Exhibit 10.19


     

      
        

      

    

     

    Back to Form 10-Q

     

    Exhibit
      10.19

    STATE
      OF
      MISSOURI

    OFFICE
      OF
      ADMINISTRATION

    DIVISION
      OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)

    CONTRACT
      AMENDMENT

    


    



    
      	
              AMENDMENT
                NO.: 001

            	
              REQ
                NO.: NR 886 25757002047 

            
	
              CONTRACT
                NO.; C306118005

            	
              BUYER
                Laura Ortmeyer 

            
	
              TITLE:
                Medicaid Managed Care-Eastern Region

            	
              PHONE
                NO.: (573) 751-4579 

            
	
              ISSUE
                DATE: 07/27/06

            	
              E-MAIL:
                Laura.Ortmeyer@oa.mo.gov

            
	 	 
	
              TO:
                HARMONY HEALTH PLAN INC

            	 
	
              23
                PUBLIC SQUARE, SUITE 400

            	 
	
              BELLEVILLE,
                IL 62220

            	 
	 	 
	
               RETURN
                AMENDMENT
                NO LATER
                THAN:
                August 14, 2006 AT 5:00 PM CENTRAL TIME

              RETURN
                AMENDMENT TO:

               

            	 
	
               (U.S. Mail)

              Division of Purchasing & Matls Mgt
                (DPMM)

              P.O Box 809
                
                Jefferson
                  City, MO 65102-0809
                  
                  Or
                    Fax to 573-526-9817 (either mail or fax, not both)

                   

                

              

            	
              Courier Services

              Division of Purchasing & Matl Mgt
                (DPMM)

              301 West High Street, Room 630
                
                Jefferson
                  City, MO 65101

              

            
	
               DELIVER SUPPLIES/SERVICES FOB (Free On Board)
                DESTINATION TO THE FOLLOWING ADDRESS:

               

              
                Department
                  of Social Service 

                Division
                  of Medical Services 

                P.O.
                  Box 6500 

                Jefferson
                  City, MO 65102-6500

              

            	 


    

     

    


    
      	
              DOING
                BUSINESS AS (DBA) NAME:

              Harmony
                Health Plan of Missouri

               

            	
              LEGAL
                NAME OF ENTITY/INDIVIDUAL FILED WITH IRS FOR THIS TAX ID NO.

              Harmony
                Health Plan of Illinois, Inc.

            
	
              MAILING
                ADDRESS

              23
                Public Square, Suite 400

            	
              IRS
                FORM 1099 MAILING ADDRESS

              200
                West Adams Street, Suite 800

               

            
	
              CITY,
                STATE, ZIP CODE

              Belleville,
                IL 62220

            	
              CITY,
                STATE, ZIP CODE

              Chicago,
                IL 60606

               

            
	
              CONTACT
                PERSON

              Ms.
                Tina Gallagher

            	
              EMAIL
                ADDRESS

              Tina.Gallagher@wellcare.com

               

            
	
              PHONE
                NUMBER

              800-608-8158
                Ext. 2405

            	
              FAX
                NUMBER

              312-630-2022

               

            
	
              TAXPAYER
                ID NUMBER (TIN)

              36-4050495

            	
              TAXPAYER
                IF (TIN) TYPE (CHECK ONE)

              X
                FEIN
                ___ SSN

            	
              VENDOR
                NUMBER

              3640504950-1

               

            
	
              VENDOR
                TAX FILING TYPE WITH IRS (CHECK ONE)

              X
                Corporation ___ Individual ____ State/Local government ___ Partnership
                ____ Sole Proprietor ___ Other _____________

               

            
	
              AUTHORIZED
                SIGNATURE

              /s/
                Thaddeus Bereday

            	
              DATE

              August
                9, 2006

               

            
	
              PRINTED
                NAME

              Thaddeus
                Bereday

            	
              TITLE

              Secretary

            


    

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    Contract
      C306 II 8005 Page 2

     

    AMENDMENT
      #001 TO CONTRACT C306118005

     

    CONTRACT
      TITLE:
      Medicaid
      Managed Care - Eastern, Region

     

    CONTRACT PERIOD:
      July
      1,2006 through June 30, 2007

     

    The
      State
      of Missouri hereby desires to amend the above-referenced contract, as follows,
      effective July 1,2006:

     

    1.
      Paragraph 2.4.9 is hereby amended as follows:

     

    2.4.9
      The
      health plan shall maintain the fee schedule for office visit services and dental
      services located in Attachment 14 at no lower than the Medicaid fee-for-service
      fee schedule in effect at the time of service.

     

    2.
      Paragraph 2.7,1 I, is hereby amended as follows:

     

    2.7.1.1
      Optical services include one comprehensive or one limited eye examination every
      two years for refractive error, services related to trauma or treatment of
      disease/medical condition (including eye prosthetics), and one pair eyeglasses
      following cataract surgery.

     

    3.
      Paragraphs 2.7,1 r. is hereby amended as follows:

     

    2.7.1
      r.
      Durable medical equipment limited to: prosthetic devices (with the exception
      of
      artificial larynx), respiratory equipment and oxygen (with the exception of
      CPAP, BiPAP, and nebulizers), wheelchairs (including accessories and batteries),
      diabetic supplies and equipment, and ostomy supplies. Members with 1-lomu Health
      Plan of Care receive all medically necessary durable medical equipment services
      during the plan of care coverage period.

     

    4.
      Paragraph 2.7.2 is hereby amended as follows:

     

    2.7.2
      The
      health plan shall include all the services specified in the comprehensive
      benefit package with the exception of non-emergency medical transportation
      (NEMT) for uninsured children in Mb Codes 71-75 (Refer to Attachment 1, COA
      5)
      and children in state custody with the following ME Codes 08, 52,57, and 64
      (Refer to Attachment 1, COA 4).

     

    5.
      Paragraph 2.7.3 c is hereby amended as follows;

     

    2.7.3
      c.
      Optical services for children under age 21 include one comprehensive or one
      limited eye examination per year for refractive error, eyeglasses, and HCY/EPSDT
      optical screens and services. Optical services for pregnant women age 21 and
      over with ME codes 18, 43, 44, 45, or 61 include one comprehensive or one
      limited eye examination per year for refractive error. Eyeglasses (except the
      one pair following cataract surgery covered by the health plan) for these
      pregnant women are covered through the Fee for Service program.

     

    6.
      Paragraph 2.7-3 e. is hereby amended as follows

     

    2.7.3
      e.
      Durable medical equipment (including but not limited to: orthotic devices,
      artificial larynx, central and parenteral nutrition, walkers, CPAP, BiPAP,
      and
      nebulizers);

     

    7.
      Paragraph 2.12.7 is hereby amended as follows:

    



    Contract
      C306118005 Page 3

     

    2.12.7 Pharmacy
      Services: Pharmacy services (including physician injections) not included in
      the
      health plan's awarded proposal shall be reimbursed by the state agency on a
      fee-for-service basis according to the terms and conditions of the Medicaid
      program.

     

    8.
      Attachment 3 is hereby revised.

     

    9.
      Attachment 6 is hereby revised.

     

    10.
      Attachment 12 is hereby revised.

     

    11.
      Attachment 14 is hereby revised.

     

    The
      contractor shall indicate in Column 2 on the attached Pricing page, any changes
      to the firm fixed prices of the contract for performing the required services
      in
      accordance with the terms, conditions, and provisions of the contract, including
      the above stated changes. The contractor's firm, fixed PMPM Net Capitation
      Rate
      for Each Category of Aid (COA) Rate subgroup must not exceed the State's Maximum
      Net Capitation Rate Listed in Column 1.

     

    All
      other
      terms, conditions and provisions of the contract shall remain the same and
      apply
      hereto.

     

    The
      contractor shall sign and return this document, on or before the dale indicated,
      signifying acceptance of the amendment.

     

    



    5.3
      East Region - Firm Fixed Net Capitation Pricing Page

     

    


     

    

      

        
          	
                   

                  Category
                    of Aid

                	
                   

                  Age

                	
                   

                  Sex

                	
                  State's
                    Maximum Net Capitation Rate

                  (Per
                    member per Month)

                	
                   

                  Firm
                    Fixed Net Capitation
                    Rate

                  (Per
                    member per Month)

                
	
                  1

                	
                  Newborn
                    <
                    01

                	
                  Male
                    and Female

                	
                  $
                    777.07

                	
                  $
                    777.07

                
	
                  1

                	
                  01-06

                	
                  Male
                    and Female

                	
                  $
                    113.59

                	
                  $
                    113.59

                
	
                  1

                	
                  07-13

                	
                  Male
                    and Female

                	
                  $
                    90.07

                	
                  $
                    90.07

                
	
                  1

                	
                  14
                    - 20

                	
                  Female

                	
                  $
                    240.17

                	
                  $
                    240.17

                
	
                  1

                	
                  14
                    -20

                	
                  Male

                	
                  $
                    114.66

                	
                  $
                    114.66

                
	
                  1

                	
                  21
                    -44

                	
                  Female

                	
                  $
                       333.06

                	
                  $
                    333.06

                
	
                  1

                	
                  21
                    -44

                	
                  Male

                	
                  $
                    172.85

                	
                  $
                    172.85

                
	
                  1

                	
                  45.99

                	
                  Male
                    and Female

                	
                  $
                    399.40

                	
                  $
                    399.40

                
	
                  4

                	
                  00-20

                	
                  Male
                    and Female

                	
                  $
                    207.76

                	
                  $
                    207 76

                
	 	 	 	 
	
                  5

                	
                  00-06

                	
                  Male
                    and Female 

                	
                  $
                    140.03

                	
                  $
                    140.03

                
	
                  5

                	
                  07-13

                	
                  Male
                    and Female

                	
                  $
                    108.12

                	
                  $
                    108.12

                
	
                  5

                	
                  14-
                    18

                	
                  Male
                    and Female

                	
                  $
                    158.18

                	
                  $
                    158.18

                


        

      

    

    


    



    REVISED
      ATTACHMENT 3 

     

    MANAGED
      CARE POLICIES GOVERNING MC+ SERVICES

     

    The
      following are brief descriptions of the services included in the standard
      benefit package and the various programs and policies governing the delivery
      of
      services for the MC+ Managed Care Program. These policies follow tlie amount,
      duration, and scope of services covered under the Missouri Medicaid State Plan.
      For those services included in the MC+ Managed Care benefit package, the MC+
      Managed Care health plan must offer, at a minimum, the amount, duration, and
      scope of that service included in the Medicaid State Plan. The state agency
      produces and updates MC+ Managed Care policy statements governing the delivery
      of services under MC+ managed care. The MC+ Managed Care health plan shall
      comply with such policies governing the delivery of services and as amended
      by
      the slate agency. Detailed information regarding MC+ fee-for-service
      services is contained
      in the fec-for-service provider manuals and bulletins, and the deluxe pricing
      file.

    


    ADULT
      DAY HEALTH CARE

    Adult
      Day
      Health Care is a covered benefit for members.

    


    Adult
      Day
      Health Care is a program of organized therapeutic, medical, rehabilitative,
      and
      social activities provided outside of the home. MC+ fcc-for-service eligible
      persons are assessed to be eligible for the program by the Missouri Department
      of I iealth and Senior Services (DHSS). They must have functional impairments
      requiring nursing home level of care, but with the provision of this service
      and
      perhaps other supports, they may safely remain in their home. Adult Day Health
      Care must be provided in a DHSS licensed facility or be exempt from licensure
      by
      way of regulation.

    


    AMBULATORY
      SURGICAL CENTERS (INCLUDING BIRTHING CENTERS)

    Ambulatory
      Surgical Center services are a covered benefit. MC+ Managed Care health plans
      may utilize Ambulatory Surgical Centers as an alternative to outpatient hospital
      services. The Ambulatory Surgical Center provides a place for operative
      procedures to be accomplished that can be safely performed in an outpatient
      setting and be able to be completed within 90 minutes. This is the maximum
      length of lime that a person may be placed under anesthetic in an Ambulatory
      Surgical Center.

    Birthing
      Centers are also licensed as Ambulatory Surgical Centers and are appropriate
      settings for the delivery of services provided by a physician, advanced practice
      nurse, or certified nurse midwife. MC+ Managed Care health plans are responsible
      for Birthing Center services.

    


    ANESTHESIA
      SERVICES

    Anesthesia
      services are a covered benefit. Anesthesia services arc covered when performed
      by an Anesthesiologist or Certified Registered Nurse Anesthetist (CRNA). Medical
      direction of anesthetists by an anesthesiologist is also a covered
      service.

    


    CASE MANAGEMENT

    Case
      management is a clinical system that focuses on the accountability of an
      identified individual
      or
      group
      for coordinating a patient's care (or group of patients) across an episode
      or
      continuum of care; negotiating, procuring, and coordinating services and
      resources needed by patients/families with complex issues; insuring and
      facilitating the achievement of quality, clinical, and cost outcomes;
      intervening at key points for individual patients;

    addressing
      and resolving patterns of issues that have a negative quality cost impact;
      and
      creating opportunities and systems to enhance outcomes. (Definition used with
      permission of The Center for Case Management, 6 Pleasant Street, South Nalick,
      MA 01760.) Case management is understood as including, but not limited to the
      development of individualized treatment plans and ongoing communication and
      coordination with other systems of care. The treatment plans must
      be:

    


    
      	·  	
              Developed
                by the member's primary care provider with member participation,
                and in
                consultation with any specialists caring for the
                member;

            


    

    
      	·  	
              Approved
                by the MC+ Managed Care health plan in a timely manner, if this approval
                is required; and

            


    

    
      	·  	
              In
                accord with any applicable Stale quality assurance and utilization
                review
                standards.

            


    

     

    MC+
      Managed Care health plans shall provide case management to members with special
      health care needs and maintain a detailed case management record on each member.
      Members •with special health care needs are those members who have ongoing
      special conditions that require a course ol'treatment or regular care
      monitoring. The Case Management MC+ Managed Care Policy Statement shall include
      a list of diagnoses for children and adults that, at a minimum, the MC+ Managed
      Care health plan sliall use for identification of members with special health
      care needs requiring case management and criteria for maintaining a detailed
      case management record. The following groups of individuals are at high risk
      of
      having a special health care need:

    


    
      	·  	
              Individuals
                eligible for Supplemental Security Income
                (SS1);

            


    

    
      	·  	
              individuals
                ill foster care or other out-of-bome
                placement;

            


    

    
      	·  	
              Individuals
                receiving foster care or adoption subsidy;
                and

            


    

    
      	·  	
              Individuals
                receiving services through a family-centered community-based coordinated
                care system that receives grant funds under Section 501(a)(l)(D)
                of Title
                V, as defined by the state agency in terms of either program participant
                or special health care needs.

            


    

    


    At
      the
      time of enrollment, the MC+ Managed Care health plan shall perform an initial
      health assessment of members with special health care needs and members who
      are
      at high risk of having a special health care need and implement appropriate
      case
      management based upon that assessment appropriate to the member's
      needs.

    The
      MC-5-
      Managed Care health plan shall be responsible for providing members with special
      health care needs all services covered under the contract beginning with the
      effective date of enrollment. All services authorized prior to enrollment in
      an
      MC+ Managed Care health plan shall be terminated only after a case-specific,
      clinical decision has been made by an MC+ Managed Care health plan provider.
      The
      MC+ Managed Care health plan shall have a mechanism in place to allow members
      direct access to a specialist as appropriate for the member's condition and
      identified needs.

    


    HCY
      CASE
      MANAGEMENT: MC+ Managed Care health plans arc required to provide medically
      necessary HCY case management services for members under the age of 21. Healthy
      Children and Youth (1-ICY) Case Management is an activity under which
      responsibility for locating, coordinating, and monitoring necessary and
      appropriate services for members under age 21, rests with an MC+ Managed Care
      Health Plan or an organization or individual that the MC+ Managed Care Health
      Plan has contracted with. HCY Case Management is the process of collecting
      information on the health needs of the child, making (and following up on)
      referrals as needed, maintaining a health history, activating the Early Periodic
      Screening and Diagnostic Treatment (EPSDT) program and ensuring collaboration
      between providers.

    


    LEAD
      CASE
      MANAGEMENT: The MC+ Managed Care health plan is responsible for the provision
      of
      lead case management for those children with elevated blood lead levels. The
      MC+
      Managed Care health plan must screen children for elevated blood lead levels
      as
      part of the requirement for the EPSDT/HCY program. When a child is identified
      witli an elevated blood lead level, the MC+ Managed Care health plan is
      responsible for providing medically necessary services including case management
      for the child.

    


    CASH
      MANAGEMENT - PREGNANT WOMEN

    MC+
      Managed Care health plans arc required to provide prenatal case management
      services for at risk pregnant women enrolled in their MC+ Managed Care health
      plan. Based on the prenatal risk assessment, the case manager will formulate
      an
      individualized plan of management designed to accomplish the intended
      objectives.

    


    CHILDREN
      WITH SPECIAL HEALTH CARE NEEDS

    Children
      with special health care needs are likely to require the services of the MC+
      Managed Care health plan's special programs coordinator. These children may
      also
      be served by the Departments of Health and Senior Services, Mental Health,
      or
      Elementary and Secondary Education in early intervention programs (Individuals
      with Disabilities Education Act - Part C), school-based services,
      etc.

    


    Without
      services such as private duty nursing, personal care, home health, durable
      medical equipment/supplies, and case management these children may require
      hospilalization or institutionalization. Nursing homes are not usually an option
      for children due to their intense needs as well as their age. Some examples
      of
      children with special
      health care needs include: children with special needs due to physical and/or
      mental illnesses, foster care children, homeless children, children with serious
      and persistent mental illness and/or substance abuse, and children who arc
      disabled or chronically ill with developmental or physical disabilities. The
      following information identifies some of the special health care needs of this
      population.

    


    X   
      Requires vital functions to be sustained through unusual support such as oxygen,
      respirator support, total parenteral nutrition, inhalation therapy, and postural
      drainage.

    X   
      Requires continuous nursing attention as the result of a surgical or medical
      procedure such as trachceostomy, ilcostomy, colostomy, gastrostomy, nephrotomy,
      cast, or shunt. 

    X   
      Requires continuous maintenance because ofgavage feedings, frequent oral
      suctioning, elimination care, and positioning needs. 

    X   
      Requires therapy such as physical, occupational, and/or speech therapy to reach
      their greatest potential and to minimixc progression of disability as in
      children with cerebral palsy, rheumatoid arthritis, and
      spinabifida.

    X   
      Require continuous medical monitoring of underlying disease and its therapy.
      

    X   
      Requires monitoring of indicators of vital functions such as heart rate,
      respiration, blood sugar, oxygen levels, blood pressure, and urine output.
      

    X   
      Requires assistance in battling, toileting, eating, or other activities of
      daily
      living because of a medical condition.

    


    COMPREHENSIVE
      DAY REHABILITATION

    


    Comprehensive
      Day Rehabilitation services arc a covered benefit for children under the age
      of
      21 and pregnant women with ME codes 18, 43, 44,45, and 61. Coverage for
      comprehensive day rehabilitation services is required for certain persons with
      disabling impairments as the result of a traumatic head injury. Comprehensive
      day rehabilitation services are services beginning early post trauma as part
      of
      a coordinated system of care. Rehabilitation services must be based on an
      individualized, goal-oriented, comprehensive and coordinated treatment plan.
      The
      treatment plan must be developed, implemented, and monitored through an
      interdisciplinary assessment designed to restore an individual to optimal level
      of physical, cognitive, and behavioral function (See RSMo 208.152). MC+ Managed
      Care health plans are responsible for providing rehabilitation services to
      survivors of a Traumatic Brain Injury (TB1).

    


    DENTAL

    All
      MC+
      Managed Care members receive dental care related to trauma to the mouth, jaw,
      teeth or other contiguous sites as a result of injury. Adults age 21 and over
      receive treatment of a disease/medical condition without which the health of
      the
      recipient would be adversely affected through the fee for service program.
      Medically necessary covered dental services provided by a dentist, doctor of
      medicine, osteopathy or dentistry are the responsibility of the MC-l- Managed
      Care health plan. Medications prescribed by a dentist for MC+ Managed Care
      health plan members are the responsibility of the MC+ Managed Care health plan.
      The MC+ Managed Care health plan is not responsible for dental services which
      are exclusively for cosmetic reasons.

    


    DENTAL
      -CHILDREN UNDER AGE 21 

    Dental
      screens, dental services, and orthodontic services are covered for members
      under
      age 21.

    It
      is
      recommended that preventive dental services and oral treatment for children
      begin at age 6-12 months and be repeated every six months or as medically
      indicated.

    


    DENTAL
      - PREGNANT WOMEN AGE 21 AND OVER WITH ME CODES 18, 43, 44, 45, AND
      61:
      Dental
      services for pregnant women age 21 and over with ME codes 18, 43, 44, 45, and
      61
      shall be limited to dentures and services related to trauma to the mouth, jaw,
      teeth or other contiguous sites as a result of injury. Services to prepare
      the
      mouth for dentures, such as examinations- X-rays, or extractions will not be
      covered by the health plan. Ancillary denture services such as relining,
      rcbasing, and repairs will not be covered by the health plan. All other Medicaid
      State Plan dental services for this population is covered through the fee for
      service program and is not the responsibility of the MC+ Managed Care health
      plan,

    



    DIABETES
      SELF-MANAGEMENT TRAINING

    Coverage
      of self management training must be provided to all children under age 21 and
      pregnant women in ME Codes 18, 43, 44, 45, and 61 used in the management and
      treatment of gestational, Type I, and Type II diabetes as prescribed by a health
      care provider licensed by law to prescribe such services.

    


    DURABLE
      MEDICAL EQUIPMENT (DME)

    MC+
      Managed Care health plans arc required to provide medically necessary DME items
      to children under the age of 21, pregnant women with ME codes 18, 43, 44,45,
      and
      61, and members with a Home Health Plan of Care. MC+ Managed Care health plans
      arc required to provide limited medically necessary DME items to all other
      MC+
      Managed Care members.

    


    CHILDREN
      UNDER THE AGE OF 21 AND PREGNANT WOMEN WITH ME CODES 18. 43. 44,45, AND 61
      AND
      THOSE WITH A HOME HEALTH PLAN 01-- CARE REGARDLESS OF AGE:
      Medically necessary equipment such as hospital beds, walkers, commodes,
      ducubitus care equipment, hoyer lifts, augmentative communication devices when
      prior authorized by the MC+ Managed Care health plan, trapeze equipment, canes,
      and crutches, etc. will be provided to children under the age of 21 and pregnant
      women with ME codes 18, 43, 44, 45, and 61 and those with a home health plan
      of
      care regardless of age. The recipient must be MC+ eligible on the date the
      equipment is delivered or dispensed. Equipment that is purchased becomes the
      property of the recipient. Those with a home health plan of care receive covered
      DME items during the plan of care coverage period.

    


    In
      addition to the above-mentioned DME items, the MC+ Managed Care health plans
      arc
      required to provide the following:

    


    X   
      HCY
      DME
      items and services to members under the age of 21. This includes medically
      necessary items such as diapers, medical supplies, enteral nutrition, PKLI
      nutrition, and positioning equipment. MC+ Managed Care health plans must arrange
      for continuation of coverage ofHCY equipment and supplies presently being
      reimbursed under the HCY program.

    X   
      All medically necessary 'total Parentcral Nutrition (TPN) items and services.
      This includes TPN pumps, nutritional solutions, and supplies.

    X   
      All medically necessary non-sterile osiomy supplies.

    X   
      All medically necessary orthotic and prosthetic devices.

    X   
      All medically necessary diabetic supplies and equipment,

    X   
      All medically necessary oxygen and respiratory equipment. This includes oxygen
      and oxygen delivery systems, ventilators, nebulizers, Apnea monitors, suction
      pumps, etc. A summary of oxygen and respiratory equipment benefits and
      limitations may be found in the MC+ Durable Medical Equipment Policy
      Statement.

    X   
      Augmentative communication evaluations, devices, and training. Medically
      necessary communication devices prescribed as a result of the augmentative
      evaluation are covered as a Durable Medical Equipment (DME) benefit when the
      augmentative communication device is prior authorized by the MC+ Managed Care
      health plan.

    


    LIMITED
      DURABLE MEDICAL EQUIPMENT FOR MC+ MANAGED CARE ELIGIBLE INDIVIDUALS WHO ARE
      NOT
      CHILDREN UNDER THE AGE OF 21, PREGNANT WOMEN WITH ME CODES 1.8, 43, 44. 45.
      AND
      61. OR THOSE WITH A HOME HEALTH PLAN OF CARE INCLUDES:

    
      	·  	
              Diabetic
                supplies and equipment (insulin and needles are considered
                pharmaceuticals),

            


    

    
      	·  	
              Manual
                and power wheelchairs including wheclchair accessories and
                batteries,

            


    

    
      	·  	
              Prosthetic
                devices (artificial larynx is not
                covered),

            


    

    
      	·  	
              Respiratory
                equipment and oxygen. (Nebulizers, CPAP and BiPAP are not covered
                services
                unless medical necessity is determined through (he MC+ Managed Care
                health
                plan's exception process. If services are currently authorized, the
                MC+
                Managed Care health plan may only discontinue or reduce these services
                after a determination of medical necessity is made through the MC+
                Managed
                Care health plan's exception
                process.)

            


    

    
      	·  	
              Ostomy
                supplies.

            


    

    



    EPSDT/HCY

    The
      Omnibus Budget Reconciliation Act of 1989 (OBRA-89) mandated that MC+
      fce-for-servicc provide medically necessary services to children from birth
      through age 20 which arc necessary to treat or ameliorate defects, physical
      or
      mental illness, or conditions identified by an Early Periodic Screening,
      Diagnosis, and Treatment (EPSDT) well child visit (screen) regardless of whether
      or not the services are covered under the MC+ fee-for-service state plan. This
      program is referred to nationally as the EPSDT Program. In Missouri this program
      is referred to as the Healthy Children and Youth (HCY) Program, Services must
      be
      sufficient in amount, duration, and scope to reasonably achieve their purpose
      and may only be limited by medical necessity. The MC+ Managed Care health plans
      are responsible for providing EPSDT/HCY services for all members. If a problem
      is detected during a well child visit (screening examination), the child must
      be
      evaluated as necessary for further diagnosis and treatment services. The MC+
      Managed Care health plan is responsible for the treatment services.

    


    EPSDT/HCY
      WELL CHILD (SCREENING) SERVICES: MC+ Managed Care health plans are responsible
      for ensuring that HCY well child visits (screens) arc performed on all members
      under the age of 21. Missouri has adopted the American Academy of Pediatrics'
      (AAP) Schedule for Preventive Pcdiatric Health Care as a minimum standard for
      frequency of providing full HCY well child visits. Immunizations arc recommended
      in accordance with the Advisory Committee on Immunization Practices (AC1P)
      guidelines. MC+ Managed Care health plans are required to keep immunizations
      and
      well child visits current according to schedules as specified by the stale
      agency. The current schedules are as follows:

    


    Children
      should receive HCY/EPSDT well child visits regularly, at the ages listed
      below.

    


    
      	
              Newborn

            	
              15-17
                months

            	
              8-9
                years

            
	
              By
                age one month

            	
              18-23
                months

            	
              10-11
                years

            
	
              2-3
                months

            	
              24
                months

            	
              12-13
                years

            
	
              4-5
                months

            	
              3
                years

            	
              14-15
                years

            
	
              6-8
                months

            	
              4
                years

            	
              16-17
                years

            
	
              9-11
                months

            	
              5
                years

            	
              18-19
                years

            
	
              12-14
                months

            	
              6-7
                years

            	
              20
                years

            


    

     

    EPSDT/HCY
      LEAD SCREENING SERVICES: All children from 6 to 72 months of age arc considered
      at risk and must be assessed for lead poisoning. A verbal risk assessment must
      be completed at each 1-1CY visit and if at high risk, the child must have a
      blood lead test. A blood lead test i-s required at 12 and 24 months, regardless
      of risk or annually if residing in a high-risk area of Missouri as defined
      by
      Department of Health and Senior Services regulation 19 CSR 20-8.030. The
      Division of Medical Services requires the use of the Lead Screening Guide (MO
      886-2998) when providing services to MC+ eligible children.

    


    Childhood
      Immunization Schedule: Children should receive childhood immunizations
      regularly, at the ages listed on the Recommended Childhood Immunization
      Schedule, as amended. The current schedule appears in the Missouri Medicaid
      Provider Manuals that may be found on the Internet at the Division of Medical
      Services website, http;//www.medicaid.state.mo.us/index1.html (Look under
      Missouri Medicaid Provider Manuals, List of Forms, Recommended Childhood
      Immunization Schedule.)

    


    FAMILY
      PLANNING/STERILIZATIONS

    Family
      planning services are a covered benefit. MC+ Managed Care health plans are
      required to provide freedom of choice for family planning and reproductive
      health services which may be accessed out-of-network. Examples of reproductive
      health services are: contraception management, insertion ofNorplant,
      intrauterine devices, Depo-Provera injections, pap test, pelvic exams, sexually
      transmitted disease testing, and family planning counseling/education on various
      methods of birth control. For family planning purposes, sterilizations shall
      only be tliosc elective sterilization procedures performed for the purpose
      of
      rendering an individual permanently incapable of reproducing and must always
      be
      reported as family planning services in accordance witli mandated federal
      regulations 42 CPR 44 i .250 - 441.259.

     

    HEARING
      AlD -
      Limited
      to Children under the age of 21 and Pregnant Women with ME codes 18. 43. 44.
      45.
      and 61

    MC+
      Managed Care health plans are required to provide medically necessary hearing
      aids and related services. This includes medically necessary audiometric and
      hearing aid services for all MC+ Managed Care members under the age of 21
      including but not limited to hearing aid batteries, FM system, diagnostic
      testing, post cochlear implant training, aural habililation, auditory trainers,
      etc.

    


    HOME
      HEALTH

    MC+
      Managed Care health plans are responsible for covering medically necessary,
      physician ordered home health benefits. MC+ Managed Care health plans shall
      not
      terminate such services without a case-specific, clinical decision made by
      a
      provider. Home health services provide primarily medically oriented treatment
      or
      supervision to members with an acute illness, or an exacerbation of a chronic
      or
      long term illness which can be thcrapeutically managed at home. The delivered
      care should follow a written plan of treatment established and periodically
      reviewed by a physician.

    


    The
      home
      health program is divided into two distinct segments based on the age of the
      member. Members who are 21 years of age and older are defined as adults within
      the home health program. Members 20 and under arc classified as children and
      are
      eligible to receive expanded home health services as part of the EPSDT federal
      mandate. Services include skilled nursing, aide visits, psychiatric nursing,
      physical, occupational, and speech therapy and supplies.

    


    HOSPICE

    MC+
      Managed Care health plans are required to provide hospice services when a
      terminally ill member elects those services. The hospice benefit is designed
      to
      meet the needs of members with life-limiting illnesses and to help tlicir
      families cope with related problems and feelings. To be eligible to elect
      hospice care, members must be certified by a physician as being terminally
      ill
      with a life expectancy of six months or less. Hospice care cannot be prescribed
      or ordered by a physician, "["he member must elect hospice care and agree to
      seek oniy palliative care for the duration of the hospice election.

    


    HYSTERECTOMY
      SERVICES

    In
      order
      to be in compliance with 42 CFR 441.256, the MC+ Managed Care health plan must
      require a completed copy of the "Acknowledgement of Receipt of Hysterectomy
      Information" form from the performing provider. The MC+ Managed Care health
      plan
      must assure that the "Acknowledgement of Receipt of Hysterectomy Information"
      form meets all of the criteria required by 1 ICI-'A in 42 CFR 441-250 through
      441.259.

    


    INPATIENT/OUTPATIENT
      HOSPITAL including MENTAL HEALTH

    Inpalient
      hospitalization and outpatient services for physical health needs are the
      responsibility of the MC+ Managed Care health plan for all members, based on
      medical necessity. This includes charges for the prelransplant and post
      discharge follow-up for transplant recipients (sec Transplants).

    


    MATERNITY
      PRE-NATAL CARE AND DELIVERY MC+
      Managed Care health plans are required to cover maternity pre-natal care and
      delivery.

    


    MENTAL
      HEALTH AND SUBSTANCE ABUSE SERVICES 

    MC+
      Managed Care health plans arc responsible for all medically necessary mental
      health and substance abuse services available in the fee-tor-service program
      for
      members. Mental health and substance abuse services shall include court ordered,
      96 hour detentions and involuntary commitments. Mental health and substance
      abuse services may be provided by an acute care hospital (for a psychiatric
      stay), private or state psychiatric hospital, community mental health or
      substance abuse treatment program certified or licensed by the joint commission,
      Commission for Accreditation of Rehabilitation Facilities (CAR.F), or the
      Missouri Department of Mental Health including qualified mental health
      professional;;, licensed and provisionally licensed psychologists, licensed
      and
      provisionally licensed clinical social workers, licensed and provisionally
      licensed professional counselors, psychiatrist, psychiatric advance practice
      nurse or home health psychiatric nurse.

    


    Mental
      health and substance abuse services (including inpatient and outpatient) for
      children in Category of Aid 4 (primarily children in state custody) are
not
      the
      financial responsibility of the MC+ Managed Care health plan and will
      be
      reimbursed to MC+ fec-fbr-service enrolled providers on a fee-for-service basis.
      For inpatients with dual diagnoses (physical and mental) identified at admission
      or during the stay, the MC+ Managed Care health plans will be financially
      responsible for all inpatient hospital days if the primary, secondary, or
      tertiary diagnosis is a combination of physical and mental health.

    


    OPTICAL

    MC+
      Managed Care health plans are required to provide medically necessary optical
      services for members as described herein.

    Optical
      services include one comprehensive or one limited eye examination every two
      years for refractive error, services related to trauma or treatment of
      disease/medical condition (including eye prosthetics), and one pair eyeglasses
      following cataract surgery. Additionally:

    


    
      	·  	
              Children
                under age 21 services include one comprehensive or one limited eye
                examination per year for refraclive error, eyeglasses, HCY/EPSDT
                optical
                screens and services.

            


    

    


    
      	·  	
              Pregnant
                women age 21 and over with ME codes 18, 43, 44, 45, and 61 services
                include one comprehensive or one limited eye examination per year
                for
                refractive error. Eyeglasses (except the one pair following cataract
                surgery covered by the health plan) for these pregnant women arc
                covered
                through the Fee for Service
                program.

            


    

    


    When
      it
      is medically necessary for an optical procedure to be performed in an inpatient
      or outpatient hospital facility, emergency room, or ambulatory surgical center,
      the facility charges and ancillary services associated with the optical
      procedure are the responsibility of the MC+ Managed Care health
      plan.

    If
      the
      MC+ Managed Care health plan approves optical items which are delivered or
      placed after enrollment in the MC+ Managed Care health plan ends, the MC+
      Managed Care health plan that approves the optical ilem(s) is responsible for
      payment.

    


    PERSONAL
      CARE

    Personal
      care services are covered benefits for all
      members. Personal care services arc medically oriented tasks that may be
      reviewed by a physician. Personal care services are not physician driven.
      Persona] care services are tasks which assist an individual in activities
of
      daily
      living due to a stable, chronic condition. Personal care services are provided
      as a cost effective alternative to nursing home placement.

    


    Basic
      personal care services are
      services related to an MC+ enrollee's physical requirements, such as assistance
      with eating, bathing, dressing, personal hygiene, and activities of daily
      living. They also include services essential to the health and welfare of the
      MC+ enrollee, such as housekeeping chores like preparing meals, bedmaking,
      dusting, and vacuuming.

    


    Advanced
      personal care tasks
      are
      maintenance services provided to assist MC+ enrollees with stable, chronic
      conditions when such assistance requires devices and procedures related to
      altered body functions.

    


    Nurse
      visits
      provided
      by an RN or LPN in the personal care program arc authorized to provide increased
      supervision of the aid, assessment of the MC+ enrollee's health and the
      suitability of the care plan to meet the patient's needs as well as referral
      and/or follow-up action. In addition, nurse visits may be authorized for skilled
      tasks that must be performed by a nurse, such as filling insulin syringes,
      selling up oral medications, monitoring skin conditions, providing nail care
      for
      diabetic patients, etc.

    


    [f
      personal care services have been authorized prior to a member enrolling in
      an
      MC+ Managed Care health plan, the MC+ Managed Care health plan may only
      discontinue or reduce these services based on an assessment performed by the
      Department of Health and Senior Services

    


    PERSONAL
      CARE (HCY): Children, ages 0 through 20, are determined to be in need of
      persona! care by medical necessity. Personal care needs (including advanced
      personal care needs) for children are demonstrated by

    



    their
      need for extra assistance in bathing, toileting, eating, or olhcr activities
      of
      daily living because of a medical condition. The fact tliat a child has a
      caretaker does not make him or her ineligible for personal care services. The
      primary caretaker may not be present to deliver the required services or may
      lack the lime or ability to deliver the essential care. A family member may
      not
      be reimbursed for the delivery of personal care services.

    


    PHARMACY

    MC+
      Managed Care health plans are required to provide pharmacy services if the
      health plan included pharmacy benefits in its proposal. Under the current
      Missouri MC+ Fee-For-Service Pharmacy Program, nearly all products of
      manufacturers participating in the national rebate program are reimbursable,
      including many over-the-counter preparations. Insulin syringes are also
      reimbursable under this program.

    


    Some
      products have been excluded from coverage under the current Missouri MC+
      Fee-For-Service Pharmacy Program. MC+ Managed Care health plans may elect to
      exclude these, but may not exclude from coverage any product not excluded from
      the current Fee-For-Service Pharmacy Program (sec the MC+ Pharmacy Policy
      Statement for a list of products excluded from coverage). Protease inhibitors
      will be reimbursed by the stale agency on a fee-for-scrvice basis.

    


    It
      is not
      essential that MC+ Managed Care health plans cover pharmaceutical products
      without restriction to the same extent that current fec-for-service policy
      dictates. I-lowcver, any product (hat is reimbursable by the current
      Fee-For-Service Pharmacy Program must be made available to members, regardless
      of whether or not the prcscriber is in llic MC+ Managed Care health plan's
      network. MC+ Managed Care health plans may elect to have a restricted formulary;
      however, products not included on that fonnulary that are covered or allowed
      through prior authorization by the current Fee-For-Service Pharmacy Program
      must
      be made available to members when medically necessary. MC+ Managed Care health
      plans may also require that prior authorization be obtained for prescriptions
      generated by an out-of-nctwork prcscriber. MC+ Managed Care health plans may
      have a more extensive list of products requiring prior authori/.ation, but
      MC+
      Managed Care health plans may not exclude from coverage any products not
      excluded under the current Fee-For-Service Pharmacy Program.

    


    It
      is
      acceptable for MC+ Managed Care health plans to implement a drug authorization
      program in order to provide this access. Any drug prior authorization program
      implemented by an MC+ Managed Care health plan must meet The following
      criteria:

    
      	·  	
              MC+
                Managed Care health plans must provide response by telephone or other
                telecommunication device within 24 hours of a request for prior
                authorization.

            


    

    
      	·  	
              MC+
                Managed Care health plans must provide for the dispensing of at least
                a
                72-hour supply of a drug product that requires prior authorization
                in an
                emergency situation. 

            


    

    
      	·  	
              Approvals
                must be granted for any medically accepted use. Medically accepted
                use is
                defined as any use for an PDA approved drug product which appears
                in
                peer-reviewed literature or which is accepted by one or more of the
                following compendia: the American Hospital Formulary Service - Drug
                Information and the United Stales Pharmacopeia - Drug Information
                and
                DRUGDEX.

            


    

    


    In
      addition, MC+ Managed Care health plans must have a mechanism whereby drugs
      can
      be prior-authorized if a member is out of the MC+ Managed Care health plans'
      service area and during the time lag between the dale of a members' effective
      enrollment and that members' assignment to a primary care provider.

    


    PHARMACY
      DISPENSING FEES:
      The
      recipient portion of the pharmacy dispensing fee is to be collected according
      to
      current fec-for-service policy. Unlike traditional copayment requirements,
      the
      current Fee-For-Service Pharmacy fee requirement is considered a portion of
      the
      professional dispensing fee and is not deducted from reimbursement to providers.
      Therefore, the recipient portion of the dispensing fees is required to be
      collected for pharmacy services provided by MC+ Managed Care health plans.
      Providers of service may not deny or reduce services to MC+ members solely
      on
      the basis of the member's inability to pay the fee when charged, A member's
      inability to pay a required amount as due and charged when a service is
      delivered, shall in no way extinguish the member's liability to pay the amount
      due. Fee responsibility and amounts collectible shall be as
      follows:

    



    
      	
              MC+
                Fee-For-Service Maximum Allowable 

              Ingredient
                Cost for Each Prescription $10.00 or less

              $10.01
                to $25.00 

              $25.01
                or greater

            	
              Beneficiary
                Participation in Professional 

              Dispensing
                Fee 

              $0.50
                

              $1.00
                

              $2.00

            


    

    



    


    Under
      the
      current pharmacy dispensing tee policy all Missouri eligible beneficiaries
      are
      subject to the fee requirement when provided covered pharmacy services, with
      the
      exception of the following which are excluded:

    


    X   
      Beneficiaries underage 19;

    X   
      Services related to Early Periodic Screening, Diagnosis and Treatment
      (EPSDT);

    X   
      Institutionalized beneficiaries who are residing in a skilled nursing facility,
      a psychiatric hospital, a residential care facility, or an adult boarding
      home;

    X   
      Foster Care children up to 21 years of age;

    X   
      All Medicarc/MCt [-"cc-l-'or-Scrvice crossover claims as primary coverage is
      afforded by the Medicare Program;

    X   
      Those services specifically identified as relating to Family Planning
      services;

    X   
      Emergency services; and X Services provided to pregnant women which arc directly
      related to the pregnancy or a complication of the pregnancy.

    


    Participation
      in each MC+ Managed Care health plan's pharmacy network shall be limited to
      providers who accept, as payment in full, the amounts paid by the MC+ Managed
      Care health plan plus any fee amount required of the member and collected by
      the
      provider.

    


    PHARMACY
      - GENERIC DRUG REIMBURSEMENT OVERRIDE POLICY: The current MC+ Fec-For-Service
      Pharmacy Program reimbursement methodology limits payment at a. generic level
      for many drugs that are available gcncrically from multiple sources. The
      majority of these reimbursement limitations arc established as federal upper
      limits by the Centers for Medicare and Mcdicaid Services (CMS). Other such
      limitations have been established by the state agency (Missouri Maximum
      Allowable Cost or MAC).

    


    Both
      CMS
      and the Missouri Division of Medical Services recognize that there are
      situations in which trade name products are necessary for patient's treatment.
      There is currently a generic reimbursement override procedure. If the MC+
      Managed Care health plan intends to implement similar generic reimbursement
      limitations on multiple source products, a mechanism must exist so that trade
      name reimbursement is available when it is medically necessary. This mechanism
      may not be more restrictive than current fee-lbr-service policy.

    


    PHYSICIAN
      INJECTIONS: Under the current Fee-For-Service Pharmacy Program, all PDA approved
      injectable products are reimbursable when billed by National Drug Code (NDC)
      on
      a pharmacy claim form by a private physician for administration in his/her
      office. MC+ Managed Care health pians are required to provide pharmacy services
      (including physician injections) if the health plan included pharmacy benefits
      in it's proposal. In addition, certain non-injcctable products arc also
      reimbursable when billed by a private physician. These products include Norplant
      and irrigation solutions. Every prod'jct that is reimbursable by the current
      Fee-For-Service Pharmacy Program either without restriction or through prior
      authorization, must be covered by the MC+ Managed Care health plans either
      without restriction or through prior authorization except for protcase
      inhibitors which arc excluded from MC+ Managed Care. However, it is not
      essential that health plans cover injectable pharmaceutical products without
      restriction to the same extent that current policy dictates. Coverage must
      be
      granted for any medically accepted use.

    


    PHYSICAL,
      OCCUPATIONAL AND SPEECH THERAPY FOR ADULT PREGNANT WOMEN WITH ME CODES 18,
      43,44, 45, AND 61

    MC+
      Managed Care health plans are required to provide physical therapy (PT),
      occupational therapy (OT), and speech therapy (ST) services for adult pregnant
      women with ME codes 18, 43, 44,45, and 61 as follows.

     

    Medically
      necessary pliysical therapy (PT) benefits arc covered in the outpatient hospital
      setting and as part. of home health when the patient is medically homebound.
      PT
      is covered in a rehabilitation center if the services are for adaptive training
      for a prosthetic or onholic device.

    Occupational
      therapy (OT) is covered in a rehabilitation center for adaptive training for
      a
      prosthetic or ortholic device. Medically necessary OT is covered as part of
      home
      health if the patient is medically homebound.

    Speech
      therapy (ST) is covered in a rehabilitation center for adaptive training for
      an
      artificial larynx. Medically necessary ST is covered in as part of home health
      if the patient is medically homebound.

    


    PHYSICAL,
      OCCUPATIONAL AND SPEECH THERAPY (HCY)

    MC+
      Managed Care licaltli plans are required to provide medically necessary physical
      (PT), occupational (OT), and speech (ST) therapy and supplies used for casting
      and splinting to children age 20 and under. Physical, occupational, and speech
      therapy services identified in a child's Individual Education Plan (IEP) or
      Individualized Family Service Plan (IFSP) will not be the responsibility of
      the
      MC+ Managed Care health plan. These services will be paid fee-for-servicc by
      the
      state agency. Medically necessary PT, OT, and ST services beyond the scope
      identified in a child's IEP or IFSP arc tlic responsibility of the MC+ Managed
      Care health plan. This includes developmental as well as maintenance
      therapy.

    


    Medically
      necessary equipment and supplies used in connection with PT, OT, and ST services
      are the responsibility of (he MC+ Managed Care health plan.

    


    PHYSICIAN/ADVANCED
      PRACTICE
      NURSE
      SERVICES

    MC+
      Managed Care health plans arc required to provide medically necessary
      physician/advanced practice nurse services within their scope of
      practice.

    


    FEDERALLY
      QUALIFIED HEALTH CENTER. (FOHC); Federally Qualified Health Center (FQHC)
      services are Ihe responsibility of the MC+ Managed Care health plans. FQHC
      core
      services that must be performed in an FQHC setting are listed in Attachment
      2.
      To receive FQHC provider status, a health center must be certified by the Public
      Health Services, be certified for participation in MC+ Fcc-For-Service and
      enrolled with Missouri MC+ Fcc-For-Scrviee as an FQHC. FQHCs are entitled to
      cost-based reimbursement from the state agency for FQHC services provided to
      MC+
      enrollccs. The cost settlement will be performed by the state agency through
      an
      FQHC MC+ Fee-For-Servicc cost report.

    


    PODIATRY SERVICES

    MC+
      Managed Care health plans arc required to provide medically necessary podiatry
      services that are within the scope of practice of the podiatrist for children
      under the age of 21 or pregnant women with ME codes 18, 43, 44, 45, and 61.
      All
      other MC+ Managed Care cnrollees are eligible for podiatry services with the
      exception of trimming ofnondystrophic nails, any number; debridement ofnail(s)
      by any method(s), one to five; debridement of nail(s) by any mcthod(s), six
      or
      more; excision of nail and nail matrix, partial or complete; and strapping
      of
      ankle and/or fool.

    


    PRIVATE
      DUTY NURSING
      (HCY)

    Private
      Duty Nursing services arc covered under the Healthy Children and Youth (HCY)
      program. The HCY program serves children age 20 and under. Private duty nursing
      is shift care delivered either by an R.N. or an L.P.N acting within the scope
      of
      the Missouri Nurse Practice Act according to an individual h-ed plan of care
      approved by a physician. The duration of care can extend up to twenty-four
      (24)
      hours per day. The duration and frequency of care is dependent upon the child's
      need and physician orders. Children receiving private duty nursing care are
      high
      risk children that are medically fragile. The MC+ Managed Care health plans
      shall only terminate such services after a case-specific, clinical decision
      has
      been reached by a provider,

    


    RADIOLOGY
      AND LABORATORY SERVICES

    MC+
      Managed Care health plans are required to provide medically necessary radiology
      and laboratory services. The MC+ Managed Care health plan must assure that
      the
      criteria required by CMS defined under the CLIA Act of 1988 as defined in 42
      CFR
      493.2 and Section 2303 of the Deficit Reduction Act of 1984 (P.L. 98-369) for
      Clinical Diagnostic Laboratory Procedures are met.

    



    TRANSPLANTS

    MC+
      Managed Care health plans arc responsible for the pre-surgery
      assessment/evaluation, care (excluding the solid organ procurement or bone
      marrow/stem eel! harvest), post-transplant discharge follow-up care, and
      iminuno-suppressive pharmacy products prescribed after the inpatient transplant
      discharge.

    


    The
      transplant must be prior authorized by the Division of Medical Services (DMS)
      and must be performed at a DMS approved transplant facility. DMS will continue
      to cover the solid organ/stem ceil/bone marrow procurement costs, the inpatient
      stay for the transplant from the date of the transplant through the date of
      discharge and the transplant surgeon's fee, all physician, lab etc. charges
      incurred during the transplant stay (date of transplant through the date of
      discharge),

    


    TRANSPORTATION

    The
      MC+
      Managed Care health plan must provide emergency (ground or air) medical
      transportation.

    


    The
      MC+
      Managed Care health plan must provide necessary non-emergency medical
      transportation (NEMT) for members accessing health care services included in
      the
      comprehensive benefit package as wcli as health care services that arc carved
      out of the MC+ Managed Care contract. The MC+ Managed Care health plan must
      arrange the least expensive and most appropriate mode of transportation based
      on
      the MC+ Managed Care member's medical needs.

    


    MC+
      Managed Care health plans are not required to provide transportation to MC+
      Managed Care members with access to free transportation at no cost to them,
      however, such members may be eligible for ancillary services. Also, MC+ Managed
      Care health plans are not required to provide NEMT services to Durable Medicai
      Equipment providers thai provide free delivery or mail order services nor to
      a
      pharmacy.

    


    An
      offer
      of transportation assistance must be made to all children prior to periodic
      screenings required under EPSDT/HCY. Parents/guardians must be informed of
      this
      transportation benefit.

    


    NEMT
      services are not
      covered
      for those MC+ enrollees with ME Codes 71 through 75.

    


    VACCINE
      FOR CHILDREN (VFC)

    VFC
      services are a covered benefit. Under the provision of the Omnibus Budget
      Reconciliation Act (OBRA) of 1993, vaccines are available free to providers
      who
      enroll with the VFC Program. MC+ Managed Care health plans and their
      subcontractors must enroll in the VFC Program administered by tlie Missouri
      Department of Health and Senior Services and must use the free vaccines when
      administering vaccines to members. A separate administration fee will not be
      paid to the MC+ Managed Care health plans as the reimbursement is included
      in
      the capitation payment. If a vaccine is medically necessary and not covered
      through the VFC program, the MC+ Managed Care health plan is responsible for
      the
      vaccine and the administration costs.

    



    Revised
      Attachment 6

    


    The
      following is the state agency's Quality Improvement (QI) Strategy. The state
      agency produces and updates the MC+ Managed Care Quality Improvement (QI)
      Strategy, MC+

    Managed
      Care contract and the MC+ Managed Care policy statements. The MC+ Managed Care
      health plan shall comply with the Quality Improvement (QI) Strategy, MC+ Managed
      Care policy statements and the MC+ Managed Care contract.

    


    MISSOURI
      DEPARTMENT OF SOCIAL SERVICES DIVISION OF MEDICAL SERVICES

    


    QUALITY
      IMPROVEMENT

    (Q
      1) STRATEGY

    


    1.
      DEPARTMENT OF SOCIAL SERVICES MISSION STATEMENT

    


    To
      maintain or improve the quality of life for people in the state of Missouri
      by
      providing the best possible services to the public, with respect, responsiveness
      and accountability which will enable individuals and families to better fulfill
      their potential.

    


    Purpose

    


    The
      Department of Social Services (DSS), Division of Medical Services (DMS) seeks
      to
      assure access and availability of quality health care services for MC+ Managed
      Care members through a Managed Care delivery system, standards setting and
      enforcement, and education of providers and members. This QI strategy supports
      the following DMS objectives:

    


    
      	·  	
              Assessment
                of the quality and appropriateness of care and services furnished
                to
                members, including those with special health care needs, centered
                on
                evidenced based practice;

            


    

    
      	·  	
              Use
                of care management with emphasis on the individual member to ensure
                that
                members have a medical home which focuses attention on the weilncss
                of the
                member and includes personal responsibility and investment on the
                part of
                the member;

            


    

    
      	·  	
              Use
                of data regarding the race, ethnicity, and primary language spoken
                of each
                member to improve care delivery;

            


    

    
      	·  	
              Use
                of national performance measures and levels when identified and developed
                by CMS in consultation with states and other relevant
                stakeholders;

            


    

    
      	·  	
              An
                effective information system that supports initial and ongoing operation
                and review of the quality strategy;

            


    

    
      	·  	
              A
                process for public input that provides for the integration of
                various perspectives and priorities and will facilitate improvements
                in
                member health stains;

            


    

    
      	·  	
              Appropriate
                use of sanctions, including intermediate sanctions, to assure appropriate
                delivery of care to members; and 

            


    

    
      	·  	
              Compliance
                with regulatory and contractual
                requirements.

            


    

    



    Goal

    The
      goal
      is to ensure that:

    
      	·  	
              Quality
                health care services are provided to MC+ Managed Care
                members;

            


    

    
      	·  	
              MC+
                Managed Care health plans are in compliance with Federal, State,
                and
                contract requirements; and 

            


    

    
      	·  	
              A
                collaborative process is maintained to collegially work with the
                MC+
                Managed Care health plans to improve
                care,

            


    

    


    Overview

    


    This
      strategy will be annually evaluated for effectiveness. This process includes
      obtaining input From stakeholders, the State Quality Assessment &
      Improvement Advisory Group, Consumer Advisory Committee, and approval from
      CMS
      prior to implementation. In the instance there is significant change in outcome
      or indicator status that is not self-limiting and impacts on more than one
      area
      of the population's health status, modifications will be made to the strategy
      reporting process. These modifications may include changes to the monthly,
      quarterly and annual MC+ Managed Care health plan reports, on-site review
      topics, and MC+ Managed Care performance measures.

    


    Each
      MC+
      Managed Care health plan must meet program standards for monitoring and
      evaluation of systems as outlined in the MC+ Managed Care contract to meet
      Federal and State regulations. Kacli MC+ Managed Care health plan must implement
      a Ql strategy that addresses the standards as noted but is not limited to the
      requirements within the MC+ Managed Care Quality Improvement (Ql) Strategy
      or
      the MC+ Managed Care contract. The MC+ Managed Care health plan's strategy
      shall
      include components to monitor, evaluate, and implement the contract standards
      and processes to improve:

    o
      Quality
      management;

    o
      Utilization management;

    o
      Records
      management;

    o
      Information management;

    o
      Care
      management;

    o
      Member
      services;

    o
      Provider services;

    o
      Organizational structure;

    o
      Crcdentialing;

    o
      Network
      Performance;

    o
      Fraud
      and abuse detection and prevention;

    o
      Access
      and availability; and o Data collection, analysis and reporting.

    


    1.1
      Program Components 

    


    1.
      MC+
      Managed Care Health Plans Reports of Quality Assessment and
      Improvement

    The
      MC+
      Managed Care health plans will provide the DMS with regular reports of
      utilization and quality assessment. These reports will be provided in accordance
      with the:

    o
      MC+
      Managed Care Policy Statements;

    o
      MC+
      Managed Care contract;

    o
      MC+
      Managed Care Performance Measures (Exhibit 1); and

    o
      MC+
      Managed Care QA & 1 Program, Reporting Period Schedule, (Exhibit
      2).

    


    The
      frequency and types of reports include:



    A.
      Monthly Reports: Monthly reports regarding special needs and lead poisoning
      prevention will be submitted to DMS in a format .specified by the slate agency.
      Monthly reports will be due the last working day of each month.

    B.
      Quarterly Reports: Quarterly reports of member grievances and appeals, provider
      complaints, grievances, and appeals, and fraud and abuse detection will be
      submitted to DMS in a format specified by the stale agency.

    C.
      Annual
      Evaluation: An annual evaluation of the MC+ Managed Care health plan's quality
      assessment and improvement program specific to the Missouri MC+ Managed Care
      Program is to be submitted in the format specified by the stale agency (Exhibit
      4). The evaluation shall contain information concerning the effectiveness and
      impact of the health plan's MC+ Managed Care quality assessment and improvement
      strategy. The annual evaluation report must provide information that indicates
      that data is collected, analyzed and reported, and health operations are in
      compliance with State, federal and MC+ Managed Care contractual requirements.
      The annual evaluation of the health plan's QA &i program must incorporate
      multiple year outcomes and trends. The evaluation must show the health plan's
      QA
& I program is ongoing, continuous and based upon evaluation of past
      outcomes. The evaluation will, at a minimum, contain information from
      subcontractors and internal processes including:


    a.
      An
      analysis and evaluation of member grievances and appeals and provider
      complaints; grievances and appeals;

    b.
      An
      analysis and evaluation of how the health plan incorporates race, ethnicity,
      and
      primary language into the health plan's quality strategy. The DSS asks each
      potential enrollee their race, ethnicity and primary language at the time of
      application in accordance with Medicaid eligibility rules. DSS uses the
      federally recognized categories for race, ethnicity and language. The stale
      agency shall electronically provide race, ethnicity and language to the health
      plan upon member enrollment.

    c.
      An
      analysis and evaluation of utilization and clinical performance data that
      supports use of evidenced based practice;

    d.
      An
      analysis and evaluation of 24 access/after hours availability, appointment
      availability and open/closed panels;

    e.
      An
      analysis and evaluation of the MC+ Managed Care health plan's provider network
      including provider/enrollec ratios;

    f.
      An
      analysis and evaluation of all MC+ Managed Care quality indicators;

    1.
      Trends
      in Missouri Medicaid Quality Indicators provided by the Department of Health
      and
      Senior Services (DHSS) (Exhibit 3);

    2.
      HED1S
      Indicators by Missouri MC+ Managed Care Health Plans Within Regions, Live Births
      provided by the Department of Health and Senior Services (DHSS) (Exhibit 3);
      and

    3.
      MC+
      Managed Care Performance Measures (Exhibit 1). h. An analysis and evaluation
      of
      quality issues and actions identified through the quality strategy and how
      these
      efforts were used to improve systems of care and health outcomes;

    i.
      An
      analysis and evaluation of action items documented in
      the
      meeting minutes of the MC+ Managed Care health plan's quality and compliance
      committce(s) including:

    t.
      Trends
      identified for focused study; results of focused studies; corrective action
      taken; evaluation of the effectiveness of the actions and outcomes.

    j.
      An
      analysis and evaluation of Performance Improvement Projects (PIP) that addresses
      clinical and non-clinical PiPs and the requirement for on-going interventions
      and improvement;

    k.
      An
      analysis; and evaluation of subcontractor relationships that addresses
      integration with the health plan's QA&I program. This analysis and
      evaluation is not a replication of the Subcontractor Oversight Annual Evaluation
      report;

    1.
      An
      analysis and evaluation of the health plan's fraud and abuse
      program;

    m.
      An
      analysis and evaluation of care management thai includes case management,
      disease management and care coordination for both medical and mental health
      services; and 

    n.
      An
      analysis and evaluation of the health plan's claims processing and Management
      Information System.

    


    D.
      Periodic Reports of Quality and Utilisation: The MC+ Managed Care health plan
      will provide periodic reports regarding case management, quality initiatives,
      and other quality analysis reports per DMS request.

    


    E.
      An
      annual report regarding multilingual services for members who speak a language
      other than English and the MC+ Managed Care health plan's methods for
      communicating with members with visual and hearing impairments and accommodating
      for the physically disabled. The health plan's report shall include but not
      be
      limited to the following;

    1.
      A
      count by language of how many members declared a language other than English
      as
      their primary language.

    2.
      A
      summary by language of translation services provided
      to
      members
      (oral and in-person),

    3.
      A
      count of members identified as needing communication accommodations due to
      visual or hearing impairments or a pliysical disability.

    4.
      A
      summary of services provided to members with visual or hearing impairments
      or
      members who are physically disabled (Braille, large print, cassette, sign
      interpreters, etc.).

    5.
      An
      inventory by language of member material translated.

    6.
      An
      inventory of member materials available in alternative formats.

    7.
      A
      summarization of grievances regarding multilingual issues and
      dispositions.

     

    F.
      Annual
      subcontractor oversight reports that reflect the health plan's monitoring
      activities in the previous
      year for each health care service subcontractor and any corrective actions
      implemented as a result of its monitoring activities. The annual subcontractor
      oversight reports shall be submitted in the format specified by the state agency
      (Exhibit 5).

    


    II.
      DMS
      Analysis and Evaluation

    


    DMS
      will
      analyse and evaluate data from a variety of sources including the state agency's
      Medicaid Management Information System (MMIS) to assess the quality and
      appropriateness of care delivery to the MC+ Managed Care population, '['he
      DMS
      will analyze and evaluate the following:

    


    •
Monthly
      reports, quarterly reports, periodic reports, annual reports, and the annual
      evaluations submitted by MC+ Managed Care health plans.

    •
      Encounter data.

    •
      Performance measures.

    •
      Performance improvement projects.

    •
      Compliance with the MC+ Managed Care contract.

    •
      Enrollment, transfer and disenrollment activity

    


    Results
      from the analysis and evaluation activities will be compiled and presented
      through regularly scheduled meetings of the State Quality Assessment &
Improvement Advisory Group. The QA & I Advisory Group will review these
      results to identify opportunities for improvement.

    



    III.
      External Quality Review

    


    An
      external quality review of the MC+ Managed Care health plans will be conducted
      annually in accordance with the "Mcdicaid Program; External Quality Review
      ofMedicaid Managed Care Organizations; Final Rule, 42 CFR Part 438, Subpart
      E".
      External quality review means the analysis and evaluation by an External Quality
      Review Organization (EQRO) of
      aggregated information on quality, timeliness, and access to health care
      services, '['he EQRO will provide an annual evaluation report to the QA & I
      Advisory Group regarding, but not limited to, the following:

    1.
      Validation of two (2) performance improvement projects thai were underway during
      the preceding 12 months for each MC+ Managed Care health plan.

    2.
      Validation of three (3) performance measures reported during the preceding
      12
      months.

    3.
      A
      review every three years to determine the MC+ Managed Care health plan's
      compliance with standards as listed within the MC+ Managed Care
      contract.

    4.
      Validation of encounter data.

    


    IV.
      Compliance

    


    A.
      Intermediate Sanctions.
      The DMS
      may establish and specify intermediate sanctions that may be imposed when a
      MC+
      Managed Care health plan ads or tails to act as specified below. The DMS may
      require a corrective action plan, as referenced in section 2.28.5, to be
      developed and approved by tile DMS in situations where intermediate sanctions
      may be imposed. The DMS shall approve and monitor implementation of such a
      plan
      and set appropriate timclines to bring activities of the MC+ Managed Care health
      plan into compliance with stale and federal regulations. The DMS may monitor
      via
      required reporting on a specified basis and/or through on-sitc evaluations,
      the
      effectiveness of the plan. Before imposing intermediate sanctions, the DMS
      shall
      give the MC+ Managed Care health plan timely written notice that explains the
      basis and nature of the sanction and any other due process protections that
      the
      DMS elects to provide.

    1.
      Fails
      substantially to provide medically necessary services that the MC+ Managed
      Care
      health plan is required to provide, under law or under this contract, to a
      member covered under tlie contract.

    2.
      Imposes on members premiums or charges that are in excess of the premiums or
      charges permitted under (he Medicaid program.

    3.
      Acts
      to discriminate among members on the basis of their health status or need for
      health care services.

    4.
      Misrepresents or falsifies information that it furnishes to CMS or to the
      DMS.

    5.
      Misrepresents or falsifies information that it furnishes to a member, potential
      member, or a health care provider.

    6.
      Fails
      to comply with the requirements for physician incentive plans, as set forth
      (for
      Medicare) in 42CFR422.208and422.2IO.

    7.
      Distribute;; directly, or indirectly through any agent or independent
      contractor, marketing materials that have nut been approved by the DMS or that
      contain false or materially misleading information.

    8.
      Violates any of the other applicable requirements of sections 1903(m) or 1932
      of
      the Act and any implementing regulations.

    9.
      Violates any of the other applicable requirements of sections 1932 or 1905(t)(3)
      of the Act and any implementing regulations.

    


    B.
      Intermediate Sanctions: Types.
      The
      types of intermediate sanctions that the DMS may impose include:

    



    1.
      Civil
      monetary penalties in the following specified amounts:

    


    a.
      A
      maximum of $25,000 for each determination of failure to provide services;
      misrepresentation or falsification of statements to members, potential members
      or health care providers; failure to comply with physician incentive plan
      requirements; or marketing violations. 

    b.
      A
      maximum of $100,000 for each determination of discrimination among members
      on
      the basis of their health status or need for services; or misrepresentation
      or
      falsification to CMS or the DMS. 

    c.
      A
      maximum of $15,000 for each member the DMS determines was discriminated against
      based on the member's health status or need for services (subject to the
      $100,000 limit above). 

    d.
      A
      maximum of $25,000 or double the amount of the excess charges (whichever is
      greater), for charging premiums or charges in excess of the amounts permitted
      under the Medicaid program. The DMS shall return the amount of overcharge to
      the
      affected member(s).

    


    2.
      Appointment of temporary management for a health plan as provided in 42 CFR
      438.706.

    3.
      Granting members the right to terminate enrollment without cause and notifying
      the affected members of their right to disenroll.

    4.
      Suspension of all new enrollment, including default enrollment, after the
      effective dale of the sanction.

    5.
      Suspension of payment for members enrolled after the effective date of the
      sanction and until CMS or the DMS is satisfied thai the reason for imposition
      of
      the sanction no longer exists and is not likely to recur.

    6.
      Additional sanctions allowed under state statutes or regulations that address
      areas of noncompliance described above.

    



    MC+MANAGED
      CARE PERFORMANCE MEASURES

    


    a.
      EFFECTIVENESS OF CARE

    


    1.
      (H)
      Childhood Immunization Status (CIS)*

    2.
      (II)
      Adolescent Immunization Status (A1S)* 3- (H) Cervical Cancer screening
      (CCS)*

    4.
      (H)
      Chlamydia Screening in Women (CHL)*

    5.
      (H)
      Follow-up After Hospitalizalion For Mental Health Disorders (FUH)

    6.
      (H)
      Use of Appropriate Medications for People with Asthma (ASM)*

    


    I)
      ACCESS/AVAILABILITY OF CARE

    


    7.
      (11)
      Prenatal and Postpartum Care(PPC)

    8.
      (H)
      Annual dental visit (ADV)*

    


    2)
      SATISFACTION WITH THE EXPERIENCE OF CARE 

     

    9.
      (H)
      CAI IPS 3.01 i Child/Adult Survey*

    


    3)
      USE OF
      SERVICES

    


    10.
      (11)
      Well child Visits in the First 15 Months of Life (W 15)

    11.
      (H)
      Well Child Visits in the Third, Fourth, Fifth, and Sixth Year of Life
      (W34)

    12.
      (11)
      Adolescent Well-Care Visits (AWC)*

    13.
      (H)
      Ambulatory Care (AMB)

    14.
      (H)
      Mental Health Utilization - Percentage of Members Receiving Inpaticnt,
      Intermediate Care and Ambulatory Services (MPT)

    15.
      (H)
      Identification of Alcohol and Other Drug Services (1AD)

    


    (H)
      =--HED1S Measure * DHSS required measure. Follow the instructions provided
      within 19 CSR 10-5.010.

    


    Note:
      The
      measures shall be collected and reported in accordance with HEDIS
      specifications. In the event that NCQA retires a DMS required measure, the
      Division will inform the health plan whether the QMS will require the health
      plan to collect and report using HEDIS specifications in effect prior to the
      measurement's retirement or whether the Division will follow NCQA’a retirement
      of the measure. NCQA rotates certain measures every year. As approved by DMS,
      rotated measures shall be reported in accordance with current HEDIS technical
      specifications for reporting rotated measures. DMS shall not approve rotation
      of
      CAHPS. DHSS measures shall be reported according to DHSS specifications as
      provided in 19 CSR 100-5.010. MC+ Managed Care health plans contracted for
      more
      than one region shall submit region specific data- All MC+ Managed Care health
      plans shall submit the measures ill an electronic formal utilizing tables
      provided by the DMS and DHSS.

    



    
      	
              MONTHLY
                REPORTING

            
	
              Time
                Period

            	
              Due
                Date

            
	
              Calendar
                Month

            	
              Last
                working day of the month

            
	
              QUARTERLY
                REPORTING

            
	
              Time
                Period

            	
              Due
                Date

            
	
              1st
                Quarter (July thru September)

            	
              December
                1st
                of
                each year

            
	
              2nd
                Quarter (October thru December)

            	
              March
                1st
                of
                each year

            
	
              3rd
                Quarter (January thru March)

            	
              June
                1st
                of
                each year

            
	
              4th
                Quarter (April thru June)

            	
              September
                1st
                of
                each year

            
	
              ANNUAL
                REPORTS-ANNUAL EVALUATION, MULTILINGUAL SERVICES, 

              SUBCONTRACTOR
                OVERSIGHT

            
	
              Time
                Period

            	
              Due
                Date

            
	
              July
                1 thru June 30

            	
              November
                30, 2007 and on November 30 of each subsequent year

            
	
              PERFORMANCE
                MEASURES

            
	
              Time
                Period

            	
              Due
                Date

            
	
              January
                1 thru December 31

            	
              June
                30 of each year

            


    

    



    Trends
      in Missouri Mcdicaid Quality Indicators (Secondary-Source
      Reporting)

    1.
      Trimester Prenatal Care Began:

    a.
      First


    b.
      Second


    c.
      Third


    d.
      None

    e.
      Total

    2.
      Inadequate Prenatal Care

    3.
      Birth
      weight (grams) - total number of births by weight category for each live birth.
      

    a.
      <500 Gins. 

    b.
      500-1499Gms. 

    c.
      15
      00-1999 Gms. 

    d.
      2000-2499 Gms. 

    e.
      .2500Gms. 

    f.
      Stillborn fetuses

    4.
      Low
      Birth Weight (<2500 grains)

    5.
      Method
      of Deliver) 

    a.
      C-Section 

    b.
      VBAC


    c.
      Repeat
      C-Section

    6.
      Smoking During Pregnancy

    7.
      Spacing <18 months since last birth

    8.
      Births
      to mothers <18 years of age

    9.
      Repeat-teen births

    10.
      Fetal
      Deaths (20+ weeks)*

    11.
      Total
      live birth or stillbirth fetuses 500 grains or more**

    12.
      Percent of pregnant women on Women's infants and Children Program
      (WIC)

    13.
      Percent of prenatals on WIC

    14.
      VLBW
      not delivered in level 111 hospitals

    15.
      Average maternal length of stay (days), Inpatient admissions

    16.
      Average behavioral health length of stay (days), Inpatient
      admissions

    17.
      Asthma inpatient admissions ages 4-17**

    18.
      Asthma emergency room visits ages 4-17**

    19.
      Asthma admissions underage 16, Inpatient admissions**

    20.
      Asthma admissions ages 18 " 64, Inpatient admissions**

    21.
      Emergency room visits under age 18**

    22.
      Emergency room visits ages 18 - 64**

    23.
      Hysterectomies**

    24.
      Vaginal hysterectomies

    25.
      Preventable hospitalization under age 18**

    


    *
      Rate
      per 1000 live births

    **Rate
      per 1000 population

     

    HEDIS
      Indicators by Missouri MC+ Managed Care Health Plans Within Regions, Live
      Births

    (Secondary-Source
      Reporting)

    


    1.
      C-Sections

    2.
      VBACs

    3.
      Adequacy of Prenatal Care

    4.
      Early
      Prenatal Care

    5.
      Low
      Birth Weight

    6.
      Low
      Birth Weight Delivered in Level It/lit Hospitals

    7.
      Very
      Low Birth Weight Delivered in Level 11/111 Hospitals

    8.
      Smoking During Pregnancy

    9.
      Spacing Less Than 18 Months

    10.
      Births to Mothers Less Than 18

    11.
      Repeat Births to Teen Mothers

    12.
      Prenatal WIC Participants

    



    MC+
      MANAGED CARE ANNUAL EVALUATION REPORT FORMAT

    


    TABLE
      OF CONTENTS EXECUTIVE SUMMARY

    Overview
      of the Quality Improvement Program 

    Overview
      of the Effectiveness of the Quality Improvement Program 

    DEVELOPMENT,
      APPROVAL AND MONITORING OF THE QI PROGRAM

    Quality
      and Compliance Committee

    Analysis
      of Quality Improvement Process

    Overall
      Effectiveness of the Quality Improvement Program 

    Strengths
      and Accomplishments 

    Opportunities
      for Improvement 

    POPULATION
      CHARACTERISTICS

    Race/Ethnicity

    Special
      Needs

    Languages
      Identified

    Opt
      Outs


    QUALITY
      INDICATORS

    Performance
      Measures

    Trends
      in
      Missouri Mcdicaid Quality Indicators

    HEDIS
      Indicators by Missouri MC+ Managed Care Health Plans Within Regions, Live Births
      ACCESSIBILITY
      OF SERVICES

    Average
      Speed of Answer

    Call
      Abandonment Rate

    Non-Routine
      Needs Appointments

    Routine
      Needs Appointments

    Access
      to
      Emergent and Urgent Care

    Network
      Adequacy — Provider/Enrollcc Ratios

    24
      Hour
      Access/After Hours Availability

    Open/Closed
      Panels

    Cultural
      Competency

    Requests
      to Change Practitioners

    FRAUD
      AND ABUSE

    Prevention,
      Detection, Investigation

    Training
      and Education 

    INFORMATION
      MANAGEMENT

    Claims
      Processing - Timeliness of Claims Payment

    Membership

    Providers
      

    QUALITY MANAGEMENT

    Provider
      Satisfaction

    Care
      Coordination

    Case
      Management

    Disease
      Management Program

    Mental
      Health Care Management including Case Management

    Clinical
      Practice Guidelines

    Credentialing
      and Re-Credentialing

    Medical
      Record Review

    Subcontractor
      Monitoring 

    RIGHTS
      AND RESPONSIBILITIES

    Provider
      Complaint, Grievance and Appeal Management

    Member
      Grievance and Appeal Management

    Confidentiality
      

    UTILIZATION MANAGEMENT

    Utilization
      Improvement Program Scope

    Discharges
      Per Year*

    Inpatient
      Visits*

    Average
      Length of Stay

    Re-Admissions*

    Emergency
      Department Utilization*

    Outpatient
      Visits*

    Over/Under
      Utilization

    Inter-Rater
      Reliability

    Timeliness
      of Care Delivery

    Timeliness
      of Prior Authorization/Certification Decision Making *Per 1000 members


    PERFORMANCE IMPROVEMENT
      PROJECTS (PIP)

    Clinical

    Non-Clinical

    On-going
      Interventions and Improvements

    Effect
      on
      I-Health Outcomes and Member Satisfaction 

    WORKPLAN
      FOR NEX
      T YEAR 

    APPENDICES

    



    SUBCONTRACTOR
      OVERSIGHT ANNUAL EVALUATION REPORT TEMPLATE 

    (Complete
      for each subcontractor — 2-5 pages)

    


    Subcontractor
      Name

    


    A.
      Overview of subcontractor including contract effective
      dates

    


    B.
      Description of delegated services/products/activities

    


    C.
      Description of MC+ Managed Care health plan's oversight
      process
      (must
      include, but shall
      not
      be limited to, the following:)

    


    1)
      Review of subcontractor contract documents compliance with requirements included
      in the MC+ Managed Care contract with state (Refer
      to Section 3.8.3 of MC-
      Managed
      Care contract)

    2)
      Subcontractor policies and procedures comply with subcontractor/MC+ Managed
      Care
      health plan's/state contract requirements

    3)
      Implementation of policies/procedures/contract
      requirements

    


    D.
      Oversight outcomes/findings
      (must
      include, but shall not be limited to, the following:)

    1)
      Access/availability

    2)
      Fraud and abuse

    3)
      Grievances and appeals

    4)
      Performance projects and measures

    5)
      Encounter data

    6)
      Prior authorization denials

    7)
      Timely payment

    


    E.
      Work plan for next year

    



    REVISED
      ATTACHMENT 12

    


    
      	
              Policies
                and Procedures Requiring Prior Approval

               

            
	
              Required
                Policy

            	
              Contract

              Reference

            	
              Required
                Policy

            	
              Contract
                Reference

            	
              Required
                Policy

            	
              Contract
                Reference

            
	
              Non-Discrimination
                in Hiring and Provisions of Services

            	
              2.2.6

            	
              24-Hour
                Coverage

            	
              2.14.1

            	
              Provider
                C, G & A

            	
              2.16

            
	
              Linking
                Members to PCPs

            	
              2.3.2

            	
              Prior
                Authorization

            	
              2.14.2

            	
              QA&I

            	
              2.17.1

            
	
              Marketing
                Guidelines

            	
              2.6.1
                a.18)

            	
              Appointment
                Standards Edu.

            	
              2.14.4
                d.1)

            	
              Utilization
                Management

            	
              2.17.5
                b

            
	
              Member
                Rights

            	
              2.6.2
                j.2)

            	
              Referral
                to non-network provider

            	
              2.14.5

            	
              Provider
                Credentialing

            	
              2.17.5
                c

            
	
              Assignment
                of PCP

            	
              2.6.2
                k.

            	
              Standing
                Referral to Specialist

            	
              2.14.6

            	
              Monitoring
                Providers

            	
              2.17.5
                c.

            
	
              Assignment
                of PCP

            	
              2.6.2
                k.4)

            	
              Referral
                to Specialty Care Cntr.

            	
              2.14.7

            	
              Records
                Retention

            	
              2.26.4

            
	
              Transfers
                Between Health Plans

            	
              2.6.2
                r.

            	
              Transitioning
                of Care

            	
              2.14.10

            	
              Medical
                Records

            	
              2.26.5

            
	
              Disenrollment
                Effective Dates

            	
              2.6.2
                u.

            	
              Care
                Management

            	
              2.14.11
                c.

            	
              Fraud
                & Abuse

            	
              2.31

            
	
              Provider
                Listing Updates

            	
              2.9.1
                g.

            	
              Certification
                Review

            	
              2.14.12

            	
              Subcontractor
                Oversight

            	
              3.8.3

            
	
              Second
                Opinion

            	
              2.13

            	
              Member
                Grievance System

            	
              2.15

            	 	 


    

    Revised
      July 2006

    



    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      	
              
                Revised
                  Attachment 14 

                Page
                  I
                  of 5

                 

              

              OFFICE
                VISIT SERVICES

               

            
	
              Procedure
                Code

            	
              Program
                Type

            	
              Allowable
                Fee for Dates of 

              Service
                July 1, 2006 and after

            
	
              99201

            	
              Medical
                Services

            	
              $21.52

            
	
              99201
                GE

            	
              Medical
                Services

            	
              $21.52

            
	
              99201
                GT

            	
              Medical
                Services

            	
              $21.52

            
	
              99201

            	
              Nurse
                Midwife

            	
              $21.52

            
	
              99201

            	
              Podiatry

            	
              $21.52

            
	
              99201
                GE

            	
              Podiatry

            	
              $21.52

            
	
              99201
                W2

            	
              Podiatry

            	
              $21.52

            
	
              99201

            	
              Other
                Medical

            	
              $21.52

            
	
              99201
                GE

            	
              Other
                Medical

            	
              $21.52

            
	
              99202

            	
              Medical
                Services

            	
              $38.23

            
	
              99202
                EP

            	
              Medical
                Services

            	
              $38.23

            
	
              99202
                GT

            	
              Medical
                Services

            	
              $38.23

            
	
              99202
                GT EP

            	
              Medical
                Services

            	
              $38.23

            
	
              99202
                GE

            	
              Medical
                Services

            	
              $38.23

            
	
              99202
                GE EP

            	
              Medical
                Services

            	
              $38.23

            
	
              99202

            	
              Nurse
                Midwife

            	
              $38.23

            
	
              99202
                EP

            	
              Nurse
                Midwife

            	
              $38.23

            
	
              99202

            	
              Podiatry

            	
              $38.23

            
	
              99202
                W2

            	
              Podiatry

            	
              $38.23

            
	
              99202
                GE

            	
              Podiatry

            	
              $38.23

            
	
              99202

            	
              Other
                Medical

            	
              $38.23

            
	
              99202
                EP

            	
              Other
                Medical

            	
              $38.23

            
	
              99202
                GE

            	
              Other
                Medical

            	
              $38.23

            
	
              99202
                GE EP

            	
              Other
                Medical

            	
              $38.23

            	
            
	
              99203

            	
              Medical
                Services

            	
              $56.93

            
	
              99203
                EP

            	
              Medical
                Services

            	
              $56,93

            
	
              99203
                GE

            	
              Medical
                Services

            	
              $56.93

            
	
              99203
                GE EP

            	
              Medical
                Services

            	
              $56.93

            
	
              99203
                GT

            	
              Medical
                Services

            	
              $56.93

            
	
              99203
                GT EP

            	
              Medical
                Services

            	
              $56.93

            
	
              99203

            	
              Nurse
                Midwife

            	
              $56.93

            
	
              99203
                EP

            	
              Medical
                Services

            	
              $56.93

            
	
              99203

            	
              Podiatry

            	
              $56.93

            
	
              99203
                W2 

            	
              Podiatry

            	
              $56.93

            
	
              99203

            	
              Other
                Medical

            	
              $56.93

            
	
              99203
                EP 

            	
              Other
                Medical

            	
              $56.93

            
	
              99203
                GE

            	
              Other
                Medical

            	
              $56.93

            
	
              99203
                GE EP

            	
              Other
                Medical

            	
              $56.93

            
	
              99204

            	
              Medical
                Services

            	
              $80.62

            


    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      	
              
                 

                Revised
                  Attachment 14 

                Page
                  2 of 5


              

              OFFICE
                VISIT SERVICES

            
	
              Procedure
                Code

            	
              Program
                Type

            	
              Allowable
                Fee for Dates of 

              Service
                July 1,2006 and after

            
	
              99204
                EP

            	
              Medical
                Services

            	
              $80.62

            
	
              99204
                GT

            	
              Medical
                Services

            	
              $80.62

            
	
              99204
                GT EP

            	
              Medical
                Services

            	
              $80.62

            
	
              99204

            	
              Nurse
                Midwife

            	
              $80,62

            
	
              99204
                EP

            	
              Nurse
                Midwife

            	
              $80.62

            
	
              99204

            	
              Podiatry

            	
              $80.62

            
	
              99204
                W2

            	
              Podiatry

            	
              $80.62

            
	
              99204

            	
              Other
                Medical

            	
              $80.62

            
	
              99204
                EP

            	
              Other
                Medical

            	
              $80.62

            
	
              99205

            	
              Medical
                Services

            	
              $102.58

            
	
              99205
                EP

            	
              Medical
                Services

            	
              $102.58

            
	
              99205
                GT 

            	
              Medical
                Services

            	
              $102.58

            
	
              99205
                GT EP

            	
              Medical
                Services

            	
              $102.58

            
	
              99205

            	
              Nurse
                Midwife

            	
              $102.58

            
	
              99205
                EP

            	
              Nurse
                Midwife

            	
              $102.58

            
	
              99205

            	
              Podiatry

            	
              $102.58

            
	
              99205
                W2

            	
              Podiatry

            	
              $102.58

            
	
              99205

            	
              Other
                Medical

            	
              $102.58

            
	
              99205
                EP

            	
              Other
                Medical

            	
              $102.58

            
	
              99211

            	
              Medical
                Services

            	
              $12.55

            
	
              99211
                GE

            	
              Medical
                Services

            	
              $12,55

            
	
              99211
                GT

            	
              Medical
                Services

            	
              $12.551

            
	
              99211

            	
              Nurse
                Midwife

            	
              $12.55

            
	
              99211

            	
              Podiatry

            	
              $12.55

            
	
              99211
                W2

            	
              Podiatry

            	
              $12.55

            
	
              99211
                GE

            	
              Podiatry

            	
              $12.55

            
	
              99211

            	
              Other
                Medical

            	
              $12.55

            
	
              99211
                GE

            	
              Other
                Medical

            	
              $12.55

            
	
              99212

            	
              Medical
                Services

            	
              $22.60

            
	
              99212
                GT

            	
              Medical
                Services

            	
              $22,60

            
	
              99212
                GE

            	
              Medical
                Services

            	
              $22.60

            
	
              99212

            	
              Nurse
                Midwife

            	
              $22,60

            
	
              99212

            	
              Podiatry
                

            	
              $22.60

            
	
              99212
                W2

            	
              Podiatry
                

            	
              $22,60

            
	
              99212
                GE

            	
              Podiatry

            	
              $22.60

            
	
              99212

            	
              Other
                Medical

            	
              $22.60

            
	
              99212
                GE

            	
              Other
                Medical

            	
              $22,60

            
	
              99213

            	
              Medical
                Services

            	
              $30.86

            
	
              99213
                GE

            	
              Medical
                Services

            	
              $30.86

            


    

    


     

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      	
              
                 

                
                  Revised
                    Attachment 14 

                  Page
                    3 of 5

                

                 

              

              OFFICE
                VISIT SERVICES

            
	
              Procedure
                Code

            	
              Program
                Type

            	
              Allowable
                Fee for Dates of 

              Service
                July 1, 2006 and after l

            
	
              99213
                GT

            	
              Medical
                Services

            	
              $30.86

            
	
              99213

            	
              Nurse
                Midwife

            	
              $30.86

            
	
              99213

            	
              Podiatry

            	
              $30.86

            
	
              99213
                W2

            	
              Podiatry

            	
              $30.86

            
	
              99213
                GE

            	
              Podiatry

            	
              $30.86

            
	
              99213

            	
              Other
                Medical

            	
              $30.86

            
	
              99213
                GE

            	
              Other
                Medical

            	
              $30.86

            
	
              99214

            	
              Medical
                Services

            	
              $48.45

            
	
              99214
                EP

            	
              Medical
                Services

            	
              $48.45

            
	
              99214
                GT

            	
              Medical
                Services

            	
              $48.45

            
	
              99214
                GT EP

            	
              Medical
                Services

            	
              $48.45

            
	
              99214

            	
              Nurse
                Midwife

            	
              $48.45

            
	
              99214
                EP

            	
              Nurse
                Midwife

            	
              $48.45

            
	
              99214

            	
              Podiatry

            	
              $48.45

            
	
              99214
                W2

            	
              Podiatry

            	
              $48.45

            
	
              99214

            	
              Other
                Medical 

            	
              $48.45

            
	
              99214
                EP

            	
              Other
                Medical 

            	
              $48.45

            
	
              99215

            	
              Medical
                Services

            	
              $70.63

            
	
              99215
                EP

            	
              Medical
                Services

            	
              $70.63

            
	
              99215
                GT

            	
              Medical
                Services

            	
              $70.63

            
	
              99215GTEP

            	
              Medical
                Services

            	
              $70.63

            
	
              99215

            	
              Nurse
                Midwife

            	
              $70.63

            
	
              99215
                EP

            	
              Nurse
                Midwife

            	
              $70.63

            
	
              99215

            	
              Podiatry

            	
              $70.63

            
	
              99215
                W2

            	
              Podiatry

            	
              $70,63

            
	
              99215

            	
              Other
                Medical

            	
              $70.63

            
	
              99215
                EP 

            	
              Other
                Medical

            	
              $70.63
                

            


    

    


    


    
      	
              DENTAL
                SERVICES

            
	
              Procedure
                Code

            	
              Age

            
	
              D0210

            	
              0-125

            


    

    


    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    
      Revised
        Attachment 14

      Page
        4 of 5

      
 

    

    
      
        	
                DENTAL
                  SERVICES

              
	
                Procedure
                  Code

              	
                Age

              
	
                D0270

              	
                0-125

              
	
                D0272

              	
                0-125

              
	
                D0330

              	
                0-125

              
	
                D0340

              	
                0-20

              
	
                D0350

              	
                0-20

              
	
                D1110

              	
                13-125

              
	
                D1203

              	
                0-20

              
	
                D1204

              	
                21-125

              
	
                D1351

              	
                0-20

              
	
                D2140

              	
                0-125

              
	
                D2150

              	
                0-125

              
	
                D2160

              	
                0-125

              
	
                D2161

              	
                0-125

              
	
                D2330

              	
                0-125

              
	
                D2331

              	
                0-125

              
	
                D2332

              	
                0-125

              
	
                D2335

              	
                0-125

              
	
                D2910

              	
                0-125

              
	
                D2920

              	
                0-125

              
	
                D2930

              	
                0-125

              
	
                D2931

              	
                0-125

              
	
                U2932

              	
                0-125

              
	
                D2940

              	
                0-125

              
	
                D3220

              	
                0-125

              
	
                D3310

              	
                0-125

              
	
                D3320

              	
                0-125

              
	
                D3330

              	
                0-125

              
	
                D3346

              	
                0-125

              
	
                03347

              	
                0-125

              
	
                D3348

              	
                0-125

              
	
                D3410

              	
                0-125

              
	
                D3421

              	
                0-125

              
	
                D3425

              	
                0-125

              
	
                D4210

              	
                0-125

              
	
                D5510

              	
                0-125

              
	
                D5520

              	
                0-125

              
	
                D5610

              	
                0-125

              
	
                D5630

              	
                0-125

              
	
                D5640

              	
                0-125

              
	
                D5650

              	
                0-125

              
	
                D5660

              	
                0-125

              
	
                D5710

              	
                0-125

              


      

       

       

       

      Revised Attachment 14


      Page 5 of 5

    

    


    



    
      	
              DENTAL
                SERVICES

            
	
              Procedure
                Code

            	
              Age

            
	
              D5711

            	
              0-125

            
	
              D5721

            	
              0-125

            
	
              D5730

            	
              0-125

            
	
              D5731

            	
              0-125

            
	
              D5740

            	
              0-125

            
	
              D5741

            	
              0-125

            
	
              D5750

            	
              0-125

            
	
              D5751

            	
              0-125

            
	
              D5760

            	
              0-125

            
	
              D5761

            	
              0-125

            
	
              D5820

            	
              0-125

            
	
              D5821

            	
              0-125

            
	
              D6930

            	
              0-125

            
	
              D7220

            	
              0-125

            
	
              D7230

            	
              0-125

            
	
              D7240

            	
              0-125

            
	
              D7241

            	
              0-125

            
	
              D7960

            	
              0-125

            
	
              D7970

            	
              0-125

            
	
              D9110

            	
              0-125

            
	
              D9241

            	
              0-125

            
	
              D9910
                

            	
              0-125

            
	
              D9951

            	
              0-125

            


    


     

    NOTE:
      The
      health plan shall review provider bulletins posted on the DMS website for future
      code changes due to HCPCS and HIPAA.