            


    

    
      	
               

            	
              3.

            	
              city
                and county agencies (e.g., welfare departments, housing programs,
                etc.);

            


    

    
      	
               

            	
              4.

            	
              civic
                and religious organizations; and

            


    

    
      	
               

            	
              5.

            	
              consumer
                groups, advocates, and councils (e.g., legal aid offices, consumer/family
                support groups, permanency planning,
                etc.).

            


    

    


    
      	
              8.3.2.3

            	
              Discharge
                Planning

            


    

    


    The
      HMO
      must have a protocol for quickly assessing the needs of Members discharged
      from
      a Hospital or other care or treatment facility.

    


    The
      HMO’s
      Service Coordinator must work with the Member’s PCP, the hospital discharge
      planner(s), the attending physician, the Member, and the Member’s family to
      assess and plan for the Member’s discharge. When long-term care is needed, the
      HMO must ensure that the Member’s discharge plan includes arrangements for
      receiving community-based care whenever possible. The HMO must ensure that
      the
      Member, the Member’s family, and the Member’s PCP are all well informed of all
      service options available to meet the Member’s needs in the
      community.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.3.2.4

            	
              Transition
                Plan for New STAR+PLUS
                Members

            


    

    


    The
      HMO
      must provide a transition plan for Members enrolled in the STAR+PLUS Program.
      HHSC, and/or the previous STAR+PLUS HMO contractor, will provide the HMO with
      detailed Care Plans, names of current providers, etc., for newly enrolled
      Members already receiving long-term care services at the time of enrollment.
      The
      HMO must ensure that current providers are paid for Medically Necessary Covered
      Services that are delivered in accordance with the Member’s existing
      treatment/long-term care services plan after the Member has become enrolled
      in
      the HMO and until the transition plan is developed.

    


    The
      transition planning process must include, but is not limited to, the
      following:

    


    
      	
               

            	
              1.

            	
              review
                of existing DADS long-term care services
                plans;

            


    

    
      	
               

            	
              2.

            	
              preparation
                of a transition plan that ensures continuous care under the Member’s
                existing Care Plan during the transfer into the HMO’s Network while the
                HMO conducts an appropriate assessment and development of a new plan,
                if
                needed;

            


    

    
      	
               

            	
              3.

            	
              if
                durable medical equipment or supplies had been ordered prior to enrollment
                but have not been received by the time of enrollment, coordination
                and
                follow-through to ensure that the Member receives the necessary supportive
                equipment and supplies without undue delay;
                and

            


    

    
      	
               

            	
              4.

            	
              payment
                to the existing provider of service under the existing authorization
                until
                the HMO has completed the assessment and service plans and issued
                new
                authorizations.

            


    

    


    The
      HMO
      must review any existing care plan and develop a transition plan within 30
      days
      of receiving the Member’s enrollment. The transition plan will remain in place
      until the HMO contacts the Member and coordinates modifications to the Member’s
      current treatment/long-term care services plan. The HMO must ensure that the
      existing services continue and that there are no breaks in services. For initial
      implementation of the STAR+PLUS program in a Service Area, the HMO must complete
      this process within 90-days of the Member’s enrollment.

    


    The
      HMO
      must ensure that the Member is involved in the assessment process and fully
      informed about options, is included in the development of the care plan, and
      is
      in agreement with the plan when completed.

    


    
      	
              8.3.2.5

            	
              Centralized
                Medical Record and
                Confidentiality

            


    

    


    The
      Service Coordinator shall be responsible for maintaining a centralized record
      related to Member contacts, assessments and service authorizations. The HMO
      shall ensure that the organization of and documentation included in the
      centralized Member record meets all applicable professional standards ensuring
      confidentiality of Member records, referrals, and documentation of
      information.

    


    The
      HMO
      must have a systematic process for generating or receiving referrals and sharing
      confidential medical, treatment, and planning information across
      providers.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
              8.3.2.6

            	
              Nursing
                Facilities

            


    

    


    Nursing
      facility care, although a part of the care continuum, presents a challenge
      for
      managed care. Because of the process for becoming eligible for Medicaid
      assistance in a nursing facility, there is frequently a significant time gap
      between entry into the nursing home and determination of Medicaid eligibility.
      During this gap from entry to Medicaid eligibility, the resident has “nested” in
      the facility and many of the community supports are no longer available. To
      require participation of all nursing facility residents would result in the
      HMO
      maintaining a Member in the nursing facility without many options for managing
      their health. For this reason, persons who qualify for Medicaid as a result
      of
      nursing facility residency are not enrolled in STAR+PLUS.

    


    The
      STAR+PLUS HMO must participate in the Promoting Independence initiative for
      such
      individuals. Promoting Independence (PI) is a philosophy that aged and disabled
      individuals remain in the most integrated setting to receive long-term care
      services. PI is Texas' response to the U.S. Supreme Court ruling in Olmstead
      v. L.C. that requires states to provide community-based services for
      persons with disabilities who would otherwise be entitled to institutional
      services, when:

    


    
      	
               

            	
              •

            	
              the
                state's treatment professionals determine that such placement is
                appropriate;

            


    

    
      	
               

            	
              •

            	
              the
                affected persons do not oppose such treatment;
                and

            


    

    
      	
               

            	
              •

            	
              the
                placement can be reasonably accommodated, taking into account the
                resources available to the state and the needs of others who are
                receiving
                state supported disability
                services.

            


    

    


    In
      accordance with legislative direction, the HMO must designate a point of contact
      to receive referrals for nursing facility residents who may potentially be
      able
      to return to the community through the use of 1915(c) Nursing Facility Waiver
      services. To be eligible for this option, an individual must reside in a nursing
      facility until a written plan of care for safely moving the resident back into
      a
      community setting has been developed and approved.

    


    A
      STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS Member
      for a total of four months. The nursing facility will bill the state directly
      for covered nursing facility services delivered while the Member is in the
      nursing facility. See Section 8.3.2.7 for further
      information.

    


    The
      HMO
      is responsible for the Member at the time of nursing facility entry and must
      utilize the Service Coordinator staff to complete an assessment of the Member
      within 30 days of entry in the nursing facility, and develop a plan of care
      to
      transition the Member back into the community if possible. If at this initial
      review, return to the community is possible, the Service Coordinator will work
      with the resident and family to return the Member to the community using 1915(c)
      Waiver Services.

    


    If
      the
      initial review does not support a return to the community, the Service
      Coordinator will conduct a second assessment 90 days after the initial
      assessment to determine any changes in the individual’s condition or
      circumstances that would allow a return to the community. The Service
      Coordinator will develop and implement the transition plan.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    The
      HMO
      will provide these services as part of the Promoting Independence initiative.
      The HMO must maintain the documentation of the assessments completed and make
      them available for state review at any time.

    


    It
      is
      possible that the STAR+PLUS HMO will be unaware of the Member’s entry into a
      nursing facility. It is the responsibility of the nursing facility to review
      the
      Member’s Medicaid card upon entry into the facility and notify the HMO. The
      nursing facility is also required to notify HHSC of the entry of a new
      resident.

    


    
      	
              8.3.2.7

            	
              HMO
                Four-Month Liability for Nursing Facility
                Care

            


    

    


    A
      STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS Member
      for a total of four months. The four months do not have to be consecutive.
      Upon
      completion of four months of nursing facility care, the individual will be
      disenrolled from the STAR+PLUS Program and the Medicaid Fee-for-Service program
      will provide Medicaid benefits. A STAR+PLUS Member may not change HMOs while
      in
      a nursing facility.

    


    Tracking
      the four months of liability is done through a counter system. The four-month
      counter starts with the Medicaid admission or on the 21st day of a Medicare
      stay. A partial month counts as a full month. In other words, the month in
      which
      the Medicaid admission occurs or the month on which the 21st day of the Medicare
      stay occurs, is counted as one of the four months.

    


    An
      amount
      will be included in the capitation rates to cover the cost of four months of
      nursing facility services (based upon experience from STAR+PLUS in Harris
      County) for the historical average number of admissions to nursing facilities.
      Nursing facility costs for STAR+PLUS in Harris County have accounted for less
      than one percent of premiums in recent years. HHSC believes that these costs
      will not deviate substantially from this experience.

    


    The
      HMO
      will be liable for the cost of care in a nursing facility care and, for
      Medicaid-only Members, the cost of all other Covered Services. The HMO will
      not
      maintain nursing facilities in its Network and will not reimburse the nursing
      facilities directly. Nursing facilities will use the traditional Fee-for-Service
      system of billing HHSC rather than billing the HMO. The HMO's liability will
      be
      established based on the amount paid through the Fee-for-Service billing system
      on behalf of the Member. HHSC will recoup those costs from the HMO by an offset
      to the monthly Capitation Payment. The offset will be recognized as a nursing
      facility expense.. The HMO will record the nursing facility liability recoupment
      as nursing facility expense on its Financial-Statistical Reports (FSR). The
      HMO
      will be responsible for direct payment of all non-nursing facility Medicaid
      expenses on behalf of the Member.

    


    
      	
              8.3.3

            	
              STAR+PLUS
                Assessment Instruments

            


    

    


    The
      HMO
      must have and use functional assessment instruments to identify Members with
      significant health problems, Members requiring immediate attention, and Members
      who need or are at risk of needing long-term care services. The HMO, a
      subcontractor, or a Provider may complete assessment instruments, but the HMO
      remains responsible for the data recorded.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    HMOs
      must
      use the DHS Form 2060, as amended or modified, to assess a Member’s need for
      Functionally Necessary Personal Attendant Services. The HMO may adapt the form
      to reflect the HMO’s name or distribution instructions, but the elements must be
      the same and instructions for completion must be followed without
      amendment.

    


    The
      DHS
      Form 2060 must be completed if a need or a change in Personal Attendant Services
      is warranted at the initial contact, at the annual reassessment, and anytime
      a
      Member requests the services or requests a change in services. The DHS Form
      2060
      must also be completed if the HMO determines the Member requires the services
      or
      requires a change in the Personal Attendant Services that are
      authorized.

    


    For
      Members and applicants seeking or needing the 1915(c) Nursing Facility Waiver
      services, the HMOs must use the DADS CARE Form 3652, as amended or modified,
      to
      assess Members and to supply current medical information for Medical Necessity
      determinations. The HMO must also complete the Individual Service Plan (ISP),
      Form 3671 for each Member receiving 1915(c) Nursing Facility Waiver Services.
      The ISP is established for a one-year period. After the initial ISP is
      established, the ISP must be completed on an annual basis and the end date
      or
      expiration date does not change. Both of these forms (Form 3652 and Form 3671)
      must be completed annually at reassessment. The HMO is responsible for tracking
      the end dates of the ISP to ensure that the Member is reassessed prior to the
      expiration date. Note that the DADS CARE Form 3652 cannot be submitted earlier
      than 90 days prior to the expiration date of the ISP.

    


    HHSC
      has
      adopted a Minimum Data Set for Home Care (MDS-HC), which can be found in the
      HHSC Uniform Managed Care Manual. HHSC may adopt new versions of this instrument
      as appropriate or as directed by CMS. 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 anniversary of the Member’s date of
      enrollment.

    


    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. Because of the large number of Members
      the HMOs will be receiving initially during the implementation period of the
      STAR+PLUS Program, HHSC is allowing the following:

    


    
      	
               

            	
              •

            	
              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.

            


    

    


    In
      addition to submitting the MDS-HC instrument to HHSC, the HMO may also submit
      other supplemental assessment instruments it elects to use. As specialized
      MDS
      instruments are developed or adopted by HHSC for other living arrangements
      (e.g., assisted living), HHSC will notify HMO of the availability of the
      instrument and the date the HMO is required to begin using

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    such
      instrument in the HHSC Uniform Managed Care Manual. Any additional assessment
      instruments used by the HMO must be approved by HHSC.

    


    
      	
              8.3.4

            	
              1915(c)
                Nursing Facility Waiver Service
                Eligibility

            


    

    


    Recipients
      of 1915(c) Nursing Facility Waiver services must meet nursing facility criteria
      for participation in the waiver and must have a plan of care at initial
      determination of eligibility in which the plan’s annualized cost is equal to or
      less than the annualized cost of care if the individual were to enter a nursing
      facility.

    


    
      	
              8.3.4.1

            	
              For
                Members

            


    

    


    The
      HMO
      must notify HHSC when it initiates 1915(c) Nursing Facility Waiver eligibility
      testing on a STAR+PLUS Member. The HMO must apply risk criteria, complete the
      Form 3652 for Medical Necessity determination, complete the assessment
      documentation, and prepare a 1915(c) Nursing Facility Waiver Individual Service
      Plan (ISP) for each Member requesting 1915(c) Nursing Facility Waiver services
      and for Members the HMO has identified as needing 1915(c) Nursing Facility
      Waiver services. The HMO must provide HHSC the results of the assessment
      activities within 45 days of initiating the assessment process.

    


    HHSC
      will
      notify the Member and the HMO of the eligibility determination, which will
      be
      based on the information provided by the HMO. If the STAR+PLUS Member is
      eligible for 1915(c) Nursing Facility Waiver services, HHSC will notify the
      Member of the effective date of eligibility. If the Member is not eligible
      for
      1915(c) Nursing Facility Waiver services, HHSC will provide the Member
      information on right to Appeal the Adverse Determination. Regardless of the
      1915(c) Nursing Facility Waiver eligibility determination, HHSC will send a
      copy
      of the Member notice to the HMO.

    


    
      	
              8.3.4.2

            	
              For
                Medical Assistance Only (MAO) Non-Member
                Applicants

            


    

    


    Non-Member
      persons who are not eligible for Medicaid in the community may apply for
      participation in the 1915(c) Nursing Facility Waiver program under the financial
      and functional eligibility requirements for MAO. HHSC will inform the applicant
      that services are provided through an HMO and allow the applicant to select
      the
      HMO. HHSC will authorize the selected HMO to initiate pre-enrollment assessment
      services required under the 1915(c) Nursing Facility Waiver for the non-member.
      The HMO must complete Form 3652 for Medical Necessity determination, complete
      the assessment documentation, and prepare a 1915(c) Nursing Facility Waiver
      service plan for each applicant referred by HHSC. The initial home visit with
      the applicant must occur within 14 days of the receipt of the referral. The
      HMO
      must provide HHSC the results of the assessment activities within 45 days of
      the
      receipt of the referral.

    


    HHSC
      will
      notify the applicant and the HMO of the results of its eligibility
      determination. If the applicant is eligible, HHSC will notify the applicant
      and
      the HMO will be notified of the effective date of eligibility, which will be
      the
      first day of the month following the determination of eligibility. The HMO
      must
      initiate the Individual Service Plan (ISP) on the date of
      enrollment.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    If
      the
      applicant is not eligible, the HHSC notice will provide information on the
      applicant’s right to Appeal the Adverse Determination. HHSC will also send
      notice to the HMO if the applicant is not eligible for 1915(c) Nursing Facility
      Waiver services.

    


    
      	
              8.3.4.3

            	
              Annual
                Reassessment

            


    

    


    Prior
      to
      the end date of the annual ISP, the HMO must initiate an annual reassessment
      to
      determine and validate continued eligibility for 1915(c) Nursing Facility Waiver
      services for each Member receiving such services. The HMO will be expected
      to
      complete the same activities for the annual reassessment as required for the
      initial eligibility determination, with the following exception: the HMO does
      not need to obtain a physician’s signature on the Form 3652 for the annual
      reassessment. Existing 1915(c) Nursing Facility Waiver clients may not be denied
      1915(c) Nursing Facility Waiver services solely on the basis that the proposed
      cost of the ISP will exceed the cost of care if the Member were in a nursing
      home if the following conditions are met:

    


    
      	
               

            	
              1.

            	
              those
                services are required for that individual to live in the most integrated
                setting appropriate to his or her needs;
                and

            


    

    
      	
               

            	
              2.

            	
              HHSC
                continues to comply with the cost-effectiveness requirements from
                the
                CMS.

            


    

    


    Individuals
      receiving waiver services through the Medically Dependent Children Program
      are
      covered by the provisions in this Section when they apply for transition to
      the
      1915(c) waiver program at age 21.

    


    
      	
              8.3.5

            	
              Personal
                Attendant Services

            


    

    


    There
      are
      three options available to STAR+PLUS Members desiring the delivery of Personal
      Attendant Services (PAS): 1) Self-Directed; 2) Agency Model, Self-Directed;
      and
      3) Agency Model. The HMO must provide information to all eligible Members on
      the
      three options and must provide Member orientation in the option selected by
      the
      Member. The HMO will provide the information to any STAR+PLUS Member receiving
      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.

            


    

    


    The
      HMO
      must contract with providers who are able to offer PAS and must also
      educate/train the HMO Network Providers regarding the three PAS options. To
      participate as a PAS Network Provider, the Provider must have a contract with
      DADS for the delivery of PAS. The HMO must assure compliance with the Texas
      Administrative Code in Title 40, Part 1, Chapter 41, Sections 41.101, 41.103,
      and 41.105. The HMO must include the requirements in the Provider Manual and
      in
      the STAR+PLUS Provider training.

    


    
      	
              8.3.5.1

            	
              Personal
                Attendant Services Delivery Option – Self-Directed
                Model

            


    

    


    In
      the
      Self-Directed Model, the Member or the Member’s legal guardian is the employer
      of record and retains control over the hiring, management, and termination
      of an
      individual

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    providing
      Personal Attendant Services. The Member is responsible for assuring that the
      employee meets the requirements for Personal Attendant Services, including
      the
      criminal history check. The Member uses a Home and Community Support Services
      (HCSS) agency to handle the employer-related administrative functions such
      as
      payroll, substitute (back-up), and filing tax-related reports of Personal
      Attendant Services.

    


    
      	
              8.3.5.2

            	
              Personal
                Attendant Services Delivery Option – Agency Model,
                Self-Directed

            


    

    


    In
      the
      Agency Model, Self-Directed, the Member or the Member’s legal guardian chooses a
      Home and Community Support Services (HCSS) agency in the HMO Provider Network
      who is the employer of record. In this model, the Member selects the personal
      attendant from the HCSS agency’s personal attendant employees. The personal
      attendant’s schedule is set up based on the Member input, and the Member manages
      the Personal Attendant Services. The Member retains the right to supervise
      and
      train the personal attendant. The Member may request a different personal
      attendant and the HCSS agency would be expected to honor the request. The HCSS
      agency establishes the payment rate, benefits, and provides all administrative
      functions such as payroll, substitute (back-up), and filing tax-related reports
      of personal attendant services.

    


    
      	
              8.3.5.3

            	
              Personal
                Attendant Services Delivery Option – Agency
                Model

            


    

    


    In
      the
      Agency Model, the Member chooses a Home and Community Support Services (HCSS)
      agency to hire, manage, and terminate the individual providing Personal
      Attendant Services. The HCSS agency is selected by the Member from the HCSS
      agencies in the HMO Provider Network. The Service Coordinator and Member develop
      the schedule and send it to the HCSS agency. The Member retains the right to
      supervise and train the personal attendant. The Member may request a different
      personal attendant and the HCSS agency would be expected to honor the request.
      The HCSS agency establishes the payment rate, benefits, and provides all
      administrative functions such as payroll, substitute (back-up), and filing
      tax-related reports of personal attendant services.

    


    
      	
              8.3.6

            	
              Community
                Based Long-term Care Service
                Providers

            


    

    


    
      	
              8.3.6.1

            	
              Training

            


    

    


    The
      HMO
      must comply with Section 8.1.4.6 regarding Provider Manual and Provider training
      specific to the STAR+PLUS Program. The HMO must train all Community Long-term
      Care Service Providers regarding the requirements of the Contract and special
      needs of STAR+PLUS Members. The HMO must establish ongoing STAR+PLUS Provider
      training addressing the following issues at a minimum:

    


    
      	
               

            	
              1.

            	
              Covered
                Services and the Provider’s responsibilities for providing such services
                to STAR+PLUS Members and billing the HMO for such services. The HMO
                must
                place special emphasis on Community Long-term Care Services and STAR+PLUS
                requirements, policies, and procedures that vary from Medicaid
                Fee-for-Service and commercial coverage rules, including payment
                policies
                and procedures.

            


    

    
      	
               

            	
              2.

            	
              Inpatient
                Stay hospital services and the authorization and billing of such
                services
                for STAR+PLUS Members.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    
      	
               

            	
              3.

            	
              Relevant
                requirements of the STAR+PLUS Contract, including the role of the
                Service
                Coordinator;

            


    

    
      	
               

            	
              4.

            	
              Processes
                for making referrals and coordinating Non-capitated
                Services;

            


    

    
      	
               

            	
              5.

            	
              The
                HMO’s quality assurance and performance improvement program and the
                Provider’s role in such programs;
                and

            


    

    
      	
               

            	
              6.

            	
              The
                HMO’s STAR+PLUS policies and procedures, including those relating to
                Network and Out-of-Network
                referrals.

            


    

    


    
      	
              8.3.7.2

            	
              LTC
                Provider Billing

            


    

    


    Long-term
      care providers are not required to utilize the billing systems that most medical
      facilities use on a regular basis. For this reason, the HMO must make
      accommodations to the claims processing system for such providers to allow
      for a
      smooth transition from traditional Medicaid to Managed Care
      Medicaid.

    


    HHSC
      will
      meet with HMOs to develop a standardized method long-term care billing. All
      STAR+PLUS HMOs will be required to utilize the standardized method, which will
      be incorporated into the HHSC Uniform Managed Care
      Manual.

    


    
      	
              8.3.7.3

            	
              Rate
                Enhancement Payments for Agencies Providing Attendant
                Care

            


    

    


    All
      HMOs
      participating in the STAR+PLUS program must allow their Long-term Support
      Services (LTSS) Providers to participate in the STAR+PLUS Attendant Care
      Enhancement Program if the providers are currently participating in the enhanced
      payment program with the Department of Aging and Disability Services (DADS).
      HMOs may choose not to offer participation to DADS-contracted providers who
      do
      not currently participate in the enhancement program. Additionally, HMOs may
      choose to include Providers in the network who do not participate in the
      enhanced payment program.

    


    Attachment
      B-7, STAR+PLUS Attendant Care Enhanced Payment Methodology explains the
      methodology that the STAR+PLUS HMO will use to implement and pay the enhanced
      payments, including a description of the timing of the payments, in accordance
      with the requirements in the Uniform Managed Care Manual and
      the intent of the 2000-01 General Appropriations Act (Rider 27, House Bill
      1,
      76th Legislature, Regular Session, 1999) and T.A.C. Title 1, Part 15, Chapter
      355.

    


    
      	
              8.3.7.4

            	
              Payment
                for 1915(c) Nursing Facility Waiver Services for Non-
                Members

            


    

    


    Disenrolled
      Members: Occasionally, the Social Security Administration will place
      SSI recipients on hold for a short period of time, usually due failure to
      provide timely updates required for the continuation of SSI benefits. During
      this period, the recipients will not appear to be eligible for Medicaid or
      1915(c) Nursing Facility Waiver services. Often the Social Security
      Administration reinstates these Medicaid Eligibles retroactively without a
      break
      in Medicaid coverage. To deal with this situation, for at least thirty (30)
      days
      after disenrollment, the HMO will continue to authorize and pay for 1915(c)
      Nursing Facility Waiver services for disenrolled STAR+PLUS Members who appear
      to
      lose eligibility due to an administrative problem related to

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    SSI.
      If
      at the end of the thirty (30) days, the Medicaid Eligible’s 1915(c) Nursing
      Facility Waiver eligibility is reinstated, the Medicaid Eligible will be
      manually enrolled into the STAR+PLUS HMO back to the date of disenrollment
      and
      the retroactive adjustment system will properly reimburse the HMO. If after
      thirty (30) days, the former STAR+PLUS Member continues to be ineligible for
      Medicaid, the individual will not be retroactively enrolled, and the HMO will
      bill HHSC for 1915(c) Nursing Facility Waiver services rendered during this
      time.

    


    
      	
              8.4

            	
              Additional
                CHIP Scope of Work

            


    

    


    The
      following provisions only apply to HMOs participating in CHIP.

    


    
      	
              8.4.1

            	
              CHIP
                Provider Network

            


    

    


    In
      each
      Service Area, the HMO must seek to obtain the participation in its Provider
      Network of CHIP Significant Traditional Providers (STPs), defined by HHSC as
      PCP
      Providers currently serving the CHIP population and DSH hospitals. The
      Procurement Library includes CHIP STPs by Service Area.

    


    The
      HMO
      must give STPs the opportunity to participate in its Network if the
      STPs:

    


    
      	
               

            	
              1.

            	
              Agree
                to accept the HMO’s Provider reimbursement rate for the provider type;
                and

            


    

    
      	
               

            	
              2.

            	
              Meet
                the standard credentialing requirements of the HMO, provided that
                lack of
                board certification or accreditation by the Joint Commission on
                Accreditation of Health Care Organizations (JCAHO) is not the sole
                grounds
                for exclusion from the Provider
                Network.

            


    

    


    
      	
              8.4.2

            	
              CHIP
                Provider Complaint and
                Appeals

            


    

    


    CHIP
      Provider Complaints and Appeals are subject to disposition consistent with
      the
      Texas Insurance Code and any applicable TDI regulations. The HMO must resolve
      Provider Complaints within 30 days from the date the Complaint is
      received.

    


    
      	
              8.4.3

            	
              CHIP
                Member Complaint and Appeal
                Process

            


    

    


    CHIP
      Member Complaints and Appeals are subject to disposition consistent with the
      Texas Insurance Code and any applicable TDI regulations. HHSC will require
      the
      HMO to resolve Complaints and Appeals (that are not elevated to TDI) within
      30
      days from the date the Complaint or Appeal is received. The HMO is subject
      to
      remedies, including liquidated damages, if at least 98 percent of Member
      Complaints or Member Appeals are not resolved within 30 days of receipt of
      the
      Complaint or Appeal by the HMO. Please see the Uniform Managed Care
      Contract Terms & Conditions and Attachment B-5,
      Deliverables/Liquidated Damages Matrix. Any person, including those
      dissatisfied with a HMO’s resolution of a Complaint or Appeal, may report an
      alleged violation to TDI.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                8

            	
              Version
                1.7

            


    

    


    8.4.4                      Dental
      Coverage for CHIP Members

    


    The
      HMO
      is not responsible for reimbursing dental providers for preventive and
      therapeutic dental services obtained by CHIP Members. However, medical and/or
      hospital charges, such as anesthesia, that are necessary in order for CHIP
      Members to access standard therapeutic dental services, are Covered Services
      for
      CHIP Members. The HMO must provide access to facilities and physician services
      that are necessary to support the dentist who is providing dental services
      to a
      CHIP Member under general anesthesia or intravenous (IV) sedation.

    


    The
      HMO
      must inform Network facilities, anesthesiologists, and PCPs what authorization
      procedures are required, and how Providers are to be reimbursed for the
      preoperative evaluations by the PCP and/or anesthesiologist and for the facility
      services. For dental-related medical Emergency Services, the HMO must reimburse
      in-network and Out-of-Network providers in accordance with federal and state
      laws, rules, and regulations.

    


    
      	
              8.5

            	
              Additional
                CHIP Perinatal Scope of
                Work

            


    

    


    The
      following provisions only apply to HMOs participating in CHIP Perinatal
      Program.

    


    
      	
              8.5.1

            	
              CHIP
                Perinatal Provider Network

            


    

    


    In
      each
      Service Area, the CHIP Perinatal HMO must seek to obtain the participation
      of
      Providers for CHIP Perinate Members. CHIP Perinatal HMOs are encouraged to
      obtain the participation of Obstetricians/Gynecologists (OB/GYNs), Family
      Practice Physicians with experience in prenatal care, or other qualified health
      care Providers as CHIP Perinate Providers. See Sections 8.1.3.2, Access to
      Network Providers, and 8.1.4.2, Primary Care Providers, regarding distinctions
      in the provider networks for CHIP Perinates and CHIP Perinate
      Newborns.

    


    
      	
              8.5.2

            	
              CHIP
                Perinatal Program Provider Complaint and
                Appeals

            


    

    


    CHIP
      Perinatal Program Provider Complaints and Appeals are subject to disposition
      consistent with the Texas Insurance Code and any applicable TDI regulations.
      The
      HMO must resolve Provider Complaints within 30 days from the date the Complaint
      is received.

    


    
      	
              8.5.3

            	
              CHIP
                Perinatal Program Member Complaint and Appeal
                Process

            


    

    


    CHIP
      Perinatal Program Member Complaints and Appeals are subject to disposition
      consistent with the Texas Insurance Code and any applicable TDI regulations.
      HHSC will require the HMO to resolve Complaints and Appeals (that are not
      elevated to TDI) within 30 days from the date the Complaint or Appeal is
      received. Any person, including those dissatisfied with a HMO’s resolution of a
      Complaint or Appeal, may report an alleged violation to TDI.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                9

            	 	
               Version
                1.7

            


    

    


    DOCUMENT
      HISTORY LOG

    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	
              Baseline

            	
              n/a

            	 	
              Initial
                version Attachment B-1, Section 7

            
	
              Revision

            	
              1.1

            	
              June
                30, 2006

            	
              Contract
                amendment to include STAR+PLUS program. No change to this
                Section.

            
	
              Revision

            	
              1.2

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-1 Section 9 – Turnover
                Requirements

            
	
              Revision

            	
              1.3

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-1 Section 9 – Turnover
                Requirements

            
	
              Revision

            	
              1.4

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-1 Section 9 – Turnover
                Requirements

            
	
              Revision

            	
              1.5

            	
              January
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-1 Section 9 – Turnover
                Requirements

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-1 Section 9 – Turnover
                Requirements

            
	
              Revision

            	
              1.7

            	
              July
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-1 Section 9 – Turnover
                Requirements

            
	
              1  Status
                should be represented as “Baseline” for initial issuances, “Revision” for
                changes to the

                  Baseline
                version, and “Cancellation” for withdrawn versions

              2  Revisions
                should be numbered in accordance according to the version of the
                issuance
                and sequential

                  numbering
                of the revision—e.g., “1.2” refers to the first version of the document
                and the second

                  revision.

              3  Brief
                description of the changes to the document made in the
                revision.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                9

            	 	
               Version
                1.7

            


    

    


    9.
      Turnover
      Requirements

    


    9.1
      Introduction

    


    This
      section presents the Turnover Requirements to which the HMO must agree. Turnover
      is defined as those activities that are required for the HMO to perform upon
      termination of the Contract in situations in which the HMO must transition
      Contract operations to HHSC or a subsequent Contractor.

    


    9.2
      Transfer of Data

    


    The
      HMO
      must transfer all data regarding the provision of Covered Services to Members
      to
      HHSC or a new HMO, at the sole discretion of HHSC and as directed by HHSC.
      All
      transferred data must be compliant with HIPAA.

    


    All
      relevant data must be received and verified by HHSC or the subsequent
      Contractor. If HHSC determines that not all of the data regarding the provision
      of Covered Services to Members was transferred to HHSC or the subsequent
      Contractor, as required, or the data is not HIPAA compliant, HHSC reserves
      the
      right to hire an independent contractor to assist HHSC in obtaining and
      transferring all the required data and to ensure that all the data are HIPAA
      compliant. The reasonable cost of providing these services will be the
      responsibility of the HMO.

    


    9.3
      Turnover Services

    


    Six
      months prior to the end of the Contract Period, including any extensions to
      such
      Period, the HMO must propose a Turnover Plan covering the possible turnover
      of
      the records and information maintained to either the State or a successor HMO.
      The Turnover Plan must be a comprehensive document detailing the proposed
      schedule, activities, and resource requirements associated with the turnover
      tasks. The Turnover Plan must be approved by HHSC.

    


    As
      part
      of the Turnover Plan, the HMO must provide HHSC with copies of all relevant
      Member and service data, documentation, or other pertinent information
      necessary, as determined by the HHSC, for HHSC or a subsequent Contractor to
      assume the operational activities successfully. This includes correspondence,
      documentation of ongoing outstanding issues, and other operations support
      documentation. The plan will describe the HMO’s approach and schedule for
      transfer of all data and operational support information, as applicable. The
      information must be supplied in media and format specified by the State and
      according to the schedule approved by the State.

    


    HHSC
      is
      not limited or restricted in the ability to require additional information
      from
      the HMO or modify the turnover schedule as necessary.

    


    9.4
      Post-Turnover Services

    


    Thirty
      (30) days following turnover of operations, the HMO must provide HHSC with
      a
      Turnover Results report documenting the completion and results of each step
      of
      the Turnover Plan. Turnover will not be considered complete until this document
      is approved by HHSC.

    


    If
      the
      HMO does not provide the required relevant data and reference tables,
      documentation, or other pertinent information necessary for HHSC or the
      subsequent Contractor to assume the operational activities successfully, the
      HMO
      agrees to reimburse the State for all reasonable costs, including, but
      not

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section
                9

            	 	
               Version
                1.7

            


    

    


    limited
      to, transportation, lodging, and subsistence for all state and federal
      representatives, or their agents, to carry out their inspection, audit, review,
      analysis, reproduction and transfer functions at the location(s) of such
      records.

    


    The
      HMO
      also agrees to pay any and all additional costs incurred by the State that
      are
      the result of the HMO’s failure to provide the requested records, data or
      documentation within the time frames agreed to in the Turnover
      Plan.

    


    The
      HMO
      must maintain all files and records related to Members and Providers for five
      years after the date of final payment under the Contract or until the resolution
      of all litigation, claims, financial management review or audit pertaining
      to
      the Contract, whichever is longer. The HMO agrees to repay any valid, undisputed
      audit exceptions taken by HHSC in any audit of the Contract.

    

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      



    
      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2 – Covered Services

              	
                Version
                  1.7

              


      

      


      DOCUMENT
        HISTORY LOG

      


      
        	
                STATUS1

              	
                DOCUMENT

                REVISION2

              	
                EFFECTIVE

                DATE

              	
                DESCRIPTION3

              
	
                Baseline

              	
                n/a

              	 	
                Initial
                  version Attachment B-2, Covered Services

              
	
                Revision

              	
                1.1

              	
                June
                  30, 2006

              	
                Revised
                  Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS
                  Covered Services.

              
	
                Revision

              	
                1.2

              	
                September
                  1. 2006

              	
                Revised
                  Attachment B-2 to include provisions applicable to MCOs participating
                  in
                  the STAR and CHIP Programs.

                 

                STAR
                  Covered Services, Services Included under the HMO Capitation Payment,
                  is
                  modified to clarify the STAR covered services related to “optometry” and
                  “vision.”

                 

                CHIP
                  Covered Services is modified to correct services related to artificial
                  aids including surgical implants.

              
	
                Revision

              	
                1.3

              	
                September
                  1, 2006

              	
                Contract
                  amendment did not revise Attachment B-2, Covered
                  Services.

              
	
                Revision

              	
                1.4

              	
                September
                  1, 2006

              	
                Contract
                  amendment did not revise Attachment B-2, Covered
                  Services.

              
	
                Revision

              	
                1.5

              	
                January
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-2, Covered
                  Services.

              
	
                Revision

              	
                1.6

              	
                February
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-2, Covered
                  Services.

              
	
                Revision

              	
                1.7

              	
                July
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-2, Covered
                  Services.

              
	
                1Status
                  should be represented as “Baseline” for initial issuances, “Revision” for
                  changes to the Baseline version, and “Cancellation” for withdrawn
                  versions

                 

                2Revisions
                  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.

                 

                3Brief
                  description of the changes to the document made in the
                  revision.

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2 – Covered Services

              	
                Version
                  1.7

              


      

      


      STAR
        Covered Services

      


      The
        following is a non-exhaustive, high-level listing of Acute Care Covered Services
        included under the STAR Medicaid managed care program.

      


      Medicaid
        HMO Contractors are responsible for providing a benefit package to Members
        that
        includes all medically necessary services covered under the traditional,
        fee-for-service Medicaid programs except for Non-capitated Services provided
        to
        STAR Members outside of the HMO capitation and listed in Attachment B-1,
        Section 8.2.2.8. Medicaid HMO Contractors must coordinate care
        for Members for these Non-capitated Services so that Members have access
        to a
        full range of medically necessary Medicaid services, both capitated and
        non-capitated. A Contractor may elect to offer additional acute care Value-added
        Services.

      


      The
        STAR
        Members are provided with three enhanced benefits compared to the traditional,
        fee-forservice Medicaid coverage:

      
        	
                 

              	
                1)

              	
                waiver
                  of the three-prescription per month
                  limit;

              


      

      
        	
                 

              	
                2)

              	
                waiver
                  of the 30-day spell-of-illness limitation under fee-for-services;
                  and

              


      

      
        	
                 

              	
                3)

              	
                inclusion
                  of an annual adult well check for patients 21 years of age and
                  over.

              


      

      


      Medicaid
        HMO Contractors are responsible for providing a benefit package to Members
        that
        includes the waiver of the 30-day spell-of-illness limitation under
        fee-for-service and the inclusion of an annual adult well check for patients
        21
        years of age and over. Prescription drug benefits to Medicaid HMO Members
        are
        provided outside of the HMO capitation.

      


      Bidders
        and Contractors should refer to the current Texas Medicaid Provider
        Procedures Manual and the bi-monthly Texas Medicaid
        Bulletin for a more inclusive listing of limitations and
        exclusions that apply to each Medicaid benefit category. (These documents
        can be
        accessed online at: http://www.tmhp.com.)

      


      


      The
        services listed in this Attachment are subject to modification based on Federal
        and State laws and regulations and Programs policy updates.

      


      Services
        included under the HMO capitation payment

      
        	
                 

              	
                —

              	
                Ambulance
                  services

              


      

      
        	
                 

              	
                —

              	
                Audiology
                  services, including hearing aids for adults (hearing aids for children
                  are
                  provided through the PACT program and are a non-capitated
                  service)

              


      

      
        	
                 

              	
                —

              	
                Behavioral
                  Health Services, including:

              


      

      
        	
                 

              	
                Ø

              	
                Inpatient
                  and outpatient mental health services for children (under age
                  21)

              


      

      
        	
                 

              	
                Ø

              	
                Outpatient
                  chemical dependency services for children (under age
                  21)

              


      

      
        	
                 

              	
                Ø

              	
                Detoxification
                  services

              


      

      
        	
                 

              	
                Ø

              	
                Psychiatry
                  services

              


      

      
        	
                 

              	
                Ø

              	
                Counseling
                  services for adults (21 years of age and
                  over)

              


      

      
        	
                 

              	
                —

              	
                Birthing
                  center services

              


      

      
        	
                 

              	
                —

              	
                Chiropractic
                  services

              


      

      
        	
                 

              	
                —

              	
                Dialysis

              


      

      
        	
                 

              	
                —

              	
                Durable
                  medical equipment and supplies

              


      

      
        	
                 

              	
                —

              	
                Emergency
                  Services

              


      

      
        	
                 

              	
                —

              	
                Family
                  planning services

              


      

      
        	
                 

              	
                —

              	
                Home
                  health care services

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2 – Covered Services

              	
                Version
                  1.7

              


      

      


      
        	
                 

              	
                —

              	
                Hospital
                  services, including inpatient and
                  outpatient

              


      

      
        	
                 

              	
                —

              	
                Laboratory

              


      

      
        	
                 

              	
                —

              	
                Medical
                  check-ups and Comprehensive Care Program (CCP) Services for children
                  (under age 21)vthrough the Texas Health Steps
                  Program

              


      

      
        	
                 

              	
                —

              	
                Podiatry

              


      

      
        	
                 

              	
                —

              	
                Prenatal
                  care

              


      

      
        	
                 

              	
                —

              	
                Primary
                  care services

              


      

      
        	
                 

              	
                —

              	
                Radiology,
                  imaging, and X-rays

              


      

      
        	
                 

              	
                —

              	
                Specialty
                  physician services

              


      

      
        	
                 

              	
                —

              	
                Therapies
                  – physical, occupational and speech

              


      

      
        	
                 

              	
                —

              	
                Transplantation
                  of organs and tissues

              


      

      
        	
                —  

              	
                Vision
                  (Includes optometry and glasses. Contact lenses are only covered
                  if they
                  are medically necessary for vision correction, which can not be
                  accomplished by glasses.)

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2 – Covered Services

              	
                Version
                  1.7

              


      

      


      CHIP
        Covered Services

      


      Covered
        CHIP services must meet the CHIP definition of Medically Necessary Covered
        Services as defined in this Contract. There is no lifetime
        maximum on benefits; however, 12-month period, enrollment period (a 6-month
        period), or lifetime limitations do apply to certain services, as specified
        in
        the following chart. Please note that if services with a 12-month annual
        limit
        are all used within one 6-month enrollment period, these particular services
        are
        not available during the second 6-month enrollment period within that annual
        period. Co-pays apply until a family reaches its specific cost-sharing
        maximum.

      


      
        	
                Covered
                  Benefit

              	
                Description

              
	
                Inpatient
                  General Acute and

                Inpatient Rehabilitation Hospital
                  Services

              	
                Services
                  include, but are not limited to, the following:

                nHospital-provided
                  Physician or Provider services

                nSemi-private
                  room
                  and board (or private if medically necessary as certified by
                  attending)

                nGeneral
                  nursing
                  care

                nSpecial
                  duty
                  nursing when medically necessary

                nICU
                  and
                  services

                nPatient
                  meals and
                  special diets

                nOperating,
                  recovery and other treatment rooms

                nAnesthesia
                  and
                  administration (facility technical component)

                nSurgical
                  dressings, trays, casts, splints

                nDrugs,
                  medications
                  and biologicals

                nBlood
                  or blood
                  products that are not provided free-of-charge to the patient and
                  their
                  administration

                nX-rays,
                  imaging
                  and other radiological tests (facility technical component)

                nLaboratory
                  and
                  pathology services (facility technical component)

                nMachine
                  diagnostic
                  tests (EEGs, EKGs, etc.)

                nOxygen
                  services
                  and inhalation therapy

                nRadiation
                  and
                  chemotherapy

                nAccess
                  to
                  DSHS-designated Level III perinatal centers or Hospitals meeting
                  equivalent levels of care

                nIn-network
                  or
                  out-of-network facility and Physician services for a mother and
                  her
                  newborn(s) for a minimum of 48 hours following an uncomplicated
                  vaginal
                  delivery and 96 hours following an uncomplicated delivery by caesarian
                  section.

                nHospital,
                  physician and related medical services, such as anesthesia, associated
                  with dental care

                nSurgical
                  implants

                nOther
                  artificial
                  aids including surgical implants

                nImplantable
                  devices are covered under Inpatient and Outpatient services and
                  do not
                  count towards the DME 12-month period limit

              
	
                Skilled
                  Nursing

                Facilities

                (Includes
                  Rehabilitation

                Hospitals)

              	
                Services
                  include, but are not limited to, the following:

                nSemi-private
                  room
                  and board

                nRegular
                  nursing
                  services

                nRehabilitation
                  services

                nMedical
                  supplies
                  and use of appliances and equipment furnished by the
                  facility

              
	
                Outpatient Hospital,
                  Comprehensive Outpatient Rehabilitation Hospital, Clinic
                  (Including Health Center) and
                  Ambulatory Health Care Center

              	
                Services
                  include, but are not limited to, the following services provided
                  in a
                  hospital clinic or emergency room, a clinic or health center,
                  hospital-based emergency department or an ambulatory health care
                  setting:

                nX-ray,
                  imaging,
                  and radiological tests (technical component)

                nLaboratory
                  and
                  pathology services (technical component)

                nMachine
                  diagnostic
                  tests

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2 – Covered Services

              	
                Version
                  1.7

              


      

      


      
        	
                Covered
                  Benefit

              	
                Description

              
	 	
                nAmbulatory
                  surgical facility services

                nDrugs,
                  medications
                  and biologicals

                nCasts,
                  splints,
                  dressings

                nPreventive
                  health
                  services

                nPhysical,
                  occupational and speech therapy

                nRenal
                  dialysis

                nRespiratory
                  services

                nRadiation
                  and
                  chemotherapy

                nBlood
                  or blood
                  products that are not provided free-of-charge to the patient and
                  the
                  administration of these products

                nFacility
                  and
                  related medical services, such as anesthesia, associated with dental
                  care,
                  when provided in a licensed ambulatory surgical facility.

                nSurgical
                  implants

                nOther
                  artificial
                  aids including surgical implants

                nImplantable
                  devices are covered under Inpatient and Outpatient services and
                  do not
                  count towards the DME 12-month period limit

              
	
                Physician/Physician
                  Extender Professional Services

              	
                Services
                  include, but are not limited to, the following:

                nAmerican Academy
                  of Pediatrics recommended well-child exams and preventive health
                  services (including, but not limited to, vision and hearing screening
                  and immunizations)

                nPhysician
                  office
                  visits, in-patient and out-patient services

                nLaboratory,
                  x-rays, imaging and pathology services, including technical component
                  and/or professional interpretation

                nMedications,
                  biologicals and materials administered in Physician’s office

                nAllergy
                  testing,
                  serum and injections

                nProfessional
                  component (in/outpatient) of surgical services, including:

                -Surgeons
                  and assistant surgeons for surgical procedures including appropriate
                  follow-up care

                -Administration
                  of anesthesia by Physician (other than surgeon) or CRNA

                -Second
                  surgical opinions

                -Same-day
                  surgery performed in a Hospital without an over-night stay

                -Invasive
                  diagnostic procedures such as endoscopic examinations

                nHospital-based
                  Physician services (including Physician-performed technical and
                  interpretive components)

                nIn-network
                  and
                  out-of-network Physician services for a mother and her newborn(s) for
                  a minimum of 48 hours following an uncomplicated vaginal delivery and
                  96 hours following an uncomplicated delivery by
                  caesarian section.

                nPhysician
                  services
                  medically necessary to support a dentist providing dental services to
                  a CHIP member such as general anesthesia or intravenous
                  (IV) sedation.

              
	
                Durable
                  Medical Equipment (DME), Prosthetic Devices and Disposable Medical
                  Supplies

              	
                $20,000
                  12-month period limit for DME, prosthetics, devices and disposable
                  medical
                  supplies (diabetic supplies and equipment are not counted against
                  this ccap). Services include DME (equipment which can withstand
                  repeated use and is primarily and customarily used to serve a medical
                  purpose, generally is not useful to a person in the absence of
                  Illness, Injury, or Disability, and is appropriate for use in the
                  home), including devices and supplies that are medically necessary
                  and necessary for one or more activities of daily living
                  and appropriate to assist in the treatment of a medical condition,
                  including:

                nOrthotic
                  braces
                  and orthotics

                nProsthetic
                  devices
                  such as artificial eyes, limbs, and braces

                nProsthetic
                  eyeglasses and contact lenses for the management of
                  severe

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2 – Covered Services

              	
                Version
                  1.7

              


      

      


      
        	
                Covered
                  Benefit

              	
                Description

              
	 	
                ophthalmologic
                  disease

                nHearing
                  aids

                nDiagnosis-specific
                  disposable medical supplies, including diagnosis-specific prescribed
                  specialty formula and dietary supplements. (See Attachment
                  A)

              
	
                Home
                  and Community Health Services

              	
                Services
                  that are provided in the home and community, including, but not
                  limited
                  to:

                nHome
                  infusion

                nRespiratory
                  therapy

                nVisits
                  for private
                  duty nursing (R.N., L.V.N.)

                nSkilled
                  nursing
                  visits as defined for home health purposes (may include R.N. or
                  L.V.N.).

                nHome
                  health aide
                  when included as part of a plan of care during a period that skilled
                  visits have been approved.

                nSpeech,
                  physical
                  and occupational therapies.

                nServices
                  are not
                  intended to replace the CHILD'S caretaker or to provide relief for
                  the caretaker

                nSkilled
                  nursing
                  visits are provided on intermittent level and not intended to provide
                  24-hour skilled nursing services

                nServices
                  are not
                  intended to replace 24-hour inpatient or skilled nursing facility
                  services

              
	
                Inpatient
                  Mental Health

                Services

              	
                Mental
                  health services, including for serious mental illness, furnished
                  in a
                  freestanding psychiatric hospital, psychiatric units of general acute
                  care hospitals and state-operated facilities, including, but not
                  limited to:

                nNeuropsychological
                  and psychological testing.

                nInpatient
                  mental
                  health services are limited to:

                n45
                  days 12-month
                  inpatient limit

                nIncludes
                  inpatient
                  psychiatric services, up to 12-month period limit, ordered by a court
                  of competent jurisdiction under the provisions of Chapters 573 and
                  574 of the Texas Health and Safety Code, relating to court
                  ordered commitments to psychiatric facilities. Court order serves as
                  binding determination of medical necessity. Any modification or
                  termination of services must be presented to the court with
                  jurisdiction over the matter for determination

                n25
                  days of the
                  inpatient benefit can be converted to residential
                  treatment, therapeutic foster care or other 24-hour therapeutically
                  planned and structured services or sub-acute outpatient (partial
                  hospitalization or rehabilitative day treatment) mental health
                  services on the basis of financial equivalence against the inpatient
                  per diem cost

                n20
                  of the
                  inpatient days must be held in reserve for inpatient use only

                nDoes
                  not require
                  PCP referral

              
	
                Outpatient
                  Mental Health Services

              	
                Mental
                  health services, including for serious mental illness, provided
                  on an
                  outpatient basis, including, but not limited to:

                nMedication
                  management visits do not count against the outpatient visit
                  limit.

                nThe
                  visits can be
                  furnished in a variety of community-based settings (including school
                  and
                  home-based) or in a state-operated facility

                nUp
                  to 60 days
                  12-month period limit for rehabilitative day treatment

                n60
                  outpatient
                  visits 12-month period limit

                n60
                  rehabilitative
                  day treatment days can be converted to outpatient visits on the
                  basis of
                  financial equivalence against the day treatment per diem cost

                n60
                  outpatient
                  visits can be converted to skills training (psycho educational
                  skills
                  development) or rehabilitative day treatment on the basis of
                  financial equivalence against the outpatient visit
                  cost

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2 – Covered Services

              	
                Version
                  1.7

              


      

      


      
        	
                Covered
                  Benefit

              	
                Description

              
	 	
                nIncludes
                  outpatient psychiatric services, up to 12-month period limit, ordered
                  by a
                  court of competent jurisdiction under the provisions of Chapters 573
                  and 574 of the Texas Health and Safety Code, relating to
                  court ordered commitments to psychiatric facilities. Court order
                  serves as binding determination of medical necessity. Any
                  modification or termination of services must be presented to the
                  court with jurisdiction over the matter
                  for determination

                nInpatient
                  days
                  converted to sub-acute outpatient services are in addition to the
                  outpatient limits and do not count towards those limits

                nA
                  Qualified Mental
                  Health Professional (QMHP), as defined by and credentialed through
                  Texas
                  Department of State Health Services (DSHS) standards (TAC Title 25,
                  Part II, Chapter 412), is a Local Mental Health Authorities provider.
                  A QMHP must be working under the authority of an DSHS entity and be
                  supervised by a licensed mental health professional or physician.
                  QMHPs are acceptable providers as long as the services would
                  be within the scope of the services that are typically provided by
                  QMHPs. Those services include individual and group skills training
                  (which can be components of interventions such as day treatment and
                  in-home services), patient and family education, and crisis
                  services

                nDoes
                  not require
                  PCP referral

              
	
                Inpatient
                  Substance Abuse Treatment Services

              	
                Services
                  include, but are not limited to:

                nInpatient
                  and
                  residential substance abuse treatment services
                  including detoxification and crisis stabilization, and 24-hour
                  residential rehabilitation programs

                nDoes
                  not require
                  PCP referral

                nMedically
                  necessary detoxification/stabilization services, limited to 14
                  days per
                  12-month period.

                n24-hour
                  residential rehabilitation programs, or the equivalent, up to 60
                  days per
                  12-month period

                n30
                  days may be
                  converted to partial hospitalization or intensive
                  outpatient rehabilitation, on the basis of financial equivalence
                  against the inpatient per diem cost

                n30
                  days must be
                  held in reserve for inpatient use only.

              
	
                Outpatient
                  Substance Abuse Treatment Services

              	
                nServices
                  include,
                  but are not limited to, the following:

                nPrevention
                  and
                  intervention services that are provided by physician and nonphysician
                  providers, such as screening, assessment and referral for
                  chemical dependency disorders.

                nIntensive
                  outpatient services is defined as an organized non-residential
                  service
                  providing structured group and individual therapy,
                  educational services, and life skills training which consists of at
                  least 10 hours per week for four to 12 weeks, but less than 24
                  hours per
                  day

                nOutpatient
                  treatment service is defined as consisting of at least one to two
                  hours
                  per week providing structured group and individual
                  therapy, educational services, and life skills training

                nOutpatient
                  treatment services up to a maximum of:

                nIntensive
                  outpatient program (up to 12 weeks per 12-month period)

                nOutpatient
                  services (up to six-months per 12-month period)

                nDoes
                  not require
                  PCP referral

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2 – Covered Services

              	
                Version
                  1.7

              


      

      


      
        	
                Covered
                  Benefit

              	
                Description

              
	
                Rehabilitation
                  Services

              	
                Services
                  include, but are not limited to, the following:

                nHabilitation
                  (the
                  process of supplying a child with the means to reach
                  ageappropriate developmental milestones through therapy or treatment)
                  and rehabilitation services include, but are not limited to the
                  following:

                nPhysical,
                  occupational and speech therapy

                nDevelopmental
                  assessment

              
	
                Hospice
                  Care Services

              	
                Services
                  include, but are not limited to:

                nPalliative
                  care,
                  including medical and support services, for those children who have
                  six months or less to live, to keep patients comfortable during
                  the last
                  weeks and months before death

                nTreatment
                  for
                  unrelated conditions is unaffected

                nUp
                  to a maximum of
                  120 days with a 6 month life expectancy

                nPatients
                  electing
                  hospice services waive their rights to treatment related to their
                  terminal
                  illnesses; however, they may cancel this election at anytime

                nServices
                  apply to
                  the hospice diagnosis

              
	
                Emergency
                  Services, including Emergency Hospitals, Physicians, and
                  Ambulance Services

              	
                HMO
                  cannot require authorization as a condition for payment for emergency
                  conditions or labor and delivery.

                Covered
                  services include, but are not limited to, the following:

                nEmergency
                  services
                  based on prudent lay person definition of emergency health
                  condition

                nHospital
                  emergency
                  department room and ancillary services and physician services 24
                  hours a
                  day, 7 days a week, both by in-network and
                  out-of-network providers

                nMedical
                  screening
                  examination

                nStabilization
                  services

                nAccess
                  to DSHS
                  designated Level 1 and Level II trauma centers or hospitals meeting
                  equivalent levels of care for emergency services

                nEmergency
                  ground,
                  air and water transportation

                nEmergency
                  dental
                  services, limited to fractured or dislocated jaw, traumatic damage to
                  teeth, and removal of cysts.

              
	
                Transplants

              	
                Services
                  include, but are not limited to, the following:

                nUsing
                  up-to-date
                  FDA guidelines, all non-experimental human organ and tissue transplants
                  and all forms of non-experimental corneal, bone marrow and peripheral
                  stem cell transplants, including donor medical
                  expenses.

              
	
                Vision
                  Benefit

              	
                The
                  health plan may reasonably limit the cost of the
                  frames/lenses.

                Services
                  include:

                nOne
                  examination of
                  the eyes to determine the need for and prescription for corrective
                  lenses
                  per 12-month period, without authorization

                nOne
                  pair of
                  non-prosthetic eyewear per 12-month period

              
	
                Chiropractic
                  Services

              	
                Services
                  do not require physician prescription and are limited to
                  spinal subluxation

              
	
                Tobacco
                  Cessation

                Program

              	
                Covered
                  up to $100 for a 12- month period limit for a plan- approved
                  program

                nHealth
                  Plan
                  defines plan-approved program.

                nMay
                  be subject to
                  formulary requirements.

              
	
                [Value-added
                  services]

              	
                See
                  Attachment B-3

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2 – Covered Services

              	
                Version
                  1.7

              


      

      


      CHIP
        EXCLUSIONS FROM COVERED SERVICES

      


      
        	
                n

              	
                Inpatient
                  and outpatient infertility treatments or reproductive services
                  other than
                  prenatal care, labor and delivery, and care related to disease,
                  illnesses, or abnormalities related to the reproductive
                  system

              


      

      
        	
                n

              	
                Personal
                  comfort items including but not limited to personal care kits provided
                  on
                  inpatient admission, telephone, television, newborn infant
                  photographs, meals for guests of patient, and other articles which
                  are not required for the specific treatment of sickness or
                  injury

              


      

      
        	
                n

              	
                Experimental
                  and/or investigational medical, surgical or other health care procedures
                  or services which are not generally employed or recognized within
                  the
                  medical community

              


      

      
        	
                n

              	
                Treatment
                  or evaluations required by third parties including, but not limited
                  to,
                  those for schools, employment, flight clearance, camps, insurance or
                  court

              


      

      
        	
                n

              	
                Private
                  duty nursing services when performed on an inpatient basis or in
                  a skilled
                  nursing facility.

              


      

      
        	
                n

              	
                Mechanical
                  organ replacement devices including, but not limited to artificial
                  heart

              


      

      
        	
                n

              	
                Hospital
                  services and supplies when confinement is solely for diagnostic
                  testing
                  purposes, unless otherwise pre-authorized by Health
                  Plan

              


      

      
        	
                n

              	
                Prostate
                  and mammography screening

              


      

      
        	
                n

              	
                Elective
                  surgery to correct vision

              


      

      
        	
                n

              	
                Gastric
                  procedures for weight loss

              


      

      
        	
                n

              	
                Cosmetic
                  surgery/services solely for cosmetic
                  purposes

              


      

      
        	
                n

              	
                Out-of-network
                  services not authorized by the Health Plan except for emergency
                  care
                  and physician services for a mother and her newborn(s) for a minimum
                  of 48 hours following an uncomplicated vaginal delivery and 96 hours
                  following an uncomplicated delivery by caesarian
                  section

              


      

      
        	
                n

              	
                Services,
                  supplies, meal replacements or supplements provided for weight
                  control or
                  the treatment of obesity, except for the services associated with the
                  treatment for morbid obesity as part of a treatment plan approved by
                  the Health Plan

              


      

      
        	
                n

              	
                Acupuncture
                  services, naturopathy and
                  hypnotherapy

              


      

      
        	
                n

              	
                Immunizations
                  solely for foreign travel

              


      

      
        	
                n

              	
                Routine
                  foot care such as hygienic care

              


      

      
        	
                n

              	
                Diagnosis
                  and treatment of weak, strained, or flat feet and the cutting or
                  removal
                  of corns, calluses and toenails (this does not apply to the removal
                  of nail roots or surgical treatment of conditions underlying corns,
                  calluses or ingrown toenails)

              


      

      
        	
                n

              	
                Replacement
                  or repair of prosthetic devices and durable medical equipment due
                  to
                  misuse, abuse or loss when confirmed by the Member or the
                  vendor

              


      

      
        	
                n

              	
                Corrective
                  orthopedic shoes

              


      

      
        	
                n

              	
                Convenience
                  items

              


      

      
        	
                n

              	
                Orthotics
                  primarily used for athletic or recreational
                  purposes

              


      

      
        	
                n

              	
                Custodial
                  care (care that assists a child with the activities of daily living,
                  such
                  as assistance in walking, getting in and out of bed, bathing,
                  dressing, feeding, toileting, special diet preparation, and
                  medication supervision that is usually self-administered or provided
                  by
                  a parent. This care does not require the continuing attention of
                  trained medical or paramedical personnel.) This exclusion does not
                  apply to hospice services.

              


      

      
        	
                n

              	
                Housekeeping

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2 – Covered Services

              	
                Version
                  1.7

              


      

      


      
        	
                n

              	
                Public
                  facility services and care for conditions that federal, state,
                  or local
                  law requires be provided in a public facility or care provided while
                  in the custody of legal authorities

              


      

      
        	
                n

              	
                Services
                  or supplies received from a nurse, which do not require the skill
                  and
                  training of a nurse

              


      

      
        	
                n

              	
                Vision
                  training and vision therapy

              


      

      
        	
                n

              	
                Reimbursement
                  for school-based physical therapy, occupational therapy, or speech
                  therapy services are not covered except when ordered by a
                  Physician/PCP

              


      

      
        	
                n

              	
                Donor
                  non-medical expenses

              


      

      
        	
                n

              	
                Charges
                  incurred as a donor of an organ when the recipient is not covered
                  under
                  this health plan

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2 – Covered Services

              	
                Version
                  1.7

              


      

      


      CHIP
        DME/SUPPLIES

      


      
        	
                SUPPLIES

              	
                COVERED

              	
                EXCLUDED

              	
                COMMENTS/MEMBER

                CONTRACT
                  PROVISIONS

              
	
                Ace
                  Bandages

              	 	
                X

              	
                Exception:
                  If provided by and billed through the clinic or home care agency it
                  is covered as an incidental supply.

              
	
                Alcohol,
                  rubbing

              	 	
                X

              	
                Over-the-counter
                  supply.

              
	
                Alcohol,
                  swabs

                (diabetic)

              	
                X

              	 	
                Over-the-counter
                  supply not covered, unless RX provided at time
                  of dispensing.

              
	
                Alcohol,
                  swabs

              	
                X

              	 	
                Covered
                  only when received with IV therapy or central
                  line kits/supplies.

              
	
                Ana
                  Kit Epinephrine

              	
                X

              	 	
                A
                  self-injection kit used by patients highly allergic to bee
                  stings.

              
	
                Arm
                  Sling

              	
                X

              	 	
                Dispensed
                  as part of office visit.

              
	
                Attends
                  (Diapers)

              	
                X

              	 	
                Coverage
                  limited to children age 4 or over only when prescribed by a physician
                  and
                  used to provide care for a covered diagnosis as outlined in a treatment
                  care plan

              
	
                Bandages

              	 	
                X

              	 
	
                Basal
                  Thermometer

              	 	
                X

              	
                Over-the-counter
                  supply.

              
	
                Batteries
                  – initial

              	
                X

              	 	
                For
                  covered DME items

              
	
                Batteries
                  – replacement

              	
                X

              	 	
                For
                  covered DME when replacement is necessary due to normal
                  use.

              
	
                Betadine

              	 	
                X

              	
                See
                  IV therapy supplies.

              
	
                Books

              	 	
                X

              	 
	
                Clinitest

              	
                X

              	 	
                For
                  monitoring of diabetes.

              
	
                Colostomy
                  Bags

              	 	 	
                See
                  Ostomy Supplies.

              
	
                Communication
                  Devices

              	 	
                X

              	 
	
                Contraceptive
                  Jelly

              	 	
                X

              	
                Over-the-counter
                  supply. Contraceptives are not covered under
                  the plan.

              
	
                Cranial
                  Head Mold

              	 	
                X

              	 
	
                Diabetic
                  Supplies

              	
                X

              	 	
                Monitor
                  calibrating solution, insulin syringes, needles, lancets, lancet
                  device,
                  and glucose strips.

              
	
                Diapers/Incontinent

                Briefs/Chux

              	
                X

              	 	
                Coverage
                  limited to children age 4 or over only when prescribed by a physician
                  and
                  used to provide care for a covered diagnosis as outlined in a
                  treatment care plan

              
	
                Diaphragm

              	 	
                X

              	
                Contraceptives
                  are not covered under the plan.

              
	
                Diastix

              	
                X

              	 	
                For
                  monitoring diabetes.

              
	
                Diet,
                  Special

              	 	
                X

              	 
	
                Distilled
                  Water

              	 	
                X

              	 
	
                Dressing

                Supplies/Central
                  Line

              	
                X

              	 	
                Syringes,
                  needles, Tegaderm, alcohol swabs, Betadine swabs or ointment, tape.
                  Many
                  times these items are dispensed in a kit when includes all necessary
                  items for one dressing site change.

              
	
                Dressing

                Supplies/Decubitus

              	
                X

              	 	
                Eligible
                  for coverage only if receiving covered home care for
                  wound care.

              
	
                Dressing

                Supplies/Peripheral
                  IV

                Therapy

              	
                X

              	 	
                Eligible
                  for coverage only if receiving home IV therapy.

              
	
                Dressing

                Supplies/Other

              	 	
                X

              	 
	
                Dust
                  Mask

              	 	
                X

              	 
	
                Ear
                  Molds

              	
                X

              	 	
                Custom
                  made, post inner or middle ear surgery

              
	
                Electrodes

              	
                X

              	 	
                Eligible
                  for coverage when used with a covered DME.

              
	
                Enema
                  Supplies

              	 	
                X

              	
                Over-the-counter
                  supply.

              
	
                Enteral
                  Nutrition

              	
                X

              	 	
                Necessary
                  supplies (e.g., bags, tubing, connectors, catheters, etc.)
                  are

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2 – Covered Services

              	
                Version
                  1.7

              


      

      


      
        	
                SUPPLIES

              	
                COVERED

              	
                EXCLUDED

              	
                COMMENTS/MEMBER

                CONTRACT
                  PROVISIONS

              
	
                Supplies

              	 	 	
                eligible
                  for coverage. Enteral nutrition products are not covered except
                  for those
                  prescribed for hereditary metabolic disorders, a nonfunction or
                  disease of the structures that normally permit food to reach the
                  small bowel, or malabsorption due to disease

              
	
                Eye
                  Patches

              	
                X

              	 	
                Covered
                  for patients with amblyopia.

              
	
                Formula

              	 	
                X

              	
                Exception:
                  Eligible for coverage only for chronic hereditary metabolic disorders
                  a
                  non-function or disease of the structures that normally permit food
                  to reach the small bowel; or malabsorption due to disease (expected
                  to last longer than 60 days when prescribed by the physician and
                  authorized by plan.) Physician documentation to

                justify
                  prescription of formula must include:

                •Identification
                  of a metabolic disorder, dysphagia that results in a medical need for
                  a liquid diet, presence of a gastrostomy, or disease resulting in
                  malabsorption that requires a medically necessary nutritional
                  product

                Does
                  not include formula:

                •For
                  members who could be sustained on an
                  age-appropriate diet.

                •Traditionally
                  used for infant feeding

                •In
                  pudding form (except for clients with documented oropharyngeal motor
                  dysfunction who receive greater than 50 percent of their daily
                  caloric intake from this product)

                •For
                  the primary diagnosis of failure to thrive, failure to gain weight,
                  or lack of growth or for infants less than twelve months of age
                  unless medical necessity is documented and other criteria, listed
                  above, are met.

                 

                Food
                  thickeners, baby food, or other regular grocery products that can
                  be
                  blenderized and used with an enteral system that are
                  not medically necessary, are not covered, regardless of
                  whether these regular food products are taken orally or
                  parenterally.

              
	
                Gloves

              	 	
                X

              	
                Exception: 
                  Central line dressings or wound care provided by home care
                  agency.

              
	
                Hydrogen
                  Peroxide

              	 	
                X

              	
                Over-the-counter
                  supply.

              
	
                Hygiene
                  Items

              	 	
                X

              	 
	
                Incontinent
                  Pads

              	
                X

              	 	
                Coverage
                  limited to children age 4 or over only when prescribed by a physician
                  and
                  used to provide care for a covered diagnosis as outlined in a
                  treatment care plan

              
	
                Insulin
                  Pump (External) Supplies

              	
                X

              	 	
                Supplies
                  (e.g., infusion sets, syringe reservoir and dressing, etc.)
                  are eligible for coverage if the pump is a covered
                  item.

              
	
                Irrigation
                  Sets, Wound Care

              	
                X

              	 	
                Eligible
                  for coverage when used during covered home care for wound
                  care.

              
	
                Irrigation
                  Sets, Urinary

              	
                X

              	 	
                Eligible
                  for coverage for individual with an indwelling
                  urinary catheter.

              
	
                IV
                  Therapy Supplies

              	
                X

              	 	
                Tubing,
                  filter, cassettes, IV pole, alcohol swabs, needles, syringes and any
                  other related supplies necessary for home IV therapy.

              
	
                K-Y
                  Jelly

              	 	
                X

              	
                Over-the-counter
                  supply.

              
	
                Lancet
                  Device

              	
                X

              	 	
                Limited
                  to one device only.

              
	
                Lancets

              	
                X

              	 	
                Eligible
                  for individuals with diabetes.

              
	
                Med
                  Ejector

              	
                X

              	 	 
	
                Needles
                  and

              	 	 	
                See
                  Diabetic Supplies

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2 – Covered Services

              	
                Version
                  1.7

              


      

      


      
        	
                SUPPLIES

              	
                COVERED

              	
                EXCLUDED

              	
                COMMENTS/MEMBER

                CONTRACT
                  PROVISIONS

              
	
                Syringes/Diabetic

              	 	 	 
	
                Needles
                  and Syringes/IV and Central Line

              	 	 	
                See
                  IV Therapy and Dressing Supplies/Central Line.

              
	
                Needles
                  and Syringes/Other

              	
                X

              	 	
                Eligible
                  for coverage if a covered IM or SubQ medication is being administered
                  at home.

              
	
                Normal
                  Saline

              	 	 	
                See
                  Saline, Normal

              
	
                Novopen

              	
                X

              	 	 
	
                Ostomy
                  Supplies

              	
                X

              	 	
                Items
                  eligible for coverage include: belt, pouch, bags, wafer, face plate,
                  insert, barrier, filter, gasket, plug, irrigation kit/sleeve,
                  tape, skin prep, adhesives, drain sets, adhesive remover, and pouch
                  deodorant.

                Items
                  not eligible for coverage include: scissors, room
                  deodorants, cleaners, rubber gloves, gauze, pouch covers, soaps, and
                  lotions.

              
	
                Parenteral Nutrition/Supplies

              	
                X

              	 	
                Necessary
                  supplies (e.g., tubing, filters, connectors, etc.) are eligible
                  for
                  coverage when the Health Plan has authorized the parenteral
                  nutrition.

              
	
                Saline,
                  Normal

              	
                X

              	 	
                Eligible
                  for coverage:

                a)
                  when used to dilute medications for nebulizer treatments;

                b)
                  as part of covered home care for wound care;

                c)
                  for indwelling urinary catheter irrigation.

              
	
                Stump
                  Sleeve

              	
                X

              	 	 
	
                Stump
                  Socks

              	
                X

              	 	 
	
                Suction
                  Catheters

              	
                X

              	 	 
	
                Syringes

              	 	 	
                See
                  Needles/Syringes.

              
	
                Tape

              	 	 	
                See
                  Dressing Supplies, Ostomy Supplies, IV Therapy
                  Supplies.

              
	
                Tracheostomy
                  Supplies

              	
                X

              	 	
                Cannulas,
                  Tubes, Ties, Holders, Cleaning Kits, etc. are eligible
                  for coverage.

              
	
                Under
                  Pads

              	 	 	
                See
                  Diapers/Incontinent Briefs/Chux.

              
	
                Unna
                  Boot

              	
                X

              	 	
                Eligible
                  for coverage when part of wound care in the home setting. Incidental
                  charge when applied during office visit.

              
	
                Urinary,
                  External Catheter & Supplies

              	 	
                X

              	
                Exception:
                  Covered when used by incontinent male where injury to the urethra
                  prohibits use of an indwelling catheter ordered by the PCP and
                  approved by the plan

              
	
                Urinary,
                  Indwelling Catheter & Supplies

              	
                X

              	 	
                Cover
                  catheter, drainage bag with tubing, insertion tray, irrigation
                  set and
                  normal saline if needed.

              
	
                Urinary,
                  Intermittent

              	
                X

              	 	
                Cover
                  supplies needed for intermittent or straight
                  catherization.

              
	
                Urine
                  Test Kit

              	
                X

              	 	
                When
                  determined to be medically necessary.

              
	
                Urostomy
                  supplies

              	 	 	
                See
                  Ostomy Supplies.

              


      

       

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
 

    
      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	 
	
                Subject:
                  Attachment B-2.1 – STAR+PLUS Covered Services

              	 	
                Version
                  1.7

              


      

      


      DOCUMENT
        HISTORY LOG

      
        	
                STATUS1

              	
                DOCUMENT
                  REVISION2

              	
                EFFECTIVE
                  DATE

              	
                DESCRIPTION3

              
	
                Baseline

              	
                n/a

              	 	
                Initial
                  version of Attachment B-2, Covered Services.

              
	
                Revision

              	
                1.1

              	
                June
                  30, 2006

              	
                 

                Revised
                  Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS
                  Covered Services. This is the initial version of Attachment B-2.1,
                  STAR+PLUS Covered Services, which lists the Acute Care Services
                  and the
                  Community Based Long Term Care Services.

                 

              
	
                Revision

              	
                1.2

              	
                September
                  1, 2006

              	
                Contract
                  Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
                  Services.

              
	
                Revision

              	
                1.3

              	
                September
                  1, 2006

              	
                Contract
                  Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
                  Services.

              
	
                Revision

              	
                1.4

              	
                September
                  1, 2006

              	
                Contract
                  Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
                  Services.

              
	
                Revision

              	
                1.5

              	
                January
                  1, 2007

              	
                 

                Revised
                  Attachment B-2.1, STAR+PLUS Covered Services, to include inpatient
                  and
                  outpatient mental health services for adults.

              
	
                Revision

              	
                1.6

              	
                February
                  1, 2007

              	
                 

                Revised
                  Attachment B-2.1, STAR+PLUS Covered Services, to exclude inpatient
                  mental
                  health services for adults and children, and to establish monetary
                  limits
                  on Transition Assistance Services.

                 

                Personal
                  Attendant Services is clarified to include the three service delivery
                  options described in Attachment B-1, Section 8.3.5.  Consumer
                  Directed Personal Attendant Services is deleted from the list since
                  it is
                  one of the three service delivery options under Personal Attendant
                  Services.

                 

              
	
                Revision

              	
                1.7

              	
                June
                  1, 2007

              	
                 

                Revised
                  Attachment B-2.1, STAR+PLUS Covered Services, to include inpatient
                  mental
                  health services for adults and children and to include effective
                  dates by
                  service area.

              
	
                1
Status
                  should
                  be represented as “Baseline” for initial issuances, “Revision” for changes
                  to the Baseline version, and “Cancellation” for withdrawn
                  versions

                2  Revisions
                  should be numbered in accordance according to the version of the
                  issuance
                  and sequential numbering of the revision—e.g., “1.2” refers to the first
                  version of the document and the second revision.

                3
Brief
                  description of the changes to the document made in the
                  revision.

              


      


      
        
                

                    1
              of
              4

          

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	 
	
                Subject:
                  Attachment B-2.1 – STAR+PLUS Covered Services

              	 	
                Version
                  1.7

              


      

      


      STAR+PLUS
        Covered Services

      


      Acute
        Care Services

      


      The
        following is a non-exhaustive, high-level listing of Acute Care Covered Services
        included under the STAR+PLUS Medicaid managed care program.

      


      Medicaid
        HMO Contractors are responsible for providing a benefit package to Members
        that
        includes all medically necessary services covered under the traditional,
        fee-for-service Medicaid programs except for Non-capitated Services provided
        to
        Medicaid Members outside of the HMO capitation and listed in Attachment B-1,
        Section 8.2.2.8. In addition to the non-capitated services listed in Attachment
        B-1, Section 8.2.2.8, Hospital Inpatient Stays are excluded from the capitation
        payment to STAR+PLUS HMOs and are paid through HHSC’s Administrative Contractor
        responsible for payment of Traditional Medicaid fee-for-service claims. Medicaid
        HMO Contractors must coordinate care for Members for these Non-capitated
        Services so that Members have access to a full range of medically necessary
        Medicaid services, both capitated and non-capitated. A Contractor may elect
        to
        offer additional acute care Value-added Services.

      


      The
        STAR+PLUS Members are provided with two enhanced benefits compared to the
        traditional, fee-for-service Medicaid coverage:

      1)      waiver
        of the three-prescription per month limit, for members not covered by
        Medicare;

      2)      inclusion
        of an annual adult well check for patients 21 years of age and
        over.

      


      Medicaid
        HMO Contractors are responsible for providing a benefit package to Members
        that
        includes an annual adult well check for patients 21 years of age and
        over.  Prescription drug benefits to HMO Members are provided outside
        of the HMO capitation.

      


      STAR+PLUS
        HMO Contractors should refer to the current Texas Medicaid Provider
        Procedures Manual and the bi-monthly Texas Medicaid
        Bulletin for a more inclusive listing of limitations and
        exclusions that apply to each Medicaid benefit category. (These documents
        can be
        accessed online at: http://www.tmhp.com.)

      


      The
        services listed in this Attachment are subject to modification based on Federal
        and State laws and regulations and Programs policy updates.

      


      Services
        included under the HMO capitation payment

      
        	
                •

              	
                Ambulance
                  services

              


      

      
        	
                •

              	
                Audiology
                  services, including hearing aids for adults (hearing aids for children
                  are
                  provided through the PACT program and are a non-capitated
                  service)

              


      

      
        	
                •

              	
                Behavioral
                  Health Services, including:

              


      

      
        	
                 

              	
                o

              	
                Inpatient
                  mental health services for Adults and Children (Effective 6/01/07
                  in the
                  Harris Service Area; and effective 9/01/07 in the Bexar, Nueces
                  and Travis
                  Service Areas.)

              


      

      
        	
                 

              	
                o

              	
                Outpatient
                  mental health services for Adults and
                  Children

              


      

      
        	
                 

              	
                o

              	
                Outpatient
                  chemical dependency services for children (under age
                  21)

              


      

      
        	
                 

              	
                o

              	
                Detoxification
                  services

              


      

      
        	
                 

              	
                o

              	
                Psychiatry
                  services

              


      

      
        	
                 

              	
                o

              	
                Counseling
                  services for adults (21 years of age and
                  over)

              


      

      
        	
                •

              	
                Birthing
                  center services

              


      

      
        	
                •

              	
                Chiropractic
                  services

              


      


      
        
                

            2
              of 4    
    

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	 
	
                Subject:
                  Attachment B-2.1 – STAR+PLUS Covered Services

              	 	
                Version
                  1.7

              


      

      


      
        	
                •

              	
                Dialysis

              


      

      
        	
                •

              	
                Durable
                  medical equipment and supplies

              


      

      
        	
                •

              	
                Emergency
                  Services

              


      

      
        	
                •

              	
                Family
                  planning services

              


      

      
        	
                •

              	
                Home
                  health care services

              


      

      
        	
                •

              	
                Hospital
                  services, outpatient

              


      

      
        	
                •

              	
                Laboratory

              


      

      
        	
                •

              	
                Medical
                  check-ups and Comprehensive Care Program (CCP) Services for children
                  (under age 21) through the Texas Health Steps
                  Program

              


      

      
        	
                •

              	
                Optometry,
                  glasses, and contact lenses, if medically
                  necessary

              


      

      
        	
                •

              	
                Podiatry

              


      

      
        	
                •

              	
                Prenatal
                  care

              


      

      
        	
                •

              	
                Primary
                  care services

              


      

      
        	
                •

              	
                Radiology,
                  imaging, and X-rays

              


      

      
        	
                •

              	
                Specialty
                  physician services

              


      

      
        	
                •

              	
                Therapies
                  – physical, occupational and speech

              


      

      
        	
                •

              	
                Transplantation
                  of organs and tissues

              


      

      
        	
                •

              	
                Vision

              


      

      


      Community
        Based Long Term Care Services

      


      The
        following is a non-exhaustive, high-level listing of Community Based Long
        Term
        Care Covered Services included under the STAR+PLUS Medicaid managed care
        program.

      


      •           Community
        Based Long Term Care Services for all Members

      
        	
                 

              	
                o

              	
                Personal
                  Attendant Services – All Members of a STAR+PLUS HMO may receive medically
                  and functionally necessary personal attendant services
                  (PAS).

              


      

      
        	
                 

              	
                o

              	
                Day
                  Activity and Health Services – All Members of a STAR+PLUS HMO may receive
                  medically and functionally necessary Day Activity and Health Care
                  Services
                  (DAHS).

              


      

      
        	
                •

              	
                1915
                  (c) Nursing Facility Waiver Services for those Members who qualify
                  for
                  such services

              


      

      The
        state
        provides an enriched array of services to clients who would otherwise qualify
        for nursing facility care through a Home and Community Based Medicaid
        Waiver.  In traditional Medicaid, this is known as the Community Based
        Alternatives (CBA) waiver.  The STAR+PLUS HMO must also provide the
        services that are available to clients through the CBA waiver in traditional
        Medicaid to those clients that meet the functional and financial eligibility
        for
        the 1915 (c) Nursing Facility Waiver Services.

      
        	
                 

              	
                o

              	
                Personal
                  Attendant Services (including the three service delivery options:
                  Self-Directed; Agency Model, Self Directed; and Agency
                  Model)

              


      

      
        	
                 

              	
                o

              	
                Nursing
                  Services (in home)

              


      

      
        	
                 

              	
                o

              	
                Emergency
                  Response Services (Emergency call
                  button)

              


      

      
        	
                 

              	
                o

              	
                Home
                  Delivered Meals

              


      

      
        	
                 

              	
                o

              	
                Minor
                  Home Modifications

              


      

      
        	
                 

              	
                o

              	
                Adaptive
                  Aids and Medical Equipment

              


      

      
        	
                 

              	
                o

              	
                Medical
                  Supplies

              


      

      
        	
                 

              	
                o

              	
                Physical
                  Therapy, Occupational Therapy, Speech
                  Therapy

              


      

      
        	
                 

              	
                o

              	
                Adult
                  Foster Care

              


      

      
        	
                 

              	
                o

              	
                Assisted
                  Living

              


      


      
        
                

              3
              of
              4     
    

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	 
	
                Subject:
                  Attachment B-2.1 – STAR+PLUS Covered Services

              	 	
                Version
                  1.7

              


      

      


      
        	
                 

              	
                o

              	
                Transition
                  Assistance Services (These services are limited to a maximum of
                  $2,500.00.  If the HMO determines that no other resources are
                  available to pay for the basic services/items needed to assist
                  a Member,
                  who is leaving a nursing facility, with setting up a household,
                  the HMO
                  may authorize up to $2,500.00 for Transition Assistance Services
                  (TAS).  The $2,500.00 TAS benefit is part of the expense ceiling
                  when determining the Total Annual Individual Service Plan (ISP)
                  Cost.)

              


      

      


      



      
        
                

                 4
              of
              4     
    

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      



    
      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      DOCUMENT
        HISTORY LOG

      
        	
                STATUS1

              	
                DOCUMENT
                  REVISION2

              	
                EFFECTIVE
                  DATE

              	
                DESCRIPTION3

              
	
                Baseline

              	
                n/a

              	 	
                Initial
                  version of Attachment B-2, Covered Services

              
	
                Revision

              	
                1.1

              	
                June
                  30, 2006

              	
                Revised
                  Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS
                  Covered Services.

              
	
                Revision

              	
                1.2

              	
                September
                  1, 2006

              	
                Revised
                  Attachment B-2, Covered Services, by updating provisions applicable
                  to
                  MCOs participating in the STAR and CHIP Programs.

              
	
                Revision

              	
                1.3

              	
                September
                  1, 2006

              	
                Revised
                  Attachment B-2, Covered Services, by adding Attachment B-2.2, CHIP
                  Perinatal Covered Services. This is the initial version of Attachment
                  B-2.2, which lists the CHIP Perinatal Covered Services, exclusions
                  and
                  DME/Supplies.

              
	
                Revision

              	
                1.4

              	
                September
                  1, 2006

              	
                Contract
                  Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
                  Services.

              
	
                Revision

              	
                1.5

              	
                January
                  1, 2007

              	
                Contract
                  Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
                  Services.

              
	
                Revision

              	
                1.6

              	
                February
                  1, 2007

              	
                Contract
                  Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
                  Services.

              
	
                Revision

              	
                1.7

              	
                June
                  1, 2007

              	
                Contract
                  Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
                  Services.

              
	
                1  Status
                  should be represented as “Baseline” for initial issuances, “Revision” for
                  changes to the Baseline version, and “Cancellation” for withdrawn
                  versions

                2  Revisions
                  should be numbered in accordance according to the version of the
                  issuance
                  and sequential numbering of the revision—e.g., “1.2” refers to the first
                  version of the document and the second revision.

                3  Brief
                  description of the changes to the document made in the
                  revision.

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      CHIP
        Perinatal Program Covered Services

      


      Covered
        CHIP Perinatal Program services must meet the definition of Medically Necessary
        Covered Services as defined in this Contract. There is no
        lifetime maximum on benefits; however, 12-month enrollment period or lifetime
        limitations do apply to certain services, as specified in the following chart.
        Co-pays do not apply to CHIP Perinatal Program Members. CHIP Perinatal Program
        Members are eligible for 12-months continuous coverage following enrollment
        in
        the program.

      


      
        	
                Covered

                Benefit

              	
                CHIP
                  Perinate Newborn

                 

              	
                CHIP
                  Perinate

                 

              
	
                Inpatient
                  General Acute and Inpatient Rehabilitation Hospital
                  Services

                 

              	
                For
                  CHIP Perinate Newborns in families with incomes at or below 185%
                  of the
                  Federal Poverty Level, the facility charges are not a covered benefit
                  for
                  the initial Perinate Newborn admission; however, facility charges
                  are a
                  covered benefit after the initial Perinate Newborn admission. "Initial
                  Perinate Newborn admission" means the hospitalization associated
                  with the
                  birth.

                 

                For
                  CHIP Perinate Newborns in families with incomes at or below 185%
                  of the
                  Federal Poverty Level, professional service charges are a covered
                  benefit
                  for the initial Perinate Newborn admission and subsequent admissions.
                  "Initial Perinate Newborn admission" means the hospitalization
                  associated
                  with the birth.

                 

                Services
                  include, but are not limited to, the following:

                §Hospital-provided
                  Physician or Provider services

                §Semi-private
                  room
                  and board (or private if medically necessary as certified by
                  attending)

                §General
                  nursing
                  care

                §Special
                  duty
                  nursing when medically necessary

                §ICU
                  and
                  services

                §Patient
                  meals and
                  special diets

                §Operating,
                  recovery and other treatment rooms

                §Anesthesia
                  and
                  administration (facility technical component)

                 

              	
                For
                  CHIP Perinates in families with incomes at or below 185% of the
                  Federal
                  Poverty Level, the facility charges are not a covered benefit;
                  however,
                  professional services charges associated with labor with delivery
                  are a
                  covered benefit.

                 

                For
                  CHIP Perinates in families with incomes between 186% and 200% of
                  the
                  Federal Poverty Level, benefits are limited to professional service
                  charges and facility charges associated with labor with
                  delivery.

                 

                Covered
                  medically necessary Hospital-provided services are limited to labor
                  with
                  delivery until birth.

                 

                Services
                  include:

                §Operating,
                  recovery and other treatment rooms

                §Anesthesia
                  and
                  administration (facility technical component

                §Medically
                  necessary surgical services are limited to services that directly
                  relate
                  to the delivery of the unborn
                  child.

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      


      
        	
                Covered

                Benefit

              	
                CHIP
                  Perinate Newborn

                 

              	
                CHIP
                  Perinate

                 

              
	 	
                §Surgical
                  dressings, trays, casts, splints

                §Drugs,
                  medications
                  and biologicals

                §Blood
                  or blood
                  products that are not provided free-of-charge to the patient and
                  their
                  administration

                §X-rays,
                  imaging
                  and other radiological tests (facility technical component)

                §Laboratory
                  and
                  pathology services (facility technical component)

                §Machine
                  diagnostic
                  tests (EEGs, EKGs, etc.)

                §Oxygen
                  services
                  and inhalation therapy

                §Radiation
                  and
                  chemotherapy

                §Access
                  to
                  DSHS-designated Level III perinatal centers or Hospitals meeting
                  equivalent levels of care

                §In-network
                  or
                  out-of-network facility and Physician services for a mother and
                  her
                  newborn(s) for a minimum of 48 hours following an uncomplicated
                  vaginal
                  delivery and 96 hours following an uncomplicated delivery by caesarian
                  section.

                §Hospital,
                  physician and related medical services, such as anesthesia, associated
                  with dental care

                §Surgical
                  implants

                §Other
                  artificial
                  aids including surgical implants

                §Implantable
                  devices are covered under Inpatient and Outpatient services and
                  do not
                  count towards the DME 12- month period limit

                 

              	 
	
                Skilled
                  Nursing Facilities (Includes Rehabilitation
                  Hospitals)

                 

              	
                Services
                  include, but are not limited

                to,
                  the following:

                §Semi-private
                  room
                  and board

                §Regular
                  nursing
                  services

                §Rehabilitation
                  services

                §Medical
                  supplies
                  and use of

                 

              	
                Not
                  a covered benefit.

                 

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      


      
        	
                Covered

                Benefit

              	
                CHIP
                  Perinate Newborn

                 

              	
                CHIP
                  Perinate

                 

              
	 	
                appliances
                  and equipment furnished by the facility

                 

              	 
	
                Outpatient
                  Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic
                  (Including Health Center) and Ambulatory Health Care
                  Center

                 

              	
                Services
                  include, but are not limited to, the following services provided
                  in a
                  hospital clinic or emergency room, a clinic or health center,
                  hospital-based emergency department or an ambulatory health care
                  setting:

                §X-ray,
                  imaging,
                  and radiological tests (technical component)

                §Laboratory
                  and
                  pathology services (technical component)

                §Machine
                  diagnostic
                  tests

                §Ambulatory
                  surgical facility services

                §Drugs,
                  medications
                  and biologicals

                §Casts,
                  splints,
                  dressings

                §Preventive
                  health
                  services

                §Physical,
                  occupational and speech therapy

                §Renal
                  dialysis

                §Respiratory
                  services

                §Radiation
                  and
                  chemotherapy

                §Blood
                  or blood
                  products that are not provided free-of-charge to the patient and
                  the
                  administration of these products

                §Facility
                  and
                  related medical services, such as anesthesia, associated with dental
                  care,
                  when provided in a licensed ambulatory surgical facility.

                §Surgical
                  implants

                §Other
                  artificial
                  aids including surgical implants

                §Implantable
                  devices are covered under Inpatient and Outpatient services and
                  do not
                  count towards the DME 12- month period limit.

                 

              	
                Services
                  include, the following services provided in a hospital clinic or
                  emergency
                  room, a clinic or health center, hospital-based emergency department
                  or an
                  ambulatory health care setting:

                §X-ray,
                  imaging,
                  and radiological tests (technical component)

                §Laboratory
                  and
                  pathology services (technical component)

                §Machine
                  diagnostic
                  tests

                §Drugs,
                  medications
                  and biologicals that are medically necessary prescription and injection
                  drugs.

                 

                (1)
                  Laboratory and radiological services are limited to services that
                  directly
                  relate to ante partum care and/or the delivery of the covered CHIP
                  Perinate until birth.

                 

                (2)
                  Ultrasound of the pregnant uterus is a covered benefit when medically
                  indicated. Ultrasound may be indicated for suspected genetic defects,
                  high-risk pregnancy, fetal growth retardation, or gestational age
                  confirmation.

                 

                (3)
                  Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion (FIUT)
                  and
                  Ultrasonic Guidance for Cordocentesis, FIUT are covered benefits
                  with an
                  appropriate diagnosis.

                 

                (4)
                  Laboratory tests are limited to: nonstress testing, contraction,
                  stress
                  testing, hemoglobin or hematocrit repeated once a trimester and
                  at 32-36
                  weeks of pregnancy; or complete blood count (CBC), urinanalysis
                  for
                  protein and glucose every visit, blood type and RH antibody screen;
                  repeat
                  antibody screen for Rh negative women at 28 weeks followed by RHO
                  immune
                  globulin

                 

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      


      
        	
                Covered

                Benefit

              	
                CHIP
                  Perinate Newborn

                 

              	
                CHIP
                  Perinate

                 

              
	 	 	
                administration
                  if indicated; rubella antibody titer, serology for syphilis, hepatitis
                  B
                  surface antigen, cervical cytology, pregnancy test, gonorrhea test,
                  urine
                  culture, sickle cell test, tuberculosis (TB) test, human immunodeficiency
                  virus (HIV) antibody screen, Chlamydia test, other laboratory tests
                  not
                  specified but deemed medically necessary, and multiple marker screens
                  for
                  neural tube defects (if the client initiates care between 16 and
                  20
                  weeks); screen for gestational diabetes at 24-28 weeks of pregnancy;
                  other
                  lab tests as indicated by medical condition of client.

                 

              
	
                Physician/Physician
                  Extender Professional Services

                 

              	
                Services
                  include, but are not limited to, the following:

                §American
                  Academy
                  of Pediatrics recommended well-child exams and preventive health
                  services
                  (including, but not limited to, vision and hearing screening and
                  immunizations)

                §Physician
                  office
                  visits, in-patient and out-patient services

                §Laboratory,
                  x-rays, imaging and pathology services, including technical component
                  and/or professional interpretation

                §Medications,
                  biologicals and materials administered in Physician’s office

                §Allergy
                  testing,
                  serum and injections

                §Professional
                  component (in/outpatient) of surgical services, including:

                -Surgeons
                  and assistant surgeons for surgical procedures including appropriate
                  follow-up care

                 -Administration
                  of anesthesia by Physician (other than surgeon) or CRNA

                -Second
                  surgical opinions

                -Same-day
                  surgery

                 

              	
                Services
                  include, but are not limited to the following:

                §Medically
                  necessary physician services are limited to prenatal and postpartum
                  care
                  and/or the delivery of the covered unborn child until birth

                §Physician
                  office
                  visits, inpatient and out-patient services

                §Laboratory,
                  x-rays, imaging and pathology services including technical component
                  and
                  /or professional interpretation

                §Medically
                  necessary medications, biologicals and materials administered in
                  Physician’s office

                §Professional
                  component (in/outpatient) of surgical services, including:

                OSurgeons
                  and assistant surgeons for surgical procedures directly related
                  to the
                  labor with delivery of the covered unborn child until birth.

                OAdministration
                  of anesthesia by Physician (other than surgeon) or CRNA

                OInvasive
                  diagnostic procedures directly related to the labor-with
                  delivery

                 

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      


      
        	
                Covered

                Benefit

              	
                CHIP
                  Perinate Newborn

                 

              	
                CHIP
                  Perinate

                 

              
	 	
                performed
                  in a Hospital

                without
                  an over-night stay

                -Invasive
                  diagnostic  procedures such as  endoscopic
                  examinations

                §Hospital-based
                  Physician services
                  (including
                  Physician-performed technical and interpretive components)
                  

                §In-network
                  and out-of-network
                  Physician services for a mother and her newborn(s) for a minimum
                  of 48
                  hours following an uncomplicated vaginal delivery and 96 hours
                  following
                  an uncomplicated delivery by caesarian
                  section.
                  

                §Physician
                  services
                  medically necessary to support a dentist providing dental services
                  to a
                  CHIP member such as general anesthesia or intravenous (IV)
                  sedation.

              	
                of
                  the unborn child.

                §Hospital-based
                  Physician

                services
                  (including Physician

                performed
                  technical and

                interpretive
                  components)

                §Professional
                  component of the

                ultrasound
                  of the pregnant

                uterus
                  when medically

                indicated
                  for suspected genetic

                defects,
                  high-risk pregnancy,

                fetal
                  growth retardation, or

                gestational
                  age confirmation.

                §Professional
                  component of

                Amniocentesis,
                  Cordocentesis,

                Fetal
                  Intrauterine Transfusion

                (FIUT)
                  and Ultrasonic

                Guidance
                  for Amniocentesis,

                Cordocentrsis,
                  and FIUT.

              
	
                Prenatal
                  Care and Pre-Pregnancy Family Services and
                  Supplies

              	
                Not
                  a covered benefit.

              	
                Services
                  are limited to an initial

                visit
                  and subsequent prenatal (ante

                partum)
                  care visits that include:

                 

                (1)
                  One visit every four weeks for the first 28 weeks or
                  pregnancy;

                (2)
                  one visit every two to three weeks from 28 to 36 weeks of

                pregnancy;
                  and

                (3)
                  one visit per week from 36 weeks to delivery.

                 

                More
                  frequent visits are allowed as Medically Necessary. Benefits are
                  limited
                  to:

                 

                Limit
                  of 20 prenatal visits and 2 postpartum visits (maximum within 60
                  days)
                  without documentation of a complication of pregnancy. More frequent
                  visits
                  may be necessary for high-risk pregnancies. High-risk prenatal
                  visits are
                  not limited to 20 visits per pregnancy. Documentation supporting
                  medical
                  necessity must be maintained in the physician’s files and is subject to
                  retrospective review.

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	 
	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      


      
        	
                Covered

                Benefit

              	
                CHIP
                  Perinate Newborn

                 

              	
                CHIP
                  Perinate

                 

              
	 	 	
                Visits
                  after the initial visit must

                include:

                §interim
                  history
                  (problems, marital status, fetal status);

                §physical
                  examination (weight, blood pressure, fundalheight, fetal position
                  and
                  size, fetal heart rate, extremities) and

                §laboratory
                  tests
                  (urinanalysis for protein and glucose every visit; hematocrit or
                  hemoglobin repeated once a trimester and at 32-36 weeks of pregnancy;
                  multiple marker screen for fetal abnormalities offered at 16-20
                  weeks of
                  pregnancy; repeat antibody screen for Rh negative women at 28 weeks
                  followed by Rho immune globulin administration if indicated; screen
                  for
                  gestational diabetes at 24-28 weeks of pregnancy; and other lab
                  tests as
                  indicated by medical condition of client).

              
	
                Durable
                  Medical Equipment (DME), Prosthetic Devices and Disposable Medical
                  Supplies

              	
                $20,000
                  12-month period limit for DME, prosthetics, devices and disposable
                  medical
                  supplies (diabetic supplies and equipment are not counted against
                  this
                  cap). Services include DME (equipment which can withstand repeated
                  use and
                  is primarily and customarily used to serve a medical purpose, generally
                  is
                  not useful to a person in the absence of Illness, Injury, or Disability,
                  and is appropriate for use in the home), including devices and
                  supplies
                  that are medically necessary and necessary for one or more activities
                  of daily living and appropriate to assist in the treatment of a
                  medical
                  condition, including:

                §Orthotic
                  braces
                  and orthotics

                §Prosthetic
                  devices
                  such as artificial eyes, limbs, and braces

                §Prosthetic
                  eyeglasses and contact lenses for the management of severe ophthalmologic
                  disease

                §Hearing
                  aids

                §Diagnosis-specific
                  disposable

              	
                Not
                  a covered benefit.

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      


      
        	
                Covered

                Benefit

              	
                CHIP
                  Perinate Newborn

                 

              	
                CHIP
                  Perinate

                 

              
	 	
                medical
                  supplies, including diagnosis-specific prescribed specialty formula
                  and
                  dietary supplements. (See Attachment A)

              	 
	
                Home
                  and Community Health Services

              	
                Services
                  that are provided in the

                home
                  and community, including,

                but
                  not limited to:

                §Home
                  infusion

                §Respiratory
                  therapy

                §Visits
                  for private
                  duty nursing (R.N.,
                  L.V.N.)

                §Skilled
                  nursing
                  visits as defined for
                  home health purposes (may include
                  R.N. or L.V.N.).

                §Home
                  health aide
                  when included
                  as part of a plan of care
                  during a period that skilled visits
                  have been approved.

                §Speech,
                  physical
                  and occupational therapies.

                §Services
                  are not
                  intended to replace the CHILD'S caretaker or to provide relief
                  for the
                  caretaker

                §Skilled
                  nursing
                  visits are provided on intermittent level and not intended to provide
                  24-hour skilled nursing services

                §Services
                  are not
                  intended to replace 24-hour inpatient or skilled nursing facility
                  services

              	
                Not
                  a covered benefit.

              
	
                Inpatient
                  Mental Health Services

              	
                Mental
                  health services, including for serious mental illness, furnished in a
                  free-standing psychiatric hospital, psychiatric units of general
                  acute
                  care hospitals and state-operated facilities, including, but not
                  limited
                  to:

                §Neuropsychological
                  and psychological testing.

                §Inpatient
                  mental
                  health services are limited to:

                §45
                  days 12-month
                  inpatient limit

                §Includes
                  inpatient
                  psychiatric services, up to 12-month period limit, ordered by a
                  court
                  of

              	
                Not
                  a covered benefit.

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      


      
        	
                Covered

                Benefit

              	
                CHIP
                  Perinate Newborn

                 

              	
                CHIP
                  Perinate

                 

              
	 	
                competent
                  jurisdiction under the provisions of Chapters 573 and 574 of the
                  Texas
                  Health and Safety Code, relating to court ordered commitments to
                  psychiatric facilities. Court order serves as binding determination
                  of
                  medical necessity. Any modification or termination of services
                  must be
                  presented to the court with jurisdiction over the matter for
                  determination

                §25
                  days of the
                  inpatient benefit can be converted to residential treatment, therapeutic
                  foster care or other 24-hour therapeutically planned and structured
                  services or sub-acute outpatient (partial hospitalization or
                  rehabilitative day treatment) mental health services on the basis
                  of
                  financial equivalence against the inpatient per diem cost

                §20
                  of the
                  inpatient days must be held in reserve for inpatient use only

                §Does
                  not require
                  PCP referral

              	 
	
                Outpatient
                  Mental Health

                Services

              	
                Mental
                  health services, including for serious mental illness, provided
                  on an
                  outpatient basis, including, but not limited to:

                §Medication
                  management visits do not count against the outpatient visit
                  limit.

                §The
                  visits can be
                  furnished in a variety of community-based settings (including school
                  and
                  home-based) or in a state-operated facility

                §Up
                  to 60 days
                  12-month period limit for rehabilitative day treatment

                §60
                  outpatient
                  visits 12-month period limit

                §60
                  rehabilitative
                  day treatment days can be converted to outpatient visits on the
                  basis of
                  financial equivalence against the day treatment per diem
                  cost

              	
                Not
                  a covered benefit.

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      


      
        	
                Covered

                Benefit

              	
                CHIP
                  Perinate Newborn

                 

              	
                CHIP
                  Perinate

                 

              
	 	
                §60
                  outpatient
                  visits can be converted to skills training (psycho educational
                  skills
                  development) or rehabilitative day treatment on the basis of financial
                  equivalence against the outpatient visit cost

                §Includes
                  outpatient psychiatric services, up to 12-month period limit, ordered
                  by a
                  court of competent jurisdiction under the provisions of Chapters
                  573 and
                  574 of the Texas Health and Safety Code, relating to court ordered
                  commitments to psychiatric facilities. Court order serves as binding
                  determination of medical necessity. Any modification or termination
                  of
                  services must be presented to the court with jurisdiction over
                  the matter
                  for determination

                §Inpatient
                  days
                  converted to sub-acute outpatient services are in addition to the
                  outpatient limits and do not count towards those limits

                §A
                  Qualified Mental
                  Health Professional (QMHP), as defined by and credentialed through
                  Texas
                  Department of State Health Services (DSHS) standards (TAC Title
                  25, Part
                  II, Chapter 412), is a Local Mental Health Authorities provider.
                  A QMHP
                  must be working under the authority of an DSHS entity and be supervised
                  by
                  a licensed mental health professional or physician. QMHPs are acceptable
                  providers as long as the services would be within the scope of
                  the
                  services that are typically provided by QMHPs. Those services include
                  individual and group skills training (which can be components of
                  interventions such as day treatment and in-home services), patient
                  and

              	 


      

      



      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      


      
        	
                Covered

                Benefit

              	
                CHIP
                  Perinate Newborn

                 

              	
                CHIP
                  Perinate

                 

              
	 	
                family
                  education, and crisis services

                §Does
                  not require
                  PCP referral

              	 
	
                Inpatient
                  Substance Abuse Treatment Services

              	
                Services
                  include, but are not limited

                to:

                §Inpatient
                  and
                  residential substance abuse treatment services including detoxification
                  and crisis stabilization, and 24-hour residential rehabilitation
                  programs

                §Does
                  not require
                  PCP referral

                §Medically
                  necessary detoxification/stabilization services, limited to 14
                  days per
                  12-month period.

                §24-hour
                  residential rehabilitation programs, or the equivalent, up to 60
                  days per
                  12-month period.

                §30
                  days may be
                  converted to partial hospitalization or intensive outpatient
                  rehabilitation, on the basis of financial equivalence against the
                  inpatient per diem cost

                §30
                  days must be
                  held in reserve for inpatient use only.

              	
                Not
                  a covered benefit.

              
	
                Outpatient
                  Substance Abuse Treatment Services

              	
                §Services
                  include,
                  but are not limited to, the following:

                §Prevention
                  and
                  intervention services that are provided by physician and non-physician
                  providers, such as screening, assessment and referral for chemical
                  dependency disorders.

                §Intensive
                  outpatient services is defined as an organized non-residential
                  service
                  providing structured group and individual therapy, educational
                  services,
                  and life skills training which consists of at least 10 hours per
                  week for
                  four to 12 weeks, but less than 24 hours per day

                §Outpatient
                  treatment service is defined as consisting of at least one to two
                  hours
                  per week

              	
                Not
                  a covered benefit.

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      


      
        	
                Covered

                Benefit

              	
                CHIP
                  Perinate Newborn

                 

              	
                CHIP
                  Perinate

                 

              
	 	
                providing
                  structured group and individual therapy, educational services,
                  and life
                  skills training

                §Outpatient
                  treatment services up to a maximum of:

                §Intensive
                  outpatient program (up to 12 weeks per 12-month period)

                §Outpatient
                  services (up to six-months per 12-month period)

                §Does
                  not require
                  PCP referral

                 

              	 
	
                Rehabilitation
                  Services

              	
                Services
                  include, but are not limited to, the following:

                §Habilitation
                  (the
                  process of supplying a child with the means to reach age-appropriate
                  developmental milestones through therapy or treatment) and rehabilitation
                  services include, but are not limited to the following:

                §Physical,
                  occupational and speech therapy

                §Developmental
                  assessment

              	
                Not
                  a covered benefit.

              
	
                Hospice
                  Care Services

              	
                Services
                  include, but are not limited to:

                §Palliative
                  care,
                  including medical and support services, for those children who
                  have six
                  months or less to live, to keep patients comfortable during the
                  last weeks
                  and months before death

                §Treatment
                  for
                  unrelated conditions is unaffected

                §Up
                  to a maximum of
                  120 days with a 6 month life expectancy

                §Patients
                  electing
                  hospice services waive their rights to treatment related to their
                  terminal
                  illnesses; however, they may cancel this election at anytime

                §Services
                  apply to
                  the hospice diagnosis

              	
                Not
                  a covered benefit.

              
	
                Emergency
                  Services, including Emergency Hospitals, Physicians, and Ambulance
                  Services

              	
                HMO
                  cannot require authorization as a condition for payment for emergency
                  conditions labor and

              	
                HMO
                  cannot require authorization as a condition for payment for emergency
                  conditions related to

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      


      
        	
                Covered

                Benefit

              	
                CHIP
                  Perinate Newborn

                 

              	
                CHIP
                  Perinate

                 

              
	 	
                delivery.

                 

                Covered
                  services include, but are not limited to, the following:

                §Emergency
                  services
                  based on prudent lay person definition of emergency health
                  condition

                §Hospital
                  emergency
                  department room and ancillary services and physician services 24
                  hours a
                  day, 7 days a week, both by in-network and out-of-network
                  providers

                §Medical
                  screening
                  examination

                §Stabilization
                  services

                §Access
                  to DSHS
                  designated Level 1 and Level II trauma centers or hospitals meeting
                  equivalent levels of care for emergency services

                §Emergency
                  ground,
                  air and water transportation

                §Emergency
                  dental
                  services, limited to fractured or dislocated jaw, traumatic damage
                  to
                  teeth, and removal of cysts.

              	
                labor
                  with delivery.

                 

                Covered
                  services are limited to those emergency services that are directly
                  related
                  to the delivery of the unborn child until birth.

                 

                §Emergency
                  services
                  based on prudent lay person definition of emergency health
                  condition

                §Medical
                  screening
                  examination to determine emergency when directly related to the
                  delivery
                  of the covered unborn child.

                § Stabilization
                  services related to the labor with delivery of the covered unborn
                  child.

                §Emergency
                  ground,
                  air and water transportation for labor and threatened labor is
                  a covered
                  benefit

                 

                Benefit
                  limits: Post-delivery services or complications resulting in the
                  need for
                  emergency services for the mother of the CHIP Perinate are not
                  a covered
                  benefit.

              
	
                Transplants

              	
                Services
                  include, but are not limited to, the following:

                §Using
                  up-to-date
                  FDA guidelines, all non-experimental human organ and tissue transplants
                  and all forms of non-experimental corneal, bone marrow and peripheral
                  stem
                  cell transplants, including donor medical expenses.

              	
                Not
                  a covered benefit.

              
	
                Vision
                  Benefit

              	
                The
                  health plan may reasonably limit the cost of the frames/lenses.
                  Services
                  include:

                §One
                  examination of
                  the eyes to determine the need for and prescription for corrective
                  lenses
                  per 12-month period, without authorization

                §One
                  pair of
                  non-prosthetic eyewear per 12-month period

              	
                Not
                  a covered benefit.

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	 
	
                Contractual
                  Document (CD)

              
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      


      
        	
                Covered

                Benefit

              	
                CHIP
                  Perinate Newborn

                 

              	
                CHIP
                  Perinate

                 

              
	
                Chiropractic
                  Services

              	
                §Services
                  do not
                  require physician prescription and are limited to spinal
                  subluxation.

              	
                Not
                  a covered benefit.

              
	
                Tobacco
                  Cessation Program

              	
                Covered
                  up to $100 for a 12- month period limit for a plan- approved program
                  .

                §Health
                  Plan
                  defines plan-approved program.

                §May
                  be subject to
                  formulary requirements.

              	
                Not
                  a covered benefit.

              
	
                Case
                  Management and Care Coordination Services

              	
                These
                  services include outreach informing, case management, care coordination
                  and community referral.

              	
                Covered
                  benefit.

              
	
                Value-added
                  services

              	
                See
                  Attachment B-3.2

              	 


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      CHIP
        PERINATAL PROGRAM EXCLUSIONS FROM COVERED

      SERVICES
        FOR CHIP
        PERINATES

      
        	
                 

              	
                ·

              	
                For
                  CHIP Perinates in families with incomes at or below 185% of the
                  Federal
                  Poverty Level, inpatient facility charges are not a covered benefit
                  for
                  the initial Perinatal Newborn admission. "Initial Perinatal Newborn
                  admission" means the hospitalization associated with the
                  birth.

              


      

      
        	
                 

              	
                ·

              	
                Inpatient
                  and outpatient treatments other than prenatal care, labor with
                  delivery,
                  and postpartum care related to the covered unborn child until
                  birth.

              


      

      
        	
                 

              	
                ·

              	
                Inpatient
                  mental health services.

              


      

      
        	
                 

              	
                ·

              	
                Outpatient
                  mental health services.

              


      

      
        	
                 

              	
                ·

              	
                Durable
                  medical equipment or other medically related remedial
                  devices.

              


      

      
        	
                 

              	
                ·

              	
                Disposable
                  medical supplies.

              


      

      
        	
                 

              	
                ·

              	
                Home
                  and community-based health care
                  services.

              


      

      
        	
                 

              	
                ·

              	
                Nursing
                  care services.

              


      

      
        	
                 

              	
                ·

              	
                Dental
                  services.

              


      

      
        	
                 

              	
                ·

              	
                Inpatient
                  substance abuse treatment services and residential substance abuse
                  treatment services.

              


      

      
        	
                 

              	
                ·

              	
                Outpatient
                  substance abuse treatment services.

              


      

      
        	
                 

              	
                ·

              	
                Physical
                  therapy, occupational therapy, and services for individuals with
                  speech,
                  hearing, and language disorders.

              


      

      
        	
                 

              	
                ·

              	
                Hospice
                  care.

              


      

      
        	
                 

              	
                ·

              	
                Skilled
                  nursing facility and rehabilitation hospital
                  services.

              


      

      
        	
                 

              	
                ·

              	
                Emergency
                  services other than those directly related to the labor with delivery
                  of
                  the covered unborn child.

              


      

      
        	
                 

              	
                ·

              	
                Transplant
                  services.

              


      

      
        	
                 

              	
                ·

              	
                Tobacco
                  Cessation Programs.

              


      

      
        	
                 

              	
                ·

              	
                Chiropractic
                  Services.

              


      

      
        	
                 

              	
                ·

              	
                Medical
                  transportation not directly related to the labor or threatened
                  labor
                  and/or delivery of the covered unborn
                  child.

              


      

      
        	
                 

              	
                ·

              	
                Personal
                  comfort items including but not limited to personal care kits provided
                  on
                  inpatient admission, telephone, television, newborn infant photographs,
                  meals for guests of patient, and other articles which are not required
                  for
                  the specific treatment related to labor with delivery or post partum
                  care.

              


      

      
        	
                 

              	
                ·

              	
                Experimental
                  and/or investigational medical, surgical or other health care procedures
                  or services which are not generally employed or recognized within
                  the
                  medical community

              


      

      
        	
                 

              	
                ·

              	
                Treatment
                  or evaluations required by third parties including, but not limited
                  to,
                  those for schools, employment, flight clearance, camps, insurance
                  or
                  court

              


      

      
        	
                 

              	
                ·

              	
                Private
                  duty nursing services when performed on an inpatient basis or in
                  a skilled
                  nursing facility.

              


      

      
        	
                 

              	
                ·

              	
                Mechanical
                  organ replacement devices including, but not limited to artificial
                  heart

              


      

      
        	
                 

              	
                ·

              	
                Hospital
                  services and supplies when confinement is solely for diagnostic
                  testing
                  purposes and not a part of labor with
                  delivery

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      


      
        	
                 

              	
                ·

              	
                Prostate
                  and mammography screening

              


      

      
        	
                 

              	
                ·

              	
                Elective
                  surgery to correct vision

              


      

      
        	
                 

              	
                ·

              	
                Gastric
                  procedures for weight loss

              


      

      
        	
                 

              	
                ·

              	
                Cosmetic
                  surgery/services solely for cosmetic
                  purposes

              


      

      
        	
                 

              	
                ·

              	
                Out-of-network
                  services not authorized by the Health Plan except for emergency
                  care
                  related to the labor with delivery of the covered unborn
                  child.

              


      

      
        	
                 

              	
                ·

              	
                Services,
                  supplies, meal replacements or supplements provided for weight
                  control or
                  the treatment of obesity

              


      

      
        	
                 

              	
                ·

              	
                Acupuncture
                  services, naturopathy and
                  hypnotherapy

              


      

      
        	
                 

              	
                ·

              	
                Immunizations
                  solely for foreign travel

              


      

      
        	
                 

              	
                ·

              	
                Routine
                  foot care such as hygienic care

              


      

      
        	
                 

              	
                ·

              	
                Diagnosis
                  and treatment of weak, strained, or flat feet and the cutting or
                  removal
                  of corns, calluses and toenails (this does not apply to the removal
                  of
                  nail roots or surgical treatment of conditions underlying corns,
                  calluses
                  or ingrown toenails)

              


      

      
        	
                 

              	
                ·

              	
                Corrective
                  orthopedic shoes

              


      

      
        	
                 

              	
                ·

              	
                Convenience
                  items

              


      

      
        	
                 

              	
                ·

              	
                Orthotics
                  primarily used for athletic or recreational
                  purposes

              


      

      
        	
                 

              	
                ·

              	
                Custodial
                  care (care that assists with the activities of daily living, such
                  as
                  assistance in walking, getting in and out of bed, bathing, dressing,
                  feeding, toileting, special diet preparation, and medication supervision
                  that is usually self-administered or provided by a caregiver. This
                  care
                  does not require the continuing attention of trained medical or
                  paramedical personnel.)

              


      

      
        	
                 

              	
                ·

              	
                Housekeeping

              


      

      
        	
                 

              	
                ·

              	
                Public
                  facility services and care for conditions that federal, state,
                  or local
                  law requires be provided in a public facility or care provided
                  while in
                  the custody of legal authorities

              


      

      
        	
                 

              	
                ·

              	
                Services
                  or supplies received from a nurse, which do not require the skill
                  and
                  training of a nurse

              


      

      
        	
                 

              	
                ·

              	
                Vision
                  training, vision therapy, or vision
                  services

              


      

      
        	
                 

              	
                ·

              	
                Reimbursement
                  for school-based physical therapy, occupational therapy, or speech
                  therapy
                  services are not covered

              


      

      
        	
                 

              	
                ·

              	
                Donor
                  non-medical expenses

              


      

      
        	
                 

              	
                ·

              	
                Charges
                  incurred as a donor of an
                  organ

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      CHIP
        PERINATAL PROGRAM EXCLUSIONS FROM COVERED

      SERVICES
        FOR CHIP PERINATE
        NEWBORNS

      With
        the
        exception of the first bullet, all the following exclusions match those found
        in

      the
        CHIP
        Program.

      
        	
                 

              	
                ·

              	
                For
                  CHIP Perinate Newborns in families with incomes at or below 185%
                  of the
                  Federal Poverty Level, inpatient facility charges are not a covered
                  benefit for the initial Perinate Newborn admission. "Initial Perinate
                  Newborn admission" means the hospitalization associated with the
                  birth.

              


      

      
        	
                 

              	
                ·

              	
                Inpatient
                  and outpatient infertility treatments or reproductive services
                  other than
                  prenatal care, labor and delivery, and care related to disease,
                  illnesses,
                  or abnormalities related to the reproductive
                  system

              


      

      
        	
                 

              	
                ·

              	
                Personal
                  comfort items including but not limited to personal care kits provided
                  on
                  inpatient admission, telephone, television, newborn infant photographs,
                  meals for guests of patient, and other articles which are not required
                  for
                  the specific treatment of sickness or
                  injury

              


      

      
        	
                 

              	
                ·

              	
                Experimental
                  and/or investigational medical, surgical or other health care procedures
                  or services which are not generally employed or recognized within
                  the
                  medical community

              


      

      
        	
                 

              	
                ·

              	
                Treatment
                  or evaluations required by third parties including, but not limited
                  to,
                  those for schools, employment, flight clearance, camps, insurance
                  or
                  court

              


      

      
        	
                 

              	
                ·

              	
                Private
                  duty nursing services when performed on an inpatient basis or in
                  a skilled
                  nursing facility.

              


      

      
        	
                 

              	
                ·

              	
                Mechanical
                  organ replacement devices including, but not limited to artificial
                  heart

              


      

      
        	
                 

              	
                ·

              	
                Hospital
                  services and supplies when confinement is solely for diagnostic
                  testing
                  purposes, unless otherwise pre-authorized by Health
                  Plan

              


      

      
        	
                 

              	
                ·

              	
                Prostate
                  and mammography screening

              


      

      
        	
                 

              	
                ·

              	
                Elective
                  surgery to correct vision

              


      

      
        	
                 

              	
                ·

              	
                Gastric
                  procedures for weight loss

              


      

      
        	
                 

              	
                ·

              	
                Cosmetic
                  surgery/services solely for cosmetic
                  purposes

              


      

      
        	
                 

              	
                ·

              	
                Out-of-network
                  services not authorized by the Health Plan except for emergency
                  care and
                  physician services for a mother and her newborn(s) for a minimum
                  of 48
                  hours following an uncomplicated vaginal delivery and 96 hours
                  following
                  an uncomplicated delivery by caesarian
                  section

              


      

      
        	
                 

              	
                ·

              	
                Services,
                  supplies, meal replacements or supplements provided for weight
                  control or
                  the treatment of obesity, except for the services associated with
                  the
                  treatment for morbid obesity as part of a treatment plan approved
                  by the
                  Health Plan

              


      

      
        	
                 

              	
                ·

              	
                Acupuncture
                  services, naturopathy and
                  hypnotherapy

              


      

      
        	
                 

              	
                ·

              	
                Immunizations
                  solely for foreign travel

              


      

      
        	
                 

              	
                ·

              	
                Routine
                  foot care such as hygienic care

              


      

      
        	
                 

              	
                ·

              	
                Diagnosis
                  and treatment of weak, strained, or flat feet and the cutting or
                  removal
                  of corns, calluses and toenails (this does not apply to the removal
                  of
                  nail roots or surgical treatment of conditions underlying corns,
                  calluses
                  or ingrown toenails)

              


      

      
        	
                 

              	
                ·

              	
                Replacement
                  or repair of prosthetic devices and durable medical equipment due
                  to
                  misuse, abuse or loss when confirmed by the Member or the
                  vendor

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      
        	
                 

              	
                ·

              	
                Corrective
                  orthopedic shoes

              


      

      
        	
                 

              	
                ·

              	
                Convenience
                  items

              


      

      
        	
                 

              	
                ·

              	
                Orthotics
                  primarily used for athletic or recreational
                  purposes

              


      

      
        	
                 

              	
                ·

              	
                Custodial
                  care (care that assists a child with the activities of daily living,
                  such
                  as assistance in walking, getting in and out of bed, bathing, dressing,
                  feeding, toileting, special diet preparation, and medication supervision
                  that is usually self-administered or provided by a parent. This
                  care does
                  not require the continuing attention of trained medical or paramedical
                  personnel.) This exclusion does not apply to hospice
                  services.

              


      

      
        	
                 

              	
                ·

              	
                Housekeeping

              


      

      
        	
                 

              	
                ·

              	
                Public
                  facility services and care for conditions that federal, state,
                  or local
                  law requires be provided in a public facility or care provided
                  while in
                  the custody of legal authorities

              


      

      
        	
                 

              	
                ·

              	
                Services
                  or supplies received from a nurse, which do not require the skill
                  and
                  training of a nurse

              


      

      
        	
                 

              	
                ·

              	
                Vision
                  training and vision therapy

              


      

      
        	
                 

              	
                ·

              	
                Reimbursement
                  for school-based physical therapy, occupational therapy, or speech
                  therapy
                  services are not covered except when ordered by a
                  Physician/PCP

              


      

      
        	
                 

              	
                ·

              	
                Donor
                  non-medical expenses

              


      

      
        	
                 

              	
                ·

              	
                Charges
                  incurred as a donor of an organ when the recipient is not covered
                  under
                  this health plan

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      CHIP
        & CHIP PERINATAL PROGRAM DME/SUPPLIES

      Note:
        DME/SUPPLIES are not a covered benefit for CHIP Perinate
        Members

      but
        are a benefit for CHIP Perinate Newborns.

      


      
        	
                SUPPLIES

              	
                COVERED

              	
                EXCLUDED

              	
                COMMENTS/MEMBER

                CONTRACT
                  PROVISIONS

              
	
                Ace
                  Bandages

              	 	
                X

              	
                Exception:
                  If provided by and billed through the clinic or home care

                agency
                  it is covered as an incidental supply.

              
	
                Alcohol,
                  rubbing

              	 	
                X

              	
                Over-the-counter
                  supply.

              
	
                Alcohol,
                  swabs

                (diabetic)

              	
                X

              	 	
                Over-the-counter
                  supply not covered, unless RX provided at time of

                dispensing.

              
	
                Alcohol,
                  swabs

              	
                X

              	 	
                Covered
                  only when received with IV therapy or central line

                kits/supplies.

              
	
                Ana
                  Kit Epinephrine

              	
                X

              	 	
                A
                  self-injection kit used by patients highly allergic to bee
                  stings.

              
	
                Arm
                  Sling

              	
                X

              	 	
                Dispensed
                  as part of office visit.

              
	
                Attends
                  (Diapers)

              	
                X

              	 	
                Coverage
                  limited to children age 4 or over only when prescribed by

                a
                  physician and used to provide care for a covered diagnosis as

                outlined
                  in a treatment care plan.

              
	
                Bandages

              	 	
                X

              	 
	
                Basal
                  Thermometer

              	 	
                X

              	
                Over-the-counter
                  supply.

              
	
                Batteries
                  – initial

              	
                X

              	
                .

              	
                For
                  covered DME items

              
	
                Batteries
                  – replacement

              	
                X

              	 	
                For
                  covered DME when replacement is necessary due to normal
                  use.

              
	
                Betadine

              	 	
                X

              	
                See
                  IV therapy supplies.

              
	
                Books

              	 	
                X

              	 
	
                Clinitest

              	
                X

              	 	
                For
                  monitoring of diabetes.

              
	
                Colostomy
                  Bags

              	 	 	
                See
                  Ostomy Supplies.

              
	
                Communication

                Devices

              	 	
                X

              	 
	
                Contraceptive
                  Jelly

              	 	
                X

              	
                Over-the-counter
                  supply. Contraceptives are not covered under the

                plan.

              
	
                Cranial
                  Head Mold

              	 	
                X

              	 
	
                Diabetic
                  Supplies

              	
                X

              	 	
                Monitor
                  calibrating solution, insulin syringes, needles, lancets,

                lancet
                  device, and glucose strips.

              
	
                Diapers/Incontinent

                Briefs/Chux

              	
                X

              	 	
                Coverage
                  limited to children age 4 or over only when prescribed by

                a
                  physician and used to provide care for a covered diagnosis as

                outlined
                  in a treatment care plan

              
	
                Diaphragm

              	 	
                X

              	
                Contraceptives
                  are not covered under the plan.

              
	
                Diastix

              	
                X

              	 	
                For
                  monitoring diabetes.

              
	
                Diet,
                  Special

              	 	
                X

              	 
	
                Distilled
                  Water

              	 	
                X

              	 
	
                Dressing

                Supplies/Central
                  Line

              	
                X

              	 	
                Syringes,
                  needles, Tegaderm, alcohol swabs, Betadine swabs or

                ointment,
                  tape. Many times these items are dispensed in a kit when

                includes
                  all necessary items for one dressing site change.

              
	
                Dressing

                Supplies/Decubitus

              	
                X

              	 	
                Eligible
                  for coverage only if receiving covered home care for wound

                care.

              
	
                Dressing

                Supplies/Peripheral
                  IV

                Therapy

              	
                X

              	 	
                Eligible
                  for coverage only if receiving home IV therapy.

              
	
                Dressing

                Supplies/Other

              	 	
                X

              	 
	
                Dust
                  Mask

              	 	
                X

              	 
	
                Ear
                  Molds

              	
                X

              	 	
                Custom
                  made, post inner or middle ear
                  surgery

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      


      
        	
                SUPPLIES

              	
                COVERED

              	
                EXCLUDED

              	
                COMMENTS/MEMBER

                CONTRACT
                  PROVISIONS

              
	
                Electrodes

              	
                X

              	 	
                Eligible
                  for coverage when used with a covered DME.

              
	
                Enema
                  Supplies

              	 	
                X

              	
                Over-the-counter
                  supply.

              
	
                Enteral
                  Nutrition

                Supplies

              	
                X

              	 	
                Necessary
                  supplies (e.g., bags, tubing, connectors, catheters, etc.)
                  are

                eligible
                  for coverage. Enteral nutrition products are not covered

                except
                  for those prescribed for hereditary metabolic disorders, a
                  non-

                function
                  or disease of the structures that normally permit food to

                reach
                  the small bowel, or malabsorption due to disease

              
	
                Eye
                  Patches

              	
                X

              	 	
                Covered
                  for patients with amblyopia.

              
	
                Formula

              	 	
                X

              	
                Exception:
                  Eligible for coverage only for chronic hereditary metabolic disorders
                  a
                  non-function or disease of the structures that normally permit
                  food to
                  reach the small bowel; or malabsorption due to disease (expected
                  to last
                  longer than 60 days when prescribed by the physician and authorized
                  by
                  plan.) Physician documentation to justify prescription of formula
                  must
                  include:

                ·Identification
                  of a metabolic disorder, dysphagia that results in a medical need
                  for a
                  liquid diet, presence of a gastrostomy, or disease resulting in
                  malabsorption that requires a medically necessary nutritional
                  product

                Does
                  not include formula:

                ·For
                  members
                  who could be sustained on an age-appropriate diet.

                ·Traditionally
                  used for infant feeding

                ·In
                  pudding
                  form (except for clients with documented oropharyngeal motor dysfunction
                  who receive greater than 50 percent of their daily caloric intake
                  from
                  this product)

                ·For
                  the
                  primary diagnosis of failure to thrive, failure to gain weight,
                  or lack of
                  growth or for infants less than twelve months of age unless medical
                  necessity is documented and other criteria, listed above, are
                  met.

                 

                Food
                  thickeners, baby food, or other regular grocery products that

                can
                  be blenderized and used with an enteral system that are not

                medically
                  necessary, are not covered, regardless of whether these

                regular
                  food products are taken orally or parenterally.

              
	
                Gloves

              	 	
                X

              	
                Exception:
                  Central line dressings or wound care provided by home care
                  agency.

              
	
                Hydrogen
                  Peroxide

              	 	
                X

              	
                Over-the-counter
                  supply.

              
	
                Hygiene
                  Items

              	 	
                X

              	 
	
                Incontinent
                  Pads

              	
                X

              	 	
                Coverage
                  limited to children age 4 or over only when prescribed by

                a
                  physician and used to provide care for a covered diagnosis as outlined
                  in
                  a treatment care plan

              
	
                Insulin
                  Pump (External)

                Supplies

              	
                X

              	 	
                Supplies
                  (e.g., infusion sets, syringe reservoir and dressing, etc.)
                  are

                eligible
                  for coverage if the pump is a covered item.

              
	
                Irrigation
                  Sets, Wound

                Care

              	
                X

              	 	
                Eligible
                  for coverage when used during covered home care for

                wound
                  care.

              
	
                Irrigation
                  Sets, Urinary

              	
                X

              	 	
                Eligible
                  for coverage for individual with an indwelling urinary

                catheter.

              
	
                IV
                  Therapy Supplies

              	
                X

              	 	
                Tubing,
                  filter, cassettes, IV pole, alcohol swabs, needles, syringes

                and
                  any other related supplies necessary for home IV
                  therapy.

              
	
                K-Y
                  Jelly

              	 	
                X

              	
                Over-the-counter
                  supply.

              
	
                Lancet
                  Device

              	
                X

              	 	
                Limited
                  to one device only.

              


      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	
                Subject:
                  Attachment B-2.2 – CHIP Perinatal Covered
                  Services

              	
                Version
                  1.7

              


      

      


      


      
        	
                SUPPLIES

              	
                COVERED

              	
                EXCLUDED

              	
                COMMENTS/MEMBER

                CONTRACT
                  PROVISIONS

              
	
                Lancets

              	
                X

              	 	
                Eligible
                  for individuals with diabetes.

              
	
                Med
                  Ejector

              	
                X

              	 	 
	
                Needles
                  and

                Syringes/Diabetic

              	 	 	
                See
                  Diabetic Supplies

              
	
                Needles
                  and

                Syringes/IV
                  and

                Central
                  Line

              	 	 	
                See
                  IV Therapy and Dressing Supplies/Central Line.

              
	
                Needles
                  and

                Syringes/Other

              	
                X

              	 	
                Eligible
                  for coverage if a covered IM or SubQ medication is being

                administered
                  at home.

              
	
                Normal
                  Saline

              	 	 	
                See
                  Saline, Normal

              
	
                Novopen

              	
                X

              	 	 
	
                Ostomy
                  Supplies

              	
                X

              	 	
                Items
                  eligible for coverage include: belt, pouch, bags, wafer, face plate,
                  insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape,
                  skin
                  prep, adhesives, drain sets, adhesive remover, and pouch
                  deodorant.

                Items
                  not eligible for coverage include: scissors, room deodorants, cleaners,
                  rubber gloves, gauze, pouch covers, soaps, and lotions.

              
	
                Parenteral

                Nutrition/Supplies

              	
                X

              	 	
                Necessary
                  supplies (e.g., tubing, filters, connectors, etc.) are
                  eligible

                for
                  coverage when the Health Plan has authorized the parenteral

                nutrition.

              
	
                Saline,
                  Normal

              	
                X

              	 	
                Eligible
                  for coverage:

                a)
                  when used to dilute medications for nebulizer treatments;

                b)
                  as part of covered home care for wound care;

                c)
                  for indwelling urinary catheter irrigation.

              
	
                Stump
                  Sleeve

              	
                X

              	 	 
	
                Stump
                  Socks

              	
                X

              	 	 
	
                Suction
                  Catheters

              	
                X

              	 	 
	
                Syringes

              	 	 	
                See
                  Needles/Syringes.

              
	
                Tape

              	 	 	
                See
                  Dressing Supplies, Ostomy Supplies, IV Therapy
                  Supplies.

              
	
                Tracheostomy
                  Supplies

              	
                X

              	 	
                Cannulas,
                  Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for

                coverage.

              
	
                Under
                  Pads

              	 	 	
                See
                  Diapers/Incontinent Briefs/Chux.

              
	
                Unna
                  Boot

              	
                X

              	 	
                Eligible
                  for coverage when part of wound care in the home setting.

                Incidental
                  charge when applied during office visit.

              
	
                Urinary,
                  External

                Catheter
                  & Supplies

              	 	
                X

              	
                Exception:
                  Covered when used by incontinent male where injury to

                the
                  urethra prohibits use of an indwelling catheter ordered by
                  the

                PCP
                  and approved by the plan

              
	
                Urinary,
                  Indwelling

                Catheter
                  & Supplies

              	
                X

              	 	
                Cover
                  catheter, drainage bag with tubing, insertion tray,
                  irrigation

                set
                  and normal saline if needed.

              
	
                Urinary,
                  Intermittent

              	
                X

              	 	
                Cover
                  supplies needed for intermittent or straight
                  catherization.

              
	
                Urine
                  Test Kit

              	
                X

              	 	
                When
                  determined to be medically necessary.

              
	
                Urostomy
                  supplies

              	 	 	
                See
                  Ostomy Supplies.

              


      

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
 

    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-3 – Value-added Services

            	
              Version
                1.7

            


    

    


    
      	
              DOCUMENT
                HISTORY LOG

            
	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	
              Baseline

            	
              n/a

            	 	
              Initial
                version of Attachment B-3, Value-added Services.

            
	
              Revision

            	
              1.1

            	
              June
                30, 2006

            	
              Contract
                amendment did not revise Attachment B-3, Value-added
                Services.

            
	
              Revision

            	
              1.2

            	
              September
                1. 2006

            	
              Revised
                Physical Health Value-added Services to include Home Visits to New
                Mothers. Revised the certification provision by changing the start
                date
                for the 12-month provision of services.

            
	
              Revision

            	
              1.3

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-3, Value-added
                Services.

            
	
              Revision

            	
              1.4

            	
              September
                1, 2006

            	
              Contract
                amendment removed the separate signature requirement for Attachment
                B-3,
                Value-added Services. By signing the Contract and/or Contract Amendment,
                the HMO certifies that it will provide the Value-added Services from
                September 1, 2006 through August 31, 2007.

            
	
              Revision

            	
              1.5

            	
              January
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-3, Value-added
                Services.

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-3, Value-added
                Services.

            
	
              Revision

            	
              1.7

            	
              July
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-3, Value-added
                Services.

            
	
              1
                Status should be represented as “Baseline” for initial issuances,
                “Revision” for changes to the Baseline version, and “Cancellation” for
                withdrawn versions

              2
Revisions
                should be numbered in accordance according to the version of the
                issuance
                and sequential numbering of the revision—e.g., “1.2” refers to the first
                version of the document and the second revision.

              3
Brief
                description of the changes to the document made in the
                revision.

            


    

    


    
      
        
                

                     1 of
              5    

          

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-3 – Value-added Services

            	
              Version
                1.7

            


    

    


    ATTACHMENT
      B-3: VALUE-ADDED SERVICES

    September
      1, 2006 – August 31, 2007

    


    
      	
              HMO:

            	
              Superior
                HealthPlan, Inc.

            	 


    

    


    
      	
              HMO
                PROGRAM:

            	
              CHIP

            	 


    

    


    
      	
              SERVICE
                AREA(S):

            	
              Bexar,
                El Paso, Lubbock, Nueces, and Travis

            	 


    

    


    
      	
              Physical
                Health Value-added Services

            
	
              Value-added
                Service

            	
              Description
                of Value-added Services and Members Eligible to Receive the
                Services

            	
              Limitations
                or Restrictions

            	
              Provider(s)
                responsible for providing this service

            
	
              Vision

            	
              20%
                discount off of Upgraded Hardware- The Member will receive a 20%
                discount
                on upgraded hardware.

            	
              There
                is no limitation on the number of times the discount can be
                utilized.

            	
              TVHP
                contracted providers.

            
	
              Pharmacy

            	
              Provides
                members with a $15.00 per household per quarter credit toward over
                the
                counter medications and supplies.

            	
              Services
                must be sought from contracted pharmacies only. Items eligible for
                purchase under this benefit are over-the-counter, health related
                items
                only.

            	
              Pharmacy
                Data Management contracted
                providers.

            


    

    


    
      
        
                

                2
              of
              5     
    

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-3 – Value-added Services

            
	
              Version
                1.7

            


    

    


    Physical
      Health Value-added Services

    


    
      	
              Physical
                Health Value-added Services

            
	
              Value-added
                Service

            	
              Description
                of Value-added Services and Members Eligible to Receive the
                Services

            	
              Limitations
                or Restrictions

            	
              Provider(s)
                responsible for providing this service

            
	
              Transportation

            	
              For
                Members in need of transportation that cannot access transportation
                in a
                timely manner, Superior will provide bus tokens to ensure that Members
                have a means of accessing their provider appointment.

            	
              Members
                in the Nueces Service Area. The Transportation Authority in this
                area will
                not agree to allow the plan to purchase bus vouchers or tokens. The
                bus
                tokens must be requested in advance of a provider visit and authorized
                by
                Superior’s Member Services Department.

            	
              Transit
                Authorities in applicable Service Area.

            
	
              NurseWise

            	
              Twenty-four
                hour nurse advice line

            	
              Available
                to all members by calling the Member Services toll-free
                number

            	
              NurseWise,
                an affiliate of Centene Corporation

            
	
              Home
                Visits to New Mothers

            	
              Superior
                Social Work and/or CONNECTIONS staff will make home visits to any
                Member
                with a new baby. This visit provides for resource and education
                coordination as identified in the visit, [what does this mean?] and
                ensures Members and the new babies are keeping all post natal and
                newborn
                doctor visits. This  benefit is available to all Superior
                Members who have delivered a baby.

            	
              Only
                that a member consent to the home visit.

            	
              Superior’s
                CONNECTIONS and Social Work staff provide this
                service.

            


    

    


    
      
        
                

              3
              of
              5     
    

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-3 – Value-added Services

            
	
              Version
                1.7

            


    

    


    
      	
              Behavioral
                Health Value-added Services for Members Under
                21

            
	
              Value-added
                Service

            	
              Description
                of Value-added Services and Members Eligible to Receive the
                Services

            	
              Limitations
                or Restrictions

            	
              Provider(s)
                responsible for providing this service

            
	 	 	 	 
	 	 	 	 


    

    


    


    
      	
              Behavioral Health
                Value-added Services for Members 21 and Over

            
	
              Value-added
                Service

            	
              Description
                of Value-added Services and Members Eligible to Receive the
                Services

            	
              Limitations
                or Restrictions

            	
              Provider(s)
                responsible for providing this service

            
	 	 	 	 
	 	 	 	 


    

    


    ADDITIONAL
      INFORMATION:

    


    
      	
              1.

            	
              Explain
                how and when Providers and Members will be notified about the availability
                of the value-added services to be
                provided.

            


    

    


    
      	
              Value
                Added Services information will be included in the Superior Provider
                Manual and also during training sessions. Members will receive this
                information via the Plan Comparison Chart, in the Member Handbook,
                with
                New Member Packets and during orientations. Periodically, Superior
                will
                also highlight Value Added Services in the Provider and Member
                Newsletters

               

            


    

    


    
      
        
                

            4
              of 5   
    

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-3 – Value-added Services

            
	
              Version
                1.7

            


    

    


    


    
      	
              2.

            	
              Describe
                how a Member may obtain or access the value-added services to be
                provided.

            


    

    


    
      	
              See
                explanations provided above for accessing services.

            
	 
	
              A
                Member may access the Home Visits to New Mothers service by accepting
                a
                home visit appointment from a Superior Social Work or CONNECTIONS
                staff
                member.

            
	 


    

    


    
      	
              3.

            	
              Describe
                how the HMO will identify the Value-added Service in administrative
                (encounter) data.

            


    

    


    
      	
              Superior
                will track the value added services through our claims system for
                those
                value-adds that HIPAA-compliant procedural codes are available (vision,
                behavioral health, flu shots). Superior will create a specific benefit
                category to track and report the value added services 'separately'
                from
                our 'capitated' service data. In addition, Superior will have the
                ability
                to pass this information to the State utilizing the encounter submission
                process, as long as the State is able to segregate the value adds
                data
                from the capitated services data.

               

            
	 
	
              For
                pharmacy services, Superior will receive a data file from the pharmacy
                vendor to capture all utilization of the pharmacy value-add
                benefit.

            
	 
	
              For
                transportation services, Superior will maintain an electronic file
                of
                transportation services provided for Superior’s
                membership.

            
	 
	
              Home
                visits to new mothers are tracked through Superior’s case management
                system. Each staff member logs each member visit and the outcome/findings
                of the visit in Superior’s computer system. Superior will work with HHSC
                to establish the most efficient transmission of the
                data.

            


    

    


    
      	
              4.

            	
              By
                signing the Contract and/or Contract Amendment HMO certifies that
                it will
                provide the approved Value-added Services described herein from September
                1, 2006 through August 31, 2007.

            


    

    


    


    
      
        
                

               5
              of
              5   
    

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    

      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	 	 
	
                Subject:
                  Attachment B-3 – Value-added Service

              	
                Version
                  1.7

              


      

      


      DOCUMENT
        HISTORY LOG

      


      
        	
                STATUS1

              	
                DOCUMENT

                REVISION2

              	
                EFFECTIVE

                DATE

              	
                DESCRIPTION3

              
	
                Baseline

              	
                n/a

              	 	
                Initial
                  version of Attachment B-3, Value-added Services.

              
	
                Revision

              	
                1.1

              	
                June
                  30, 2006

              	
                Contract
                  amendment did not revise Attachment B-3, Value-added
                  Services.

              
	
                Revision

              	
                1.2

              	
                September
                  1, 2006

              	
                Revised
                  the Physical Health Value-added Services to include Home Visits to
                  New Mothers. Revised the certification provision by changing the
                  start
                  date for the 12-month provision of services.

              
	
                Revision

              	
                1.3

              	
                September
                  1, 2006

              	
                Contract
                  amendment did not revise Attachment B-3, Value-added
                  Services.

              
	
                Revision

              	
                1.4

              	
                September
                  1, 2006

              	
                Contract
                  amendment removed the separate signature requirement for Attachment
                  B-3,
                  Value-added Services. By signing the Contract and/or Contract Amendment,
                  the HMO certifies that it will provide the Value-added Services
                  from
                  September 1, 2006 through August 31, 2007.

              
	
                Revision

              	
                1.5

              	
                January
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-3, Value-added
                  Services.

              
	
                Revision

              	
                1.6

              	
                February
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-3, Value-added
                  Services.

              
	
                Revision

              	
                1.7

              	
                July
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-3, Value-added
                  Services.

              
	
                1
                  Status should be represented as “Baseline” for initial
                  issuances, “Revision” for changes to the Baseline version, and
                  “Cancellation” for withdrawn versions

                2
Revisions
                  should be numbered in accordance according to the version of the
                  issuance
                  and sequential numbering of the revision—e.g., “1.2” refers to the first
                  version of the document and the second revision.

                3
Brief
                  description of the changes to the document made in the
                  revision.

              


      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	 	 
	
                Subject:
                  Attachment B-3 – Value-added Service

              	
                Version
                  1.7

              


      

      


      ATTACHMENT
        B-3: VALUE-ADDED SERVICES

      September
        1, 2006 – August 31, 2007

      


      
        	
                HMO:

              	
                 Superior
                  HealthPlan, Inc.

              
	
                HMO
                  PROGRAM:

              	
                 Medicaid

              
	
                SERVICE
                  AREA(S):

              	
                Bexar,
                  El Paso, Lubbock, Nueces, and
                  Travis

              


      

      


      
        	
                Physical
                  Health Value-added Services

              
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	
                Vision

              	
                Members
                  are allowed to purchase any prescription eyewear and apply a $100
                  allowance toward the purchase of that eyewear.

              	
                Members
                  are responsible for any charges that exceed the $100 allowance.
                  Disposable
                  contact lenses are excluded from this $100 allowance. This Value-Added
                  benefit is only allowed one time per benefit period (i.e.
                  24-months).

              	
                TVHP
                  contracted providers.

              
	
                Pharmacy

              	
                Provides
                  members with a $15.00 per household per quarter credit toward over
                  the
                  counter medications and supplies.

              	
                Services
                  must be sought from contracted pharmacies only. Items eligible
                  for
                  purchase under this benefit are over-the-counter, health related
                  items
                  only.

              	
                Pharmacy
                  Data Management contracted
                  providers.

              


      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	 	 
	
                Subject:
                  Attachment B-3 – Value-added Service

              	
                Version
                  1.7

              


      

      


      
        	
                Physical
                  Health Value-added Services

              
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	
                Transportation

              	
                HMO
                  will offer tokens or vouchers for bus services to HMO members that
                  have
                  trouble accessing the State's Medical Transportation Program in
                  a timely
                  manner to ensure access to their provider appointments. In addition,
                  HMO
                  will provide transportation to non-medical services such as health
                  education programs, nutrition classes, and birth preparation classes.
                  HMO's member service staff will approve and coordinate the transportation
                  service".

              	
                Members
                  in the Nueces Service Area. The Transportation Authority in this
                  area will
                  not agree to allow the plan to purchase bus vouchers or
                  tokens.

                The
                  bus tokens must be requested in advance of a provider visit and
                  authorized
                  by Superior’s Member Services Department.

              	
                Transit
                  Authorities in applicable Service Area.

              
	
                Adult
                  Flu Shot

              	
                During
                  the flu season months of October through December, Members age
                  21 or older
                  will be provided with a flu shot through their Primary Care Provider
                  (PCP).

              	
                This
                  benefit is available to all STAR Adult Members age 21 and over.
                  These
                  services must be obtained from the Member’s Primary Care
                  Provider.

              	
                It
                  is anticipated that the Member’s designated Primary Care Provider (PCP)
                  will render this service.

              
	
                NurseWise

              	
                Twenty-four
                  hour nurse advice line

              	
                Available
                  to all members by calling the Member Services toll-free
                  number

              	
                NurseWise,
                  an affiliate of Centene Corporation

              
	
                Home
                  visits to New Mothers

                 

              	
                Superior
                  Social Work and/or CONNECTIONS staff will make home visits to any
                  Member
                  with a new baby. This visit provides for resource and education
                  coordination as identified in the visit, and ensures Members and
                  the new
                  babies are keeping all post natal and newborn doctor visits. This
                  benefit
                  is available to all Superior Members who have delivered a
                  baby.

              	
                Only
                  that a member consent to the home visit.

              	
                Superior’s
                  CONNECTIONS and Social Work staff provide this
                  service.

              


      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	 	 
	
                Subject:
                  Attachment B-3 – Value-added Service

              	
                Version
                  1.7

              


      

      


      
        	
                Behavioral
                  Health Value-added Services for Members Under
                  21

              
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	
                Behavioral
                  Health

              	
                Rehabilitation/skills
                  training. These are services provided to pregnant and parenting
                  substance
                  abusers at MHMR centers or in other treatment settings, focusing
                  both on
                  substance abuse and parenting issues. An augmentation of standard
                  substance abuse treatment to focus on the special needs of this
                  population. Authorized in increments of 15 minutes, with amount,
                  duration,
                  and scope based on medical necessity. This benefit is available
                  to all
                  Members. It is geared to pregnant women and parenting
                  Members.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                  In addition, the service will be authorized for15-minute increments.
                  The
                  amount, duration, and scope are based on medical
                  necessity.

              	
                It
                  is anticipated that Superior’s contracted MHMR providers specializing in
                  Rehabilitation/Skills training in each Service Area will render
                  this
                  service.

              
	
                Behavioral
                  Health

              	
                Superior’s
                  Behavioral Health Subcontractor will authorize Behavioral Health
                  practitioners in medical settings to provide health psychology
                  interventions focused on the effective management of chronic medical
                  conditions. These might include psycho-educational groups for chronic
                  conditions, individual coaching for patients with chronic disease
                  states,
                  or skills training activities.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                  The authorization will be tied to medical necessity.

              	
                It
                  is anticipated that these services will be rendered by Superior’s
                  behavioral health practitioners located in Superior’s contracted Federally
                  Qualified Health Centers.

              
	
                Behavioral
                  Health

              	
                Partial
                  Hospitalization/Extended Day Treatment- An alternative to, or a
                  step down
                  from, inpatient care.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                  Services are authorized for a minimum of five hours, but for less
                  than
                  24-hours per day. The amount, duration, and scope will be based
                  on
                  medical

              	
                It
                  is anticipated that Superior’s contracted Behavioral Health Providers such
                  as its’ MHMR facilities and other contracted facilities in
                  each

              


      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	 	 
	
                Subject:
                  Attachment B-3 – Value-added Service

              	
                Version
                  1.7

              


      

      


      
        	
                Behavioral
                  Health Value-added Services for Members Under
                  21

              
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	 	 	
                necessity

              	
                Service
                  Area will render this service.

              
	
                Behavioral
                  Health

              	
                Intensive
                  Outpatient Treatment/Day Treatment (IOP)- Used as an alternative
                  to or
                  step down from more restrictive levels of care.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Material
                  Subcontractor. In addition, the service will be authorized for
                  greater
                  than one and one half hours, but less than five hours per day.
                  Amount,
                  duration, and scope are based on medical necessity.

              	
                It
                  is anticipated that Superior’s contracted Behavioral Health Providers such
                  as the MHMR or other facilities in each Service Area will render
                  this
                  service.

              


      

      


      


      
        	
                Behavioral
                  Health Value-added Services for Members 21 and
                  Over

              
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	
                Behavioral
                  Health

              	
                Rehabilitation/skills
                  training. These are services provided to pregnant and parenting
                  substance
                  abusers at MHMR centers or in other treatment settings, focusing
                  both on
                  substance abuse and parenting issues. An augmentation of standard
                  substance abuse treatment to focus on the special needs of this
                  population. This benefit is available to all Members. It is geared
                  to
                  pregnant women and parenting Members.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                  In addition, the service will be authorized for15-minute increments.
                  The
                  amount, duration, and scope are based on medical

              	
                It
                  is anticipated that Superior’s contracted MHMR providers specializing in
                  Rehabilitation/Skills training in each Service Area will render
                  this
                  service.

              


      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	 	 
	
                Subject:
                  Attachment B-3 – Value-added Service

              	
                Version
                  1.7

              


      

      


      
        	
                Behavioral
                  Health Value-added Services for Members 21 and
                  Over

              
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	 	 	
                necessity

              	 
	
                Behavioral
                  Health

              	
                Partial
                  Hospitalization/Extended Day Treatment- An alternative to, or a
                  step down
                  from, inpatient care.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                  Services are authorized for a minimum of five hours, but for less
                  than
                  24-hours per day. The amount, duration, and scope will be based
                  on medical
                  necessity.

              	
                It
                  is anticipated that Superior’s contracted Behavioral Health Providers such
                  as its’ MHMR facilities and other contracted facilities in each Service
                  Area will render this service.

              
	
                Behavioral
                  Health

              	
                Superior’s
                  Behavioral Health Subcontractor, will authorize Behavioral Health
                  practitioners in medical settings to provide health psychology
                  interventions focused on the effective management of chronic medical
                  conditions. These might include psycho-educational groups for chronic
                  conditions, individual coaching for patients with chronic disease
                  states,
                  or skills training activities.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                  The authorization will be tied to medical necessity.

              	
                It
                  is anticipated that these services will be rendered by Superior’s
                  behavioral health practitioners located in Superior’s contracted Federally
                  Qualified Health Centers.

              


      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	 	 
	
                Subject:
                  Attachment B-3 – Value-added Service

              	
                Version
                  1.7

              


      

      


      
        	
                Behavioral
                  Health Value-added Services for Members 21 and
                  Over

              
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	
                Behavioral
                  Health

              	
                Intensive
                  Outpatient Treatment/Day Treatment (IOP)- Used as an alternative
                  to or
                  step down from more restrictive levels of care.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                  In addition, the service will be authorized for greater than one
                  and one
                  half hours, but less than five hours per day. Amount, duration,
                  and scope
                  are based on medical necessity.

              	
                It
                  is anticipated that Superior’s contracted Behavioral Health Providers such
                  as the MHMR or other facilities in each Service Area will render
                  this
                  service.

              
	
                Behavioral
                  Health

              	
                Off-site
                  Services such as home-based services, , mobile crisis, intensive
                  case
                  management. It should be noted that staff must go off-site to provide
                  such
                  services. These services are provided to Members to help reduce
                  or avoid
                  inpatient admissions by a community based, mobile, multi-disciplinary
                  team
                  of licensed clinicians and trained, unlicensed workers working
                  under the
                  direction of a licensed professional.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                  The amount, duration and scope are based on medical
                  necessity.

              	
                It
                  is anticipated that Superior’s contracted Behavioral Health Providers such
                  as the MHMR in each Service Area will render this
                  service.

              


      

      


      ADDITIONAL
        INFORMATION:

      


      
        	
                1.

              	
                Explain
                  how and when Providers and Members will be notified about the availability
                  of the value-added services to be
                  provided.

              


      

      


      
        	
                Value
                  Added Services information will be included in the Superior Provider
                  Manual and also during training sessions. Members will receive
                  this
                  information via the Plan Comparison Chart, in the Member Handbook,
                  with
                  New Member Packets and during orientations.
                  Periodically,

              


      

      


      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      


      


      
        	
                Contractual
                  Document (CD)

              
	 
	
                Responsible
                  Office: HHSC Office of General Counsel (OGC)

              
	 	 
	
                Subject:
                  Attachment B-3 – Value-added Service

              	
                Version
                  1.7

              


      

      


      Superior
        will also highlight Value Added Services in the Provider and Member
        Newsletters.

      


      
        	
                2.

              	
                Describe
                  how a Member may obtain or access the value-added services to be
                  provided.

              


      

      


      
        	
                See
                  explanations provided above for accessing services.

                 

                A
                  Member may access the Home Visits to New Mothers service by accepting
                  a
                  home visit appointment from a Superior Social Work or CONNECTIONS
                  staff
                  member.

              


      

      


      
        	
                3.

              	
                Describe
                  how the HMO will identify the Value-added Service in administrative
                  (encounter) data.

              


      

      


      
        	
                Superior
                  will track the value added services through our claims system for
                  those
                  value-adds that HIPAA-compliant procedural codes are available
                  (vision,
                  behavioral health, flu shots). Superior will create a specific
                  benefit
                  category to track and report the value added services 'separately'
                  from
                  our 'capitated' service data. In addition, Superior will have the
                  ability
                  to pass this information to the State utilizing the encounter submission
                  process, as long as the State is able to segregate the value adds
                  data
                  from the capitated services data.  For pharmacy services,
                  Superior will receive a data file from the pharmacy vendor to capture
                  all
                  utilization of the pharmacy value-add benefit

                 

                For
                  transportation services, Superior will maintain an electronic file
                  of
                  transportation services provided for Superior’s membership.

                 

                Home
                  visits to new mothers are tracked through Superior’s case management
                  system. Each staff member logs each member visit and the outcome/findings
                  of the visit in Superior’s computer system. Superior will work with HHSC
                  to establish the most efficient transmission of the
                  data.

              


      

      


      
        	
                4.

              	
                By
                  signing the Contract and/or Contract Amendment HMO certifies that
                  it will
                  provide the approved Value-added Services described herein from
                  September
                  1, 2006 through August 31, 2007

              


      

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
 

    
      	
              Contractual
                Document (CD)

            
	 	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            	 
	
              Subject:
                Attachment B-3.1 – STAR+PLUS Value-added Services

            	
              Version
                1.7

            


    

    


    DOCUMENT
      HISTORY LOG

    
      	
              STATUS1

            	
              DOCUMENT

              REVISION2

            	
              EFFECTIVE

              DATE

            	
              DESCRIPTION3

            
	
              Baseline

            	
              1.0

            	 	
              Initial
                version of Attachment B-3, Value-added Services

               

            
	
              Revision

            	
              1.1

            	
              June
                30, 2006

            	
              Revised
                Attachment B-3, Value Added Services, by adding Attachment B-3.1,
                STAR+PLUS Value Added Services. This is the initial version of Attachment
                B-3.1, STAR+PLUS Value Added Services. 

            
	
              Revision

            	
              1.2

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-3.1, STAR+PLUS Value Added
                Services

            
	
              Revision

            	
              1.3

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-3.1, STAR+PLUS Value Added
                Services

            
	
              Revision

            	
              1.4

            	
              September
                1, 2006

            	
              Contract
                amendment removed the separate signature requirement for Attachment
                B-3.1,
                STAR+PLUS Value-added Services.  By signing the Contract and/or
                Contract Amendment, the HMO certifies that it will provide the Value-added
                Services from January 1, 2007 through August 31, 2007.

            
	
              Revision

            	
              1.5

            	
              January
                1, 2007

            	
              Revised
                Attachment B-3.1, STAR+PLUS Value Added Services to state that only
                non-dual members are eligible for dental benefits and to clarify
                description of Out-of-Home Respite.

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

            	
              Revised
                Attachment B-3.1, Value Added Services, to clarify the coverage period
                for
                the VAS.

            
	
              Revision

            	
              1.7

            	
              July
                1, 2007

            	
              Revised
                Attachment B-3.1, Value Added Services, to clarify the coverage period
                for
                the VAS.

            
	
               1  Status
                should be represented as “Baseline” for initial issuances, “Revision” for
                changes to the Baseline version, and “Cancellation” for withdrawn
                versions

              2
Revisions
                should be numbered in accordance according to the version of the
                issuance
                and sequential numbering of the revision—e.g., “1.2” refers to the first
                version of the document and the second revision.

              3  Brief
                description of the changes to the document made in the
                revision.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	 	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            	 
	
              Subject:
                Attachment B-3.1 – STAR+PLUS Value-added Services

            	
              Version
                1.7

            


    

    


    ATTACHMENT
      B-3.1:  STAR+PLUS VALUE-ADDED SERVICES

    February
      1, 2007 through August 31, 2007

    


    HMO:  Superior
      HealthPlan, Inc.

    


    SERVICE
      AREA(S):
Bexar
      & Nueces

    


    
      	
               

              Physical
                Health Value-added Services

            
	
              Value-added
                Service

            	
              Description
                of Value-added Services and Members Eligible to Receive the
                Services

            	
              Limitations
                or Restrictions

            	
              Provider(s)
                responsible for providing this service

            
	
              Pharmacy

            	
              Provides
                members with a $15.00 per household quarter credit toward over the
                counter
                medications and supplies.

            	
              Services
                must be sought from contracted pharmacies only.  Items eligible
                for purchase under this benefit are over-the-counter health related
                items
                only.

            	
              Pharmacy
                Data Management contracted providers.

            
	
              Dental

            	
              Basic
                dental coverage, which includes the following CPT codes:  0140-
                Emergency Evaluation; 0120- Periodic Oral Evaluation; 0220- Intra-oral
                Periapaical First Film; 0230- Intraoral Periapical- Each Additional;
                0240-
                Intra-oral Occlusal Film; 0270- Bitewings- single film; 0272- Bitewings-
                two films; 07110- Extraction- Single Tooth/Routine to Difficult;
                and 07120
                Extraction- Each Additional.

            	
              If
                a Member receives services that are outside of the scope of the CPT
                Codes
                listed, the Member will be subject to a co-payment of 75% of the
                dentists’
                usual and customary charges for those services.

              Only
                non-dual members are eligible for dental benefits.

            	
              OraQuest
                Dental Network

            
	
              Adult
                Flu Shot 

            	
              During
                the flu season months of  October through December, Members age
                21 or older will be provided with a flu shot through their Primary
                Care
                Provider (PCP).

            	
              This
                benefit is limited to non-dual STAR+PLUS Adult members age 21 and
                over.  Members may self-refer for this service.

            	
              Designated
                Primary Care Provider

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-3.1 – STAR+PLUS Value-added Services

            	
              Version
                1.7

            


    

    


    
      	
              Physical
                Health Value-added Services

            
	
              NurseWise

            	
              Twenty-four
                hour nurse advice line

            	
              Available
                to all members by calling the Member Services toll-free
                number

            	
              NurseWise,
                an affiliate of Centene Corporation

            


    

    


    
      	
              Community
                Based Long Term Care Value-added Services

            
	
              Value-added
                Service

            	
              Description
                of Value-added Services and Members Eligible to Receive the
                Services

            	
              Limitations
                or Restrictions

            	
              Provider(s)
                responsible for providing this service

            
	
              Out-of-Home
                Respite

            	
              Respite
                services for a caretaker who needs relief from their care-giving
                responsibilities because of severe physical or mental stress or who
                is
                temporarily unable to provide care because of illness, hospitalization,
                family emergency or other obligation. Services will be provided in
                the
                setting most appropriate to the Member's needs including assisted
                living
                facilities, adult foster care homes, or adult day activity
                centers.

            	
              This
                benefit is limited to non-dual Adult non-Waiver Members age 21 and
                over.  Must be prior authorized. Limited to up to ten hours per
                month of in home respite services.

            	
              Network
                providers.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-3.1 – STAR+PLUS Value-added Services

            	
              Version
                1.7

            


    

    


    
      	
              Behavioral
                Health Value-added Services for Members 21 and
                Over

            
	
              Value-added
                Service

            	
              Description
                of Value-added Services and Members Eligible to Receive the
                Services

            	
              Limitations
                or Restrictions

            	
              Provider(s)
                responsible for providing this service

            
	
              Behavioral
                Health

            	
              Health
                Psychology Interventions provided by a behavioral health practitioner
                in a
                medical setting that focuses on the effective management of chronic
                medical conditions.  This might include psycho-educational
                groups for chronic conditions, individual coaching for patients with
                chronic disease states, or skills training activities.

            	
              Limited
                to non-dual Members only.  Services must be authorized and is
                based on medical necessity.

            	
              Network
                Federally Qualified Health Centers (FQHCs)

            
	
              Behavioral
                Health

            	
              Intensive
                Outpatient Treatment/Day Treatment (IOP)- Used as an alternative
                to step
                down from more restrictive levels of care.

            	
              Limited
                to non-dual Members only.  Services must be authorized and is
                based on medical necessity.  Services will be authorized for
                greater than one and one half hours, but less than five hours per
                day.

            	
              It
                is anticipated that behavioral health providers such as the MHMR
                or other
                facilities within the Service Area will render this
                service.

            
	
              Behavioral
                Health

            	
              Partial
                Hospitalization/Extended Day Treatment- An alternative to, or a step
                down
                from, inpatient care.

            	
              Limited
                to non-dual Members only.  Services must be authorized and is
                based on medical necessity.  Services will be authorized for a
                minimum of five hours, but for less than 24-hours per day.

            	
              It
                is anticipated that behavioral health providers such as the MHMR
                or other
                facilities within the Service Area will render this
                service.

            
	
              Behavioral
                Health

            	
              Off-site
                services such as intensive case management.  It should be noted
                that staff must go off-site to provide such services.  These
                services are provided to Members to help reduce or avoid inpatient
                admissions by a community based, mobile, multi-disciplinary team
                of
                licensed clinicians and trained, unlicensed workers working under
                the
                direction of a licensed professional.

            	
              Limited
                to non-dual Members only.  Services must be authorized and is
                based on medical necessity.

            	
              It
                is anticipated that behavioral health providers such as the MHMR
                or other
                facilities within the Service Area will render this
                service.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	 	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            	 
	
              Subject:
                Attachment B-3.1 – STAR+PLUS Value-added Services

            	
              Version
                1.7

            


    

    


    ADDITIONAL
      INFORMATION: 

    


    
      	
              1.

            	
              Explain
                how and when Providers and Members will be notified about the availability
                of the value-added services to be
                provided.

            


    

    


    
      	
              Value
                added services information will be included in the Superior Provider
                Manual and also during training sessions.  Members will receive
                this information via the Plan Comparison Chart, in the Member Handbook,
                with New Member Packets and during orientations.  Periodically,
                Superior will also highlight Value Added Services in the Provider
                and
                member Newsletters.

            


    

    


    
      	
              2.

            	
              Describe
                how a Member may obtain or access the value-added services to be
                provided.

            


    

    


    
      	
              See
                explanations provided above for accessing
                services.

            


    

    


    
      	
              3.

            	
              Describe
                how the HMO will identify the Value-added Service in administrative
                (encounter) data.

            


    

    


    
      	
              Superior
                will track value added services through our claims system for those
                value
                –adds that are IIPAA-compliant procedural codes are available (flu
                shots,
                podiatry, etc.).  Superior will create specific benefit
                categories to track and report the value added services “separately” from
                our “capitated” service data.  In addition, Superior will have
                the ability to pass this information to the State utilizing the encounter
                submission process, as long as the Sate is able to segregate the
                value
                adds data from the capitated services data.  For pharmacy
                services, Superior will receive a data file from the pharmacy vendor
                to
                capture all utilization of pharmacy value added benefits. The same
                is true
                for dental services.

            


    

    


    
      	
              4.

            	
              By
                signing the Contract and/or Contract Amendment HMO certifies that
                it will
                provide the approved Value-added Services described herein from February
                1, 2007 through August 31, 2007.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
 

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-3.2 – CHIP Perinatal Program Value-added
                Services

            	
              Version
                1.7

            


    

    


    DOCUMENT
      HISTORY LOG

    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	
              Baseline

            	
              1.0

            	 	
              Initial
                version of Attachment B-3, Value-added Services

            
	
              Revision

            	
              1.1

            	
              June
                30, 2006

            	
              Revised
                Attachment B-3, Value Added Services, by addingAttachment B-3.1,
                STAR+PLUS
                Value Added Services.

            
	
              Revision

            	
              1.2

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-3, Value Added
                Services

            
	
              Revision

            	
              1.3

            	
              September
                1, 2006

            	
              Revised
                Attachment B-3, Value Added Services, by adding Attachment B-3.2,
                CHIP
                Perinatal Program Value Added Services. This is the initial version
                of
                Attachment B-3.2, CHIP Perinatal Program Value Added
                Services.

            
	
              Revision

            	
              1.4

            	
              September
                1, 2006

            	
              Contract
                amendment removed the separate signature requirement for Attachment
                B-3.2,
                CHIP Perinatal Program Value-added Services. By signing the Contract
                and/or Contract Amendment, the HMO certifies that it will provide
                the
                Value-added Services from January 1, 2007 through August 31,
                2007.

            
	
              Revision

            	
              1.5

            	
              January
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-3.2, CHIP Perinatal Program
                Value
                Added Services.

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-3.2, CHIP Perinatal Program
                Value
                Added Services.

            
	
              Revision

            	
              1.7

            	
              July
                1, 2007.

            	
              Contract
                amendment did not revise Attachment B-3.2, CHIP Perinatal Program
                Value
                Added Services

            
	
              1
                Status should be represented as “Baseline” for initial issuances,
                “Revision” for changes to the Baseline version,
                and   “Cancellation” for withdrawn versions

              2
                Revisions should be numbered in accordance according to the version
                of the
                issuance and sequential numbering of the   revision—e.g.,
                “1.2” refers to the first version of the document and the second
                revision.

              3
                Brief description of the changes to the document made in the
                revision.

            


    

    


    
      
        
                

                    1
              of
              4    

          

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-3.2 – CHIP Perinatal Program Value-added
                Services

            	
              Version
                1.7

            


    

    


    ATTACHMENT
      B-3.2: CHIP PERINATAL PROGRAM VALUE-ADDED SERVICES

    January
      1, 2007 through August 31, 2007

    


    
      	
              HMO:

            	 
	 	 
	
              SERVICE
                AREA(S):

            	 


    

    


    
      	
              Physical
                Health Value-added Services

            
	
              Value-added

              Service

            	
              Description
                of Value-added Services and Members Eligible to Receive the
                Services

            	
              Limitations
                or Restrictions

            	
              Provider(s)
                responsible for providing this service

            
	 	 	 	 
	 	 	 	 
	 	 	 	 


    

    


    
      	
              Behavioral
                Health Value-added Services for Members Under 21

            
	
              Value-added
                Service

            	
              Description
                of Value-added Services and Members Eligible to Receive the
                Services

            	
              Limitations
                or Restrictions

            	
              Provider(s)
                responsible for providing this service

            
	 	 	 	 
	 	 	 	 
	 	 	 	 


    

    


    
      
        
                

            2
              of
              4     
    

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-3.2 – CHIP Perinatal Program Value-added
                Services

            	
              Version
                1.7

            


    

    


    
      	
              Behavioral
                Health Value-added Services for Members 21 and
                Over

            
	
              Value-added
                Service

            	
              Description
                of Value-added Services and Members Eligible to Receive the
                Services

            	
              Limitations
                or Restrictions

            	
              Provider(s)
                responsible for providing this service

            
	 	 	 	 
	 	 	 	 
	 	 	 	 


    

    


    ADDITIONAL
      INFORMATION:

    


    
      	
              1.

            	
              Explain
                how and when Providers and Members will be notified about the availability
                of the value-added services to be
                provided.

            


    

    


    
      	 


    

    


    
      	
              2.

            	
              Describe
                how a Member may obtain or access the value-added services to be
                provided.

            


    

    


    
      	 


    

    


    
      
        
                

            3
              of
              4     
    

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-3.2 – CHIP Perinatal Program Value-added
                Services

            	
              Version
                1.7

            


    

    


    
      	
              3.

            	
              Describe
                how the HMO will identify the Value-added Service in administrative
                (encounter) data.

            


    

    


    
      	 


    

    


    
      	
              4.

            	
              By
                signing the Contract and/or Contract Amendment HMO certifies that
                it will
                provide the approved Value-added Services described herein from January
                1,
                2007 through August 31, 2007.

            


    

    


    


    


    
      
        
                

                    
              4 of
              4
    

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-4 –Performance Improvement Goals

            	
              Version
                1.7

            


    

    DOCUMENT
      HISTORY LOG

    
      	
              STATUS1

            	
              DOCUMENT

              REVISION2

            	
              EFFECTIVE

              DATE

            	
              DESCRIPTION3

            
	
               

              Baseline

               

            	
               

              n/a

               

            	 	
               

              Initial
                version Attachment B-4, Performance Improvement Goals.

               

            
	
              Revision

            	
              1.1

            	
              June
                30, 2006

            	
              Contract
                amendment to include STAR+PLUS program (Attachment B-4.1). No change
                to
                this Section.

            
	
              Revision

            	
              1.2

            	
              September
                1, 2006

            	
              Revised
                version of Attachment B-4 that includes provisions applicable to
                MCOs
                participating in the STAR and CHIP Programs.

              Updates
                the attachment to reflect the changes made in Attachment B-1, Section
                8.1.1.1.

            
	
              Revision

            	
              1.3

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-4, Performance Improvement
                Goals.

            
	
              Revision

            	
              1.4

            	
              September
                1, 2006

            	
              Contract
                amended to include Attachment B-4, Performance Improvement Goals
                for
                SFY2007 and format change.

            
	
              Revision

            	
              1.5

            	
              January
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-4, Performance Improvement
                Goals.

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-4, Performance Improvement
                Goals.

            
	
              Revision

            	
              1.7

            	
              July
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-4, Performance Improvement
                Goals.

            
	
               

              1Status
                should be represented as “Baseline” for initial issuances, “Revision” for
                changes to the Baseline version, and “Cancellation” for withdrawn
                versions

              2
Revisions
                should be numbered in accordance according to the version of the
                issuance
                and sequential numbering of the revision—e.g., “1.2” refers to the first
                version of the document and the second revision.

              3Brief
                description of the changes to the document made in the
                revision.

            


    

    


    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    Texas
      Health and Human Services Commission

    STAR
      and CHIP HMO

    


    Performance
      Improvement Goals

    SFY
      2007

    (September
      1, 2006 – August 31, 2007)

    


    


    
      	
              A.
                Health Plan Information

              Plan
                Name: Superior HealthPlan

              HMO
                Program: CHIP

              HMO
                Service Delivery Area: Bexar SDA

            
	
              B.
                Overarching Goal

            	
              C.
                Sub Goals:

            
	
              Goal
                1:

               

              Improve
                Access to Primary Care Services for Members

               

            	
               

              §90%
                of Pediatricians will have open panels

               

              §90%
                of initial credentialing of PCPs will be finalized within 90 days
                of
                receipt of application

               

            
	
              Goal
                2:

               

              Improve
                Access to Behavioral Health Services for Members

            	
               

              §Increase
                urgent care appointment availability by 5 percentage points over
                the
                baseline

               

              §Improve
                the percent of psychiatrists accepting new member referrals by 5
                percentage points over the baseline

               

            
	
              Goal
                3:

               

              Improve
                Current Member Understanding About the CHIP Benefit Renewal
                Processes

               

            	
               

              §Member
                Services staff will provide verbal reminders about re-enrollment
                to 90% of
                members

               

              §Member
                Services will research 100% of undelivered member mail
                for updated and valid demographic
                information

               

               

            


    

    


    Additional
      information related to the Performance Improvement Goals can be found in
Attachment B-1,

    Section
      8.1.1.1, to the Contract.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    Texas
      Health and Human Services Commission

    STAR
      and CHIP HMO

    


    Performance
      Improvement Goals

    SFY
      2007

    (September
      1, 2006 – August 31, 2007)

    


    


    
      	
              A.
                Health Plan Information

              Plan
                Name: Superior HealthPlan

              HMO
                Program: CHIP

              HMO
                Service Delivery Area: El Paso SDA

               

            
	
              B.
                Overarching Goal

            	
              C.
                Sub Goals:

            
	
              Goal
                1:

               

              Improve
                Access to Primary Care Services for Members

               

            	
               

              §90%
                of
                Pediatricians will have open panels

               

              §90%
                of
                initial credentialing of PCPs will be finalized within 90 days of
                receipt
                of application

               

            
	
              Goal
                2:

               

              Improve
                Access to Behavioral Health Services for Members

            	
               

              §Increase
                urgent care appointment availability by 5 percentage points over
                the
                baseline

               

              §Improve
                the percent of psychiatrists accepting new member referrals by 5
                percentage points over the baseline

               

            
	
              Goal
                3:

               

              Improve
                Current Member Understanding About the CHIP Benefit Renewal
                Processes

               

            	
               

              §Member
                Services staff will provide verbal reminders about re-enrollment
                to 90% of
                members

               

              §Member
                Services will research 100% of undelivered member mail
                for updated and valid demographic
                information

               

            


    

    


    Additional
      information related to the Performance Improvement Goals can be found in
Attachment B-1,

    Section
      8.1.1.1, to the Contract.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    Texas
      Health and Human Services Commission

    STAR
      and CHIP HMO

    


    Performance
      Improvement Goals

    SFY
      2007

    (September
      1, 2006 – August 31, 2007)

    


    


    
      	
              A.
                Health Plan Information

              Plan
                Name: Superior HealthPlan

              HMO
                Program: CHIP

              HMO
                Service Delivery Area: Lubbock SDA

               

            
	
              B.
                Overarching Goal

            	
              C.
                Sub Goals:

            
	
              Goal
                1:

               

              Improve
                Access to Primary Care Services for Members

               

            	
               

              §90%
                of
                Pediatricians will have open panels

               

              §90%
                of
                initial credentialing of PCPs will be finalized within 90 days of
                receipt
                of application

               

            
	
              Goal
                2:

               

              Improve
                Access to Behavioral Health Services for Members

            	
               

              §Increase
                urgent care appointment availability by 5 percentage points over
                the
                baseline

               

              §Improve
                the percent of psychiatrists accepting new member referrals by 5
                percentage points over the baseline

               

            
	
              Goal
                3:

               

              Improve
                Current Member Understanding About the CHIP Benefit Renewal
                Processes

               

            	
               

              §Member
                Services staff will provide verbal reminders about re-enrollment
                to 90% of
                members

               

              §Member
                Services will research 100% of undelivered member mail
                for updated and valid demographic
                information

               

            


    

    


    Additional
      information related to the Performance Improvement Goals can be found in
Attachment B-1,

    Section
      8.1.1.1, to the Contract.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    Texas
      Health and Human Services Commission

    STAR
      and CHIP HMO

    


    Performance
      Improvement Goals

    SFY
      2007

    (September
      1, 2006 – August 31, 2007)

    


    


    


    
      	
              A.
                Health Plan Information

              Plan
                Name: Superior HealthPlan

              HMO
                Program: CHIP

              HMO
                Service Delivery Area: Nueces SDA

               

            
	
              B.
                Overarching Goal

            	
              C.
                Sub Goals:

            
	
              Goal
                1:

               

              Improve
                Access to Primary Care Services for Members

               

            	
               

              §90%
                of
                Pediatricians will have open panels

               

              §90%
                of
                initial credentialing of PCPs will be finalized within 90 days of
                receipt
                of application

               

            
	
              Goal
                2:

               

              Improve
                Access to Behavioral Health Services for Members

            	
               

              §Increase
                urgent care appointment availability by 5 percentage points over
                the
                baseline

               

              §Improve
                the percent of psychiatrists accepting new member referrals by 5
                percentage points over the baseline

               

            
	
              Goal
                3:

               

              Improve
                Current Member Understanding About the CHIP Benefit Renewal
                Processes

               

            	
               

              §Member
                Services staff will provide verbal reminders about re-enrollment
                to 90% of
                members

               

              §Member
                Services will research 100% of undelivered member mail
                for updated and valid demographic
                information

               

            


    

    


    Additional
      information related to the Performance Improvement Goals can be found in
Attachment B-1,

    Section
      8.1.1.1, to the Contract.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    Texas
      Health and Human Services Commission

    STAR
      and CHIP HMO

    


    Performance
      Improvement Goals

    SFY
      2007

    (September
      1, 2006 – August 31, 2007)

    


    


    


    
      	
              A.
                Health Plan Information

              Plan
                Name: Superior HealthPlan

              HMO
                Program: CHIP

              HMO
                Service Delivery Area: Travis SDA

               

            
	
              B.
                Overarching Goal

            	
              C.
                Sub Goals:

            
	
              Goal
                1:

               

              Improve
                Access to Primary Care Services for Members

               

            	
               

              §90%
                of
                Pediatricians will have open panels

               

              §90%
                of
                initial credentialing of PCPs will be finalized within 90 days of
                receipt
                of application

               

            
	
              Goal
                2:

               

              Improve
                Access to Behavioral Health Services for Members

            	
               

              §Increase
                urgent care appointment availability by 5 percentage points over
                the
                baseline

               

              §Improve
                the percent of psychiatrists accepting new member referrals by 5
                percentage points over the baseline

               

            
	
              Goal
                3:

               

              Improve
                Current Member Understanding About the CHIP Benefit Renewal
                Processes

               

            	
               

              §Member
                Services staff will provide verbal reminders about re-enrollment
                to 90% of
                members

               

              §Member
                Services will research 100% of undelivered member mail
                for updated and valid demographic
                information

               

            


    

    


    Additional
      information related to the Performance Improvement Goals can be found in
Attachment B-1,

    Section
      8.1.1.1, to the Contract.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    Texas
      Health and Human Services Commission

    STAR
      and CHIP HMO

    


    Performance
      Improvement Goals

    SFY
      2007

    (September
      1, 2006 – August 31, 2007)

    


    


    
      	
              A.
                Health Plan Information

              Plan
                Name: Superior HealthPlan

              HMO
                Program: STAR

              HMO
                Service Delivery Area: Bexar SDA

               

            
	
              B.
                Overarching Goal

            	
              C.
                Sub Goals:

            
	
              Goal
                1:

               

              Improve
                Access to Primary Care Services for Members

               

            	
               

              §90%
                of
                Pediatricians will have open panels

               

              §90%
                of
                initial credentialing of PCPs will be finalized within 90 days of
                receipt
                of application

               

            
	
              Goal
                2:

               

              Improve
                Access to Behavioral Health Services for Members

            	
               

              §Increase
                urgent care appointment availability by 5 percentage points over
                the
                baseline

               

              §Improve
                the percent of psychiatrists accepting new member referrals by 5
                percentage points over the baseline

               

            
	
              Goal
                3:

               

              Improve
                Access to Clinically Appropriate Alternatives to Emergency Room Services
                Outside of Regular Office Hours

               

            	
               

              §Increase
                the number of providers, including urgent care clinics offering after
                hour
                appointments, by 5% over baseline

               

              §Target
                outreach and education 90% of members who have utilized the emergency
                room
                for primary care services > 2
                times

               

            


    

    


    Additional
      information related to the Performance Improvement Goals can be found in
Attachment B-1,

    Section
      8.1.1.1, to the Contract.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    Texas
      Health and Human Services Commission

    STAR
      and CHIP HMO

    


    Performance
      Improvement Goals

    SFY
      2007

    (September
      1, 2006 – August 31, 2007)

    


    


    
      	
              A.
                Health Plan Information

              Plan
                Name: Superior HealthPlan

              HMO
                Program: STAR

              HMO
                Service Delivery Area: El Paso SDA

               

            
	
              B.
                Overarching Goal

            	
              C.
                Sub Goals:

            
	
              Goal
                1:

               

              Improve
                Access to Primary Care Services for Members

               

            	
               

              §90%
                of
                Pediatricians will have open panels

               

              §90%
                of
                initial credentialing of PCPs will be finalized within 90 days of
                receipt
                of application

               

            
	
              Goal
                2:

               

              Improve
                Access to Behavioral Health Services for Members

            	
               

              §Increase
                urgent care appointment availability by 5 percentage points over
                the
                baseline

               

              §Improve
                the percent of psychiatrists accepting new member referrals by 5
                percentage points over the baseline

               

            
	
              Goal
                3:

               

              Improve
                Access to Clinically Appropriate Alternatives to Emergency Room Services
                Outside of Regular Office Hours

               

            	
               

              §Increase
                the number of providers, including urgent care clinics offering after
                hour
                appointments, by 5% over baseline

               

              §Target
                outreach and education 90% of members who have utilized the emergency
                room
                for primary care services > 2
                times

               

            


    

    


    Additional
      information related to the Performance Improvement Goals can be found in
Attachment B-1,

    Section
      8.1.1.1, to the Contract.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    Texas
      Health and Human Services Commission

    STAR
      and CHIP HMO

    


    Performance
      Improvement Goals

    SFY
      2007

    (September
      1, 2006 – August 31, 2007)

    


    


    
      	
              A.
                Health Plan Information

              Plan
                Name: Superior HealthPlan

              HMO
                Program: STAR

              HMO
                Service Delivery Area: Lubbock SDA

               

            
	
              B.
                Overarching Goal

            	
              C.
                Sub Goals:

            
	
              Goal
                1:

               

              Improve
                Access to Primary Care Services for Members

               

            	
               

              §90%
                of
                Pediatricians will have open panels

               

              §90%
                of
                initial credentialing of PCPs will be finalized within 90 days of
                receipt
                of application

               

               

            
	
              Goal
                2:

               

              Improve
                Access to Behavioral Health Services for Members

            	
               

              §Increase
                urgent care appointment availability by 5 percentage points over
                the
                baseline

               

              §Improve
                the percent of psychiatrists accepting new member
                referrals by 5 percentage points
                over the baseline

               

            
	
              Goal
                3:

               

              Improve
                Access to Clinically Appropriate Alternatives to Emergency Room Services
                Outside of Regular Office Hours

               

            	
               

              §Increase
                the number of providers, including urgent care clinics offering after
                hour
                appointments, by 5% over baseline

               

              §Target
                outreach and education to 90% of members who have
                utilized the emergency room for
                primary care services ≥2 times

               

               

            


    

    


    Additional
      information related to the Performance Improvement Goals can be found in
Attachment B-1,

    Section
      8.1.1.1, to the Contract.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    Texas
      Health and Human Services Commission

    STAR
      and CHIP HMO

    


    Performance
      Improvement Goals

    SFY
      2007

    (September
      1, 2006 – August 31, 2007)

    


    


    
      	
              A.
                Health Plan Information

              Plan
                Name: Superior HealthPlan

              HMO
                Program: STAR

              HMO
                Service Delivery Area: Nueces SDA

               

            
	
              B.
                Overarching Goal

            	
              C.
                Sub Goals:

            
	
              Goal
                1:

               

              Improve
                Access to Primary Care Services for Members

               

            	
               

              §90%
                of
                Pediatricians will have open panels

               

              §90%
                of
                initial credentialing of PCPs will be finalized within 90 days of
                receipt
                of application

               

               

            
	
              Goal
                2:

               

              Improve
                Access to Behavioral Health Services for Members

            	
               

              §Increase
                urgent care appointment availability by 5 percentage points over
                the
                baseline

               

              §Improve
                the percent of psychiatrists accepting new member
                referrals by 5 percentage points
                over the baseline

               

            
	
              Goal
                3:

               

              Improve
                Access to Clinically Appropriate Alternatives to Emergency Room Services
                Outside of Regular Office Hours

               

            	
               

              §Increase
                the number of providers, including urgent care clinics offering after
                hour
                appointments, by 5% over baseline

               

              §Target
                outreach and education to 90% of members who have
                utilized the emergency room for
                primary care services ≥2 times

               

               

            


    

    


    Additional
      information related to the Performance Improvement Goals can be found in
Attachment B-1,

    Section
      8.1.1.1, to the Contract.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    Texas
      Health and Human Services Commission

    STAR
      and CHIP HMO

    


    Performance
      Improvement Goals

    SFY
      2007

    (September
      1, 2006 – August 31, 2007)

    


    


    
      	
              A.
                Health Plan Information

              Plan
                Name: Superior HealthPlan

              HMO
                Program: STAR

              HMO
                Service Delivery Area: Travis SDA

               

            
	
              B.
                Overarching Goal

            	
              C.
                Sub Goals:

            
	
              Goal
                1:

               

              Improve
                Access to Primary Care Services for Members

               

            	
               

              §90%
                of
                Pediatricians will have open panels

               

              §90%
                of
                initial credentialing of PCPs will be finalized within 90 days of
                receipt
                of application

               

               

            
	
              Goal
                2:

               

              Improve
                Access to Behavioral Health Services for Members

            	
               

              §Increase
                urgent care appointment availability by 5 percentage points over
                the
                baseline

               

              §Improve
                the percent of psychiatrists accepting new member
                referrals by 5 percentage points
                over the baseline

               

            
	
              Goal
                3:

               

              Improve
                Access to Clinically Appropriate Alternatives to Emergency Room Services
                Outside of Regular Office Hours

               

            	
               

              §Increase
                the number of providers, including urgent care clinics offering after
                hour
                appointments, by 5% over baseline

               

              §Target
                outreach and education to 90% of members who have
                utilized the emergency room for
                primary care services ≥2 times

               

               

            


    

    


    Additional
      information related to the Performance Improvement Goals can be found in
Attachment B-1,

    Section
      8.1.1.1, to the Contract.

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      



    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-4.1 – FY2008 Performance Improvement
                Goals

            	
              Version
                1.7

            


    

    


    DOCUMENT
      HISTORY LOG

    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	
              Baseline

            	
              1.0

            	 	
              Initial
                version of Attachment B-4, Performance Improvement
                Goals.

            
	
              Revision

            	
              1.1

            	
              June
                30, 2006

            	
              Revised
                Attachment B-4, Performance Improvement Goals Template, by adding
                Attachment B-4.1, FY2008 Performance Improvement Goals Template.
                This is
                the initial version of Attachment B-4.1, FY2008 Performance Improvement
                Goals.

            
	
              Revision

            	
              1.2

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
                Goals.

            
	
              Revision

            	
              1.3

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
                Goals.

            
	
              Revision

            	
              1.4

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
                Goals, but did change format.

            
	
              Revision

            	
              1.5

            	
              January
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
                Goals.

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
                Goals.

            
	
              Revision

            	
              1.7

            	
              July
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
                Goals.

            
	
              1
Status
                should be represented as “Baseline” for initial issuances, “Revision” for
                changes to the Baseline version, and

              “Cancellation”
                for withdrawn versions

              2
Revisions
                should be
                numbered in accordance according to the version of the issuance and
                sequential numbering of the

              revision—e.g.,
                “1.2” refers to the first version of the document and the second
                revision.

              3
Brief
                description of the
                changes to the document made in the
                revision.

            


    

    


    Additional
      information related to the Performance Improvement Goals can be found in
      Attachment B-1, Section 8.1.1.1, to the Contract

    


    
      
        
                 1
            of
            2  
          

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	 
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	 
	
              Subject:
                Attachment B-4.1 – FY2008 Performance Improvement
                Goals

            	
              Version
                1.7

            


    

    


    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:

              HMO
                Program:

              HMO
                Service Delivery Area:

            
	
              B.
                Overarching Goal

            	
              C.
                Sub Goals:

            
	
              Goal
                1-5:

               

              Three
                to five Goals for all applicable HMO Programs to be determined
                and negotiated prior to FY2008.

            	
              To
                be determined for FY2008.

            
	
              Goal
                6:

               

              (STAR+PLUS
                HMOs) Increase the use of the Consumer

              Directed
                  Services (CDS)

              Program

               

            	
              Increase
                the percentage of enrollees receiving Personal Assistance Services
                (PAS)
                through the Consumer Directed Services (CDS) Program by 15% as compared
                to
                the baseline rate of ____

            


    

    


    Specific
      percentages for Sub-Goals will be negotiated by HHSC and the HMO before the
      beginning
      of FY2008.

    


    
      
        
                

                        
      

                    
      
    

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    



    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            	 
	
              Subject:
                Attachment B-5 –Deliverables/Liquidated Damages
                Matrix

            	
              Version
                1.6

            


    

    


    DOCUMENT
      HISTORY LOG

    
      	
              STATUS1

            	
              DOCUMENT

              REVISION2

            	
              EFFECTIVE

              DATE

            	
              DESCRIPTION3

            
	
              Baseline

            	
              n/a

            	 	
              Initial
                version of Attachment B-5, Deliverables/Liquidated Damage
                Matrix.

               

            
	
              Revision

            	
              1.1

            	
              June
                30, 2006

            	
              Contract
                amendment did not revise Attachment B-5, Deliverables/Liquidated
                Damage
                Matrix.

               

            
	
              Revision

            	
              1.2

            	
              September
                1, 2006

            	
              Amended
                Attachment B-5, Deliverables/Liquidated Damages Matrix, to add a
                footnote
                clarifying the deliverable due dates. Also amended the provisions
                regarding Claims Processing Requirements and the Reporting Requirements
                for the Claims Summary Report.

               

            
	
              Revision

            	
              1.3

            	
              September
                1, 2006

            	
              Amended
                Attachment B-5, Deliverables/Liquidated Damages Matrix, performance
                standard for Provider Directories for the CHIP Perinatal
                Program.

               

            
	
              Revision

            	
              1.4

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-5, Deliverables/Liquidated
                Damage
                Matrix.

               

            
	
              Revision

            	
              1.5

            	
              January
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-5, Deliverables/Liquidated
                Damage
                Matrix.

               

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-5, Deliverables/Liquidated
                Damage
                Matrix.

               

            
	
              Revision

            	
              1.7

            	
              July
                1, 2007

            	
              Amended
                Attachment B-5, Deliverables/Liquidated Damages Matrix, to add
                clarifications to the provisions addressing Claims Processing Requirements
                and the Reporting Requirements for the Claims Summary Report.

               

            
	
              1Status
                should be represented as “Baseline” for initial issuances, “Revision” for
                changes to the Baseline version, and “Cancellation” for withdrawn
                versions

              2Revisions
                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.

              3Brief
                description of the changes to the document made in the
                revision.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            	 
	
              Subject:
                Attachment B-5 –Deliverables/Liquidated Damages
                Matrix

            	
              Version
                1.6

            


    

    


    Deliverables/Liquidated
      Damages Matrix

    


    
      	
              Service/

              Component1

            	
              Performance

              Standard2

            	
              Measurement

              Period3

            	
              Measurement

              Assessment4

            	
              Liquidated
                Damages

            
	
              Contract
                Attachment B-1, RFP §7.3 --Transition Phase Schedule

               

               

              Contract
                Attachment B-1, RFP §7.3.1 -- Transition Phase Tasks

               

               

              Contract
                Attachment B-1, RFP §8.1 -- General Scope

            	
              The
                HMO must be operational no later than the agreed upon Operations
                Start
                Date. HHSC, or its agent, will determine when the HMO is considered
                to be
                operational based on the requirements in Section 7 and 8 of Attachment
                B-1

            	
              Operations
                Start Date

            	
              Each
                calendar 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 §7.3.1.5 – Systems Readiness Review

            	
              The
                HMO must submit to HHSC or to the designated Readiness Review Contractor
                the following plans for review, by December 14, 2005 for STAR and
                CHIP,
                and by July 31, 2006 for STAR+PLUS:

              •Joint
                Interface
                Plan;

              •Disaster
                Recovery
                Plan;

            	
              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.

            


    

    


    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.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            	 
	
              Subject:
                Attachment B-5 –Deliverables/Liquidated Damages
                Matrix

            	
              Version
                1.6

            


    

    


    
      	
              Service/

              Component1

            	
              Performance

              Standard2

            	
              Measurement

              Period3

            	
              Measurement

              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.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            	 
	
              Subject:
                Attachment B-5 –Deliverables/Liquidated Damages
                Matrix

            	
              Version
                1.6

            


    

    


    
      	
              Service/

              Component1

            	
              Performance

              Standard2

            	
              Measurement

              Period3

            	
              Measurement

              Assessment4

            	
              Liquidated
                Damages

            
	
              Attachment
                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.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            	 
	
              Subject:
                Attachment B-5 –Deliverables/Liquidated Damages
                Matrix

            	
              Version
                1.6

            


    

    


    
      	
              Service/

              Component1

            	
              Performance

              Standard2

            	
              Measurement

              Period3

            	
              Measurement

              Assessment4

            	
              Liquidated
                Damages

            
	
               

              Uniform
                Managed Care Manual – Chapter 5

            	
              final
                report is due no later than July 15th after 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-compliance

            
	
              Contract
                Attachment B-1 RFP §8.1.18.3 – Management Information System (MIS)
                Requirements: System-Wide Functions

            	
              The
                HMO’s MIS system must meet all requirements in Section 8.1.18.3 of
                Attachment B-1.

            	
              Measured
                Quarterly during the Operations Period

            	
              Per
                calendar day of non-compliance, per HMO Program, per SA.

            	
              HHSC
                may assess up to $5,000 per calendar day of
                non-compliance.

            
	
              Contract
                Attachment B-1 RFP §8.1.18.5 -- Claims Processing
                Requirements

            	
              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.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            	 
	
              Subject:
                Attachment B-5 –Deliverables/Liquidated Damages
                Matrix

            	
              Version
                1.6

            


    

    


    
      	
              Service/

              Component1

            	
              Performance

              Standard2

            	
              Measurement

              Period3

            	
              Measurement

              Assessment4

            	
              Liquidated
                Damages

            
	
               

              Uniform
                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.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            	 
	
              Subject:
                Attachment B-5 –Deliverables/Liquidated Damages
                Matrix

            	
              Version
                1.6

            


    

    


    
      	
              Service/

              Component1

            	
              Performance

              Standard2

            	
              Measurement

              Period3

            	
              Measurement

              Assessment4

            	
              Liquidated
                Damages

            
	
              Manual
                Chapters 2 and 5

            	 	 	 	 
	
              Contract
                Attachment B-1 RFP §8.1.5.9—Member Complaint and Appeal
                Process

               

              Contract
                Attachment B-1 RFP §8.2.7.1 – Member Complaint Process

               

              Contract
                Attachment B-1 RFP §8.4.3 – CHIP Member Complaint and Appeal
                Process

            	
              The
                HMO must resolve at least 98% of Member Complaints within 30 calendar
                days
                from the date the Complaint is received by the HMO

            	
              Measured
                Quarterly during the Operations Period

            	
              Per
                reporting period, per HMO Program, per SA.

            	
              HHSC
                may assess up to $250 per reporting period if the HMO fails to meet
                the
                performance standard.

            
	
              Contract
                Attachment B-1 RFP §8.3.3 – 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.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            	 
	
              Subject:
                Attachment B-5 –Deliverables/Liquidated Damages
                Matrix

            	
              Version
                1.6

            


    

    


    
      	
              Service/

              Component1

            	
              Performance

              Standard2

            	
              Measurement

              Period3

            	
              Measurement

              Assessment4

            	
              Liquidated
                Damages

            
	
              Managed
                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 noncompliance (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.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            	 
	
              Subject:
                Attachment B-5 –Deliverables/Liquidated Damages
                Matrix

            	
              Version
                1.6

            


    

    


    
      	
              Service/

              Component1

            	
              Performance

              Standard2

            	
              Measurement

              Period3

            	
              Measurement

              Assessment4

            	
              Liquidated
                Damages

            
	 	
              including
                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.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
       

      

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

       

       

      

      
        
        

      

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-7 – STAR+PLUS Attendant Care Enhanced Payments
                Methodology

            	 	
              Version
                1.7

            


    

    


    


    DOCUMENT
      HOSTORY LOG

    


    
      	
              STATUS1

            	
              DOCUMENT

              REVISION2

            	
              EFFECTIVE

              DATE

            	
              DESCRIPTION3

            
	
              Baseline

            	
              n/a

            	
              January
                1, 2007

            	
              Initial
                version of Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments
                Methodology, was incorporated into Version 1.5 of the
                Contract.

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-7, STAR+PLUS Attendant Care
                Enhanced
                Payments Methodology.

            
	
              Revision

            	
              1.7

            	
              July
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-7, STAR+PLUS Attendant Care
                Enhanced
                Payments Methodology.

            
	
              1
                Status should
                be represented as “Baseline” for initial issuances, “Revision” for changes
                to the Baseline version, and “Cancellation” for

                withdrawn
                versions

              2
                Revisions
                should be numbered in accordance according to the version of the
                issuance
                and sequential numbering of the revision—

                e.g.,
                “1.2” refers to the first version of the document and the second
                revision.

              3
                Brief
                description of the changes to the document made in the
                revision.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-7 – STAR+PLUS Attendant Care Enhanced Payments
                Methodology

            	 	
              Version
                1.7

            


    

    


    


    ATTACHMENT
      B-7: STAR+PLUS ATTENDANT CARE ENHANCED PAYMENTS
      METHODOLOGY

    


    
      	
              HMO:

            	
              Superior
                Health Plan

            


    

    


    
      	
              SERVICE
                AREA(S):

            	
              Bexar
                & Nueces

            


    

    


    


    
      	
               

              I.Provider
                Contracting

            	
               

              (a)
                Description of criteria the HMO will use to allow participation in
                the
                STAR+PLUS Attendant Care Enhanced Payments.  Will the HMO have a
                enrollment period that corresponds to the DADS enrollment period
                to allow
                new providers to participate in the HMO's Attendant Care Enhanced
                Payments, or will the HMO have it's own enrollment period that is
                separate
                and not tied to the DADS enrollment?

              (b)
                Description of any limitations or
                restrictions.

            
	 	
               

              Superior
                HealthPlan will only allow those providers that are currently
                participating in the DADS Attendant Compensation Rate Enhancements
                to
                participate in the STAR+PLUS Attendant Care Enhanced Payments. SHP
                will
                have an enrollment period corresponding to the DADS enrollment period
                to
                allow new providers to participate in the SHP Attendant Care Enhanced
                Payments.

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-7 – STAR+PLUS Attendant Care Enhanced Payments
                Methodology

            	 	
              Version
                1.7

            


    

    


    
      	
               

              II.Payment
                for STAR+PLUS Attendant Care Enhanced Payments

            	
               

              Description
                of methodology the HMO will use to pay for the Attendant Care Enhanced
                Payments.  Provide sufficient detail to fully explain the
                planned methodology.

            
	 	
               

              Superior
                will not use the DADS rates. SHP will establish an additional amount
                to be
                added on to the unit rate by type of service.

               

               

               

               

            
	
               

              III.  Timing
                of the Attendant Care Enhanced Payments

            	
               

              Description
                of when the payments will be made to the Providers and the frequency
                of
                payments.  Also include timeframes for Providers complaints and
                appeals regarding enhanced payments.

            
	 	
               

              The
                enhanced rate payment amount will be paid at the time of claims payment
                so
                the frequency will depend on the frequency with which providers file
                their
                claims. Provider complaints and appeals will be handled through the
                normal
                complaint and appeal process and finalized within 30 days from
                receipt.

               

               

               

               

               

               

               

               

               

            


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    


    
      	
              Contractual
                Document (CD)

            
	
              Responsible
                Office: HHSC Office of General Counsel (OGC)

            
	
              Subject:
                Attachment B-7 – STAR+PLUS Attendant Care Enhanced Payments
                Methodology

            	 	
              Version
                1.7

            


    

    


    
      	
               

              IV.  Assurances
                from Participating Providers

            	
               

              Description
                of how the HMO will ensure that the participating Providers are using
                the
                enhancement funds to compensate direct care workers as intended by
                the
                2000-01 General Appropriations Act (Rider 27, House Bill 1, 76th
                Legislature, Regular Session, 1999) and by T.A.C. Title 1, Part 15,
                Chapter 355.

            
	 	
               

              Participating
                Providers will be required by contract to complete and submit an
                affidavit
                annually stating they applied the enhancement funds to the compensation
                for direct care staff. Compensation may include increased hourly
                rates,
                bonuses, paid holidays or additional benefits such as employer paid
                insurance.

               

            
	
              V.  Monitoring
                of Attendant Care Enhanced Payments

            	
              Explanation
                of the Monitoring Process that the HMO will use to monitor whether
                the
                Attendant Care Enhanced Payments are used for the purposes intended
                by the
                Texas Legislature.

            
	 	
               

              Each
                Provider’s compliance with the attendant compensation spending requirement
                for the reporting period will be monitored on an annual basis via the
                submission of the affidavit stating they applied the enhancement
                funds to
                the compensation for direct care staff. Compensation may include
                increased
                hourly rates, bonuses, paid holidays or additional benefits such
                as
                employer paid insurance. In addition, providers may be audited on
                as
                as-needed basis to ensure financial records support the pass through
                of
                the enhanced funds. Enhanced payments could potentially be recouped
                for
                those Providers who fail to pass the funds to their direct care
                staff.

               

            


    

    


    By
      signing the Contract and/or Contract Amendment, HMO certifies that the approved
      STAR+PLUS Attendant Care Enhanced Payments Methodology described herein is
      the
      methodology the HMO will use to make the legislatively mandated payments to
      its
      Long Term Services and Support (LTSS) Providers participating in the Attendant
      Care Enhanced Payments.

    


    Additional
      information related to the Attendant Care Enhanced Payments can be found in
      Attachment B-1, Section 8.3.7.3 of the Contract.