EX-10.1






AHCA Form 2100-0007 (Rev. JAN05)




Contract No. FA614



STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STANDARD CONTRACT




THIS CONTRACT is entered into between the State of Florida, AGENCY FOR HEALTH CARE
ADMINISTRATION, hereinafter referred to as the “Agency”, whose address is 2727 Mahan Drive,
Tallahassee, Florida 32308, and AMERIGROUP COMMUNITY CARE, INC., hereinafter referred to as the
“Vendor” or “Health Plan”, whose address is 4200 W. Cypress Street, Suite 950, Tampa, Florida
33607, a Florida For-Profit Corporation, to provide Health Care Services to Medicaid Beneficiaries.



I. THE VENDOR HEREBY AGREES:




A. General Provisions




	 	1.	 	To provide services according to the terms and conditions set forth in
this Contract, Attachment I, Scope of Services, and Attachment II, Medicaid Prepaid
Health Plan Model Contract and all other attachments named herein which are
attached hereto and incorporated by reference.






	 	2.	 	To perform as an independent vendor and not as an agent,
representative, or employee of the Agency.






	 	3.	 	To recognize that the State of Florida, by virtue of its sovereignty,
is not required to pay any taxes on the services or goods purchased under the terms
of this Contract.






B. Federal Laws and Regulations




	 	1.	 	If this Contract contains federal funds, the Vendor shall comply with
the provisions of 45 CFR, Part 74, and/or 45 CFR, Part 92, and other applicable
regulations as specified in Attachments I and II.






	 	2.	 	If this Contract contains federal funding in excess of $100,000, the
Vendor must, upon Contract execution, complete the Certification Regarding Lobbying
form, Attachment IV. If a Disclosure of Lobbying Activities form, Standard Form
LLL, is required, it may be obtained from the Agency’s Contract Manager. All
disclosure forms as required by the Certification Regarding Lobbying form must be
completed and returned to the Agency’s Contract Manager.






	 	3.	 	Pursuant to 45 CFR, Part 76, if this Contract contains federal funding
in excess of $25,000, the Vendor must, upon Contract execution, complete the
Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary
Exclusion Contracts/Subcontracts, Attachment V.






C. Audits and Records




	 	1.	 	To maintain books, records, and documents (including electronic storage
media) pertinent to performance under this Contract in accordance with generally
accepted accounting procedures and practices which sufficiently and properly
reflect all revenues and expenditures of funds provided by the Agency under this
Contract.





AHCA Contract No. FA614, Page 1 of 10




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2. AHCA Form 2100-0007 (Rev. JAN05)




	 	 	 	To assure that these records shall be subject at all reasonable times to inspection,
review, or audit by state personnel and other personnel duly authorized by the Agency,
as well as by federal personnel.






	 	3.	 	To maintain and file with the Agency such progress, fiscal and inventory
reports as specified in Attachment II, and other reports as the Agency may require
within the period of this Contract. In addition, access to relevant computer data and
applications which generated such reports should be made available upon request.






	 	4.	 	To ensure that all related party transactions are disclosed to the Agency
Contract Manager. Additional audit requirements are specified in Attachment II, Special
Provisions, Section XII.






	 	5.	 	To include these aforementioned audit and record keeping requirements in all
approved subcontracts and assignments.





D. Retention of Records




	 	1.	 	To retain all financial records, supporting documents, statistical records, and
any other documents (including electronic storage media) pertinent to performance under
this Contract for a period of five (5) years after termination of this Contract, or if
an audit has been initiated and audit findings have not been resolved at the end of five
(5) years, the records shall be retained until resolution of the audit findings.






	 	2.	 	Persons duly authorized by the Agency and federal auditors, pursuant to 45 CFR,
Part 74 and/or 45 CFR, Part 92, shall have full access to and the right to examine any
of said records and documents.






	 	3.	 	The rights of access in this section must not be limited to the required
retention period but shall last as long as the records are retained.





E. Monitoring




	 	1.	 	To provide reports as specified in Attachment II. These reports will be used for
monitoring progress or performance of the contractual services as specified in
Attachments I and II.






	 	2.	 	To permit persons duly authorized by the Agency to inspect any records, papers,
documents, facilities, goods and services of the Vendor which are relevant to this
Contract.





F. Indemnification




The Vendor shall save and hold harmless and indemnify the State of Florida and the Agency
against any and all liability, claims, suits, judgments, damages or costs of whatsoever kind
and nature resulting from the use, service, operation or performance of work under the terms
of this Contract, resulting from any act, or failure to act, by the Vendor, his
subcontractor, or any of the employees, agents or representatives of the Vendor or
subcontractor.




AHCA Contract No. FA614, Page 2 of 10



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G. Insurance




	 	1.	 	To the extent required by law, the Vendor will be self-insured
against, or will secure and maintain during the life of the Contract, Worker’s
Compensation Insurance for all his employees connected with the work of this
project and, in case any work is subcontracted, the Vendor shall require the
subcontractor similarly to provide Worker’s Compensation Insurance for all of the
latter’s employees unless such employees engaged in work under this Contract are
covered by the Vendor’s self insurance program. Such self insurance or insurance
coverage shall comply with the Florida Worker’s Compensation law. In the event
hazardous work is being performed by the Vendor under this Contract and any class
of employees performing the hazardous work is not protected under Worker’s
Compensation statutes, the Vendor shall provide, and cause each subcontractor to
provide, adequate insurance satisfactory to the Agency, for the protection of his
employees not otherwise protected.






	 	2.	 	The Vendor shall secure and maintain Commercial General Liability
insurance including bodily injury, property damage, personal & advertising injury
and products and completed operations. This insurance will provide coverage for
all claims that may arise from the services and/or operations completed under this
Contract, whether such services and/or operations are by the Vendor or anyone
directly, or indirectly employed by him. Such insurance shall include a Hold
Harmless Agreement in favor of the State of Florida and also include the State of
Florida as an Additional Named Insured for the entire length of the Contract. The
Vendor is responsible for determining the minimum limits of liability necessary to
provide reasonable financial protections to the Vendor and the State of Florida
under this Contract.






	 	3.	 	All insurance policies shall be with insurers licensed or eligible to
transact business in the State of Florida. The Vendor’s current certificate of
insurance shall contain a provision that the insurance will not be canceled for
any reason except after thirty (30) days written notice to the Agency’s Contract
Manager.






H. Assignments and Subcontracts




To neither assign the responsibility of this Contract to another party nor subcontract
for any of the work contemplated under this Contract without prior written approval of
the Agency. No such approval by the Agency of any assignment or subcontract shall be
deemed in any event or in any manner to provide for the incurrence of any obligation of
the Agency in addition to the total dollar amount agreed upon in this Contract. All such
assignments or subcontracts shall be subject to the conditions of this Contract and to
any conditions of approval that the Agency shall deem necessary.




Financial Reports



To provide financial reports to the Agency as specified in Attachment II. J. Return
of Funds




To return to the Agency any overpayments due to unearned funds or funds disallowed
pursuant to the terms of this Contract that were disbursed to the Vendor by the Agency.
The Vendor shall return any overpayment to the



AHCA Form 2100-0007 (Rev. JAN05)




AHCA Contract No. FA614, Page 3 of 10




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AHCA Form 2100-0007 (Rev. JAN05)




Agency within forty (40) calendar days after either discovery by the Vendor, its
independent auditor, or notification by the Agency, of the overpayment.



K. Purchasing




1. P.R.I.D.E.




It is expressly understood and agreed that any articles which are the subject of, or
required to carry out this Contract shall be purchased from the corporation identified
under Chapter 946, Florida Statutes, if available, in the same manner and under the same
procedures set forth in Section 946.515(2), (4), Florida Statutes; and for purposes of
this Contract the person, firm or other business entity carrying out the provisions of
this Contract shall be deemed to be substituted for this agency insofar as dealings with
such corporation are concerned.




The “Corporation identified” is PRISON REHABILITATIVE INDUSTRIES AND DIVERSIFIED
ENTERPRISES, INC. (P.R.I.D.E.) which may be contacted at:




P.R.I.D.E.


2720-G Blair Stone Road
Tallahassee, Florida 32301 (850)
487-3774


Toll Free: 1-800-643-8459
Website: www.pridefl.com




2. RESPECT of Florida




It is expressly understood and agreed that any articles that are the subject of, or
required to carry out, this Contract shall be purchased from a nonprofit agency for the
blind or for the severely handicapped that is qualified pursuant to Chapter 413, Florida
Statutes, in the same manner and under the same procedures set forth in Section
413.036(1) and (2), Florida Statutes; and for purposes of this Contract the person, firm,
or other business entity carrying out the provisions of this Contract shall be deemed to
be substituted for the state agency insofar as dealings with such qualified nonprofit
agency are concerned.




The “nonprofit agency” identified is RESPECT of Florida which may be contacted at:




RESPECT of Florida.


2475 Apalachee Parkway, Suite 205
Tallahassee, Florida 32301-4946 (850)
487-1471


Website: www.respectofflorida.org




3. Procurement of Products or Materials with Recycled Content




It is expressly understood and agreed that any products which are required to carry out
this Contract shall be procured in accordance with the provisions of Section 403.7065,
Florida Statutes.




AHCA Contract No. FA614, Page 4 of 10



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AHCA Form 2100-0007 (Rev. JAN05)




	L.	 	Civil Rights Requirements/Vendor Assurance The Vendor
assures that it will comply with:	 






	 	1.	 	Title VI of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000d et seq.,
which prohibits discrimination on the basis of race, color, or national origin.






	 	2.	 	Section 504 of the Rehabilitation Act of 1973, as amended, 29 U.S.C. 794,
which prohibits discrimination on the basis of handicap.






	 	3.	 	Title IX of the Education Amendments of 1972, as amended, 20 U.S.C. 1681 et
seq., which prohibits discrimination on the basis of sex.






	 	4.	 	The Age Discrimination Act of 1975, as amended, 42 U.S.C. 6101 et seq., which
prohibits discrimination on the basis of age.






	 	5.	 	Section 654 of the Omnibus Budget Reconciliation Act of 1981, as amended, 42
U.S.C. 9849, which prohibits discrimination on the basis of race, creed, color,
national origin, sex, handicap, political affiliation or beliefs.






	 	6.	 	The Americans with Disabilities Act of 1990, P.L. 101-336, which prohibits
discrimination on the basis of disability and requires reasonable accommodation for
persons with disabilities.






	 	7.	 	All regulations, guidelines, and standards as are now or may be lawfully
adopted under the above statutes.






The Vendor agrees that compliance with this assurance constitutes a condition of continued
receipt of or benefit from funds provided through this Contract, and that it is binding upon
the Vendor, its successors, transferees, and assignees for the period during which services
are provided. The Vendor further assures that all contractors, subcontractors, subgrantees,
or others with whom it arranges to provide services or benefits to participants or employees
in connection with any of its programs and activities are not discriminating against those
participants or employees in violation of the above statutes, regulations, guidelines, and
standards.



M. Discrimination




An entity or affiliate who has been placed on the discriminatory vendor list may not submit
a bid, proposal, or reply on a contract to provide any goods or services to a public entity;
may not submit a bid, proposal, or reply on a contract with a public entity for the
construction or repair of a public building or public work; may not submit bids, proposals,
or replies on leases of real property to a public entity; may not be awarded or perform work
as a contractor, supplier, subcontractor, or consultant under a contract with any public
entity; and may not transact business with any public entity. The Florida Department of
Management Services is responsible for maintaining the discriminatory vendor list and
intends to post the list on its website. Questions regarding the discriminatory vendor list
may be directed to the Florida Department of Management Services, Office of Supplier
Diversity at (850) 487-0915.



N. Requirements of Section 287.058, Florida Statutes




	 	1.	 	To submit bills for fees or other compensation for services or expenses in
sufficient detail for a proper pre-audit and post-audit thereof.






	 	2.	 	Where applicable, to submit bills for any travel expenses in accordance with
Section 112.061, Florida Statutes.






AHCA Contract No. FA614, Page 5 of 10



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3. Q.




AHCA Form 2100-0007 (Rev. JAN05)




	 	 	 	To provide units of deliverables, including reports, findings, and drafts, in writing
and/or in an electronic format agreeable to both parties, as specified in Attachment I
and Attachment II, to be received and accepted by the Contract Manager prior to
payment.






	 	4.	 	To comply with the criteria and final date by which such criteria must be met
for completion of this Contract as specified in Section III, Paragraph A. of this
Contract.






	 	5.	 	To allow public access to all documents, papers, letters, or other material
made or received by the Vendor in conjunction with this Contract, unless the records
are exempt from Section 24(a) of Article I of the State Constitution and Section
119.07(1), Florida Statutes. It is expressly understood that substantial evidence of
the Vendor’s refusal to comply with this provision shall constitute a breach of
Contract.





0. Sponsorship




As required by Section 286.25, Florida Statutes, if the Vendor is a nongovernmental
organization which sponsors a program financed wholly or in part by state funds, including
any funds obtained through this Contract, it shall, in publicizing, advertising or
describing the sponsorship of the program, state:




“Sponsored by AMERIGROUP COMMUNITY CARE, INC. and the State of Florida, AGENCY
FOR HEALTH CARE ADMINISTRATION”.




If the sponsorship reference is in written material, the words “State of Florida, AGENCY FOR
HEALTH CARE ADMINISTRATION” shall appear in the same size letters or type as the name of the
organization.



P. Final Invoice




The Vendor must submit the final invoice for payment to the Agency no more than 90 days after
the Contract ends or is terminated. If the Vendor fails to do so, all right to payment is
forfeited and the Agency will not honor any requests submitted after the aforesaid time
period. Any payment due under the terms of this Contract may be withheld until all reports
due from the Vendor and necessary adjustments thereto have been approved by the Agency.



Use Of Funds For Lobbying Prohibited



To comply with the provisions of Section 216.347, Florida Statutes, which prohibits the
expenditure of Contract funds for the purpose of lobbying the Legislature, the judicial branch or
a state agency.



R. Public Entity Crime




A person or affiliate who has been placed on the convicted vendor list following a
conviction for a public entity crime may not be awarded or perform work as a contractor,
supplier, subcontractor, or consultant under a contract with any public entity, and may not
transact business with any public entity in excess of the threshold amount provided in
Section 287.017, Florida Statutes, for category two, for a period of 36 months from the date
of being placed on the convicted vendor list.




AHCA Contract No. FA614, Page 6 of 10



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S. AHCA Form 2100-0007 (Rev. JAN05)





Health Insurance Portability and Accountability Act




To comply with the Department of Health and Human Services Privacy Regulations in the
Code of Federal Regulations, Title 45, Sections 160 and 164, regarding disclosure of
protected health information as specified in Attachment III.




T. Confidentiality of Information




Not to use or disclose any confidential information, including social security numbers
that may be supplied under this Contract pursuant to law, and also including the
identity or identifying information concerning a Medicaid recipient or services under
this Contract for any purpose not in conformity with state and federal laws, except
upon written consent of the recipient, or his/her guardian.




U. Employment




To comply with Section 274A (e) of the Immigration and Nationality Act. The Agency
shall consider the employment by any contractor of unauthorized aliens a violation of
this Act. If the Vendor knowingly employs unauthorized aliens, such violation shall be
cause for unilateral cancellation of this Contract. The Vendor shall be responsible
for including this provision in all subcontracts with private organizations issued as
a result of this Contract.




V. Vendor Performance



Penalties or sanctions for unsatisfactory performance under this Contract are
specified in Attachment I and Attachment II, if applicable.



II. THE AGENCY HEREBY AGREES:




A. Contract Amount




To pay for contracted services according to the conditions of Attachment I in an amount
not to exceed $1,003,036,292.00, subject to the availability of funds. The State of
Florida’s performance and obligation to pay under this Contract is contingent upon an
annual appropriation by the Legislature.




B. Contract Payment



Section 215.422, Florida Statutes, provides that agencies have 5 working days to
inspect and approve goods and services, unless bid specifications, Contract or
purchase order specifies otherwise. With the exception of payments to health care
providers for hospital, medical, or other health care services, if payment is not
available within forty (40) days, measured from the latter of the date the invoice is
received or the goods or services are received, inspected and approved, a separate
interest penalty set by the Comptroller pursuant to Section 55.03, F. S., will be due
and payable in addition to the invoice amount. To obtain the applicable interest rate,
please contact the Agency’s Fiscal Section at (850) 488-5869, or utilize the
Department of Financial Services website at www.dfs.state.fl.us/interest.html.
Payments to health care providers for hospitals, medical or other health care
services, shall be made not more than 35 days from the date of eligibility for payment
is determined, and the daily interest rate is .0003333%. Invoices returned to a vendor
due to preparation errors will result in a payment delay. Invoice payment requirements
do not start until a properly completed invoice is provided to the



AHCA Contract No. FA614, Page 7 of 10





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AHCA Form 2100-0007 (Rev. JAN05)




Agency. A Vendor Ombudsman, whose duties include acting as an advocate for vendors
who may be experiencing problems in obtaining timely payment(s) from a State agency, may
be contacted at (850) 410-9724 or by calling the State Comptroller’s Hotline,
1-800-848-3792.



III. THE VENDOR AND AGENCY HEREBY MUTUALLY AGREE:




A. Effective/End Date




This Contract shall begin upon execution by both parties on September 1, 2006,
(whichever is later) and end August 31, 2009, inclusive.




B. Termination




1. Termination at Will




This Contract may be terminated by either party upon no less than thirty (30)
calendar days written notice, without cause, unless a lesser time is mutually agreed
upon by both parties. Said notice shall be delivered by certified mail, return
receipt requested, or in person with proof of delivery.




2. Termination Due To Lack of Funds




In the event funds to finance this Contract become unavailable, the Agency may
terminate the Contract upon no less than twenty-four (24) hours written notice to
the Vendor. Said notice shall be delivered by certified mail, return receipt
requested, or in person with proof of delivery. The Agency shall be the final
authority as to the availability of funds.




3. Termination for Breach




Unless the Vendor’s breach is waived by the Agency in writing, the Agency may, by
written notice to the Vendor, terminate this Contract upon no less than twenty-four
(24) hours written notice. Said notice shall be delivered by certified mail, return
receipt requested, or in person with proof of delivery. If applicable, the Agency
may employ the default provisions in Chapter 60A-1.006(4), Florida Administrative
Code.




Waiver of breach of any provisions of this Contract shall not be deemed to be a
waiver of any other breach and shall not be construed to be a modification of the
terms of this Contract. The provisions herein do not limit the Agency’s right to
remedies at law or to damages.




C. Contract Managers




	 	1.	 	The Agency’s Contract Manager’s name, address and telephone number for
this Contract is as follows:






G. Douglas Harper


Agency for Health Care Administration 2727 Mahan
Drive, MS# 50


Tallahassee, FL 32308


(850) 487-2355




AHCA Contract No. FA614, Page 8 of 10



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2. AHCA Form 2 W0-0007 (Rev. JAN05)




	 	 	 	The Vendor’s Contract Manager’s name, address and telephone number for this Contract is
as follows:






Mitch Wright


Amerigroup Community Care, Inc. 4425
Corporation Lane


Virginia Beach, VA 23562


(757) 473-2737




	 	3.	 	All matters shall be directed to the Contract Managers for appropriate action
or disposition. A change in Contract Manager by either party shall be reduced to
writing through an amendment to this Contract by the Agency.





D. Renegotiation or Modification




	 	1.	 	Modifications of provisions of this Contract shall only be valid when they have
been reduced to writing and duly signed during the term of the Contract. The parties
agree to renegotiate this Contract if federal and/or state revisions of any applicable
laws, or regulations make changes in this Contract necessary.






	 	2.	 	The rate of payment and the total dollar amount may be adjusted retroactively to
reflect price level increases and changes in the rate of payment when these have been
established through the appropriations process and subsequently identified in the
Agency’s operating budget.





E. Name, Mailing and Street Address of Payee




	 	1.	 	The name (Vendor name as shown on Page 1 of this Contract) and mailing address of
the official payee to whom the payment shall be made:





Amerigroup Community Care, Inc. 4425
Corporation Lane Virginia Beach, VA 23562




	 	2.	 	The name of the contact person and street address where financial and
administrative records are maintained:





Margaret Mary Roomsberg 4425
Corporation Lane Virginia Beach, VA
23562



F. All Terms and Conditions




This Contract and its attachments as referenced herein contain all the terms and conditions
agreed upon by the parties.




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AHCA Contract No. FA614, Page 9 of 10



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AHCA Form 2100-0007 (Rev. JAN05)



IN WITNESS THEREOF, the parties hereto have caused this three-hundred eleven (311)
page Contract, which includes any referenced attachments, to be executed by their
undersigned officials as duly authorized. This Contract is not valid until signed and
dated by both parties.



	 	 	 
	AMERIGROUP COMMUNITY CARE, INC.	 	STATE OF FLORIDA, AGENCY FOR
	 	 	HEALTH CARE ADMINISTRATION
	SIGNED	 	SIGNED
	BY:

	 	BY:






S.CONTNAME: TITLE: DATE:



NAME: Christa Calamas



TITLE: Secretary



DATE:


FEDERAL ID NUMBER (or SS Number for an individual): 65-0318864
VENDOR FISCAL YEAR ENDING DATE: 12/31 List of attachments/exhibits
included as part of this Contract:



	 	 	 	 	 
	Attachment

Attachment

Attachment

Attachment

Attachment

	 	I

II

III

IV

V
	 	Scope of Services (9 Pages)

Medicaid Prepaid Health Plan Model Contract (287) Pages

Business Associate Agreement (3 Pages)

Lobbying Certification (1 Page)

Debarment Certification (1 Page)







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AHCA Contract No. FA614, Page 10 of 10



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AHCA Contract No. FA614, Attachment I, Page 1 of 9




ATTACHMENT I




SCOPE OF SERVICES





	A.	 	Manner of Service (s)
Provision: Policies and Procedures	 






The Health Plan shall comply with all provisions of this Contract and any subsequent
amendments, and shall act in good faith in the performance of the Contract’s provisions. The
Health Plan shall develop, maintain and implement written policies and procedures covering
all provisions of this Contract. All policies and procedures shall be prior-approved by the
Agency in writing. The Health Plan agrees that failure to comply with all provisions of this
Contract shall result in the assessment of penalties and/or termination of this Contract, in
whole or in part, as set forth in this Contract.



B. Method of Payment:




1. General




Notwithstanding the payment amounts which may be computed with the rate tables specified
in Exhibit III, the sum of total capitation payments under this Contract shall not exceed
the total Contract amount of $1,003,036,292.00.




	 	a.	 	The Health Plan shall be paid capitation payments for each Agency Service
Area, based upon Exhibit II, Table 4, attached hereto.






	 	c.	 	All payments made to the Health Plan shall be in accordance with this
section (Section B, Method of Payment) and Attachment II, Section XIII, Method of
Payment.






2. Enrollment Levels




The Agency assigns the Health Plan an authorized maximum Enrollment level for each
operational county. The authorized maximum Enrollment level is in effect on September 1,
2006, or upon Contract execution, whichever is later.




	 	a.	 	The Agency must approve, in writing, any increase in the Health Plan’s
maximum Enrollment level for each operational county and subpopulation to be served,
as applicable. Such approval shall not be unreasonably withheld, and shall be based
upon the Health Plan’s satisfactory performance of terms of the Contract and upon
the Agency’s approval of the Health Plan’s administrative and service resources, as
specified in this Contract, in support of each Enrollment level.





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AHCA Contract No. FA614, Attachment 1, Page 2 of 9




	 	b.	 	Exhibit I, Table 1, attached hereto, indicates the Health Plan’s maximum authorized
Enrollment levels for each Medicaid Reform county and each applicable authorized
eligibility category.





3. Health Plan Capitation Rate




Exhibit II, Table 4 provide the capitation rates respective to the authorized areas of
operation, as identified in subsection B, Method of Payment, Item 2, above. The Capitation
Rate payment shall be in accordance with Attachment II, Section XIII, Payment Methodology.



4. Capitation Rate Tables




Exhibit III lists the Capitation Rates for the Health Plan’s authorized Service Areas.




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AHCA Contract No. FA614, Attachment I, Page 3 of 9

EXHIBIT I

MAXIMUM ENROLLMENT LEVELS




TABLE 1




ENROLLMENT LEVELS




County

Maximum Enrollment Level




	 	 	 	 	 
	Brevard
	 	 	8,000	 
	Broward
	 	 	14,000	 
	Miami-Dade
	 	 	25,000	 
	Hillsborough
	 	 	40,000	 
	Lee
	 	 	18,000	 
	Manatee
	 	 	3,500	 
	Orange
	 	 	30,000	 
	Osceola
	 	 	8,500	 
	Palm Beach
	 	 	12,000	 
	Pasco
	 	 	15,000	 
	Pinellas
	 	 	25,000	 
	Polk
	 	 	30,000	 
	Sarasota
	 	 	8,000	 
	Seminole
	 		8,000	






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AHCA Contract No. FA614, Attachment I, Page 4 of 9



EXHIBIT II

CAPITATION RATES





	 	A.	 	Table 4 — General Capitation Rates plus Mental Health Rates:





	 	 	 	 	 
	County	 	Provider Number
	Hillsborough
	 	 	015005300	 
	Polk
	 	 	015005307	 
	Manatee
	 	 	015005318	 
	County
	 	Provider Number
	Orange
	 	 	015005308	 
	Seminole
	 	 	015005313	 
	Osceola
	 	 	015005314	 
	Brevard
	 	 	015005336	 
	Area 8 Counties:
	 	 	 	 
	County
	 	Provider Number
	Lee
	 	 	015005302	 
	Sarasota
	 	 	015005306	 
	Area 9 Counties:
	 	 	 	 
	County
	 	Provider Number
	Palm Beach
	 	 	015005310	 
	Area 10 Counties:
	 	 	 	 
	County
	 	Provider Number
	Broward
	 	 	015005311	 
	Area 11 Counties:
	 	 	 	 
	County
	 	Provider Number
	Miami-Dade
	 	 	015005312	 







AHCA Contract No. FA614, Attachment I, Page 5 of 9
HMO_CapRates_200607-200608.xls 05/22/06



EXHIBIT III

September 1, 2006- August 31, 2007 HMO RATES

(MEDICAID Non-Reform HMO CAPITATION RATES)

By Area , Age and Eligibility Category

Effective from September 1, 2006 thru August 31, 2007




TABLE 1 General
Rates:



TANF SSI-N SSI-B            SSI-AB



Area BTHM0+2M0 3M0.11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21.54) AGE (55+) BTHMO+2M0 3M0-11MO
AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01

02

03

04

05

06

07

08

09

10

11

	 	984.41

984.41

1,119.04

977.46

1,067.14

952.19

995.57

891.16

959.78

949.98

1,250.56
	 	187.77

187.77

215.12

188.43

205.69

184.52

192.16

172.27

184.64

183.45

239.79
	 	94.20

94.20

108.14

94.81

103.55

93.11

96.69

86.81

92.88

92.43

120.51
	 	59.28

59.28

68.68

60.52

66.12

59.80

61.72

55.56

59.08

59.18

76.32
	 	Female

124.19

124.19

142.53

124.94

136.51

122.69

127.53

114.42

122.41

121.83

158.78
	 	Male

65.47

65.47

75.76

66.54

72.78

65.63

68.03

61.12

65.01

65.12

84.09
	 	Female

240.45

240.45

277.34

243.67

266.02

239.77

248.61

223.35

238.25

237.80

308.55
	 	Male

153.59

153.59

177.97

156.49

170.99

154.53

159.82

143.81

152.88

153.08

197.83
	 	

321.77

321.77

374.11

329.66

360.08

326.30

336.93

303.33

321.72

322.61

415.51
	 	

9,105.00

9,105.00

9,838.59

9,496.04

10,493.86

9,506.98

9,869.04

8,573.17

9,678.19

12,128.14

13,040.05
	 	

1,514.90

1,514.90

1,650.55

1,594.91

1,761.79

1,600.98

1,664.31

1,440.41

1,630.65

2,049.58

2,192.54
	 	

418.36

418.36

455.86

440.11

486.26

441.82

459.14

397.64

450.09

566.06

605.29
	 	

193.71

193.71

214.24

207.52

229.33

209.34

218.22

187.66

213.75

269.77

286.46
	 	

221.49

221.49

243.93

236.40

261.00

238.56

247.85

213.40

242.41

306.61

325.12
	 	

689.79

689.79

761.80

737.11

813.88

743.00

773.41

665.88

757.35

956.09

1,014.84
	 	

663.38

663.38

733.75

710.51

784.20

716.54

746.36

641.84

730.08

922.33

978.59
	 	

224.43 81.78 72.80

224.43 81.78 72.80

222.99 76.64 68.22

281.10 80.69 71.81

227.89 75.00 66.73

266.50 71.11 63.33

258.48 74.69 66.44

199.48 70.72 62.90

187.44 75.59 67.24

227.28 85.14 75.76

283.70 121.23 107.80






TABLE 2



General + Mental
Health rates



TANF SSI-N SSI-B            SSI-AB



Area BTHM0+2M0 3M0.11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) BTHMO+2M0 3M0-11MO
AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01

02

03

04

05

06

07

08

09

10

11

	 	984.43

984.43

1,119.05

977.47

1,067.15

952.21

995.59

891.17

959.79

960.00

1,250.58
	 	187.79

187.79

215.13

188.44

205.70

184.54

192.18

172.28

184.65

183.47

239.81
	 	95.93

96.79

109.27

96.10

104.70

95.20

98.58

87.87

94.38

94.50

122.43
	 	71.39

78.05

76.84

69.88

74.42

74.40

75.44

63.26

69.92

74.19

90.20
	 	Female

136.48

138.03

148.55

131.84

142.63

137.52

137.65

120.10

130.40

132.90

169.02
	 	Male

77.76

79.31

81.78

73.44

78.90

80.46

78.15

66.80

73.00

76.19

94.33
	 	Female

244.40

243.59

278.71

245.24

267.41

244.53

250.91

224.64

240.06

240.31

310.87
	 	Male

157.54

156.73

179.34

158.06

172.38

159.29

162.12

145.10

154.69

155.59

200.15
	 	

325.26

324.95

375.49

331.24

361.49

330.50

339.25

304.63

323.55

325.15

417.86
	 	

9,105.08

9,105.06

9,838.63

9,496.10

10,493.90

9,507.04

9,869.10

8,573.21

9,678.23

12,128.19

13,040.10
	 	

1,514.98

1,514.99

1,650.59

1,594.97

1,761.83

1,601.04

1,664.37

1,440.45

1,630.69

2,049.63

2,192.59
	 	

430.15

432.97

462.53

450.87

492.59

451.42

468.64

403.68

457.28

574.97

613.63
	 	

264.67

271.86

249.94

265.05

263.20

267.12

269.01

219.96

252.19

317.41

331.07
	 	

289.33

269.95

266.07

272.08

282.00

293.80

279.35

233.43

266.25

336.15

352.78
	 	

793.42

740.56

784.99

774.49

835.88

827.38

806.41

686.87

782.32

987.04

1,043.82
	 	

700.39

685.53

743.87

726.81

793.80

746.67

760.75

650.99

740.97

935.83

991.23
	 	

227.58

246.33

230.86

300.20

232.83

267.56

264.02

205.52

192.43

232.19

291.36
	 	

94.88 85.90

96.76 87.78

84.31 75.89

98.57 89.69

83.72 75.45

74.98 67.20

87.29 79.04

83.04 75.22

85.84 77.49

91.90 77.4

127.80 114.37






14





AHCA Contract No. FA614, Attachment I, Page 6 of 9
HMO—CapRates—200607-200608.xls 05/22/06



EXHIBIT III




September 1, 2006- August 31, 2007 HMO RATES

(MEDICAID Non-Reform HMO CAPITATION RATES)

By Area , Age and Eligibility Category

Effective from September 1, 2006 thru August 31, 2007




	 	 	 	 	 
	TABLE 3	 	 	 	 
	General + MH + Dental Rates:

	 	

	 	

	TANF

	 	SSI-N
	 	SSI-B SSI-AB






Area BTHM0+2M0 3M0.11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21.54) AGE (55+) BTHMO+2M0 3M0-11MO
AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01

02

03

	 	984.43

984.43

1,119.05
	 	187.80

187.80

215.14
	 	98.41

99.27

112.34
	 	76.67

83.33

83.37
	 	Female

142.09

143.64

155.49
	 	Male

82.41

83.96

87.52
	 	Female

245.26

244.45

281.35
	 	Male

158.28

157.47

181.61
	 	

326.24

325.93

378.51
	 	

9,105.08

9,105.09

9,838.63
	 	

1,515.00

1,515.01

1,650.61
	 	

432.51

435.33

465.60
	 	

268.70

275.89

255.18
	 	

292.89

273.51

270.70
	 	

795.68

742.82

788.49
	 	

702.46

687.60

747.08
	 	

227.77

246.52

231.90
	 	

96.63

98.51

87.26
	 	

86.76

88.64

77.34






04 977.47 188.45 98.28 74.52 136.78 77.53 247.57 160.06 333.90 9,496.10 1,594.99 453.16 268.97
275.55 777.64 729.71 301.57 101.51 91.14



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	05

06

07

08

09

10

11

	 	1,067.16

952.21

995.59

891.17

959.79

950.00

1,250.59
	 	205.72

184.55

192.19

172.29

184.66

183.48

239.83
	 	108.38

97.98

100.95

90.51

97.52

97.54

126.08
	 	82.24

80.32

80.49

68.89

76.58

80.65

97.97
	 	150.94

143.81

143.01

126.08

137.48

139.77

177.28
	 	85.79

85.67

82.60

71.75

78.87

81.87

101.17
	 	275.45

248.64

253.93

227.84

242.05

242.34

312.69
	 	179.28

162.82

164.71

147.84

156.40

157.32

201.72
	 	370.68

335.19

342.70

308.28

325.82

327.46

419.94
	 	10,493.91

9,507.05

9,869.10

8,573.21

9,678.23

12,128.20

13,040.11
	 	1,761.87

1,601.07

1,664.39

1,440.47

1,630.71

2,049.66

2,192.62
	 	497.23

454.57

471.63

406.25

460.05

578.71

617.59
	 	271.12

272.52

274.11

224.35

256.93

323.81

337.84
	 	289.01

298.58

283.87

237.32

270.44

341.82

358.76
	 	842.94

832.70

810.02

691.37

784.62

989.96

1,047.74
	 	800.28

751.55

764.07

655.12

743.09

938.51

994.82
	 	237.48

270.73

266.03

207.65

193.17

234.27

294.22
	 	92.44

80.85

90.77

87.12

88.23

94.95

131.90
	 	79.75

70.09

80.76

77.23

78.67

84.02

116.39






TABLE 4



General + MH + Transportation



TANF SSI-N SSI-B SSI-AB



Area BTHM0+2M0 3M0.11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) BTHMO+2M0 3M0-11MO
AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01

02

03

04

05

06

07

08

09

10

11

	 	989.41

989.41

1,124.90

981.69

1,070.82

956.09

998.64

896.29

964.64

953.74

1,253.13
	 	189.41

189.41

217.03

189.81

206.90

185.80

193.18

173.95

186.23

184.69

240.64
	 	97.06

97.92

110.60

97.06

105.54

96.08

99.28

89.03

95.47

95.35

123.00
	 	72.23

78.89

77.82

70.59

75.03

75.05

75.95

64.12

70.73

74.82

90.63
	 	Female

138.71

140.26

151.16

133.73

144.28

139.25

139.01

122.39

132.56

134.57

170.16
	 	Male

79.17

80.72

83.44

74.63

79.94

81.66

79.01

68.25

74.37

77.25

95.05
	 	Female

248.03

247.22

282.97

248.31

270.09

247.35

253.13

228.37

243.58

243.04

312.73
	 	Male

159.83

159.02

182.02

160.00

174.06

161.07

163.62

147.45

156.91

157.31

201.33
	 	

329.39

329.08

380.34

334.75

364.54

333.72

341.78

308.88

327.57

328.25

419.99
	 	

9,129.34

9,129.35

9,868.98

9,525.59

10,513.00

9,527.20

9,889.65

8,596.82

9,702.53

12,156.21

13,058.07
	 	

1,535.05

1,535.06

1,675.69

1,619.35

1,777.63

1,617.71

1,681.36

1,459.97

1,650.78

2,072.80

2,207.46
	 	

440.25

443.07

475.17

463.16

500.55

459.82

477.19

413.52

467.40

586.63

621.12
	 	

267.63

274.82

253.66

268.67

265.53

269.59

271.52

222.85

255.16

320.83

333.27
	 	

294.48

275.10

272.53

278.36

286.05

298.08

283.71

238.44

271.41

342.12

356.60
	 	

813.36

760.50

809.95

798.72

851.58

843.95

823.30

706.27

802.29

1,010.07

1,058.59
	 	

714.87

700.01

761.99

744.42

805.21

758.71

773.02

665.08

755.47

952.55

1,001.97
	 	

239.52

258.27

241.15

307.55

239.28

273.49

269.96

214.93

198.62

239.40

296.79
	 	

112.65

114.53

110.17

122.56

100.41

90.97

103.61

101.16

107.13

118.00

144.07
	 	

93.54

95.42

87.01

100.01

82.63

74.07

86.01

83.01

86.64

93.74

121.37






15





AHCA Contract No. FA614, Attachment I, Page 7 of 9
HMO—CapRates—200607-200608.xls 05/22/06



EXHIBIT III

September 1, 2006- August 31, 2007 HMO RATES

(MEDICAID Non-Reform HMO CAPITATION RATES)

By Area , Age and Eligibility Category

Effective from September 1, 2006 thru August 31, 2007




TABLE 5


General + Transportation Rates:



TANF SSI-N SSI-B            SSI-AB



Area BTHM0+2M0 3M0.11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) BTHMO+2M0 3M0-11MO
AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01989.39189.39

02989.39189.39

031,124.89217.02

04981.68189.80

051,070.81206.89

06956.07185.78

07998.62193.16

08896.28173.94

09964.63186.22

10953.72184.67

111,253.11240.62

	 	95.33

95.33

109.47

95.77

104.39

93.99

97.39

87.97

93.97

93.28

121.08
	 	60.12

60.12

69.66

61.23

66.73

60.45

62.23

56.42

59.89

59.81

76.75
	 	126.42

126.42

145.14

126.83

138.16

124.42

128.89

116.71

124.57

123.50

159.92
	 	66.88

66.88

77.42

67.73

73.82

66.73

68.89

62.57

66.38

66.18

84.81
	 	244.08

244.08

281.60

246.74

268.70

242.59

250.83

227.08

241.77

240.53

310.41
	 	155.88

155.88

180.65

158.43

172.67

156.31

161.22

146.16

155.10

154.80

199.01
	 	325.90

325.90

378.96

333.17

363.13

329.52

339.46

307.58

325.74

325.71

417.64
	 	9,129.26

9,129.26

9,868.94

9,525.53

10,512.96

9,527.14

9,889.59

8,596.7

9,702.49

12,156.16

13,058.02
	 	1,534.97

1,534.97

1,675.65

1,619.29

1,777.59

1,617.65

1,681.30

1,459.93

1,650.74

2,072.75

2,207.41
	 	428.46

428.46

468.50

452.40

494.22

450.22

467.69

407.48

460.21

577.72

612.78
	 	196.67

196.67

217.96

211.14

231.66

211.81

220.73

190.55

216.72

273.19

288.66
	 	226.64

226.64

250.39

242.68

265.05

242.84

252.21

218.41

247.57

312.58

328.94
	 	709.73

709.73

786.76

761.34

829.58

759.57

790.30

685.28

777.32

979.12

1,029.61
	 	677.86 236.37 99.55

677.86236.37 99.55

751.87233.28 102.50 79.34

728.12288.45 104.68 82.13

795.61234.34 91.69 73.91

728.58272.43 87.10 70.20

758.63264.42 90.91 73.41

655.93208.89 88.84 70.69

744.58193.63 96.88 76.39

939.05234.49 111.24 86.98

989.33289.13 137.50 114.80
	 	80.44

80.44



















	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	TABLE 6

General + Dental Rates:

	 	



	 	



	 	



	 	



	 	



	 	



	 	



	 	



	 	



	 	



	 	



	 	



	 	



	 	



	 	



	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	TANF

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N
	 	 	 	 	 	 	 	 	 	 	 	SSI-B SSI-AB
	 	







Area BTHM0+2M0 3M0.11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) BTHMO+2M0 3M0-11MO
AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01

02

03

04

05

06

07

08

09

10

11

	 	984.41

984.41

1,119.04

977.46

1,067.15

952.19

995.57

891.16

959.78

949.98

1,250.67
	 	187.78

187.78

215.13

188.44

205.71

184.53

192.17

172.28

184.65

183.46

239.81
	 	96.68

96.68

111.21

96.99

107.23

95.89

99.06

89.45

96.02

95.47

124.16
	 	64.56

64.56

75.21

65.16

73.94

65.72

66.77

61.19

65.74

65.64

84.09
	 	Female

129.80

129.80

149.47

129.88

144.82

128.98

132.89

120.40

129.49

128.70

167.04
	 	Male

70.12

70.12

81.50

70.63

79.67

70.84

72.48

66.07

70.88

70.80

90.93
	 	Female

241.31

241.31

279.98

246.00

274.06

243.88

251.63

226.55

240.24

239.83

310.37
	 	Male

154.33

154.33

180.24

158.49

177.89

158.06

162.41

146.55

154.59

154.81

199.40
	 	

322.75

322.75

377.1

332.32

369.27

330.99

340.38

306.98

323.99

324.92

417.59
	 	

9,105.00

9,105.00

9,838.59

9,496.04

10,493.87

9,506.99

9,869.04

8,573.17

9,678.19

12,128.15

13,040.06
	 	

1,514.92

1,514.92

1,650.57

1,594.93

1,761.83

1,601.01

1,664.33

1,440.43

1,630.67

2,049.61

2,192.57
	 	

420.72

420.72

458.93

442.40

490.90

444.97

462.13

400.21

452.86

569.80

609.25
	 	

197.74

197.74

219.48

211.44

237.25

214.74

223.32

192.05

218.49

276.17

293.23
	 	

225.05

225.05

248.56

239.87

268.01

243.34

252.37

217.29

246.60

312.28

331.10
	 	

692.05

692.05

765.30

740.26

820.94

748.32

777.02

670.38

759.65

959.01

1,018.76
	 	

665.45

665.45

736.96

713.41

790.68

721.42

749.68

645.97

732.20

925.01

982.18
	 	

224.62 83.53

224.62 83.53

224.03 79.59 69.67

282.47 83.63

232.54 83.72

269.67 76.98 66.22

260.49 78.17 68.16

201.61 74.80 64.91

188.18 77.98 68.42

229.36 88.19

286.56 125.33 109.82
	 	

73.66

73.66



73.26

71.03









77.26









16





AHCA Contract No. FA614, Attachment I, Page 8 of 9
HMO—CapRates—200607-200608.xls 05/22/06



EXHIBIT III

September 1, 2006- August 31, 2007 HMO RATES

(MEDICAID Non-Reform HMO CAPITATION RATES)

By Area , Age and Eligibility Category

Effective from September 1, 2006 thru August 31, 2007




	 	 	 	 	 
	TABLE 7	 	 	 	 
	General + Dental + Transportation Rates:

	 	

	 	

	TANF

	 	SSI-N
	 	SSI-B SSI-AB






Area BTHM0+2M0 3M0.11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) BTHMO+2M0 3M0-11MO
AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01989.39189.4097.8165.40132.03	 	71.53	 	244.94	 	156.62	 	326.88	 	9,129.26	 	1,534.99	 	430.82	 	200.70	 	230.20	 	711.99	 	679.93236.56	101.30 81.30
	02989.39189.4097.8165.40132.03	 	71.53	 	244.94	 	156.62	 	326.88	 	9,129.2	 	1,534.99	 	430.82	 	200.70	 	230.20	 	711.99	 	679.93236.56	101.30 81.30
	031,124.89217.03112.5476.19152.08	 	83.16	 	284.24	 	182.92	 	381.98	 	9868.94	 	1,675.67	 	471.57	 	223.20	 	255.02	 	790.26	 	755.08234.32	105.45 80.79
	04981.68189.8197.9565.87131.77	 	71.82	 	249.07	 	160.43	 	335.85	 	9525.53	 	1,619.31	 	454.69	 	215.06	 	246.15	 	764.49	 	731.02289.82	107.62 83.58
	051,070.82206.91108.0774.55146.47	 	80.71	 	276.74	 	179.57	 	372.32	 	10,512.97	 	1,777.63	 	498.86	 	239.58	 	272.06	 	836.64	 	802.09238.99	100.41 78.21
	06956.07185.7996.7766.37130.71	 	71.94	 	246.70	 	159.84	 	334.21	 	9,527.15	 	1,617.68	 	453.37	 	217.21	 	247.62	 	764.89	 	733.46275.60	92.97 73.09
	07998.62193.1799.7667.28134.25	 	73.34	 	253.85	 	163.81	 	342.91	 	9,889.59	 	1,681.32	 	470.68	 	225.83	 	256.73	 	793.91	 	761.95266.43	94.39 75.13
	08896.28173.9590.6162.05122.69	 	67.52	 	230.28	 	148.90	 	311.23	 	8,596.78	 	1,459.95	 	410.05	 	194.94	 	222.30	 	689.78	 	660.06211.02	92.92 72.70
	09964.63186.2397.1166.55131.65	 	72.25	 	243.76	 	156.8	 	328.01	 	9,702.49	 	1,650.76	 	462.98	 	221.46	 	251.76	 	779.62	 	746.70194.37	99.27 77.57
	10953.72184.6896.3266.27130.37	 	71.86	 	242.56	 	156.53	 	328.02	 	12,156.17	 	2,072.78	 	581.46	 	279.59	 	318.25	 	982.04	 	941.73236.57	114.29 88.48
	111,253.12240.64124.7384.52168.18	 	91.65	 	312.23	 	200.58	 	419.72	 	13,058.03	 	2,207.44	 	616.74	 	295.43	 	334.92	 	1,033.53	 	992.92291.99	141.60 116.82
	TABLE 8

General + Mental health + Dental + Transportation Rates:

	 	



	 	



	 	



	 	



	 	



	 	



	 	



	 	



	 	



	 	



	 	



	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	TANF

	 	 	 	 	 	 	 	 	 	SSI-N
	 	 	 	 	 	 	 	 	 	 	 	SSI-B SSI-AB






Area BTHM0+2M0 3M0.11MO AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) BTHMO+2M0 3M0-11MO
AGE (1-5) AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+) AGE (65-) AGE (65+)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01

02

03

04

05

06

07

08

09

10

11

	 	989.41

989.41

1,124.90

981.69

1,070.83

956.09

998.64

896.29

964.64

953.74

1,253.14
	 	189.42

189.42

217.04

189.82

206.92

185.81

193.19

173.96

186.24

184.70

240.66
	 	99.54

100.40

113.67

99.24

109.22

98.86

101.65

91.67

98.61

98.39

126.65
	 	77.51

84.17

84.35

75.23

82.85

80.97

81.00

69.75

77.39

81.28

98.40
	 	Female

144.32

145.87

158.10

138.67

152.59

145.54

144.37

128.37

139.64

141.44

178.42
	 	Male

83.82

85.37

89.18

78.72

86.83

86.77

83.46

73.20

80.24

82.93

101.89
	 	Female

248.89

248.08

285.61

250.64

278.13

261.46

256.15

231.57

245.57

245.07

314.55
	 	Male

160.57

159.76

184.29

162.00

180.96

164.60

166.11

150.19

158.62

159.04

202.90
	 	

330.37

330.06

383.36

337.41

373.73

338.41

345.23

312.53

329.84

330.56

422.07
	 	

9,129.34

9,129.35

9,868.98

9,525.59

10,513.01

9,527.21

9,889.65

8,596.82

9,702.53

12,156.22

13,058.08
	 	

1,535.07

1,535.08

1,675.71

1,619.37

1,777.67

1,617.74

1,681.38

1,459.99

1,650.80

2,072.83

2,207.49
	 	

442.61

445.43

478.24

465.45

505.19

462.97

480.18

416.09

470.17

590.37

625.08
	 	

271.66

278.85

258.90

272.59

273.45

274.99

276.62

227.24

259.90

327.23

340.04
	 	

298.04

278.66

277.16

281.83

293.06

302.86

288.23

242.33

275.60

347.79

362.58
	 	

815.62

762.76

813.45

801.87

858.64

849.27

826.91

710.77

804.59

1,012.99

1,062.51
	 	

716.94

702.08

765.20

747.32

811.69

763.59

776.34

669.21

757.59

955.23

1,005.56
	 	

239.71 114.40 94.40

258.46 116.28 96.28

242.19 113.12 88.86

308.92 125.50 101.46

243.93 109.13 86.93

276.66 96.84 76.96

271.97 106.99 87.73

217.06 105.24 85.02

199.36 109.52 87.82

241.48 121.05 95.24

299.65 148.17 123.39






17




Area


Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Area 9 Area 10 Area 11




AHCA Contract No. FA614, Attachment I,
Page 9 of 9



EXHIBIT III

September 1, 2006- August 31, 2007 HMO RATES

(MEDICAID Non-Reform HMO CAPITATION RATES)

By Area , Age and Eligibility Category

Effective from September 1, 2006 thru August 31, 2007




Corresponding Counties



Escambia, Okaloosa, Santa Rosa, Walton


Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor,
Washington, Wakulla


Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hemando, Lafayette, Lake,
Levy, Marion, Putnam, Sumter, Suwannee, Union Baker, Clay, Duval, Flagler, Nassau, St. Johns,
Volusia


Pasco, Pinellas


Hardee, Highlands, Hillsborough, Manatee, Polk


Brevard, Orange, Osceola, Seminole


Charlotte, Collier, De Soto, Glades, Hendry, Lee, Sarasota


Indian River, Okeechobee, St. Lucie, Martin, Palm Beach


Broward



Dade, Monroe



created on august 11,2006





18






Medicaid Prepaid Health Plan Model Contract




Attachment II




August 15, 2006




19




Table of Contents




20




Section I




Definitions and Acronyms





	A.	 	Definitions






The following terms as used in this Contract shall be construed and/or interpreted as follows,
unless the Contract otherwise expressly requires a different construction and/or interpretation.




Abandoned Call — A call in which the caller elects an option and is either not permitted
access to that option or disconnects from the system.




Abuse — Provider practices that are inconsistent with generally accepted business or
medical practices and that result in an unnecessary cost to the Medicaid program or in
reimbursement for goods or services that are not medically necessary or that fail to meet
professionally recognized standards for health care; or recipient practices that result in
unnecessary cost to the Medicaid program.




Action — The denial or limited authorization of a requested service, including the type
or level of service, pursuant to 42 CFR 438.400(b). The reduction, suspension or termination of
a previously authorized service. The denial, in whole or in part, of payment for a service.
The failure to provide services in a timely manner, as defined by the State. The failure of the
Health Plan to act within ninety (90) days from the date the Health Plan receives a Grievance,
or forty-five (45) days from the date the Health Plan receives an Appeal. For a resident of a
Rural area with only one (1) managed care entity, the denial of an Enrollee’s request to
exercise his or her right to obtain services outside the network.




Advance Directive — A written instruction, such as a living will or durable power of
attorney for health care, recognized under State law (whether statutory or as recognized by the
courts of the State), relating to the provision of health care when the individual is
incapacitated.




Advanced Registered Nurse Practitioner (ARNP) — A licensed advanced registered nurse
practitioner who works in collaboration with a physician according to protocol, to provide
diagnostic and clinical interventions. An ARNP must be authorized to provide these services by
Chapter 464, F.S., and protocols filed with the Board of Medicine.




Agency — State of Florida, Agency for Health Care Administration.




Agent — An entity that contracts with the State to perform administrative functions,
including but not limited to: Fiscal Agent activities; outreach and education, eligibility and
Enrollment activities; Systems and Technical support.




Ancillary Provider — A Provider of ancillary medical services who has contracted with a
Health Plan to provide ancillary medical services to the Health Plan’s Enrollees.




Authoritative Host: — A system that contains the master or “authoritative” data for a
particular data type, e.g. Enrollee, Provider, Health Plan, etc. The Authoritative Host may
feed data from its master data files to other systems in real time or in batch mode. Data in an
Authoritative Host is expected to be up-to-date and reliable.




Automatic Assignment (or Auto-Assign) — The Enrollment of an eligible Medicaid
Recipient, for whom Enrollment is mandatory, in a Health Plan chosen by AHCA or its Agent,
and/or the assignment of a new Enrollee to a PCP chosen by the Health Plan.




Appeal — A request for review of an Action, pursuant to 42 CFR 438.400(b).




Baker Act — The Florida Mental Health Act, pursuant to Sections 394.479 through 394.484,
F.S..




Behavioral Health Services — Services listed in the Community Mental Health Services
Coverage & Limitations Handbook and the Targeted Case Management Coverage & Limitations Handbook
as specified in this Contract in Section VI.A Behavioral Health Care, General Provisions.




Behavioral Health Care Case Manager — An individual who provides mental health care Case
Management services directly to or on behalf of an Enrollee on an individual basis in accordance
with 65E-15, F.A.C., and the Medicaid Targeted Case Management Handbook.




Behavioral Health Care Provider — A licensed mental health professional, such as a
“Clinical Psychologist,” or registered nurse qualified due to training or competency in mental
health care, who is responsible for the provision of mental health care to patients, or a
physician licensed under Chapters 458 or 459, F.S., who is under contract to provide Behavioral
Health Services to Enrollees.




Benefits — A schedule of health care services to be delivered to Enrollees covered by
the Health Plan as set forth in Section V and Section VI of this Contract.




Blocked Call — A call that cannot be connected immediately because no circuit is
available at the time the call arrives or the telephone system is programmed to block calls from
entering the queue when the queue backs up behind a defined threshold.




Business Days — Traditional workdays, which are Monday, Tuesday, Wednesday, Thursday,
and Friday. State holidays are excluded.




Calendar Days — All seven (7) days of the week.




Capitation Rate — The per member per month amount, including any adjustments, that is
paid by the Agency to the Health Plan for each Medicaid Recipient enrolled under this Contract
for the provision of Medicaid services during the payment period.




Case Management — A process which assesses, plans, implements, coordinates, monitors and
evaluates the options and services required to meet an Enrollee’s health needs using
communication and all available resources to promote quality cost-effective outcomes. Proper
Case Management occurs across a continuum of care, addressing the ongoing individual needs of an
Enrollee rather than being restricted to a single practice setting.




Cause — Special reasons that allow Mandatory Enrollees to change their Health Plan
option outside their Open Enrollment period. May also be referred to as “Good Cause.”




Centers for Medicare & Medicaid Services (CMS) — The agency within the United States
Department of Health & Human Services that provides administration and funding for Medicare
under Title XVIII, Medicaid under Title XIX, and the State Children’s Health Insurance Program
under Title XXI of the Social Security Act.




Certification — The process of determining that a facility, equipment or an individual
meets the requirements of federal or State law, or whether Medicaid payments are appropriate or
shall be made in certain situations.




Child Health Check-Up Program (CHCUP) — A comprehensive and preventative health
examinations provided on a periodic basis that are aimed at identifying and correcting medical
conditions in Children/Adolescents. Policies and procedures are described in the Child Health
Check-Up Services Coverage and Limitations Handbook.




Children/Adolescents — Enrollees under the age of 21.




Children & Families Services Program Office — Also referred to as the Children &
Families Safety & Preservation Program Office, located in the DCF; the State agency responsible
for overseeing programs that identify and protect abused and neglected Children and attempt to
prevent domestic violence.




Choice Counselor/Enrollment Broker — The State’s contracted or designated entity that
performs functions related to outreach, education, counseling, Enrollment, and Disenrollment of
Potential Enrollees into a Health Plan.




Choice Counseling Specialists — Certified individuals authorized by an Agency-approved
process who provide one-on-one information to Medicaid Recipients, to assist the Medicaid
Recipients in choosing the Health Plan that best meets their health care needs and those of
their family.




Cold Call Marketing — Any unsolicited personal contact with a Medicaid Recipient by the
Health Plan, its staff, its volunteers or its vendors with the purpose of influencing the
Medicaid Recipient to enroll in the Health Plan or either to not enroll in, or disenroll from,
another Health Plan.




Community Living Support Plan – A written document prepared by a mental health resident
of an assisted living facility with a limited mental health license and the resident’s mental
health case manager in consultation with the administrator or the administrator’s designee of
the assisted living facility with a limited mental health license. A copy must be provided to
the administrator. The plan must include information about the supports, services, and special
needs of the resident which enable the resident to live in the assisted living facility and a
method by which facility staff can recognize and respond to the signs and symptoms particular to
that resident which indicate the need for professional services.




Continuous Quality Improvement — A management philosophy that mandates continually
pursuing efforts to improve the quality of products and services produced by an organization.




Contract — The agreement between the Health Plan and the Agency to provide Medicaid
services to Enrollees, comprised of the Contract, any addenda, appendices, attachments, or
amendments thereto.




Contract Period – The term of the contract from July 1, 2006 through August 31, 2009.




Contract Year – The period of time from September 1 through August 31 of each calendar
year.




Contracting Officer — The Secretary of the Agency or his/her delegate.




Cost Effective — The Health Plan’s per-member, per-month costs to the State, including,
but not limited to, FFS costs, administrative costs, and case-management fees, must be no
greater than the State’s costs associated with capitated Health Plans.




County Health Department (CHD) — CHDs are organizations administered by the Department
of Health for the purpose of providing health services as defined in Chapter 154, F.S., which
include the promotion of the public’s health, the control and eradication of preventable
diseases, and the provision of primary health care for special populations.




Coverage & Limitations Handbook (Handbook) — A document that provides information to a
Medicaid Provider regarding Enrollee eligibility, claims submission and processing, Provider
participation, covered care, goods and services, limitations, procedure codes and fees, and
other matters related to participation in the Medicaid program.




Covered Services — Those services provided by the Health Plan in accordance with this
Contract, and as outlined in Section V Covered Services and Section VI Behavioral Health Care in
this Contract.




Crisis Support — Services for persons initially perceived to need emergency mental
health services, but upon assessment, do not meet the criteria for such emergency care. These
are acute care services that are available twenty-four (24) hours a day, seven (7) days a week,
for intervention. Examples include: mobile crisis, crisis/emergency screening, crisis hot-line
and emergency walk-in.




Direct Ownership Interest — The ownership of stock, equity in capital or any interest in
the profits of the disclosing entity. A disclosing entity is defined as a Medicaid provider or
supplier, or other entity that furnishes services or arranges for furnishing services under
Medicaid, or health related services under the social services program.




Direct Service Behavioral Health Care Provider — An individual qualified by training or
experience to provide direct behavioral health services under the supervision of the Health
Plan’s medical director.




Disease Management – A system of coordinated health care intervention and communication
for populations with conditions in which patient self-care efforts are significant. Disease
Management supports the physician or practitioner/patient relationship and plan of care;
emphasized prevention of exacerbations and complications utilizing evidence-based practice
guidelines and patient empowerment strategies, and evaluates clinical, humanistic and economic
outcomes on an ongoing basis with the goal of improving overall health.




Disenrollment — The Agency approved discontinuance of an Enrollee’s Enrollment in a
Health Plan.




Disclosing Entities — A Medicaid provider, other than an individual practitioner or
group of practitioners, or a fiscal agent that furnishes services or arranges for furnishing
services under Medicaid, or health related services under the social services program.




Downward Substitution of Care — The use of less restrictive, lower cost services than
otherwise might have been provided, that are considered clinically acceptable and necessary to
meet specified objectives outlined in an Enrollee’s plan of treatment, provided as an
alternative to higher cost services. For services related to mental health, Downward
Substitution of Care may include care provided by private practice psychologists and social
workers, psycho-social rehabilitation, Medicaid community mental health services or Medicaid
mental health targeted Case Management, and other services considered clinically appropriate,
more cost-effective and less restrictive.




Durable Medical Equipment (DME) — Medical equipment that can withstand repeated use, is
customarily used to serve a medical purpose, is generally not useful in the absence of illness
or injury and is appropriate for use in the Enrollee’s home.




Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) —See Child Health
Check Up Program.




Emergency Behavioral Health Services — Those services required to meet the needs of an
individual who is experiencing an acute crisis, resulting from a mental illness, which is a
level of severity that would meet the requirements for an involuntary examination as specified
in Section 394.463, F.S., and in the absence of a suitable alternative or psychiatric
medication, would require hospitalization.




Emergency Medical Condition — (I) A medical condition manifesting itself by acute
symptoms of sufficient severity, which may include severe pain or other acute symptoms, such
that a prudent layperson who possesses an average knowledge of health and medicine, could
reasonably expect that the absence of immediate medical attention could reasonably be expected
to result in any of the following: (1) Serious jeopardy to the health of a patient, including a
pregnant woman or fetus; (II) Serious impairment to bodily functions; (3) Serious dysfunction of
any bodily organ or part. (b) With respect to a pregnant woman: (1) That there is inadequate
time to effect safe transfer to another Hospital prior to delivery; (2) That a transfer may pose
a threat to the health and safety of the patient or fetus; (3) That there is evidence of the
onset and persistence of uterine contractions or rupture of the membranes, in accordance with
Section 395.002, F.S.




Emergency Services and Care — Medical screening, examination and evaluation by a
physician or, to the extent permitted by applicable laws, by other appropriate personnel under
the supervision of a physician, to determine whether an Emergency Medical Condition exists. If
an Emergency Medical Condition exists, Emergency Services and Care includes the care or
treatment that is necessary to relieve or eliminate the Emergency Medical Condition within the
service capability of the facility.




Emergency Transportation – The provision of Emergency Transportation Services in
accordance with Section 409.908(13)(d)(4), F.S.




Encounter Data – A record of Covered Services provided to Enrollees of a Health Plan. An
Encounter is an interaction between a patient and Provider (health plan, rendering physician,
pharmacy, lab, etc.) who delivers services or is professionally responsible for services
delivered to a patient.




Enrollee — A Medicaid Recipient currently enrolled in the Health Plan.




Enrollment — The process by which an eligible Medicaid Recipient becomes an Enrollee in
a Health Plan.




Enrollee Suicide Attempt — An act which clearly reflects an attempt by an Enrollee to
cause his or her own death, which results in bodily injury requiring medical treatment by a
licensed health care professional.




Expanded Services — A Health Plan Covered Service for which the Health Plan receives no
direct payment from the Agency.




Expedited Appeal Process — The process by which the Appeal of an Action is accelerated
because the standard time-frame for resolution of the Appeal could seriously jeopardize the
Enrollee’s life, health or ability to obtain, maintain or regain maximum function.




External Quality Review (EQR) — The analysis and evaluation by an EQRO of aggregated
information on quality, timeliness, and access to the health care services that are furnished to
Medicaid recipients by a Health Plan.




External Quality Review Organization (EQRO) — An organization that meets the competence
and independence requirements set forth in federal regulations 42 CFR 438.354, and performs EQR,
other related activities as set forth in federal regulations or both.




Federal Fiscal Year – The United States government’s fiscal year starts October 1 and
ends on September 30.




Federally Qualified Health Center (FQHC) — An entity that is receiving a grant under
section 330 of the Public Health Service Act, as amended, and Section 1905(1)(2)(B) of the
Social Security Act. FQHCs provide primary health care and related diagnostic
services and may provide dental, optometric, podiatry, chiropractic and mental health services.




Fee-for-Service (FFS) — A method of making payment by which the Agency sets prices for
defined medical or allied care, goods or services.




Fiscal Agent — Any corporation, or other legal entity, that enters into a contract with
the Agency to receive, process and adjudicate claims under the Medicaid program.




Fiscal Year — The State of Florida’s Fiscal Year starts July 1 and ends on June 30.




Florida Medicaid Management Information System (FMMIS) — The information system used to
process Florida Medicaid claims and payments to Health Plans, and to produce management
information and reports relating to the Florida Medicaid program. This system is used to
maintain Medicaid eligibility data and provider enrollment data.




Florida Mental Health Act — Includes the Baker Act that covers admissions for persons
who are considered to have an emergency mental health condition (a threat to themselves or
others), as specified in Sections 394.479 through 394.484, Florida Statutes.




Fraud — An intentional deception or misrepresentation made by a person with the
knowledge that the deception results in unauthorized benefit to herself or himself or another
person. The term includes any act that constitutes fraud under applicable federal or state law.




Full-Time Equivalent Position (FTE) — The equivalent of one (1) full-time employee who
works 40 hours per week.




Good Cause — See Cause.




Grievance — An expression of dissatisfaction about any matter other than an Action.
Possible subjects for grievances include, but are not limited to, the quality of care, the
quality of services provided and aspects of interpersonal relationships such as rudeness of a
Provider or employee or failure to respect the Enrollee’s rights.




Grievance Procedure — The procedure for addressing Enrollees’ grievances.




Grievance System — The system for reviewing and resolving Enrollee Grievances and
Appeals. Components must include a Grievance process, an Appeal process and access to the
Medicaid Fair Hearing system.




Health Assessment — A complete health evaluation combining health history, physical
assessment and the monitoring of physical and psychological growth and development.




Health Care Professional — A physician or any of the following: podiatrist, optometrist,
chiropractor, psychologist, dentist, Physician Assistant, physical or occupational therapist,
therapist assistant, speech-language pathologist, audiologist, Registered or practical Nurse
(including nurse practitioner, clinical nurse specialist, certified Registered Nurse anesthetist
and certified nurse midwife), a licensed certified social worker, registered respiratory
therapist and certified respiratory therapy technician.




Health Fair — An event conducted in a setting that is open to the public or segment of
the public (such as the “elderly” or “schoolchildren”) during which information about
health-care services, facilities, research, preventative techniques or other health-care
subjects is disseminated. At least two (2) health-related organizations that are not affiliated
under common ownership must actively participate in the Health Fair.




Health Maintenance Organization (HMO) — An organization or entity licensed in accordance
with Section 641 of the Florida Statutes or in accordance with the Florida Medicaid State plan
definition of an HMO.




Health Plan — An entity that integrates financing and management with the delivery of
health care services to an enrolled population. It employs or contracts with an organized
system of Providers, which deliver services and frequently shares financial risk. For the
purposes of this Contract, a Health Plan has also contracted with the Agency to provide Medicaid
services under the Florida Medicaid Reform program, and includes health maintenance
organizations authorized under chapter 641 of the Florida Statutes, exclusive provider
organizations as defined in chapter 627 of the Florida Statutes, health insurers authorized
under chapter 624 of the Florida Statutes, and Provider Service Networks as defined in Section
409.912, Florida Statutes.




Hospital — A facility licensed in accordance with the provisions of Chapter 395, Florida
Statutes or the applicable laws of the state in which the service is furnished.




Hospital Services Agreement — The agreement between the Health Plan and a Hospital to
provide medical services to the Health Plan’s Enrollees.




Indirect Ownership Interest — Ownership interest in an entity that has direct or
indirect ownership interest in the disclosing entity. The amount of indirect ownership in the
disclosing entity that is held by any other entity is determined by multiplying the percentage
of ownership interest at each level. An indirect ownership interest must be reported if it
equates to an ownership interest of five percent (5%) or more in the disclosing entity.
Example: If “A” owns ten percent (10%) of the stock in a corporation that owns eighty percent
(80) of the stock of the disclosing entity, “A’s” interest equates to an eight percent (8%)
indirect ownership and must be reported.




Individuals with Special Health Care Needs — Adults and Children/Adolescents, who face
physical, mental or environmental challenges daily that place at risk their health and ability
to fully function in society. Factors include individuals with mental retardation or related
conditions; individuals with serious chronic illnesses, such as human immunodeficiency virus
(HIV), schizophrenia or degenerative neurological disorders; individuals with disabilities
resulting from many years of chronic illness such as arthritis, emphysema or diabetes; and
Children/Adolescents and adults with certain environmental risk factors such as homelessness or
family problems that lead to the need for placement in foster care.




Information — (i) Structured Data: Data that adhere to specific properties and
Validation criteria that are stored as fields in database records. Structured queries can be
created and run against structured data, where specific data can be used as criteria for
querying a larger data set; (ii) Document: Information that does not meet the definition
of structured data includes text, files, spreadsheets, electronic messages and images of forms
and pictures.




Information System(s) — A combination of computing hardware and software that is used
in: (a) the capture, storage, manipulation, movement, control, display, interchange and/or
transmission of information, i.e. structured data (which may include digitized audio and video)
and documents; and/or (b) the processing of such information for the purposes of enabling and/or
facilitating a business process or related transaction.




Insolvency — A financial condition that exists when an entity is unable to pay its debts
as they become due in the usual course of business, or when the liabilities of the entity
exceeds its assets.




Licensed — A facility, equipment, or an individual that has formally met state, county,
and local requirements, and has been granted a license by a local, state or federal government
entity.




Licensed Practitioner of the Healing Arts — A psychiatric nurse, Registered Nurse,
advanced registered nurse practitioner, Physician Assistant, clinical social worker, mental
health counselor, marriage and family therapist, or psychologist.




List of Excluded Individuals and Entities (LEIE) — A database maintained by the
Department of Health & Human Services, Office of the Inspector General. The LEIE provides
information to the public, health care providers, patients and others relating to parties
excluded from participation in Medicare, Medicaid and all other federal health care programs.




Managed Behavioral Health Organization (MBHO) — A behavioral health-care delivery system
managing quality, utilization and cost of services. Additionally, an MBHO measures performance
in the area of mental disorders.




Mandatory Assignment — The process the Agency uses to assign Potential Enrollees to a
Health Plan. The Agency automatically assigns those Mandatory Potential Enrollees who did not
voluntarily choose a Health Plan.




Market Area — The geographic area in which the Health Plan is authorized to market
and/or conduct pre-enrollment activities.




Marketing — Any activity or communication conducted by or on behalf of any Health Plan
to a Medicaid Recipient who is not Enrolled with the Health Plan, that can reasonably be
interpreted as intended to influence the Medicaid Recipient to enroll in the particular Health
Plan, or either to not enroll in, or disenroll from, another Health Plan.




Marketing Representative — A person who provides information, pre-enrollment assistance,
or otherwise promotes a Health Plan. Marketing Representatives shall be limited to licensed
insurance agents.




Medicaid Area — The specific counties designated by the Agency.




Medicaid — The medical assistance program authorized by Title XIX of the Social Security
Act, 42 U.S.C. §1396 et seq., and regulations there under, as administered in the State of
Florida by the Agency under 409.901 et seq., F.S.




Medicaid Recipient — Any individual whom DCF, or the Social Security Administration on
behalf of the DCF, determines is eligible, pursuant to federal and State law, to receive medical
or allied care, goods or services for which the Agency may make payments under the Medicaid
program, and who is enrolled in the Medicaid program.




Medicaid Reform — The program resulting from Chapter 409.91211, F.S.




Medical Record — Documents corresponding to medical or allied care, goods or services
furnished in any place of business. The records may be on paper, magnetic material, film or
other media. In order to qualify as a basis for reimbursement, the records must be dated,
legible and signed or otherwise attested to, as appropriate to the media.




Medically Necessary or Medical Necessity — Services that include medical or allied care,
goods or services furnished or ordered to:




	 	1.	 	Meet the following conditions:






	 	a.	 	Be necessary to protect life, to prevent significant illness or
significant disability or to alleviate severe pain;






	 	b.	 	Be individualized, specific and consistent with symptoms or
confirm diagnosis of the illness or injury under treatment and not in excess of
the patient’s needs;






	 	c.	 	Be consistent with the generally accepted professional medical
standards as determined by the Medicaid program, and not be experimental or
investigational;






	 	d.	 	Be reflective of the level of service that can be furnished
safely and for which no equally effective and more conservative or less costly
treatment is available statewide; and






	 	e.	 	Be furnished in a manner not primarily intended for the
convenience of the Enrollee, the Enrollee’s caretaker or the provider.






	 	2.	 	Medically Necessary or Medical Necessity for those services furnished in a
Hospital on an inpatient basis cannot, consistent with the provisions of appropriate
medical care, be effectively furnished more economically on an outpatient basis or in
an inpatient facility of a different type.






	 	3.	 	The fact that a provider has prescribed, recommended or approved medical or
allied goods or services does not, in itself, make such care, goods or services
Medically Necessary, a Medical Necessity or a Covered Service/Benefit.






Medicare — The medical assistance program authorized by Title XVIII of the Social
Security Act.




Meds AD — Those recipients up to 88% of FPL with assets up to $5,000 for an individual
and $6,000 for a couple without Medicare and those with Medicare that are not receiving
institutional care, hospice care, or home and community based services.




Neglect — A failure or omission to provide care, supervision, and services necessary to
maintain enrollee’s physical and mental health, including but not limited to, food, nutrition,
supervision and medical services that are essential for the well-being of the enrollee. Neglect
might be a single incident or repeated conduct that results in, or could reasonably expected to
result in, serious physical or psychological injury, or a substantial risk of death.




Newborn — A live child born to an Enrollee, who is a member of the Health Plan.




Non-Covered Service — A service that is not a Covered Service/Benefit of the Medicaid
State Plan or of the Health Plan.




Nursing Facility — An institutional care facility that furnishes medical or allied
inpatient care and services to individuals needing such services. See Chapters 395 and 400,
F.S.




Open Enrollment — The sixty (60) day period before the end of an Enrollee’s Enrollment
year, during which an Enrollee may choose to change Health Plans for the following Enrollment
year.




Outpatient — A patient of an organized medical facility, or distinct part of that
facility, who is expected by the facility to receive, and who does receive, professional
services for less than a twenty-four (24) hour period, regardless of the hours of admission,
whether or not a bed is used and/or whether or not the patient remains in the facility past
midnight.




Overpayment — Includes any amount that is not authorized to be paid by the Medicaid
program whether paid as a result of inaccurate or improper cost reporting, improper claiming,
unacceptable practices, fraud, abuse, or mistake. 




Participating Specialist — A physician, licensed to practice medicine in the State of
Florida, who contracts with the Health Plan to provide specialized medical services to the
Health Plan’s Enrollees.




Peer Review — An evaluation of the professional practices of a provider by the
provider’s peers in order to assess the necessity, appropriateness and quality of care furnished
as such care is compared to that customarily furnished by the provider’s peers and to recognized
health care standards.




Penultimate Saturday — The Saturday preceding the last Saturday of the month.




Penultimate Sunday — The Sunday preceding the last Sunday of the month.




Pharmacy Benefits Administrator — An entity contracted to or included in a health plan
accepting pharmacy prescription claims for enrollees in the plan, assuring these claims conform
to coverage policy and determining the allowed payment.




Physician’s Assistant — A person who is a graduate of an approved program or its
equivalent or meets standards approved by the Board of Medicine and is certified to perform
medical services delegated by the supervising physician in accordance with Chapter 458, F.S.




Physicians’ Current Procedural Terminology (CPT) —A systematic listing and coding of
procedures and services published annually by the American Medical Association.




Portable X-Ray Equipment — X-ray equipment transported to a setting other than a
hospital, Clinic or office of a physician or other Licensed Practitioner of the Healing Arts.




Post-Stabilization Care Services — Covered Services related to an Emergency Medical
Condition that are provided after an Enrollee is stabilized in order to maintain the condition,
or to improve or resolve the Enrollee’s condition pursuant to 42 CFR 422.113.




Potential Enrollee — Pursuant to 42 CFR 438.10(a), an eligible Medicaid Recipient who is
subject to Mandatory Assignment or may voluntarily elect to enroll in a given Health Plan, but
is not yet an Enrollee of a specific Health Plan.




Pre-Enrollment — The provision of Marketing and educational materials to a Medicaid
Recipient and assistance in completing the Request for Benefit Information (RBI).




Pre-Enrollment Application — See Request for Benefit Information.




Prepaid Health Plan — A Health Plan reimbursed on a prepaid basis. (see Health Plan)




Primary Care — Comprehensive, coordinated and readily-accessible medical care including:
health promotion and maintenance; treatment of illness and injury; early detection of disease;
and referral to specialists when appropriate.




Primary Care Case Management — The provision or arrangement of Enrollees’ primary care
and the referral of Enrollees for other necessary medical services on a 24-hour basis.




Primary Care Provider (PCP) — A Health Plan staff or contracted physician practicing as
a general or family practitioner, internist, pediatrician, obstetrician, gynecologist, advanced
registered nurse practitioners, physician assistants or other specialty approved by the Agency,
who furnishes Primary Care and patient management services to an Enrollee. See Sections 641.19,
641.31 and 641.51, F.S.




Prior Authorization — The act of authorizing specific services before they are rendered.




Protocols — Written guidelines or documentation outlining steps to be followed for
handling a particular situation, resolving a problem or implementing a plan of medical, nursing,
psychosocial, developmental and educational services.




Provider — A person or entity that is eligible to provide Medicaid services and has a
contractual agreement with the Health Plan to provide Medicaid services.




Provider Contract — An agreement between the Health Plan and a health care Provider as
described above.




Provider Service Network (PSN) — A network established or organized and operated by a
health care provider, or group of affiliated health care providers, including minority physician
networks and emergency room diversion programs that meet the requirements of Section 409.91211,
F.S., which provides a substantial proportion of the health care items and services
under a contract directly through the provider or affiliated group of providers and may make
arrangements with physicians or other health care professionals, health care institutions, or
any combination of such individuals or institutions to assume all or part of the financial risk
on a prospective basis for the provision of basic health services by the physicians, by other
health professionals, or through the institutions. The health care providers must have a
controlling interest in the governing body of the provider service network organization.




Public Event — An event sponsored for the public or segment of the public by two (2) or
more actively participating organizations, one (1) of which may be a health organization.




Quality — The degree to which a Health Plan increases the likelihood of desired health
outcomes of its Enrollees through its structural and operational characteristics and through the
provision of health services that are consistent with current professional knowledge.




Quality Enhancements – Certain health-related, community-based services that the Health
Plan must offer and coordinate access to for its Enrollees, such as children’s programs,
domestic violence classes, pregnancy prevention, smoking cessation, or substance abuse programs.
Health Plans are not reimbursed by the Agency for these types of services.




Quality Improvement (QI) — The process of monitoring and assuring that the delivery of
health care services are available, accessible, timely, Medically Necessary, and provided in
sufficient quantity, of acceptable Quality, within established standards of excellence, and
appropriate for meeting the needs of the Enrollees.




Quality Improvement Program (QIP) — The process of assuring the delivery of health care
is appropriate, timely, accessible, available and Medically Necessary.




Registered Nurse (RN) — An individual who is licensed to practice professional nursing
in accordance with Chapter 464, F.S.




Request for Benefit Information (RBI) — The form completed by a Potential Enrollee with
the assistance of a Health Plan representative and submitted by the Health Plan to the Choice
Counselor/Enrollment Broker to initiate the receipt of information for the Enrollment process.
Also known as Pre-Enrollment Application.




Residential Services — As applied to DJJ, refers to the out-of-home placement for use in
a level 4, 6, 8 or 10 facility as a result of a delinquency disposition order. Also referred to
as a Residential Commitment Program.




Risk Assessment — The process of collecting information from a person about hereditary,
lifestyle and environmental factors to determine specific diseases or conditions for which the
person is at risk.




Rural — An area with a population density of less than 100 individuals per square mile,
or an area defined by the most recent United State Census as rural, i.e. lacking a metropolitan
statistical area (MSA).




Rural Health Clinic (RHC) — A clinic that is located in an area that has a health-care
provider shortage. An RHC provides primary health care and related diagnostic services and may
provide optometric, podiatry, chiropractic and mental health services. An RHC employs,
contracts or obtains volunteer services from licensed health care practitioners to provide
services.




Sales Activities — Actions performed by an agent of any Health Plan, including the
acceptance of Pre-Enrollment Application Requests for Benefit Information, for the purpose of
Enrollment of Potential Enrollees.




Screen or Screening — Assessment of an Enrollee’s physical or mental condition to
determine evidence or indications of problems and need for further evaluation or services.




Service Area — The designated geographical area within which the Health Plan is
authorized by the Contract to furnish Covered Services to Enrollees.




Service Authorization — The Health Plan’s approval for services to be rendered. The
process of authorization must at least include a Health Plan Enrollee’s or a Provider’s request
for the provision of a service.




Service Location — Any location at which an Enrollee obtains any health care service
provided by the Health Plan under the terms of the Contract.




Sick Care — Non-urgent problems that do not substantially restrict normal activity, but
could develop complications if left untreated (e.g., chronic disease).




Span of Control — Information systems and telecommunications capabilities that the
Health Plan itself operates or for which it is otherwise legally responsible according to the
terms and Conditions of this Contract. The Health Plan span of control also includes Systems
and telecommunications capabilities outsourced by the Health Plan.




Special Supplemental Nutrition Program for Women, Infants & Children (WIC) — Program
administered by the Department of Health that provides nutritional counseling; nutritional
education; breast-feeding promotion and nutritious foods to pregnant, postpartum and
breast-feeding women, infants and children up to the age of five (5) who are determined to be at
nutritional risk and who have a low to moderate income. An individual who is eligible for
Medicaid is automatically income eligible for WIC benefits. Additionally, WIC income
eligibility is automatically provided to an Enrollee’s family that includes a pregnant woman or
infant certified eligible to receive Medicaid.




State — State of Florida.




Subcontract — An agreement entered into by the Health Plan for provision of
administrative services on its behalf.




Subcontractor — Any person or entity with which the Health Plan has contracted or
delegated some of its functions, services or responsibilities for providing services under this
Contract.




Subscriber Assistance Program – An external grievance program available to Medicaid
Recipients that will allow an additional avenue to resolve a Grievance or Appeal.




Surface Mail — Mail delivery via land, sea, or air, rather than via electronic
transmission.




Surplus — Net worth, i.e., total assets minus total liabilities.




System Unavailability — As measured within the Health Plan’s information systems Span of
Control, when a system user does not get the complete, correct full-screen response to an input
command within three (3) minutes after depressing the “Enter” or other function key.




Systems — See Information Systems.




Temporary Assistance to Needy Families (TANF) — Public financial assistance provided to
low-income families.




Transportation — An appropriate means of conveyance furnished to an Enrollee to obtain
Medicaid authorized/covered services.




Unborn Activation — The process by which an unborn child, who has been assigned a
Medicaid ID number is made Medicaid eligible upon birth.




Urban — An area with a population density of greater than 100 individuals per square
mile or an area defined by the most recent United State Census as urban, i.e. as having a
metropolitan statistical area (MSA).




Urgent Behavioral Health Care — Those situations that require immediate attention and
assessment within twenty-three (23) hours even though the Enrollee is not in immediate danger to
himself/herself or others and is able to cooperate in treatment.




Urgent Care — Services for conditions, which, though not life-threatening, could result
in serious injury or disability unless medical attention is received (e.g., high fever, animal
bites, fractures, severe pain, etc.) or do substantially restrict an Enrollee’s activity (e.g.,
infectious illnesses, flu, respiratory ailments, etc.).




Validation — The review of information, data, and procedures to determine the extent to
which they are accurate, reliable, free from bias and in accord with standards for data
collection and analysis.




Vendor — An entity submitting a proposal to become a Health Plan contractor.




Violation — A determination by the Agency that a Health Plan failed to act as specified
in this Contract or applicable statutes, rules or regulations governing Medicaid Health Plans.
Each day that an ongoing violation continues shall be considered, for the purposes of this
Contract, to be a separate Violation. In addition, each instance of failing to furnish
necessary and/or required medical services or items to Enrollees shall be considered, for
purposes of this Contract, to be a separate Violation. As well, each day that a Health Plan
fails to furnish necessary and/or required medical services or items to Enrollees shall be
considered, for purposes of this Contract, to be a separate Violation.




Well Care Visit — A routine medical visit for one (1) of the following: CHCUP visit,
family planning, routine follow-up to a previously treated condition or illness, adult physicals
or any other routine visit for other than the treatment of an illness.




	B.	 	Acronyms






ADL — Activities of Daily Living




ADM — Alcohol, Drug Abuse & Mental Health Office of the Florida Department of Children &
Families (aka SAMH — listed below)




ALF — Assisted Living Facility




APD — Agency for People with Disabilities




BBA — Balanced Budget Act of 1997




CAP — Corrective Action Plan




CARES — Comprehensive Assessment & Review for Long-Term Care Services




CDC — Centers for Disease Control




CHD — County Health Department




CMS — Centers for Medicare & Medicaid Services




CFR — Code of Federal Regulations




CHCUP — Child Health Check-Up Program




CPT — Physicians’ Current Procedural Terminology




DCF — Department of Children & Families




DFS – Department of Financial Services




DHHS — United States Department of Health & Human Services




DOH — Department of Health




DJJ — Department of Juvenile Justice




DEA — Drug Enforcement Administration




DME — Durable Medical Equipment




EDI — Electronic Data Interchange




EDT – Eastern Daylight Time




EPSDT — Early and Periodic Screening, Diagnosis & Treatment Program




EQR — External Quality Review




EQRO — External Quality Review Organization




EST — Eastern Standard Time




FAC — Florida Administrative Code




FFS — Fee-for-Service




FQHC — Federally Qualified Health Center




FTE — Full Time Equivalent Position




HIPAA — Health Insurance Portability & Accountability Act




HMO — Health Maintenance Organization




IBNR – Incurred but not reported




LEIE — List of Excluded Individuals & Entities




MBHO — Managed Behavioral Health Organization




ODBC — Open Database Connectivity




PCCB – Per capita capitation benchmark




PCP — Primary Care Physician




QI – Quality Improvement




QIP — Quality Improvement Program




RBI – Request for Benefit Information




RFP — Request for Proposal




RHC — Rural Health Clinic




SAMH — Alcohol, Drug Abuse & Mental Health Office of the Florida Department of Children &
Families (aka ADM — listed above)




SFTP — Secure File Transfer Protocol




SOBRA — Sixth Omnibus Budget Reconciliation Act




SQL — Structured Query Language




SSI — Supplemental Security Income




UM — Utilization Management




WIC — Special Supplemental Nutrition Program for Women, Infants & Children



21



Section II




General Overview





	A.	 	Purpose






This Contract is an agreement between the Agency and the Health Plan for the provision of
pre-paid Medicaid services.




	B.	 	Responsibilities of the State of Florida (State) and the Agency for Health Care
Administration (Agency)






	 	1.	 	The Agency will be responsible for administering the Medicaid program,
including all aspects of Medicaid Reform. The Agency will administer contracts,
monitor Health Plan performance, and provide oversight in all aspects of the Health
Plan’s operations.






	 	2.	 	The State has sole authority for determining eligibility for Medicaid and
whether Medicaid Recipients are mandated to enroll in, may enroll in, or may not enroll
in Medicaid Reform.






	 	3.	 	The Agency or its Agent will review the Florida Medicaid Management Information
System (FMMIS) file daily and will send written notification and information to all
Potential Enrollees. A Potential Enrollee will have thirty (30) Calendar Days to
select a Health Plan.






	 	4.	 	The Agency or its Agent will Auto-Assign Medicaid Recipients who do not select
a Medicaid health plan during their choice period to a health plan using a
pre-established algorithm.






	 	5.	 	Enrollment in the Health Plan, whether chosen or Auto-Assigned, is effective at
12:01 a.m. on the first (1st) Calendar Day of the month following Potential Enrollee
selection or Auto-Assignment, for those Potential Enrollees who choose or are
Auto-Assigned to the Health Plan on or between the first (1st) Calendar Day of the
month and the Penultimate Saturday of the month. For those Enrollees who choose or are
Auto-Assigned to the Health Plan between the Sunday after the Penultimate Saturday and
before the last Calendar Day of the month, Enrollment in the Health Plan will be
effective on the first (1st) Calendar Day of the second (2nd) month after choice or
Auto-assignment.






	 	6.	 	The Agency or its Agent will notify the Health Plan of an Enrollee’s selection
or assignment to the Health Plan.






	 	7.	 	The Agency or its Agent will send a written confirmation notice to Enrollees
identifying the chosen or Auto-Assigned Health Plan. If the Enrollee has not chosen a
PCP, the confirmation notice will advise the Enrollee that the Health Plan will assign
a PCP. Notice to the Enrollee will be made in writing and sent via Surface Mail.
Notice to the Health Plan will be made via file transfer.






	 	8.	 	Conditioned on continued eligibility, Mandatory Enrollees will have a Lock-In
period of twelve (12) consecutive months. After an initial ninety (90) day change
period, Mandatory Enrollees will only be able to disenroll from the Health Plan for
Cause. The Agency or its Agent will notify Enrollees at least once every twelve (12)
months, and at least sixty (60) Calendar Days prior to the date the Lock-In period ends
(the Open Enrollment period), that they have the opportunity to change health plans.
Enrollees who do not make a choice will be deemed to have chosen to remain with their
current health plan, unless the current health plan no longer participates in Medicaid
Reform. In this case, the Enrollee will be Auto-Assigned to a new health plan.






	 	9.	 	The Agency or its Agent will automatically re-enroll an Enrollee into the
health plan in which he or she was most recently enrolled if the Enrollee has a
temporary loss of eligibility, defined for purposes of this Contract as less than sixty
(60) Calendar Days. In this instance, for Mandatory Potential Enrollees, the Lock-In
period will continue as though there had been no break in eligibility, keeping the
original twelve (12) month period.






	 	10.	 	If a temporary loss of eligibility has caused the Enrollee to miss the Open
Enrollment period, the Agency or its Agent will enroll the Enrollee in the health plan
in which he or she was enrolled prior to the loss of eligibility. The Enrollee will
have ninety (90) Calendar Days to disenroll without Cause.






	 	11.	 	The State will issue a Medicaid identification (ID) number to a newborn upon
notification from the Health Plan, the hospital, or other authorized Medicaid provider,
consistent with the unborn activation process.






	 	12.	 	The Agency or its Agent will notify Enrollees of their right to request
Disenrollment as follows:






	 	a.	 	For Cause at any time; or






	 	b.	 	Without Cause, at the following times:






	 	(1)	 	During the ninety (90) days following the
Enrollee’s initial Enrollment, or the date the Agency or its Agent
sends the Enrollee notice of the enrollment, whichever is later;






	 	(2)	 	At least every twelve (12) months;






	 	(3)	 	If the temporary loss of Medicaid eligibility
has caused the Enrollee to miss the Open Enrollment period;






	 	(4)	 	When the Agency or its Agent grants the
Enrollee the right to terminate Enrollment without Cause. The Agency
or its Agent determines the Enrollee’s right to terminate Enrollment
without Cause on a case-by-case basis.






	 	13.	 	The Agency or its Agent will process all Disenrollments from the Health Plan.
The Agency or its Agent will make final determinations about granting Disenrollment
requests and will notify the Health Plan via file transfer and the Enrollee via Surface
Mail of any Disenrollment decision.






	 	14.	 	When Disenrollment is necessary because an Enrollee loses Medicaid eligibility,
Disenrollment shall be immediate.






	 	15.	 	The Agency will conduct periodic monitoring of the Health Plan’s operations for
compliance with the provisions of the Contract and applicable federal and State laws
and regulations.






	 	 	C . General Responsibilities of the Health Plan






	 	1.	 	The Health Plan shall comply with all provisions of this Contract and its
amendments, if any, and shall act in good faith in the performance of the Contract’s
provisions. The Health Plan shall develop and maintain written policies and procedures
to implement all provisions of this Contract. The Health Plan agrees that failure to
comply with all provisions of this Contract shall result in the assessment of penalties
and/or termination of the Contract, in whole or in part, as set forth in this Contract.






	 	2.	 	The Health Plan shall comply with all pertinent Agency rules in effect
throughout the duration of the Contract.






	 	3.	 	The Health Plan shall comply with all current Florida Medicaid Handbooks
(“Handbooks”) as noticed in the Florida Administrative Weekly (“FAW”), or incorporated
by reference in rules relating to the provision of services set forth in Section V,
Covered Services, and Section VI, Behavioral Health Care, except where the provisions
of the Contract alter the requirements set forth in the Handbooks promulgated in the
Florida Administrative Code (FAC). In addition, the Health Plan shall comply with the
limitations and exclusions in the Handbooks, unless otherwise specified by this
Contract. In no instance may the limitations or exclusions imposed by the Health Plan
be more stringent than those specified in the Handbooks. The Health Plan shall furnish
services in an amount, duration and scope that are no more restrictive than the
services provided in the non-Medicaid Reform FFS program and that may reasonably be
expected to achieve the purpose for which the services are furnished. The Health Plan
shall not arbitrarily deny or reduce the amount, duration or scope of a required
service solely because of the diagnosis, type of illness, or condition.






	 	4.	 	The Health Plan may offer Expanded Services, as described in Section V, Covered
Services to Enrollees, in addition to the required services and Quality Enhancements.
The Health Plan shall define with specificity its Expanded Services in regards to
amount, duration and scope, and obtain approval, in writing, by the Agency prior to
implementation.






	 	5.	 	This Contract including all attachments and exhibits, represents the entire
agreement between the Health Plan and the Agency and supersedes all other contracts
between the parties when it is executed by duly authorized signatures of the Health
Plan and the Agency. Correspondence and memoranda of understanding do not constitute
part of this Contract. In the event of a conflict of language between the Contract and
the attachments, the provisions of the Contract shall govern. The Agency reserves the
right to clarify any contractual relationship in writing and such clarification shall
govern. Pending final determination of any dispute over any Agency decision, the
Health Plan shall proceed diligently with the performance of its duties as specified
under the Contract and in accordance with the direction of the Agency’s Division of
Medicaid.






	 	6.	 	The Health Plan shall have a Quality Improvement program that ensures
enhancement of quality of care and emphasizes improving the quality of patient
outcomes. The Agency may restrict the Health Plan’s Enrollment activities if the
Health Plan does not meet acceptable Quality Improvement and performance indicators,
based on HEDIS reports and other outcome measures to be determined by the Agency. Such
restrictions may include, but shall not be limited to, the termination of Mandatory
Assignments.






	 	7.	 	The Health Plan must demonstrate that it has adequate knowledge of Medicaid
programs, provision of health care services, medical claims data, and the capability to
design and implement cost savings methodologies. The Health Plan must demonstrate the
capacity for financial analyses, as necessary to fulfill the requirements of this
Contract. Additionally, the Health Plan must meet all requirements for doing business
in the State of Florida.






	 	8.	 	The Health Plan may be required to provide to the Agency or its Agent
information or data that is not specified under this Contract. In such instances, and
at the direction of the Agency, the Health Plan shall fully cooperate with such
requests and furnish all information in a timely manner, in the format in which it is
requested. The Health Plan shall have at least thirty (30) Calendar Days to fulfill
such ad hoc requests.






	 	9.	 	The Health Plan shall fully cooperate with, and provide necessary data to, the
Agency and its Agent for the design, management, operations and monitoring of the
Enhanced Benefits Program.






	 	10.	 	The Health Plan shall provide care management services and monitor utilization
of services through the prior authorization of claims for Covered Services for its
Enrollees.






	 	11.	 	The Health Plans shall collect and submit Encounter Data for each Contract Year
in the format required by the Agency and within the time frames specified by the
Agency. An encounter guide along with technical assistance will be forthcoming. At a
minimum the Health Plans shall be responsible for the following:






	 	a.	 	Health Plans shall collect and submit to the Agency or its
designee, Enrollee service level encounter data for all Covered Services;






	 	b.	 	Encounter data shall be submitted following HIPAA standards,
namely the ANSI X12N 837 Transaction formats (P — Professional, I -
Institutional, and D – Dental), and the National Council for Prescription Drug
Programs NCPDP format (for Pharmacy services); and






	 	c.	 	All Covered Services rendered to Enrollees shall result in the
creation of an encounter record.





22




REMAINDER OF PAGE INTENTIONALLY LEFT BLANKSection III




Eligibility and Enrollment





	A.	 	Eligibility






The following Populations represent broad categories that contain multiple eligibility
groups. Certain exceptions may apply within the broad categories and will be determined by
the Agency.




	 	1.	 	Eligible Populations






	 	a.	 	The categories of eligible Medicaid Recipients authorized to be
enrolled in the Health Plan are:






	 	(1)	 	Low Income Families and Children;






	 	(2)	 	Sixth Omnibus Budget Reconciliation Act (SOBRA)
Children;






	 	(3)	 	Supplemental Security Income (SSI) Medicaid
Only;






	 	(4)	 	SSI Medicare, Part B only;






	 	(5)	 	SSI Medicare, Parts A and B;






	 	(6)	 	Medicaid Recipients who are residents in ALFs
and are not enrolled in an ALF waiver program;






	 	(7)	 	Refugees;






	 	(8)	 	The Meds AD population;






	 	(9)	 	Individuals with Medicare coverage
(e.g., dual eligible individuals) who are not enrolled in a Medicare
Advantage Plan;






	 	(10)	 	Title XXI MediKids are eligible for Enrollment
in the Health Plan in accordance with Section 409.8132, F.S. Except as
otherwise specified in this Contract, Title XXI MediKids eligible
participants are entitled to the same conditions and services as
currently eligible Title XIX Medicaid Recipients; and






	 	(11)	 	Women enrolled in the Health Plan who change
eligibility categories to the SOBRA eligibility category due to
pregnancy remain eligible for Enrollment in the Health Plan.






	 	2.	 	Ineligible Populations






	 	a.	 	The following categories describe Medicaid Recipients who are
not eligible to enroll in a Health Plan:






	 	(1)	 	Pregnant women who have not enrolled in
Medicaid Reform prior to the effective date of their SOBRA eligibility;






	 	(2)	 	Medicaid Recipients who, at the time of
application for Enrollment and/or at the time of Enrollment, are
domiciled or residing in an institution, including:






(a) Nursing facilities (and have been CARES assessed);




(b) Sub-acute inpatient psychiatric (SIPP) facilities,




	 	(c)	 	Intermediate care facility for
persons with developmental disabilities (ICF-DD);






(d) State hospitals; or




(e) Correctional institutions.




	 	(3)	 	Medicaid Recipients whose Medicaid eligibility
was determined through the medically needy program.






	 	(4)	 	Qualified Medicare Beneficiaries (“QMBs”),
Special Low Income Medicare Beneficiaries (SLMBs), or Qualified
Individuals at Level 1 (QI-1s);






	 	(5)	 	Medicaid Recipients who have other creditable
health-care coverage, such as TriCare or a private health maintenance
organization (HMO);






(6) Medicaid Recipients who reside in the following:




	 	(a)	 	Residential commitment
programs/facilities operated through the Department of Juvenile
Justice (DJJ);






	 	(b)	 	Residential group care operated
by the Family Safety & Preservation Program of the DCF;






	 	(c)	 	Children’s residential treatment
facilities purchased through the Substance Abuse & Mental Health
District (“SAMH”) Offices of the DCF (also referred to as
Purchased Residential Treatment Services — “PRTS”);






	 	(d)	 	SAMH residential treatment
facilities licensed as Level I and Level II facilities; and






	 	(e)	 	Residential Level I and Level II
substance abuse treatment programs.  See Sections
65D-30.007(2)(a) and (b), F.A.C.






	 	(7)	 	Medicaid Recipients participating in the Family Planning waiver;






	 	(8)	 	Children/Adolescents with chronic conditions
who are enrolled in Children’s Medical Services (CMS);






	 	(9)	 	Women eligible for Medicaid due to breast
and/or cervical cancer;






	 	(10)	 	Individuals eligible under a hospice-related
eligibility group;






	 	(11)	 	Medicaid Recipients who are members of the
Florida Assertive Community Treatment Team (FACT team);






	 	(12)	 	Medicaid Recipients who are receiving services
through a hospice program, the Medicaid AIDS waiver (Project AIDS Care)
program, a prescribed pediatric extended care center;






	 	(13)	 	Medicaid Recipients who are also members of a
Medicare-funded health maintenance organization (HMO);






	 	(14)	 	Medicaid Recipients whose Medicaid eligibility
has been determined through the medically needy program; or






	 	(15)	 	Family Planning waiver beneficiaries.






	B.	 	Enrollment






	 	1.	 	General Provisions






	 	a.	 	Only Medicaid Recipients who are included in the eligible
population and living in counties with authorized Health Plans are eligible to
enroll and receive services from the Health Plan.






	 	b.	 	The Agency or its Agent shall be responsible for Enrollment,
including Enrollment into a Health Plan, Disenrollment, and outreach and
education activities. The Health Plan shall coordinate with the Agency and its
Agent as necessary for all Enrollment and Disenrollment functions.






	 	c.	 	The Health Plan shall accept Medicaid Recipients without
restriction and in the order in which they enroll. The Health Plan shall not
discriminate against Medicaid Recipients on the basis of religion, gender,
race, color, age, or national origin, and shall not use any policy or practice
that has the effect of discriminating on the basis of religion, gender, race,
color, or national origin, or on the basis of health, health status,
pre-existing condition, or need for health care services.






	 	d.	 	The Health Plan shall accept new Enrollees through-out the
Contract period up to the authorized maximum enrollment levels approved in
Attachment I.






	 	2.	 	Enrollment with a Primary Care Provider (PCP)






	 	a.	 	The Health Plan shall offer each Enrollee a choice of PCPs.
After making a choice, each Enrollee shall have a single PCP.






	 	b.	 	The Health Plan shall assign a PCP to those Enrollees who did
not choose a PCP at the time of Health Plan selection. The Health Plan shall
take into consideration the Enrollee’s last PCP (if the PCP is known and
available in the Health Plan’s network), closest PCP to the Enrollee’s home
address, ZIP code location, keeping Children/Adolescents within the same family
together, age (adults versus Children/Adolescents) and gender (OB/GYN).






	 	c.	 	The Health Plan shall provide written notice of the following via Surface
Mail to the Enrollee, by the first day of the Enrollee’s enrollment or within
five (5) Calendar Days following the availability of the Enrollment file from
the Agency or its Agent, whichever is later:






	 	(1)	 	The actual date of Enrollment, and the name,
telephone number and address of the Enrollee’s PCP assignment;






(2) The Enrollee’s ability to choose a different PCP;




	 	(3)	 	An explanation that a provider directory has
been mailed separately with other member materials; and






	 	(4)	 	The procedures for changing PCPs, including
provision of the Health Plan’s toll-free member services telephone
number, etc.






	 	d.	 	The Health Plan shall permit Enrollees to change PCPs at any time.






	 	e.	 	The Health Plan shall assign all Enrollees that are reinstated
after a temporary loss of eligibility to the PCP who was treating them prior to
loss of eligibility, unless the Enrollee specifically requests another PCP, the
PCP no longer participates in the Health Plan or is at capacity, or the
Enrollee has changed geographic areas.






	 	3.	 	Newborn Enrollment






	 	a.	 	The Health Plan shall utilize the unborn activation process to
facilitate enrollment and shall be responsible for newborns from the date they
are enrolled in the Health Plan.






	 	b.	 	Upon unborn activation, the newborn shall be enrolled in the
Health Plan in which his/her mother was enrolled during the next enrollment
cycle.






	 	c.	 	Newborn Enrollment shall occur through the following
procedures:






	 	(1)	 	Upon identification of an Enrollee’s pregnancy,
the Health Plan shall immediately notify DCF of the pregnancy and any
relevant information known (i.e., due date and gender). The Health
Plan must provide this notification by completing the DCF-ES 2039 Form
and submitting the completed form to DCF. The Health Plan shall
indicate its name and number as the entity initiating the referral.
The DCF-ES 2039 form is located on the Medicaid web site:





http://www.fdhc.state.fl.us/Medicaid/Newborn




	 	(2)	 	DCF will generate a Medicaid ID number and the
unborn child will be added to the Medicaid file. This information will
be transmitted to the Medicaid Fiscal Agent. The Medicaid ID number
will remain inactive until after the child is born.






	 	(3)	 	The Health Plan shall comply with all
requirements set forth by the Agency or its Agent related to Unborn
Activation (see Policy Transmittal 06-02, Unborn Activation Process).
To ensure the prompt enrollment of Newborns, the Health Plan shall
ensure that the form DCF-ES 2039 (Form 2039) is completed and
submitted, via electronic submission, to the local DCF Economic
Self-Sufficiency Services Office immediately upon the birth of the
child. If the Hospital is not a participating Hospital, the Health
Plan must complete and transmit the Form 2039 to DCF. With regard to
participating Hospitals, as part of its participating Hospital
contract, the Health Plan must include a clause that states whether the
Health Plan or the participating Hospital will complete and transmit
Form 2039 to DCF for all Newborns.






	 	(4)	 	Upon notification that a pregnant Enrollee has
presented to the Hospital for delivery, the Health Plan shall inform
the Hospital, the pregnant Enrollee’s attending physician and the
newborn’s attending and consulting physicians that the newborn is an
Enrollee only if the Health Plan has verified that the newborn has an
unborn record on the system that is awaiting activation. At this time
the Health Plan shall initiate the Unborn Activation process.






	 	(5)	 	Upon activation, the newborn shall be enrolled
in the Health Plan in which his/her mother was enrolled during the
month of birth.






	 	4.	 	Enrollment Cessation






The Health Plan may request that the Agency halt or reduce Enrollment temporarily if
continued full Enrollment would exceed its capacity to provide required services
under the Contract. The Agency may also limit Health Plan Enrollments when
such action is considered to be in the Agency’s best interest in accordance with the
provisions of this Contract.



5. Enrollment Notice




By the first day of the Enrollee’s enrollment or within five (5) Calendar
Days following receipt of the Enrollment file from Medicaid or its Agent, whichever
is later, the Health Plan shall mail the following information to all new Enrollees:




	 	a.	 	Notification that Enrollees can change their Health Plan
selection, subject to Medicaid limitations.






	 	b.	 	Enrollment materials regarding PCP choice as described in
Section III.B., including the Provider Directory.






c. New Enrollee Materials as described in Section IV.




	C.	 	Disenrollment






	 	1.	 	General Provisions






	 	a.	 	If the Contract is renewed, the Enrollment status of all
Enrollees shall continue uninterrupted.






	 	b.	 	The Health Plan shall ensure that it does not restrict the
Enrollee’s right to disenroll voluntarily in any way.






	 	c.	 	The Health Plan or its agents shall not provide or assist in
the completion of a Disenrollment request or assist the Agency’s contracted
Choice Counselor/Enrollment Broker in the Disesnrollment process.






	 	d.	 	The Health Plan shall ensure that Enrollees that are
disenrolled and wish to file an appeal have the opportunity to do so. All
Enrollees shall be afforded the right to file an appeal except for the
following reasons for Disenrollment:






	 	(1)	 	Moving out of the Service Area;






	 	(2)	 	Loss of Medicaid eligibility; and






	 	(3)	 	Enrollee death.






	 	e.	 	An Enrollee may submit to the Agency or its Agent a request to
disenroll from the Health Plan without Cause during the ninety (90) Calendar
Day change period following the date of the Enrollee’s initial Enrollment with
the Health Plan, or the date the Agency or its Agent sends the Enrollee notice
of the Enrollment, whichever is later. An Enrollee may request Disenrollment
without Cause every twelve (12) months thereafter.






	 	f.	 	The effective date of an approved Disenrollment shall be the
last Calendar Day of the month in which Disenrollment was made effective by the
Agency or its Agent, but in no case shall Disenrollment be later than the first
(1st) Calendar Day of the second (2nd) month following the month in which the
Enrollee or the Health Plan files the Disenrollment request. If the Agency or
its Agent fails to make a Disenrollment determination within this timeframe,
the Disenrollment is considered approved.






	 	g.	 	The Health Plan shall keep a daily written log or electronic
documentation of all oral and written Enrollee Disenrollment requests and the
disposition of such requests. The log shall include the following:






	 	(1)	 	The date the request was received by the Health
Plan;






	 	(2)	 	The date the Enrollee was referred to the
Agency’s Choice Counselor/Enrollment Broker or the date of the letter
advising the Enrollee of the Disenrollment procedure, as appropriate;
and






	 	(3)	 	The reason that the Enrollee is requesting
Disenrollment.






	 	h.	 	The Health Plan shall send to the Agency or its Agent a monthly
summary report of all submitted Disenrollment requests. This report must
specify the reason for such Disenrollment requests. It shall be reconciled to
the Health Plan Enrollment Report processed by the Agency or its Agent for the
applicable month and shall be reviewed by the Agency or its Agent for
compliance with acceptable reasons for Disenrollment. The Agency may reinstate
Enrollment for any Enrollee whose reason for Disenrollment is not consistent
with established guidelines.






	 	2.	 	Cause for Disenrollment






	 	a.	 	An Enrollee may request Disenrollment from the Health Plan for
Cause at any time. Such request shall be submitted to the Agency or its Agent.
The following reasons constitute Cause for Disenrollment from the Health Plan:






	 	(1)	 	The Enrollee moves out of the county, or
the Enrollee’s address is incorrect and the Enrollee does not live in
the county;






	 	(2)	 	The Provider is no longer with the Health Plan;






	 	(3)	 	The Enrollee is excluded from enrollment;






	 	(4)	 	A substantiated marketing violation occurred;






	 	(5)	 	The Enrollee is prevented from participating in
the development of his/her treatment plan;






	 	(6)	 	The Enrollee has an active relationship with a
provider who is not on the Health Plan’s network, but is in the network
of another health plan;






	 	(7)	 	The Enrollee is enrolled in the wrong Health
Plan as determined by the Agency;






	 	(8)	 	The Health Plan no longer participates in the
county;






	 	(9)	 	The State has imposed intermediate sanctions
upon the Health Plan, as specified in 42 CFR 438.702(a)(3);






	 	(10)	 	The Enrollee needs related services to be
performed concurrently, but not all related services are available
within the Health Plan network; or, the Enrollee’s PCP has determined
that receiving the services separately would subject the Enrollee to
unnecessary risk;






	 	(11)	 	The Health Plan does not, because of moral or
religious objections, cover the service the Enrollee seeks;






	 	(12)	 	The Enrollee missed his/her Open Enrollment due
to a temporary loss of eligibility, defined as sixty (60) days or less;
or






	 	(13)	 	Other reasons per 42 CFR 438.56(d)(2),
including, but not limited to, poor quality of care; lack of access to
services covered under the Contract; inordinate or inappropriate
changes of PCPs; service access impairments due to significant changes
in the geographic location of services; lack of access to Providers
experienced in dealing with the Enrollee’s health care needs; or
fraudulent Enrollment.






	 	3.	 	Involuntary Disenrollment






	 	a.	 	With proper written documentation, the following are acceptable
reasons for which the Health Plan shall submit Involuntary Disenrollment
requests to the Agency or its Choice Counselor/Enrollment Broker, as specified
by the Agency:






	 	(1)	 	Enrollee has moved out of the Service Area;






	 	(2)	 	Enrollee death;






	 	(3)	 	Determination that the Enrollee is ineligible
for Enrollment based on the criteria specified in this Contract in
Section III.A.3, Excluded Populations; and






	 	(4)	 	Fraudulent use of the Enrollee ID card.






	 	b.	 	The Health Plan shall promptly submit such Disenrollment
requests to the Agency or its Choice Counselor/Enrollment Broker, as specified
by the Agency. In no event shall the Health Plan submit the Disenrollment
request at such a date as would cause the Disenrollment to be effective later
than forty-five (45) Calendar Days after the Health Plan’s receipt of the
reason for Involuntary Disenrollment. The Health Plan shall ensure that
Involuntary Disenrollment documents are maintained in an identifiable Enrollee
record.






	 	c.	 	If the Health Plan submitted the Disenrollment request for one
of the above reasons, the Health Plan shall verify that the information is
accurate.






	 	d.	 	If the Health Plan discovers that an ineligible Enrollee has
been enrolled, then it shall request Disenrollment of the Enrollee and shall
notify the Enrollee in writing that the Health Plan is requesting Disenrollment
and the Enrollee will be disenrolled in the next Contract month, or earlier if
necessary. Until the Enrollee is Disenrolled, the Health Plan shall be
responsible for the provision of services to that Enrollee.






	 	e.	 	On a monthly basis, the Health Plan shall review its ongoing
Enrollment report (FLMR 8200-R0004) to ensure that all Enrollees are residing
in the same county in which they were enrolled. The Health Plan shall update
the records for all Enrollees who have moved from one county to another, but
are still residing in the Health Plan’s Service Area, and provide the Enrollee
with a new Provider Directory for that county. For Enrollees with
out-of-county addresses on the Enrollment report, the Health Plan shall notify
the Enrollee in writing that the Enrollee should contact the Choice
Counselor/Enrollment Broker or Medicaid Options, depending on whether the
Enrollee moves into a Reform or Non-Reform County, respectively, to choose
another Health Plan, or other managed care option available in the Enrollee’s
new county, and that the Enrollee will be Disenrolled as a result of the
Enrollee’s contact with the Choice Counselor/Enrollment Broker or Medicaid
Options.






	 	f.	 	The Health Plan may submit an Involuntary Disenrollment request
to the Agency or its Choice Counselor/Enrollment Broker, as specified by the
Agency, after providing to the Enrollee at least one (1) verbal warning and at
least one (1) written warning of the full implications of his or her failure of
actions:






	 	(1)	 	For an Enrollee who continues not to comply
with a recommended plan of health care. Such requests must be
submitted at least sixty (60) Calendar Days prior to the requested
effective date.






	 	(2)	 	For an Enrollee whose behavior is disruptive,
unruly, abusive or uncooperative to the extent that his or her
Enrollment in the Health Plan seriously impairs the organization’s
ability to furnish services to either the Enrollee or other Enrollees.
This Section does not apply to Enrollees with mental health diagnoses
if the Enrollee’s behavior is attributable to the mental illness.






	 	g.	 	The Agency may approve such requests provided that the Health
Plan documents that attempts were made to educate the Enrollee regarding
his/her rights and responsibilities, assistance which would enable the Enrollee
to comply was offered through Case Management, and it has been determined that
the Enrollee’s behavior is not related to the Enrollee’s medical or behavioral
condition. All requests will be reviewed on a case-by-case basis and subject
to the sole discretion of the Agency. Any request not approved is final and
not subject to dispute or appeal.






	 	h.	 	The Health Plan shall not request Disenrollment of an Enrollee
due to:






	 	(1)	 	Health diagnosis;






	 	(2)	 	Adverse changes in an Enrollee’s health status;






	 	(3)	 	Utilization of medical services;






	 	(4)	 	Diminished mental capacity;






	 	(5)	 	Pre-existing medical condition;






	 	(6)	 	Uncooperative or disruptive behavior resulting
from the Enrollee’s special needs (with the exception of C.4.f.2
above);






	 	(7)	 	Attempt to exercise rights under the Health
Plan’s Grievance System; or






	 	(8)	 	Request of one (1) PCP to have an Enrollee
assigned to a different Provider out of the Health Plan.





23




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Section IV




Enrollee Services and Marketing





	A.	 	Enrollee Services






	 	1.	 	General Provisions






	 	a.	 	The Health Plan shall have written policies and procedures for
the provision of Enrollee Services, as specified in this Contract. Such
policies and procedures shall be submitted to the Agency for approval.






	 	b.	 	The Health Plan shall ensure that Enrollees are aware of their
rights and responsibilities, the role of PCPs, how to obtain care, what to do
in an emergency or urgent medical situation, how to request a Grievance, Appeal
or Medicaid Fair Hearing, how to report suspected Fraud and Abuse, procedures
for obtaining required Behavioral Health Services, including any additional
Health Plan phone numbers to be used for obtaining services, and all other
requirements and Benefits of the Health Plan.






	 	c.	 	The Health Plan shall have the capability to answer Enrollee
inquiries via written materials, telephone, electronic transmission, and
face-to-face communication.






	 	d.	 	Mailing envelopes for Enrollee materials shall contain a
request for address correction. For Enrollees whose Enrollee Materials are
returned to the Health Plan as undeliverable, the Health Plan shall use and
maintain in a file a record of all of the following methods to contact the
Enrollee:






	 	(1)	 	Telephone contact at the telephone number
obtained from the local telephone directory, directory assistance, city
directory, or other directory;






	 	(2)	 	Telephone contact with DCF and Families
Economic Self-Sufficiency Services Office staff to determine if they
have updated address information and telephone number; and






	 	(3)	 	Routine checks (at least once a month for the
first three (3) months of Enrollment) on services or claims authorized
or denied by the Health Plan to determine if the Enrollee has received
services, and to locate updated address and telephone number
information.






	 	e.	 	New Enrollee materials are not required for a former Enrollee
who was disenrolled because of the loss of Medicaid eligibility and who regains
his/her eligibility within sixty (60) days and is automatically reinstated as a
Health Plan Enrollee. In addition, unless requested by the Enrollee, new
Enrollee materials are not required for a former Enrollee subject to Open
Enrollment who was disenrolled because of the loss of Medicaid eligibility, who
regains his/her eligibility within sixty (60) days of his/her managed care
enrollment, and is reinstated as a Health Plan Enrollee. notation of the
effective date of the reinstatement on the most recent application or
conspicuously in the Enrollee’s administrative file. Enrollees, who were
previously enrolled in a Health Plan, lose and regain eligibility after sixty
(60) days, will be treated as new Enrollees.






	 	f.	 	The Health Plan shall notify, in writing, each person who is to
be reinstated, of the effective date of the reinstatement and the assigned
Primary Care Provider. The notifications shall distinguish between Enrollees
subject to Open Enrollment and Enrollees not subject to Open Enrollment and
shall include information regarding change procedures for Cause, or general
Health Plan change procedures through the Agency’s toll-free Choice
Counselor/Enrollment Broker telephone number, as appropriate. The notification
shall also instruct the Enrollee to contact the Health Plan if a new Enrollee
card and/or a new Enrollee handbook are needed. The Health Plan shall provide
such notice to each affected Enrollee by the first (1st) Calendar Day of the
month following the Health Plan’s receipt of the notice of reinstatement.






	 	2.	 	Requirements for Written Materials






	 	a.	 	The Health Plan shall make all written materials available in
alternative formats and in a manner that takes into consideration the
Enrollee’s special needs, including those who are visually impaired or have
limited reading proficiency. The Health Plan shall notify all Enrollees and
Potential Enrollees that information is available in alternative formats and
how to access those formats.






	 	b.	 	The Health Plan shall make all written material available in
English, Spanish, and all other appropriate foreign languages. The appropriate
foreign languages comprise all languages in the Health Plan Service Area spoken
by approximately five percent (5%) or more of the total population. The Health
Plan shall provide, free of charge, interpreters for Potential Enrollees or
Enrollees whose primary language is a foreign language.






	 	c.	 	The Health Plan shall provide Enrollee information in
accordance with 42 CFR 438.10, which addresses information requirements related
to written and oral information provided to Enrollees, including: languages,
format, Health Plan features such as benefits, Service Area, Provider network
and physician incentive plans, Enrollment and Disenrollment rights and
responsibilities, the Grievance System, Advance Directives. The Health Plan
shall notify Enrollees on at least an annual basis of their right to request
and obtain information in accordance with the above regulations.






	 	d.	 	All written materials shall be at or near the fourth
(4th) grade comprehension level. Suggested reference materials to
determine whether the Health Plan’s written materials meet this requirement
are:






	 	(1)	 	Fry Readability Index;






	 	(2)	 	PROSE The Readability Analyst (software
developed by Education Activities, Inc.);






	 	(3)	 	Gunning FOG Index;






	 	(4)	 	McLaughlin SMOG Index;






	 	(5)	 	The Flesch-Kincaid Index; or






	 	(6)	 	Other software approved by the Agency.






	 	e.	 	The Health Plan shall provide written notice to the Agency of
any changes to any written materials provided to Enrollees. Written materials
shall be provided to the Agency at least forty-five (45) Calendar Days prior to
the effective date of the change. Written notice of such changes shall be
provided to Enrollees at least thirty (30) days prior to the effective date of
the change.






	 	f.	 	All written materials, including any materials for the Health
Plan Web site, shall be submitted to the Agency for written approval prior to
being distributed.






	 	3.	 	New Enrollee Materials






	 	a.	 	By the first day of the assigned Enrollee’s Enrollment
or within five (5) Calendar Days following receipt of the Enrollment file from
Medicaid or its Agent, whichever is later, the Health Plan shall mail to the
new Enrollee the Enrollee Handbook, the Provider Directory, the Enrollee
Identification and the following additional materials:






	 	(1)	 	A request for the following information to be updated: Enrollee’s
name, address (home and mailing), county of residence, and telephone
number;






	 	(2)	 	A completed, signed and dated release form
authorizing the Health Plan to release medical information to the
federal and State governments or their duly appointed agents; and,
current behavioral health care provider information;






	 	(3)	 	A notice that Enrollees who lose eligibility
and are disenrolled shall be automatically re-Enrolled in the Health
Plan if eligibility is regained within 180 days;






	 	(4)	 	Each mailing shall include a postage paid,
pre-addressed return envelope; and






	 	(5)	 	The initial mailing may be combined with the
PCP assignment notification. The Health Plan shall document each
mailing in the Health Plan’s records.





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24










	 	4.	 	Enrollee Handbook Requirements






	 	a.	 	The Enrollee services handbook shall include the following
information:






	 	(1)	 	Table of Contents;






	 	(2)	 	Terms and conditions of Enrollment including
the reinstatement process;






	 	(3)	 	Description of the Open Enrollment process;






	 	(4)	 	Description of services provided, including
limitations and general restrictions on Provider access, exclusions and
out-of-network use;






	 	(5)	 	Procedures for obtaining required services,
including second opinions, and authorization requirements, including
those services available without Prior Authorization;






	 	(6)	 	Toll-free telephone number of the appropriate
Area Medicaid Office;






	 	(7)	 	Emergency Services and procedures for obtaining
services both in and out of the Health Plan’s Service Area, including,
an explanation that Prior Authorization is not required for Emergency
Services, the locations of any emergency settings and other locations
at which Providers and Hospitals furnish Emergency Services and
Post-Stabilization Care Services and use of the 911 telephone system,
or its equivalent;






	 	(8)	 	The extent to which, and how, after-hours and
emergency coverage is provided, and that the Enrollee has a right to
use any Hospital or other setting for Emergency Care;






	 	(9)	 	Procedures for Enrollment, including Enrollee
rights and protections;






	 	(10)	 	A notice advising Enrollees how to change PCPs;






	 	(11)	 	Grievance System components and procedures;






	 	(12)	 	Enrollee rights and procedures for
Disenrollment, including the toll-free telephone number for the
Agency’s contracted Choice Counselor/Enrollment Broker;






	 	(13)	 	Procedures for filing a request for
Disenrollment for Cause;






	 	(14)	 	Information regarding Newborn enrollment,
including the mother’s responsibility to notify the Health Plan and the
mother’s DCF case worker of the Newborn’s birth and selection of a PCP;






	 	(15)	 	Enrollee rights and responsibilities, including
the extent to which, and how, Enrollees may obtain services from
out-of-network providers and the right to obtain family planning
services from any participating Medicaid provider without Prior
Authorization for such services, and other provisions in accordance
with 42 CFR 438.100;






	 	(16)	 	Information on emergency transportation and
non-emergency transportation, counseling and referral services
available under the Health Plan, and how to access these services;






	 	(17)	 	Information that interpretation services and
alternative communication systems are available, free of charge, for
all foreign languages, and how to access these services;






	 	(18)	 	Information that Post-Stabilization Services
are provided without Prior Authorization and other Post-Stabilization
Care Services rules set forth in 42 CFR 422.113(c);






	 	(19)	 	Information that services will continue upon
appeal of a suspended authorization and that the Enrollee may have to
pay in case of an adverse ruling;






	 	(20)	 	Information regarding health care Advance
Directives pursuant to Chapter 765, F.S., and 42 CFR 422.128;






	 	(21)	 	Cost sharing for the Enrollee, if any;






	 	(22)	 	Instructions explaining how Enrollees may
obtain information from the Health Plan regarding quality performance
indicators, including Enrollee information;






	 	(23)	 	How and where to access any benefits that are
available under the State Plan, but not covered under the Contract,
including cost sharing;






	 	(24)	 	Any restrictions on the Enrollee’s freedom of
choice among network Providers;






	 	(25)	 	A release document for each Enrollee
authorizing the Health Plan to release medical information to the
federal and State governments or their duly appointed Agents;






	 	(26)	 	A notice that clearly states that the Enrollee
may select an alternative Behavioral Health Care Case Manager or direct
service provider within the Health Plan, if one is available;






	 	(27)	 	A description of Behavioral Health Services
provided, including limitations, exclusions and out-of-network use;






	 	(28)	 	An explanation that Enrollees may choose to
have all family members served by the same PCP or they may choose
different PCPs;






	 	(29)	 	A description of Emergency Behavioral Health
Services procedures both in and out of the Health Plan’s Service Area;






	 	(30)	 	Information to assist the Enrollee in assessing
a potential behavioral health problem;






	 	(31)	 	Procedures for reporting Fraud, Abuse and
Overpayment; and






	 	(32)	 	Information regarding HIPAA relative to the
Enrollee’s personal health information (PHI).






	 	b.	 	For a counseling or referral service that the Health Plan does
not cover because of moral or religious objections, the Health Plan need not
furnish information on how and/or where to obtain the services.






	 	c.	 	Written information regarding Advance Directives provided by
the Health Plan must reflect changes in State law as soon as possible, but no
later than ninety (90) days after the effective date of the change.






	 	d.	 	The Health Plan, in its Enrollee handbook and provider manual,
shall clearly specify required procedural steps in the Grievance Procedure,
including the address, telephone number and office hours of the Grievance
staff. The Health Plan shall specify phone numbers for a grievant to call to
present a Grievance or to contact the Grievance staff. Each phone number shall
be toll-free within the grievant’s geographic area and provide reasonable
access to the Health Plan without undue delays. The Grievance System must
provide an adequate number of phone lines to handle incoming Grievances and
Appeals.






	 	e.	 	The Health Plan shall make information available upon request
regarding the structure and operation of the Health Plan and any physician
incentive plans, as set forth in 42 CFR 438.10(g)(3).






	 	5.	 	Provider Directory






	 	a.	 	The Health Plan shall mail a Provider Directory to all new
Enrollees, including Enrollees who reenrolled after the Open Enrollment period.
The Health Plan shall provide the most recently printed Provider Directory and
include an addendum listing those physicians, etc., no longer providing
services to Enrollees of the Health Plan and those physicians, etc., that have
entered into an agreement to provide services to Enrollees of the Health Plan
since the Health Plan published the most recently printed Provider Directory.
In lieu of the Provider Directory addendum, the Health Plan may enclose a
letter, in Times New Roman font, and at the fourth-grade reading level (as is
required of all documents mailed to Enrollees) stating that the most recent
listing of Providers is available by calling the Health Plan at its toll-free
telephone number and at the Health Plan’s website and provide the Internet
address that will take the Enrollee directly to the online Provider Directory,
without having to go to the Health Plan’s home page or any other website as a
prerequisite to viewing the online Provider Directory. The Health Plan must
obtain the Agency’s prior written approval of the letter.






	 	b.	 	The Provider Directory shall include the names, locations,
office hours, telephone numbers of, and non-English languages spoken by,
current Health Plan Providers. The Provider Directory shall include, at a
minimum, information relating to PCPs, specialists, pharmacies, hospitals,
certified nurse midwives and licensed midwives, and Ancillary Providers. The
Provider Directory shall also identify Providers that are not accepting new
patients.






	 	c.	 	The Health Plan shall maintain an online Provider Directory.
The Health Plan shall update the online Provider Directory on, at least, a
monthly basis. The Health Plan shall file an attestation to this effect with
the Bureau of Managed Health Care and the Bureau of Health Systems Development.






	 	d.	 	If the Health Plan elects to use a more restrictive pharmacy
network than the network available to Medicaid Recipients enrolled in the
Medicaid FFS program, then the Provider Directory must include the names of the
participating pharmacies. If all pharmacies are part of a chain and are within
the Health Plan’s Service Area under contract with the Health Plan, the
Provider Directory need only list the chain name.






	 	e.	 	In accordance with section 1932(b)(3) of the Social Security
Act, the Provider Directory shall include a statement that some Providers may
not perform certain services based on religious or moral beliefs.






	 	f.	 	The Health Plan shall arrange the Provider Directory as
follows:






	 	(1)	 	Providers are listed in alphabetical order,
showing the Provider’s name and specialty;






	 	(2)	 	Providers are listed by specialty, in
alphabetical order; and






	 	(3)	 	Behavioral Health Providers are listed by
provider type.






	 	6.	 	Enrollee ID Card






	 	a.	 	Immediately upon the Enrollee’s enrollment with the Health
Plan, the Health Plan shall mail, via Surface Mail, an Enrollee Identification
(ID) Card. The Enrollee ID Card shall include, at a minimum:






	 	(1)	 	The Enrollee’s name and Medicaid ID number;






	 	(2)	 	The Health Plan’s name, address and Enrollee
services number; and






	 	(3)	 	A telephone number that a non-contracted
provider may call for billing information.






	 	7.	 	Toll-Free Help Line






	 	a.	 	The Health Plan shall operate a toll-free telephone help line.
Such help line shall respond to all areas of Enrollee inquiry.






	 	b.	 	If the Health Plan has authorization requirements for
prescribed drug services and is subject to the Hernandez Settlement Agreement
(HSA), the Health Plan may allow the telephone help line staff to act as
Hernandez Ombudsman, pursuant to the terms of the HSA, so long as the Health
Plan maintains a Hernandez Ombudsman Log. The Health Plan may maintain the
Hernandez Ombudsman Log as part of the Health Plan’s telephone help line log,
so long as the Health Plan can access the Hernandez Ombudsman Log information
separately for reporting purposes. The log shall contain information as
described in Section V.D.13, Prescribed Drug Services.






	 	c.	 	The Health Plan shall have telephone call policies and
procedures that shall include requirements for staffing, personnel, hours of
operation, call response times, maximum hold times, and maximum abandonment
rates, monitoring of calls via recording or other means, and compliance with
standards.






	 	d.	 	The telephone helpline shall handle calls from non-English
speaking Enrollees, as well as calls from Enrollees who are hearing impaired.






	 	e.	 	The telephone help line shall be fully staffed between the
hours of 8:00 a.m. and 7:00 p.m., EDT or EST, as appropriate, Monday through
Friday, excluding State holidays. The telephone help line staff shall be
trained to respond to Enrollee questions in all areas, including but not
limited to, Covered Services, the Provider network, and non-emergency
transportation.






	 	f.	 	The Health Plan shall develop performance standards and monitor
telephone help line performance by recording calls and employing other
monitoring activities. Such standards shall be submitted and approved by the
Agency. At a minimum, the standards shall require that, measured on a monthly
basis:






	 	(1)	 	One hundred percent (100%) of all calls are
answered within four (4) rings (these calls may be placed in a queue);






	 	(2)	 	The wait time in the queue shall not exceed
three (3) minutes;






	 	(3)	 	The Blocked Call rate does not exceed one
percent (1%); and






	 	(4)	 	The rate of Abandoned Calls does not exceed
five percent (5%).






	 	g.	 	The Health Plan shall have an automated system available
between the hours of 8:00 p.m. and 7:00 a.m., EDT or EST, as appropriate,
Monday through Friday and at all hours on weekends and holidays. This
automated system must provide callers with operating instructions on what to do
in case of an emergency and shall include, at a minimum, a voice mailbox for
callers to leave messages. The Health Plan shall ensure that the voice mailbox
has adequate capacity to receive all messages. A Health Plan Representative
shall return all messages on the next Business Day.






	 	8.	 	Cultural Competency






	 	a.	 	In accordance with 42 CFR 438.206, the Health Plan shall have a
comprehensive written Cultural Competency Plan describing how the Health Plan
will ensure that services are provided in a culturally competent manner to all
Enrollees, including those with limited English proficiency. The Cultural
Competency Plan must describe how the Providers, Health Plan employees, and
systems will effectively provide services to people of all cultures, races,
ethnic backgrounds, and religions in a manner that recognizes, values, affirms,
and respects the worth of the individual Enrollees and protects and preserves
the dignity of each Enrollee.






	 	b.	 	The Health Plan may distribute a summary of the Cultural
Competency Plan to network Providers if the summary includes information on how
the Provider may access the full Cultural Competency Plan on the Health Plan’s
website. This summary shall also detail how the Provider can request a
hard-copy from the Health Plan at no charge to the Provider.






	 	9.	 	Translation Services






The Health Plan is required to provide oral translation services of information to
any Enrollee who speaks any non-English language regardless of whether an Enrollee
speaks a language that meets the threshold of a prevalent non-English language. The
Health Plan is required to notify its Enrollees of the availability of oral
interpretation services and to inform them of how to access oral interpretation
services. There shall be no charge to the Enrollee for translation services.




	B.	 	Marketing






	 	1.	 	General Provisions






	 	a.	 	For each new Contract period, the Health Plan shall submit to
the Agency for written approval, pursuant to Section 409.912, F.S., its
Marketing plan and all Marketing and Request for Benefit Information (RBI)
materials no later than sixty (60) Calendar Days prior to Contract renewal, and
for any changes in Marketing and RBI materials during the re-contracting and
renewal period, no later than sixty (60) Calendar Days prior to implementation.
The Marketing materials shall be distributed in the Health Plan’s entire
Service Area in accordance with Section 4707 of the Balanced Budget Act of 1997
(BBA).






	 	b.	 	Marketing materials include, but are not limited to, all
solicitation materials, forms, brochures, fact sheets, posters, lectures,
Medicaid recruitment materials and presentations, Request for Benefit
Information forms (previously known as pre-enrollment applications), etc.






	 	c.	 	To announce a specific event, the Health Plan shall submit a
request to market pursuant to Section IV.B.4, Approval Process, of this
Contract, and shall include the announcement of the event that will be given
out to the public.






	 	d.	 	The Health Plan shall be responsible for developing and
implementing a written plan designed to solicit Enrollment from Potential
Enrollees and to control the actions of its Marketing staff. All of the
Marketing policies set forth in this Contract apply to staff, Subcontractors,
Health Plan volunteers and all persons acting for, or on behalf of, the Health
Plan. All materials developed shall be governed by the requirements set forth
in this Section. Additionally, the Health Plan is vicariously liable for any
Marketing violations of its employees, agents or Subcontractors.






	 	e.	 	The Health Plan shall limit its Market Area to residents of the
Service Area and shall not market to residents of a Service Area not approved
by the Agency.






	 	2.	 	Prohibited Activities






	 	a.	 	The Health Plan is prohibited from engaging in the following
non-exclusive list of activities:






	 	(1)	 	In accordance with Sections 409.912 and
409.91211, F.S., practices that are discriminatory, including, but not
limited to, attempts to discourage Enrollment or reenrollment on the
basis of actual or perceived health status;






	 	(2)	 	Direct or indirect Cold Call Marketing for
solicitation of Medicaid Recipients, either by door-to-door, telephone
or other means, in accordance with Section 4707 of the Balanced Budget
Act of 1997, and section 409.912, F.S.






	 	(3)	 	Overly aggressive solicitation, such as
repeated telephoning, continued recruitment after an offer for
Enrollment is declined by a Medicaid Recipient, or similar techniques.
Health Plan representatives shall not directly solicit Potential
Enrollees for the purpose of enrolling in the Health Plan, except as
provided in Section IV.B.3., Permitted Activities.






	 	(4)	 	In accordance with Section 409.912, F.S.,
activities that could mislead or confuse Medicaid Recipients or
Potential Enrollees, or misrepresent the Health Plan, its Marketing
Representatives, or the Agency. No fraudulent, misleading, or
misrepresentative information shall be used in Marketing, including
information regarding other governmental programs. Statements that
could mislead or confuse include, but are not limited to, any
assertion, statement or claim (whether written or oral) that:






	 	(a)	 	The Medicaid Recipient must
enroll in the Health Plan in order to obtain Medicaid, or in
order to avoid losing Medicaid benefits;






	 	(b)	 	The Health Plan is endorsed by
any federal, State or county government, the Agency, or CMS, or
any other organization which has not certified its endorsement
in writing to the Health Plan;






	 	(c)	 	Marketing Representatives are
employees or representatives of the federal, State or county
government, or of anyone other than the Health Plan or the
organization by whom they are reimbursed;






	 	(d)	 	The State or county recommends
that a Medicaid Recipient enroll with the Health Plan; and/or






	 	(e)	 	A Medicaid Recipient will lose
benefits under the Medicaid program or any other health or
welfare benefits to which the Recipient is legally entitled, if
the Medicaid Recipient does not enroll with the Health Plan.






	 	(5)	 	In accordance with section 409.912, F.S.,
granting or offering of any monetary or other valuable consideration
for Enrollment, except as authorized by Section 409.912, F.S.;






	 	(6)	 	Offers of insurance, such as but not limited
to, accidental death, dismemberment, disability or life insurance;






	 	(7)	 	Enlisting the assistance of any employee,
officer, elected official or agent of the State in recruitment of
Medicaid Recipients, except as authorized in writing by the Agency;






	 	(8)	 	Offers of material or financial gain to any
persons soliciting, referring or otherwise facilitating Medicaid
Recipient Enrollment, except for authorized licensed Marketing
Representatives. The Health Plan shall ensure that only licensed
Marketing Representatives market the Health Plan to Medicaid
Recipients;






	 	(9)	 	Giving away promotional items in excess of one
dollar ($1.00) retail value to attract attention. Items to be given
away shall bear the Health Plan’s name and shall only be given away at
Health Fairs or other general Public Events. In addition, such
promotional items must be offered to the general public and shall not
be limited to Medicaid Recipients who indicate they will enroll in the
Health Plan;






	 	(10)	 	In accordance with Section 409.912, F.S.,
Marketing to Medicaid Recipients in State offices unless approved in
writing and approved by the affected State Agency when solicitation
occurs in the office of another State Agency. The Agency shall ensure
that Marketing Representatives stationed in State offices market to
Medicaid Recipients only in designated areas and in such a way as to
not interfere with the Medicaid Recipients’ activities in the State
office. The Health Plan shall not use any other State facility,
program, or procedure in the recruitment of Medicaid Recipients except
as authorized in writing by the Agency. Request for approval of
activities at State offices must be submitted to the Agency at least
thirty (30) Calendar Days prior to the activity;






	 	(11)	 	Marketing face-to-face to assigned Enrollees or
Medicaid Recipients unless the Enrollee or Recipient contacts the
Health Plan and requests information. Upon such request the Health
Plan shall notify the Choice Counselor/Enrollment Broker of such
request, and the Health Plan shall keep documentation of such contacts
and visits in the Enrollee’s file;






	 	(12)	 	Providing any gift, commission, or any form of
compensation to the Choice Counselor/Enrollment Broker, including the
Choice Counselor/Enrollment Broker’s full-time, part-time or temporary
employees and Subcontractors;






	 	(13)	 	The Health Plan shall not market, prior to the
Enrollment, the incentives that shall be offered to the Enrollee as
described in Section VIII.B.7., Incentive Programs. Marketing
representatives may describe the programs (not the incentives) that
shall be offered (e.g., prenatal classes). The Health Plan may inform
Enrollees once they are actually enrolled in the Health Plan about the
specific incentives available; or






	 	(14)	 	All activities included in section 641.3903,
F.S.






	 	3.	 	Permitted Activities






	 	a.	 	The Health Plan may engage in the following activities under
the supervision and with the written approval of the Agency:






	 	(1)	 	The Health Plan upon written approval of the
Agency, may have a marketer in Provider offices as long as the Provider
approves and the marketer provides information to the Potential
Enrollee only upon request. In addition, the Health Plan and the
Provider shall not require the Potential Enrollee to visit the
marketer, nor shall the marketer approach the Potential Enrollee. No
Sales Activities shall be allowed in Provider offices.






	 	(2)	 	The Health Plan may leave Agency approved
referral cards in Provider offices, at Public Events and Health Fairs.
These cards may be completed by Potential Enrollees and delivered to
the Health Plan or turned in at the Provider office. Information on
the card is limited to the name, address and telephone number of the
Potential Enrollee and space for signature. A space to note a contact
time may be provided. A follow up visit to the Potential Enrollee’s
home may not occur prior to the referral being logged by the Health
Plan’s regional or headquarters Enrollee services office. Twenty-four
(24) hours or the next Business Day shall elapse after the request is
logged before the home visit may occur.






	 	(3)	 	The Health Plan may market at State offices,
Health Fairs and Public Events and contact thereafter, in person,
Potential Enrollees who request further information about the Health
Plan, in accordance with Section 4707 of the BBA. The Health Plan
shall submit, for review and approval by the Agency, its intent to
market at Health Fairs and Public Events at least two (2) weeks prior
to the event. The Health Plan shall obtain complete disclosure of
information, in a format to be approved by the Agency, from each
organization participating in a Health Fair or Public Event prior to
the event. The information disclosure is only required when the Health
Plan is the primary organizer of the Health Fair or Public Event. If
the Health Plan has been invited by a community organization to be a
sponsor of an event, the Health Plan shall provide the Agency with a
copy of the invitation in lieu of the information disclosure. All
disclosure information shall be sent to the Agency with the Health
Plan’s request for approval of the event.






	 	(4)	 	The main purpose of a Health Fair or a Public
Event shall not be Medicaid Health Plan marketing, but Medicaid Health
Plan marketing may be provided at these events, subject to Agency rules
and oversight.






	 	(5)	 	Upon the effective date of Enrollment, Health
Plan marketing staff or other Health Plan staff may visit Enrollees in
order to obtain completed new Enrollee materials. All such visits must
be documented in the Enrollee’s file.






	 	(6)	 	The Health Plan may leave Agency approved
written materials (brochures or posters, etc.) in Provider Offices, at
Public Events, and at Health Fairs.






	 	(7)	 	Marketing face-to-face to Potential Enrollees
may be allowed if the Potential Enrollee contacts the Health Plan’s
headquarters or regional Enrollee services office directly to request a
home visit. The Health Plan shall not allow the visit to the Potential
Enrollee’s home to occur before the next Business Day or twenty-four
(24) hours have elapsed since the request for the visit. The Health
Plan must be able to provide evidence to the Agency that the
twenty-four (24) hour or next Business Day requirement has been met.
The Health Plan will be required, upon request by the Agency, to
provide a log that shows how initial contact with the Potential
Enrollee was made. Only Agency registered Marketing Representatives
shall be allowed to make home visits. Each Health Plan shall make
available to the Agency, as requested, a report of the number of home
visits made by each Agency registered Marketing Representative to
Potential Enrollee’s homes.






	 	4.	 	Approval Process






	 	a.	 	The Health Plan shall submit a detailed description of its
Marketing plan and copies of all Marketing materials, the Health Plan or its
Subcontractors’ plan to distribute, to the Agency for prior approval. This
requirement includes, but is not limited to: posters, brochures, websites, and
any materials that contain statements regarding the Health Plan’s Covered
Services and Provider network-related materials. Neither the Health Plan nor
its Subcontractors shall distribute any Marketing materials without prior
written approval from the Agency.






	 	b.	 	Health Fairs and Public Events shall be approved or denied by
the Agency using the following process:






	 	(1)	 	A Health Plan shall submit its bi-monthly
Marketing schedule to the Agency, two (2) weeks in advance of each
month. The Marketing Schedule may be revised if a Health Plan provides
notice to the Agency one (1) week prior to the Public Event or the
Health Fair. The Agency may expedite this process as needed.






	 	(2)	 	The Agency will approve or deny the Health
Plan’s bi-monthly Marketing schedule and revision request no later than
five (5) Business Days from receipt of the schedule and/or revision
request.






	 	(3)	 	The Health Plan shall use the standard Agency
format. Such format will include minimum requirements for necessary
information. The Agency will explain in writing what is sufficient
information for each requirement.






	 	(4)	 	The Agency will establish a statewide log to
track the approval and disapproval of Health Fairs and Public Events.






	 	(5)	 	The Agency may provide verbal approvals or
disapprovals to meet the five (5) Business Day requirement, but the
Agency will follow up in writing with specific reasons for disapprovals
within five (5) Business Days of verbal disapprovals.






	 	5.	 	Provider Compliance






	 	a.	 	The Health Plan shall ensure its health care Providers comply
with the following Marketing requirements:






	 	(1)	 	Health care Providers may give out Health Plan
brochures at Health Fairs or in their own offices comparing the
Benefits of different Health Plans with which they contract. However,
they cannot orally compare Benefits among Health Plans, unless
Marketing Representatives from each Health Plan are present.






	 	(2)	 	Health care Providers may co-sponsor events,
such as Health Fairs and cooperatively market and advertise with the
Health Plan in indirect ways; such as television, radio, posters,
fliers, and print advertisement.






	 	(3)	 	Health care Providers may announce a new
affiliation with a Health Plan or give a list of Health Plans with
which they contract to their patients.






	 	(4)	 	Health care Providers shall not furnish lists
of their Medicaid Recipients to Health Plans with which they contract,
or any other entity, nor can Providers furnish other Health Plans’
membership lists to any Health Plan, nor can Providers take
applications in their offices.






	 	6.	 	Marketing Representatives






	 	a.	 	The Health Plan shall not Subcontract with any brokerage firm
or independent agent for purposes of Marketing.






	 	b.	 	The Health Plan shall be required to register each Marketing
Representative with the Agency. The registration shall consist of providing
the Agency with the representative’s name, address, telephone number, cellular
telephone number, DFS license number, the names of all Medicaid health plans
with which the Marketing Representative was previously employed, and the name
of the Medicaid health plan with which the Marketing Representative is
presently employed.






	 	c.	 	The Health Plan shall provide the Agency, on a monthly basis,
information on terminations of all Marketing Representatives. The Health Plan
shall maintain and make available to the Agency upon request evidence of
current licensure and contractual agreements with all Marketing Representatives
used by the Health Plan to recruit Medicaid Recipients.






	 	d.	 	The Health Plan shall report to DFS and the Agency any
Marketing Representative who violates any requirements of this Contract, within
fifteen (15) Calendar Days of knowledge of such violation.






	 	e.	 	While Marketing, Marketing Representatives shall wear picture
identification that includes their DFS license number and identifies the Health
Plan represented.






	 	f.	 	The Marketing Representative shall inform the Medicaid
Recipient that the Representative is not an employee of the State and is not a
Choice Counseling Specialist, but is a Representative of the Health Plan.






	 	g.	 	The Health Plan shall not pay commission compensation, or shall
recoup commissions paid, to Marketing Representatives for new Enrollees whose
voluntary Disenrollment is effective within the first (1st) three (3) months of
their initial Enrollment, unless the Disenrollment is due to the Enrollee
moving out of the county in which the Health Plan has been authorized to
operate. In addition, the Health Plan shall not pay commission compensation,
or shall recoup commission paid, to Marketing Representatives for excluded
Medicaid Recipients, per Section III.A.2, Ineligible Populations, who were
enrolled in error. A Marketing Representative’s total monthly commission
cannot exceed forty percent (40%) of the Marketing Representative’s total
monthly compensation, excluding benefits.






	 	h.	 	The Health Plan shall instruct and provide initial and periodic
training to its Marketing Representatives regarding the Marketing provisions of
this Contract.






	 	i.	 	The Health Plan shall implement procedures for background and
reference checks for use in its Marketing Representative hiring practices.






	 	7.	 	Request for Benefit Information (RBI) Activities






	 	a.	 	The Health Plan shall refer Potential Enrollees interested in
enrolling in the Health Plan to the Choice Counselor/Enrollment Broker.






	 	b.	 	In accordance with Section 409.912, F.S., and Agency
guidelines, and upon approval of the Agency, the Health Plan may assist
Potential Enrollees in obtaining information through the completion of an RBI,
previously known as a pre-enrollment application for information.






	 	c.	 	RBIs may be for an individual or for a family. No health
status information may be asked on the RBI. Each RBI shall include an option
for the Potential Enrollee to request information about all Health Plan choices
and shall include the name and toll-free telephone number of the Choice
Counselor/Enrollment Broker Help Line. All RBIs shall contain the following
information only for each Potential Enrollee:






	 	(1)	 	Name;






	 	(2)	 	Address (home and mailing);






	 	(3)	 	County of residence;






	 	(4)	 	Telephone number;





	 	 	 
	(5)

	 	Date of Application;
	 
	 	 
	(6)

	 	Applicant’s signature or signature of parent or guardian; and
	 
	 	 
	(7)

	 	Marketing Representative’s signature and DFS license number.







	 	d.	 	At the time of completion of the RBI, the Health Plan shall
furnish the Potential Enrollee with a copy of the completed RBI.






	 	e.	 	The Health Plan shall accept RBIs only from Potential Enrollees
who reside within the authorized Service Area. In addition, the Health Plan
shall use the provider number associated with the county in which the Potential
Enrollee resides.






	 	f.	 	If the Voluntary Potential Enrollee is recognized to be in
foster care by the Health Plan, and is dependent, prior to Enrollment, the
Health Plan must receive written authorization from (1) a parent, (2) a legal
guardian, or (3) DCF or DCF’s delegate. If a parent is unavailable, the Health
Plan shall obtain authorization from DCF. The RBI shall include information
that the Potential Enrollee is in foster care.






	 	g.	 	The Health Plan shall provide a reasonable written explanation
of the Health Plan Benefits to the Potential Enrollee prior to accepting the
RBI. The Health Plan shall explain to all Potential Enrollees that the family
may choose to have all members served by the same PCP or they may choose
different PCPs based on each Enrollee’s needs. The information must comply
with 42 CFR 438.10.





25




REMAINDER OF PAGE INTENTIONALLY LEFT BLANKSection V




Covered Services





	A.	 	Covered Services






	 	1.	 	The Health Plan shall ensure the provision of services in sufficient amount,
duration and scope to be reasonably expected to achieve the purpose for which the
services are furnished and shall ensure the provision of the following covered services
as defined and specified in this Contract. The Health Plan shall not arbitrarily deny
or reduce the amount, duration, or scope of a required service solely because of the
diagnosis, type of illness or condition. The Health Plan may place appropriate limits
on a service on the basis of such criteria as Medical Necessity or for utilization
control, consistent with the terms of this Contract, provided the services furnished
can be reasonably expected to achieve their purpose.






	 	2.	 	The Health Plan is responsible for ensuring that all provider, service and
product standards specified in the Agency’s Medicaid Services Coverage & Limitations
Handbooks and the Health Plan’s own provider handbooks are incorporated into the Health
Plan’s participation agreements by reference. Exceptions exist where different
standards are specified elsewhere in this Contract, if the standard is waived in
writing by the Division of Medicaid on a case-by-case basis, when the Medicaid
Recipient’s medical needs would be equally or better served in an alternative care
setting, or when using alternative therapies or devices within the prevailing medical
community.






	 	3.	 	The Health Plan must require out-of-network providers to coordinate with
respect to payment and must ensure that cost to the Enrollee is no greater than it
would be if the Covered Services were furnished within the network.






	 	4.	 	The Health Plan shall ensure the provision of the following Covered Services:





	 	 	 
	Child Health Check-Up

Community Mental Health Services.

Family Planning Services

Freestanding Dialysis Centers

Hearing Services

Home Health Services and Durable

Medical Equipment

Independent Laboratory and X-Ray Services

	 	Inpatient Hospital Services

Mental Health Targeted Case Management

Outpatient Hospital and Emergency Services

Physician Services

Prescribed Drug Services



Therapy Services

Visual Services







Behavioral Health Services




	B.	 	Optional Services






	 	1.	 	These following services are rendered within Medicaid guidelines at the option
of the Health Plan and the Agency as described below:





	 	 	 	 	 
	
 
	 	Covered
	 	Not Covered
	 
	 	 	 	 
	Dental Services

	 	

	 	

	
 
	 	 
	 	 
	 
	 	 	 	 
	Transportation Services

	 	

	 	

	
 
	 	 
	 	 







	C.	 	Expanded Services






	 	1.	 	The following services are defined as Expanded Services that may be offered by
the Health Plan following the Agency’s written approval:






	 	a.	 	Services in excess of the amount, duration and scope of those
listed in Section V, Covered Services;






	 	b.	 	Services and benefits not listed in Section V, Covered
Services;






	 	c.	 	The Health Plan may offer, upon written Agency approval, an
over-the-counter expanded drug benefit, not to exceed twenty-five dollars
($25.00) per household, per month. Such benefits shall be limited to
nonprescription drugs containing a national drug code (“NDC”) number, first aid
supplies and birth control supplies. Such benefits must be offered directly
through the Health Plan’s fulfillment house or through a Subcontractor. The
Health Plan shall make payments for the over-the-counter drug benefit directly
to the Subcontractor, if applicable.






	 	2.	 	The following is a list of the Health Plan’s Expanded Services:






	D.	 	Excluded Services






	 	1.	 	The Health Plan is not obligated to provide any services not specified in this
Contract. Enrollees who require services available through Medicaid but not covered by
this Contract shall receive the services through the Medicaid fee-for-service
reimbursement system. In such cases, the Health Plan’s responsibility is limited to
case coordination and referral. Therefore, the Health Plan shall determine the need
for the services and refer the Enrollee to the appropriate service provider. The
Health Plan may request assistance from the local Medicaid Field Office for referral to
the appropriate service setting.






	 	2.	 	The Health Plan shall consult the DCF office to identify appropriate methods of
assessment and referral for those Enrollees requiring long-term care institutional
services, institutional services for persons with developmental disabilities or state
hospital services. The Health Plan is responsible for transition and referral of these
Enrollees to appropriate service providers, including helping the Enrollees to obtain
an attending physician. The Plan shall disenroll all Enrollees requiring these
services in accordance with Section III.C.3.a.(3) of this Contract.






	E.	 	Moral or Religious Objections






	 	1.	 	The Health Plan is required to provide or arrange for all Covered Services.
If, during the course of the Contract period, pursuant to 42 CFR 438.102, the Health
Plan elects not to provide, reimburse for, or provide coverage of a counseling or
referral service because of an objection on moral or religious grounds, the Health Plan
shall notify:






	 	a.	 	The Agency within one hundred and twenty (120) Calendar Days
prior to adopting the policy with respect to any service; and






	 	b.	 	Enrollees within thirty (30) Calendar Days prior to adopting
the policy with respect to any service.






	F.	 	Coverage Provisions






	 	1.	 	The Health Plan shall provide the following services in accordance with the
provisions herein, and in accordance with the Florida Medicaid Coverage and Limitations
Handbooks and the Florida Medicaid State Plan. The Health Plan shall comply with all
State and federal laws pertaining to the provision of such services.






	 	2.	 	Advance Directives






	 	a.	 	In compliance with 42 CFR 438.6(i)(1)-(2) and 42 CFR 422.128,
the Health Plan shall written policies and procedures for Advance Directives,
including health Advance Directives. Such Advance Directives shall be included
in each Enrollee’s Medical Record. The Health Plan shall provide these policies
and procedures to all Enrollee’s eighteen (18) years of age and older and shall
advise Enrollees of:






	 	(1)	 	Their rights under State law, including the
right to accept or refuse medical or surgical treatment and the right
to formulate Advance Directives; and






	 	(2)	 	The Health Plan’s written policies respecting
the implementation of those rights, including a statement of any
limitation regarding the implementation of Advance Directives as a
matter of conscience.






	 	b.	 	The information must include a description of State law and
must reflect changes in State law as soon as possible, but no later than ninety
(90) Calendar Days after the effective change.






	 	c.	 	The Health Plan’s information must inform Enrollees that
complaints may be filed with the State’s complaint hotline.






	 	d.	 	The Health Plan shall educate its staff about its policies and
procedures on Advance Directives, situations in which Advance Directives may be
of benefit to Enrollees, and their responsibility to educate Enrollees about
this tool and assist them to make use of it.






	 	e.	 	The Health Plan shall educate Enrollees about their ability to
direct their care using this mechanism and shall specifically designate which
staff and/or network Providers are responsible for providing this education.






	 	3.	 	Child Health Check-Up Program (CHCUP)






	 	a.	 	The Health Plan shall provide a health screening evaluation
that shall consist of: comprehensive health and developmental history
(including assessment of past medical history, developmental history and
behavioral health status); comprehensive unclothed physical examination;
developmental assessment; nutritional assessment; appropriate immunizations
according to the appropriate Recommended Childhood Immunization Schedule for
the United States; laboratory testing (including blood lead testing); health
education (including anticipatory guidance); dental screening (including a
direct referral to a dentist for Enrollees beginning at three (3) years of age
or earlier as indicated); vision screening, including objective testing as
required; hearing screening, including objective testing as required; diagnosis
and treatment; and referral and follow-up as appropriate.






	 	b.	 	For Children/Adolescents who the Health Plan identifies through
blood lead screenings as having abnormal levels of lead, the Health Plan shall
provide Case Management follow-up services as required in Chapter Two of the
Child Health Check-Up Services Coverage and Limitations Handbook. Screening for
lead poisoning is a required component of this Contract. The Health Plan shall
require all Providers to screen all Enrolled Children/Adolescents for lead
poisoning at twelve (12) and twenty-four (24) months of age. In addition,
Children/Adolescents between the ages of twenty-four (24) months and
seventy-two (72) months of age must receive a screening blood lead test if
there is no record of a previous test. The Health Plan shall provide additional
diagnostic and treatment services determined to be Medically Necessary to a
Child/Adolescent diagnosed with an elevated blood lead level. The Health Plan
shall recommend, but shall not require, the use of paper filter tests as part
of the lead screening requirement.






	 	c.	 	The Health Plan shall inform Enrollees of all
testing/screenings due in accordance with the periodicity schedule specified in
the Medicaid Child Health Check-Up Services Coverage and Limitations Handbook.
The Health Plan shall contact Enrollees to encourage them to obtain health
assessment and preventative care.






	 	d.	 	The Health Plan shall authorize Enrollee referrals to
appropriate Providers within four (4) weeks of these examinations for further
assessment and treatment of conditions found during the examination. The
Health Plan shall ensure that the referral appointment is scheduled for a date
within six (6) months of the initial examination, or within the time periods
set forth in Section VII.D., as applicable.






	 	e.	 	The Health Plan shall offer scheduling assistance and Transportation to
Enrollees in order to assist them to keep, and travel to, medical appointments.






	 	f.	 	The CHCUP program includes the maintenance of a coordinated
system to follow the Enrollee through the entire range of screening and
treatment, as well as supplying CHCUP training to medical care Providers.






	 	g.	 	The Health Plan shall achieve a CHCUP screening rate of at
least sixty percent (60%) for those Enrollees who are continuously enrolled for
at least eight (8) months during the Federal Fiscal Year (October 1 – September
30) in accordance with Section 409.912, F.S. This screening compliance rate
shall be based on the CHCUP screening data reported by the Health Plan and due
to the Agency by January 15 following the end of each Federal Fiscal Year as
specified in Section XII, Reporting, of this Contract. The data shall be
monitored by the Agency for accuracy and, if the Health Plan does not achieve
the sixty percent (60%) screening rate for the Federal Fiscal Year reported,
the Health Plan shall file a corrective action plan (CAP) with the Agency no
later than February 15, following the fiscal year reported. Any data reported
by the Health Plan that is found to be inaccurate shall be disallowed by the
Agency and the Agency shall consider such findings as being in violation of the
Contract and may sanction the Health Plan accordingly.






	 	h.	 	The Health Plan shall adopt annual screening and participation
goals to achieve at least an eighty percent (80%) CHCUP screening and
participation rate. For each Federal Fiscal Year that the Health Plan does not
meet the eighty percent (80%) screening and participation rate, it must file a
CAP with the Agency no later than February 15 following the Federal Fiscal Year
being reported.






	 	4.	 	Co-Payments






	 	a.	 	The Health Plan shall not require a co-payment or cost sharing
for services listed in Section V.A., Covered Services, Section V.B., Optional
Services, if provided, or Section V.C., Expanded Services, nor may the Health
Plan charge Enrollees for missed appointments.






	 	5.	 	Dental Services (Optional)






	 	a.	 	Dental services are defined in the Medicaid Dental Services
Coverage and Limitations Handbook. Children’s Medicaid dental services include
diagnostic services, preventive treatment, restorative treatment, endodontic
treatment, periodontal treatment, restorative treatment, surgical procedures
and/or extractions, orthodontic treatment and complete and partial dentures for
beneficiaries under age 21. Complete and partial denture relines and repairs
are also included, as well as adjunctive and emergency services. Adult
services include adult full and partial denture services and Medically
Necessary emergency dental procedures to alleviate pain or infection.
Emergency dental care shall be limited to emergency oral examinations,
necessary radiographs, extractions, and incision and drainage of abscess.





6. Diabetes Supplies and Education




	 	a.	 	In the same manner as specified in Section 641.31, F.S., the
Health Plan shall provide coverage for Medically Necessary equipment, supplies,
and services used to treat diabetes, including outpatient self-management
training and educational services, if the Enrollee’s PCP, or the physician to
whom the Enrollee has been referred who specializes in treating diabetes,
certifies that the equipment, supplies and services are Medically Necessary.





7. Emergency Services




	 	a.	 	The Health Plan shall advise all Enrollees of the provisions
governing Emergency Services and Care. The Health Plan shall not deny claims
for Emergency Services and Care received at a Hospital due to lack of parental
consent. In addition, the Health Plan shall not deny payment for treatment
obtained when a representative of the Health Plan instructs the Enrollee to
seek Emergency Services and Care in accordance with section 743.64, F.S.






	 	b.	 	The Health Plan shall not:






	 	(1)	 	Require Prior Authorization for an Enrollee to
receive pre-Hospital transport or treatment or for Emergency Services
and Care;






	 	(2)	 	Specify or imply that Emergency Services and
Care are covered by the Health Plan only if secured within a certain
period of time;






	 	(3)	 	Use terms such as “life threatening” or “bona
fide” to qualify the kind of emergency that is covered; or






	 	(4)	 	Deny payment based on a failure by the Enrollee
or the Hospital to notify the Health Plan before, or within a certain
period of time after, Emergency Services and Care were given.






	 	c.	 	The Health Plan shall provide pre-Hospital and Hospital-based
trauma services and Emergency Services and Care to Enrollees. See Sections
395.1041, 395.4045 and 401.45, F.S.






	 	d.	 	When an Enrollee presents himself/herself at a Hospital seeking
Emergency Services and Care, the determination that an Emergency Medical
Condition exists shall be made, for the purposes of treatment, by a physician
of the Hospital or, to the extent permitted by applicable law, by other
appropriate personnel under the supervision of a Hospital physician. See
Sections 409.9128 and 409.901, F.S.






	 	(1)	 	The physician, or the appropriate personnel,
shall indicate on the Enrollee’s chart the results of all screenings,
examinations and evaluations.






	 	(2)	 	The Health Plan shall compensate the provider
for all screenings, evaluations and examinations that are reasonably
calculated to assist the provider in arriving at the determination as
to whether the Enrollee’s condition is an Emergency Medical Condition.






	 	(3)	 	The Health Plan shall pay for all Emergency
Services and Care in accordance with this Contract.






	 	(4)	 	If the provider determines that an Emergency
Medical Condition does not exist, the Health Plan is not required to
pay for services rendered subsequent to the provider’s determination.






	 	e.	 	If the provider determines that an Emergency Medical Condition
exists, and the Enrollee notifies the Hospital or the Hospital emergency
personnel otherwise have knowledge that the patient is an Enrollee of the
Health Plan, the Hospital must make a reasonable attempt to notify the
Enrollee’s PCP, if known, or the Health Plan, if the Health Plan has previously
requested in writing that said notification be made directly to the Health
Plan, of the existence of the Emergency Medical Condition.






	 	f.	 	If the Hospital, or any of its affiliated providers, do not
know the Enrollee’s PCP, or have been unable to contact the PCP, the Hospital
must:






	 	(1)	 	Notify the Health Plan as soon as possible
before discharging the Enrollee from the emergency care area; or






	 	(2)	 	Notify the Health Plan within twenty-four (24)
hours or on the next Business Day after admission of the Enrollee as an
inpatient to the Hospital.






	 	g.	 	If the Hospital is unable to notify the Health Plan, the
Hospital must document its attempts to notify the Health Plan, or the
circumstances that precluded the Hospital’s attempts to notify the Health Plan.
The Health Plan shall not deny payment for Emergency Services and Care based on
a Hospital’s failure to comply with the notification requirements of this
Section.






	 	h.	 	If the Enrollee’s PCP responds to the Hospital’s notification,
and the Hospital physician and the PCP discuss the appropriate care and
treatment of the Enrollee, the Health Plan may have a member of the Hospital
staff with whom it has a Participating Provider contract participate in the
treatment of the Enrollee within the scope of the physician’s Hospital staff
privileges.






	 	i.	 	The Health Plan may transfer the Enrollee, in accordance with
State and federal law, to a Participating Hospital that has the service
capability to treat the Enrollee’s Emergency Medical Condition. The attending
emergency physician, or the provider actually treating the Enrollee, is
responsible for determining when the Enrollee is sufficiently stabilized for
transfer discharge, and that determination is binding on the entities
identified in 42 CFR 438.114(b) as responsible for coverage and payment.






	 	j.	 	Notwithstanding any other State law, a Hospital may request and
collect any insurance or financial information necessary to determine if the
patient is an Enrollee of the Health Plan, in accordance with federal law, from
an Enrollee, so long as Emergency Services and Care are not delayed in the
process.






	 	k.	 	In accordance with 42 CFR 438.411 and 42 CFR 422.113(c), the
Health Plan shall cover Post-Stabilization Care Services without authorization,
regardless of whether the Enrollee obtains a service within or outside the
Health Plan’s network for the following situations:






	 	(1)	 	Post-Stabilization Care Services that were
pre-approved by the Health Plan;






	 	(2)	 	Post-Stabilization Care Services that were not
pre-approved by the Health Plan because the Health Plan did not respond
to the treating provider’s request for pre-approval within one (1) hour
after the treating provider sent the request;






	 	(3)	 	The treating Provider could not contact the
Health Plan for pre-approval; and






	 	(4)	 	Those Post-Stabilization Care Services that a
treating physician viewed as Medically Necessary after stabilizing an
Emergency Medical Condition. These are non-emergency services; the
Health Plan can choose not to cover if provided by a non-participating
provider, except in those circumstances detailed in k. (1), (2), and
(3) above.






	 	l.	 	The Health Plan shall not deny claims for the provision of Emergency
Services and Care submitted by a nonparticipating provider solely based on the
period between the date of service and the date of clean claim submission,
unless that period exceeds 365 days.






	 	m.	 	Reimbursement for services provided to an Enrollee under this
Section by a non-participating provider shall be the lesser of:






	 	(1)	 	The non-participating provider’s charges;






	 	(2)	 	The usual and customary provider charges for
similar services in the community where the services were provided;






	 	(3)	 	The amount mutually agreed to by the Health
Plan and the non-participating provider within sixty (60) Calendar Days
after the non-participating provider submits a claim; or






	 	(4)	 	The Medicaid rate.






	 	n.	 	Notwithstanding the requirements set forth in this Section, the
Health Plan shall make payment on all claims for Emergency Services and Care by
nonparticipating providers pursuant to the requirements set forth in Section
641.3155, F.S.






	 	8.	 	Emergency Services — Behavioral Health Services






	 	a.	 	In cases in which the Enrollee has no identification, or is
unable to verbally identify himself/herself when presenting for Behavioral
Health Services, the out-of-area, non-participating provider shall notify the
Health Plan within twenty-four (24) hours of learning the Enrollee’s identity.
The out-of-area, non-participating provider shall deliver to the Health Plan
the Medical Records that document that the identity of the Enrollee could not
be ascertained at the time the Enrollee presented for Emergency Behavioral
Health Services due to the Enrollee’s condition.






	 	b.	 	If the out-of-area, non-participating provider fails to provide
the Health Plan with an accounting of the Enrollee’s presence and status within
twenty-four (24) hours after the Enrollee presents for treatment and provides
identification, the Health Plan shall only approve claims for the time period
required for treatment of the Enrollee’s Emergency Behavioral Health Services,
as documented by the Enrollee’s Medical Record.






	 	c.	 	The Health Plan shall review and approve or disapprove all
out-of-plan Emergency Behavioral Health Service claims within the time frames
specified for emergency claims payment in Section V.E.7., Emergency Services.






	 	d.	 	The Health Plan shall submit to the Agency for review and final
determination all denied Appeals from Behavioral Health Care Providers and
out-of-plan, non-participating behavioral health care providers for denied
Emergency Behavioral Health Service claims. The provider, whether a
participating provider or not, must submit the denied Appeal to the Agency
within ten (10) days after receiving notice of the Health Plan’s final Appeal
determination.






	 	e.	 	The Health Plan must evaluate and authorize or deny services
for Enrollees presenting at non-participating receiving facilities (that are
not Crisis Stabilization Units), within the Health Plan’s service area, for
involuntary examination within three (3) hours of being notified by phone by
the receiving facility.






	 	f.	 	The receiving facility must notify the Health Plan within four
(4) hours of the Enrollee presenting. If the Receiving Facility fails to notify
the Health Plan of the Enrollee’s presence and status within four (4) hours,
the Health Plan shall pay only for the first four (4) hours of the Enrollee’s
treatment, subject to Medical Necessity.






	 	g.	 	If the receiving facility is a non-participating receiving
facility and documents in the Medical Record that it is unable, after a good
faith effort, to identify the Enrollee and, therefore, fails to notify the
Health Plan of the Enrollee’s presence, the Health Plan shall pay for medical
stabilization lasting no more than three (3) days from the date the Enrollee
presented at the receiving facility, as documented by the Enrollee’s Medical
Record and subject to Medical Necessity, unless there is irrefutable evidence
in the Medical Record that a longer period was required to treat the Enrollee.






	 	9.	 	Family Planning Services






	 	a.	 	The Health Plan shall provide family planning services for the
purpose of enabling Enrollees to make comprehensive and informed decisions
about family size and/or spacing of births. The Health Plan shall provide the
following services: planning and referral, education and counseling, initial
examination, diagnostic procedures and routine laboratory studies,
contraceptive drugs and supplies, and follow-up care in accordance with the
Medicaid Physicians Services Coverage and Limitations Handbook. Policy
requirements include:






	 	(1)	 	The Health Plan shall furnish services on a
voluntary and confidential basis.






	 	(2)	 	The Health Plan shall allow Enrollees freedom
of choice of family planning methods covered under the Medicaid
program, including Medicaid covered implants, where there are no
medical contra-indications.






	 	(3)	 	The Health Plan shall render the services to
Enrollees under the age of eighteen (18) provided the Enrollee is
married, a parent, pregnant, has written consent by a parent or legal
guardian, or in the opinion of a physician, the Enrollee may suffer
health hazards if the services are not provided. See Section 31.0051,
F.S.






	 	(4)	 	The Health Plan shall allow each Enrollee to
obtain family planning services from any Provider and require no prior
authorization for such services. If the Enrollee receives services
from a non-network Medicaid provider, then the Plan must reimburse at
the Medicaid reimbursement rate, unless another payment rate is
negotiated.






	 	(5)	 	The Health Plan shall make available and
encourage all pregnant women and mothers with infants to receive
postpartum visits for the purpose of voluntary family planning,
including discussion of all appropriate methods of contraception,
counseling and services for family planning to all women and their
partners. The Health Plan shall direct Providers to maintain
documentation in the Enrollee’s Medical Records to reflect this
provision. See Section 409.912, F.S.






	 	(6)	 	The provisions of this subsection shall not be
interpreted so as to prevent a health care provider or other person
from refusing to furnish any contraceptive or family planning service,
supplies or information for medical or religious reasons. A health care
provider or other person shall not be held liable for such refusal.






	 	10.	 	Hospital Services — Inpatient






	 	a.	 	Inpatient Services are Medically Necessary services ordinarily
furnished by a State licensed acute care Hospital for the medical care and
treatment of inpatients provided under the direction of a physician or dentist
in a Hospital maintained primarily for the care and treatment of patients with
disorders other than mental diseases. Inpatient psychiatric Hospital services
are Medically Necessary Behavioral Health Care Services and may be provided in
a general Hospital psychiatric unit or in a specialty Hospital.






	 	(1)	 	Inpatient services include, but are not limited
to, rehabilitation Hospital care (which are counted as inpatient
Hospital days), medical supplies, diagnostic and therapeutic services,
use of facilities, drugs and biologicals, room and board, nursing care
and all supplies and equipment necessary to provide adequate care. See
the Medicaid Hospital Services Coverage & Limitations Handbook.







	 	(2)	 	Inpatient services also include inpatient care
for any diagnosis including psychiatric and mental health (Baker Act
and non-Baker Act), tuberculosis and renal failure when provided by
general acute care Hospitals in both emergent and non-emergent
conditions.






	 	(3)	 	The Health Plan may provide services in a
nursing home as downward substitution for Inpatient Services. In such
cases, said inpatient care shall not be counted as inpatient hospital
days.






	 	(4)	 	The health screening examination shall consist
of:






	 	(a)	 	Comprehensive health and
developmental history, including an assessment of past medical
history, developmental history and behavioral health status;





	 	 	 
	(b)

	 	Comprehensive unclothed physical examination;
	 
	 	 
	(c)

	 	Developmental assessment;
	 
	 	 
	(d)

	 	Nutritional assessment;







	 	(e)	 	Appropriate immunizations
according to the appropriate Recommended Childhood Immunization
Schedule for the United States;






	 	(f)	 	Laboratory testing, including
blood lead screenings, where required (for Children/Adolescents
whom the Health Plan identifies through blood lead screenings as
having abnormal levels of lead, the Health Plan shall provide
case management follow-up services as required in Chapter 2 of
the Child Health Check-Up Services Coverage and Limitations
Handbook);






	 	(g)	 	Health education (including
anticipatory guidance);






	 	(h)	 	Dental screening (including a
direct referral to a dentist, or to a Prepaid Dental Health Plan
(PDHP), where applicable, for Children/Adolescents beginning at
3 years of age or earlier as indicated);





	 	 	 
	(i)

	 	Vision screening, including objective testing, when required;
	 
	 	 
	(j)

	 	Hearing screening, including objective testing, when required;
	 
	 	 
	(k)

	 	Diagnosis, treatment, referral and follow-up, as appropriate.







	 	(5)	 	The Health Plan shall cover physical therapy
services when Medically Necessary and when provided during an
Enrollee’s inpatient stay.






	 	(6)	 	The Health Plan shall provide up to
twenty-eight (28) inpatient hospital days in an inpatient Hospital
substance abuse treatment program for pregnant substance abusers who
meet ISD Criteria with Florida Medicaid modifications, as specified in
InterQual Level of Care 2003-Acute Criteria-Pediatric and/or InterQual
Level of Care 2003-Acute Criteria-Adult (McKesson Health Solutions,
LLC, “McKesson”), 2003 Edition or the most current edition, for use in
screening cases admitted to rehabilitative Hospitals and CON approved
rehabilitative units in acute care Hospitals with admission dates of
January 1, 2003 and after. In addition, the Health Plan shall provide
inpatient Hospital treatment for severe withdrawal cases exhibiting
medical complications which meet the severity of illness criteria under
the alcohol/substance abuse system-specific set which generally
requires treatment on a medical unit where complex medical equipment is
available. Withdrawal cases (not meeting the severity of illness
criteria under the alcohol/substance abuse criteria) and substance
abuse rehabilitation (other than for pregnant women), including court
ordered services, are not covered in the inpatient Hospital setting.






	 	(7)	 	The Health Plan shall adhere to the provisions
of the Newborns and Mothers Health Protection Act (NMHPA) of 1996
regarding postpartum coverage for mothers and their newborns.
Therefore, the Health Plan shall provide for no less than a forty-eight
(48) hour Hospital length of stay following a normal vaginal delivery,
and at least a ninety-six (96) hour Hospital length of stay following a
Cesarean section. In connection with coverage for maternity care, the
Hospital length of stay is required to be decided by the attending
physician in consultation with the mother.






	 	(8)	 	The Health Plan shall provide up to forty-five
(45) days of inpatient coverage per Enrollee from July 1 or the initial
date of Enrollment, whichever comes later, through June 30 of each
year.






	 	(9)	 	The Health Plan shall prohibit the following
practices:






	 	(a)	 	Denying the mother or newborn
child eligibility, or continued eligibility, to enroll or renew
coverage under the terms of the Health Plan, solely for the
purpose of avoiding the NMHPA requirements;






	 	(b)	 	Providing monetary payments or
rebates to mothers to encourage them to accept less than the
minimum protections available under NMHPA;






	 	(c)	 	Penalizing or otherwise reducing
or limiting the reimbursement of an attending physician because
the physician provided care in a manner consistent with NMHPA;






	 	(d)	 	Providing incentives (monetary or
otherwise) to an attending physician to induce the physician to
provide care in a manner inconsistent with NMHPA;






	 	(e)	 	Restricting for any portion of
the forty-eight (48) hour, or ninety-six (96) hour, period
prescribed by NMHPA in a manner that is less favorable than the
Benefits provided for any preceding portion of the Hospital
stay; and






	 	(f)	 	The Health Plan shall pay for any
Medically Necessary duration of stay in a noncontracted facility
which results from a medical emergency until such time as the
Plan can safely transport the Enrollee to a Plan participating
facility.






	 	b.	 	The Health Plan’s inpatient Hospital services also includes the
following:






	 	(1)	 	Medically Necessary and appropriate
transplants, including:






(a) Bone marrow, all ages;




(b) Cornea, all ages; and




(c) Kidney, all ages.




	 	(2)	 	For other transplants not covered by Medicaid,
the evaluations, pre-transplant care and post-transplant follow-up care
are covered by Medicaid and, therefore, must be covered by the Health
Plan even though the transplant procedure is not covered. Transplant
service components are also covered under outpatient services,
physician services and prescribed drug services per the applicable
Medicaid Services Coverage and Limitations handbooks.






	 	(3)	 	The Health Plan is not responsible for the cost
of transplant evaluations, pre-transplant care and post-transplant
follow-up care, when an adult Enrollee (age 21 and over) is listed with
the United Network for Organ Sharing (UNOS) as a level 1A, 1B, or 2
candidate for heart transplant. The Health Plan must disenroll said
Enrollees at the conclusion of the transplant evaluation and cannot
re-enroll the Enrollee until at least one (1) year post transplant.






	 	(4)	 	The Health Plan is not responsible for the cost
of a completed adult heart transplant evaluation regardless of whether
or not the Enrollee was determined a candidate for a transplant. The
Health Plan is responsible, however, for the cost of adult heart
transplant evaluations that are not completed for any reason.






	 	(5)	 	The Health Plan is not responsible for the cost
of pre-transplant care and post transplant follow-up care when an
Enrollee has been listed as a candidate for a pediatric heart, lung or
heart/lung transplant (ages 20 and under) or a liver transplant (all
ages). If, at the conclusion of the transplant evaluation, the
Enrollee is listed with UNOS as a level 1A, 1B or 2 for heart, lung or
heart/lung or, Model End Stage Renal Disease (MELD) score of 11-25, for
a liver transplant, the Health Plan must disenroll the Enrollee. The
Enrollee will have the option to re-enroll at one (1) year post
transplant. The Health Plan is responsible for the cost of the
above-referenced transplant evaluations.






	 	11.	 	Hospital Services — Outpatient






	 	a.	 	Outpatient Hospital services consist of preventive, diagnostic,
therapeutic or palliative care under the direction of a physician or dentist at
a licensed acute care Hospital. Outpatient Hospital services include Medically
Necessary emergency room services, dressings, splints, oxygen and physician
ordered services and supplies for the clinical treatment of a specific
diagnosis or treatment.






	 	a.	 	The Health Plan shall provide outpatient
Hospital services and Emergency Services and Care as Medically
Necessary and appropriate and without any specified dollar limitations.






	 	b.	 	The Health Plan shall have a procedure for the
authorization of dental care and associated ancillary medical services
provided in an outpatient Hospital setting if that care meets the
following requirements:






	 	(1)	 	Is provided under the direction
of a dentist at a licensed Hospital; and






	 	(2)	 	Is Medically Necessary; or






	 	(3)	 	The Health Plan shall pay for any
Medically Necessary duration of stay in a noncontracted facility
which results from a medical emergency, until such time as the
Health Plan can safely transport the Enrollee to a participating
facility.






	 	12.	 	Hospital Services — Ancillary Services






	 	a.	 	The Health Plan shall provide Medically Necessary ancillary
medical services at the Hospital without limitation. Ancillary Hospital
services include, but are not limited to, radiology, pathology, neurology,
neonatology, and anesthesiology. When the Health Plan or the Health Plan’s
authorized physician authorizes these services (either inpatient or
outpatient), the Health Plan must reimburse the provider of the service at the
Medicaid line item rate, unless the Health Plan and the Hospital have
negotiated another reimbursement rate. Also, the Health Plan must reimburse
non-network physicians for emergency ancillary services provided in a Hospital
setting.






	 	b.	 	If the Health Plan provides dental services as an optional
service, the Health Plan shall have a procedure for the authorization of
Medically Necessary dental care and associated ancillary services provided in
licensed ambulatory surgical center settings if that care is provided under the
direction of a dentist as described in the State plan.






	 	13.	 	Hysterectomies, Sterilizations and Abortions






	 	a.	 	The Health Plan shall maintain a log of all hysterectomy,
sterilization and abortion procedures performed for its Enrollees. The log
must include, at a minimum, the Enrollee’s name and identifying information,
date of procedure, and type of procedure. The Health Plan shall provide
abortions only in the following situations:






	 	(1)	 	If the pregnancy is a result of an act of rape
or incest; or






	 	(2)	 	The physician certifies that the woman is in
danger of death unless an abortion is performed.






	 	14.	 	Immunizations






	 	a.	 	The Health Plan shall:






	 	1.	 	Provide immunizations in accordance with the
Recommended Childhood Immunization Schedule for the United States, or
when Medically Necessary for the Enrollee’s health;






	 	2.	 	Provide for the simultaneous administration of
all vaccines for which an Enrollee under the age of twenty (20) is
eligible at the time of each visit;






	 	3.	 	Follow only true contraindications established
by the Advisory Committee on Immunization Practices (“ACIP”), unless:






	 	(a)	 	In making a medical judgment in
accordance with accepted medical practices, such compliance is
deemed medically inappropriate; or






	 	(b)	 	The particular requirement is not
in compliance with Florida law, including Florida law relating
to religious or other exemptions;






	 	4.	 	Participate, or direct its Providers to
participate, in the Vaccines For Children Program (“VFC”). See Section
1905(r)(1) of the Social Security Act. The VFC is administered by the
Department of Health, Bureau of Immunizations, and provides vaccines at
no charge to physicians and eliminates the need to refer children to
CHDs for immunizations.






	 	5.	 	The Health Plan shall provide coverage and
reimbursement to the Participating Provider for immunizations covered
by Medicaid, but not provided through VFC;






	 	6.	 	Ensure that Providers have a sufficient supply
of vaccines if the Health Plan is the VFC enrollee. The Health Plan
shall direct those Providers that are directly enrolled in the VFC
program to maintain adequate vaccine supplies;






	 	7.	 	Pay no more than the Medicaid program vaccine
administration fee of ten dollars ($10.00) per administration, unless
another rate is negotiated with the Participating Provider.






	 	8.	 	Pay the immunization administration fee at no
less than the Medicaid rate when an Enrollee receives immunizations
from a non-participating provider, so long as:






	 	(a)	 	The non-participating provider
contacts the Health Plan at the time of service delivery;






	 	(b)	 	The Health Plan is unable to
document to the non-participating provider that the Enrollee has
already received the immunization; and






	 	(c)	 	The non-participating provider
submits a claim for the administration of immunization services
and provides Medical Records documenting the immunization to the
Health Plan.






	 	15.	 	Pregnancy Related Requirements






	 	a.	 	The Health Plan must provide the most appropriate and highest
level of quality care for pregnant Enrollees. Required care includes the
following:






	 	(1)	 	Florida’s Healthy Start Prenatal Risk Screening
– The Health Plan shall ensure that the Provider offers Florida’s
Healthy Start prenatal risk screening to each pregnant Enrollee as part
of her first prenatal visit. As required by Section 383.14, F.S., and
64C-7.009, F.A.C.






	 	(a)	 	The Health Plan shall ensure that
the Provider uses the DOH prenatal risk form (DH Form 3134),
which can be obtained from the local CHD.






	 	(b)	 	The Health Plan shall ensure that
the Provider retains a copy of the completed screening
instrument in the Enrollee’s Medical Record and provides a copy
to the Enrollee.






	 	(c)	 	The Health Plan shall ensure that
the Provider submits the completed DH Form 3134 to the CHD in
the county in which the prenatal screen was completed within ten
(10) Business Days of completion.






	 	(d)	 	The Health Plan shall collaborate
with the Healthy Start care coordinator within the Enrollee’s
county of residence to assure risk appropriate care is
delivered.






	 	(2)	 	Florida’s Healthy Start Infant (Postnatal) Risk
Screening Instrument – The Health Plan shall ensure that the Provider
completes the Florida Healthy Start Infant (Postnatal) Risk Screening
Instrument (DH Form 3135) with the Certificate of Live Birth and
transmits the documents to the CHD in the county in which the infant
was born within ten (10) Business Days of completion. The Health Plan
shall ensure that the Provider retains a copy of the completed DH Form
3135 in the Enrollee’s Medical Record and provides a copy to the
Enrollee.






	 	(3)	 	Pregnant Enrollees or infants who do not score
high enough to be eligible for Healthy Start care coordination may be
referred for services, regardless of their score on the Healthy Start
risk screen, in the following ways:






	 	(a)	 	If the referral is to be made at
the same time the Healthy Start risk screen is administered, the
Provider may indicate on the risk screening form that the
Enrollee or infant is invited to participate based on factors
other than score; or






	 	(b)	 	If the determination is made
subsequent to risk screening, the Provider may refer the
Enrollee or infant directly to the Healthy Start care
coordinator based on assessment of actual or potential factors
associated with high risk, such as HIV, hepatitis B, substance
abuse or domestic violence.






	 	(4)	 	The Health Plan shall refer all pregnant women,
breast-feeding and postpartum women, infants and Children/Adolescents
up to age five (5) to the local WIC office.






(a) The Health Plan shall provide:




	 	(i)	 	A completed
Florida WIC program Medical Referral Form with the
current height or length and weight (taken within sixty
(60) Calendar Days of the WIC appointment);






	 	(ii)	 	Hemoglobin or
hematocrit; and






	 	(iii)	 	Any identified
medical/nutritional problems.






	 	(b)	 	For subsequent WIC
certifications, the Health Plan shall ensure that Providers
coordinate with the local WIC office to provide the above
referral data from the most recent CHCUP.






	 	(c)	 	Each time the Health Plan
completes a WIC Referral Form, the Health Plan shall ensure that
the Provider gives a copy of the WIC Referral Form to the
Enrollee and retains a copy in the Enrollee’s Medical Record.






	 	(5)	 	The Health Plan shall ensure that the Providers
provide all women of childbearing age HIV counseling and offer them HIV
testing. See Chapter 381, F.S.






	 	(a)	 	The Health Plan shall ensure that
its Providers, in accordance with Florida law, offer all
pregnant women counseling and HIV testing at the initial
prenatal care visit and again at twenty-eight (28) to thirty-two
(32) weeks.






	 	(b)	 	The Health Plan shall ensure that
its Providers attempt to obtain a signed objection if a pregnant
woman declines an HIV test. See Section 384.31, F.S. and
64D-3.019, F.A.C.






	 	(c)	 	The Health Plan shall ensure that
all pregnant women who are infected with HIV are counseled about
and offered the latest antiretroviral regimen recommended by the
U.S. Department of Health & Human Services (U.S. Department of
Health & Human Services, Public Health Service Task Force Report
entitled Recommendations for the Use of Antiretroviral Drugs in
Pregnant HIV-1 Infected Women for Maternal Health and
Interventions to Reduce Perinatal HIV-1 Transmission in the
United States. To receive a copy of the guidelines, contact the
DOH, Bureau of HIV/AIDS at (850) 245-4334, or go to
http://aidsinfo.nih.gov/guidelines/).






	 	(6)	 	The Health Plan shall ensure that its Providers
screen all pregnant Enrollees receiving prenatal care for the Hepatitis
B surface antigen (HBsAg) during the first (1st) prenatal
visit.






	 	(a)	 	The Health Plan shall ensure that
the Providers perform a second (2nd) HBsAg test
between twenty-eight (28) and thirty-two (32) weeks of pregnancy
for all pregnant Enrollees who tested negative at the first
(1st) prenatal visit and are considered high-risk for
Hepatitis B infection. This test shall be performed at the same
time that other routine prenatal screening is ordered.






	 	(b)	 	All HBsAg-positive women shall be
reported to the local CHD and to Healthy Start, regardless of
their Healthy Start screening score.






	 	(7)	 	The Health Plan shall ensure that infants born
to HBsAg-positive Enrollees shall receive Hepatitis B Immune Globulin
(HBIG) and the Hepatitis B vaccine once they are physiologically
stable, preferably within twelve (12) hours of birth and shall complete
the Hepatitis B Maxine series according to the recommended vaccine
schedule established by the Recommended Childhood Immunization Schedule
for the United States.






	 	(a)	 	The Health Plan shall ensure that
its Providers test infants born to HBsAg-positive Enrollees for
HBsAg and Hepatitis B surface antibodies (anti-HBs) six (6)
months after the completion of the vaccine series to monitor the
success or failure of the therapy.






	 	(b)	 	The Health Plan shall ensure that
Providers report to the local CHD a positive HBsAg result in any
child aged twenty-four (24) months or less within twenty-four
(24) hours of receipt of the positive test results.






	 	(c)	 	The Health Plan shall ensure that
infants born to Enrollees who are HBsAg-positive are referred to
Healthy Start regardless of their Healthy Start screening score.






	 	(8)	 	The Health Plan shall report to the Perinatal
Hepatitis B Prevention Coordinator at the local CHD all prenatal or
postpartum Enrollees who test HBsAg-positive. The Health Plan also
shall report said Enrollees’ infants and contacts to the Perinatal
Hepatitis B Prevention Coordinator at the local CHD.






	 	(a)	 	The Health Plan shall report the
following information – name, date of birth, race, ethnicity,
address, infants, contacts, laboratory test performed, date the
sample was collected, the due date or EDC, whether or not the
Enrollee received prenatal care, and immunization dates for
infants and contacts.






	 	(b)	 	The Health Plan shall use the
Perinatal Hepatitis B Case and Contact Report (DH Form 1876) for
reporting purposes.






	 	(9)	 	The Health Plan shall ensure that the PCP
maintains all documentation of Healthy Start screenings, assessments,
findings and referrals in the Enrollees’ Medical Records. The Health
Plan shall ensure quick access to Enrollees’ Medical Records in the
Provider Contract.






	 	(10)	 	The Health Plan shall provide the most
appropriate and highest level of quality care for pregnant Enrollees,
including, but not limited to, the following:






	 	(a)	 	Prenatal Care – The Health Plan
shall:






	 	(i)	 	Require a
pregnancy test and a nursing assessment with referrals
to a physician, PA or ARNP for comprehensive evaluation;






	 	(ii)	 	Require Case
Management through the gestational period according to
the needs of the Enrollee;






	 	(iii)	 	Require any
necessary referrals and follow-up;






	 	(iv)	 	Schedule return
prenatal visits at least every four (4) weeks until the
thirty-second (32nd) week, every two (2) weeks until the
thirty-sixth (36th) week, and every week thereafter
until delivery, unless the Enrollee’s condition requires
more frequent visits;






	 	(v)	 	Contact those
Enrollees who fail to keep their prenatal appointments
as soon as possible, and arrange for their continued
prenatal care;






	 	(vi)	 	Assist Enrollees
in making delivery arrangements, if necessary; and






	 	(vii)	 	Ensure that all
Providers screen all pregnant Enrollees for tobacco use
and make certain that the Providers make available to
the pregnant Enrollees smoking cessation counseling and
appropriate treatment as needed.






	 	(b)	 	Nutritional Assessment/Counseling
– The Health Plan shall ensure that its Providers supply
nutritional assessment and counseling to all pregnant Enrollees.
The Health Plan shall:






	 	(i)	 	Ensure the
provision of safe and adequate nutrition for infants by
promoting breast-feeding and the use of breast milk
substitutes;






	 	(ii)	 	Offer a mid-level
nutrition assessment;






	 	(iii)	 	Provide
individualized diet counseling and a nutrition care plan
by a public health nutritionist, a nurse or physician
following the nutrition assessment; and






	 	(iv)	 	Documentation of
the nutrition care plan in the Medical Record by the
person providing counseling.






	 	(c)	 	Obstetrical Delivery – The Health
Plan shall develop and use generally accepted and approved
protocols for both low risk and high risk deliveries which
reflect the highest standards of the medical profession,
including Healthy Start and prenatal screening, and ensure that
all Providers use these protocols.






	 	(i)	 	The Health Plan
shall ensure that all Providers document preterm
delivery risk assessments in the Enrollee’s Medical
Record by the twenty-eighth (28th) week.






	 	(ii)	 	If the Provider
determines that the Enrollee’s pregnancy is high risk,
the Health Plan shall ensure that the Provider’s
obstetrical care during labor and delivery includes
preparation by all attendants for symptomatic evaluation
and that the Enrollee progresses through the final
stages of labor and immediate postpartum care.






	 	(d)	 	Newborn Care – The Health Plan
shall make certain that its Providers supply the highest level
of care for the Newborn beginning immediately after birth. Such
level of care shall include, but not be limited to, the
following:






	 	(i)	 	Instilling of
prophylactic eye medications into each eye of the
Newborn;






	 	(ii)	 	When the mother
is Rh negative, the securing of a cord blood sample for
type Rh determination and direct Coombs test;






	 	(iii)	 	Weighing and
measuring of the Newborn;






	 	(iv)	 	Inspecting the
Newborn for abnormalities and/or complications;






	 	(v)	 	Administering of
one half milligram of vitamin K;






	 	(vi)	 	APGAR scoring;






	 	(vii)	 	Any other
necessary and immediate need for referral in
consultation from a specialty physician, such as the
Healthy Start (postnatal) infant screen; and






	 	(viii)	 	Any necessary Newborn and infant hearing screenings
(to be conducted by a licensed audiologist pursuant to
Chapter 468, F.S., a physician licensed under Chapters
458 or 459, F.S., or an individual who has completed
documented training specifically for newborn hearing
screenings and who is directly or indirectly supervised
by a licensed physician or a licensed audiologist).






	 	(e)	 	Postpartum Care – The Health Plan
shall:






	 	(i)	 	Provide a
postpartum examination for the Enrollee within six (6)
weeks after delivery;






	 	(ii)	 	Ensure that its
Providers supply voluntary family planning, including a
discussion of all methods of contraception, as
appropriate;






	 	(iii)	 	Ensure that
eligible Newborns are enrolled with the Health Plan and
that continuing care of the Newborn be provided through
the CHCUP program component.






	 	16.	 	Prescribed Drug Services






	 	a.	 	The Health Plan shall provide those products and services
associated with the dispensing of medicinal drugs pursuant to a valid
prescription, as defined in Chapter 465, F.S. Prescribed Drug Services
generally include all prescription drugs listed in the Agency’s Prescribed Drug
List (“PDL”). See Section 409.91195, F.S. The PDL shall include at
least two (2) products, when available, in each therapeutic class.
Antiretroviral agents are not subject to the PDL. Pursuant to Section
409.912(39), F.S., policy requirements include, but are not limited to, the
following:






	 	(1)	 	The Health Plan shall make available those
drugs and dosage forms listed in the PDL.






	 	(2)	 	The Health Plan shall not arbitrarily deny or
reduce the amount, duration or scope of prescriptions solely based on
the Enrollee’s diagnosis, type of illness or condition. The Health
Plan may place appropriate limits on prescriptions based on criteria
such as Medical Necessity, or for the purpose of utilization control,
provided the Health Plan reasonably expects said limits to achieve the
purpose of the Prescribed Drug Services set forth in the Medicaid State
Plan.






	 	(3)	 	The Health Plan shall make available those
drugs not on the PDL, when requested and approved, if the drugs on the
PDL have been used in a step therapy sequence or when other
documentation is provided.






	 	(4)	 	The Health Plan shall submit an updated PDL to
the Agency annually, by October 1 of each Contract Year, and provide
thirty (30) days written notice of any changes to the Bureau of Managed
Health Care and Pharmacy Services.






	 	b.	 	The Health Plan shall provide to Enrollees, who desire to quit
smoking, one (1) course of nicotine replacement therapy, of twelve (12) weeks
duration, or the manufacturer’s recommended duration, per year. The Health
Plan may use either nicotine transdermal patches or nicotine gum.






	 	c.	 	If the Health Plan has authorization requirements for
prescribed drug services, the Health Plan shall comply with all aspects of the
Settlement Agreement to Hernandez, et. al. v. Medows (case number 02-20964
Civ-Gold/Simonton) (HSA). An HSA situation arises when an Enrollee attempts to
fill a prescription at a participating pharmacy location and is unable to
receive his/her prescription as a result of:






	 	(1)	 	An unreasonable delay in filling the
prescription;






	 	(2)	 	A denial of the prescription;






	 	(3)	 	The reduction of a prescribed good or service;
and/or






	 	(4)	 	The termination of a prescription.






	 	d.	 	The Health Plan shall ensure that its Enrollees are receiving
the functional equivalent of those goods and services received by non-Medicaid
Reform fee-for-service Medicaid Recipients in accordance with the HSA.






	 	(1)	 	The Health Plan shall maintain a log of all
correspondences and communications from Enrollees relating to the HSA
Ombudsman process. The “Ombudsman Log” shall contain, at a minimum,
the Enrollee’s name, address and telephone number and any other contact
information, the reason for the participating pharmacy location’s
denial (an unreasonable delay in filling a prescription, a denial of a
prescription and/or the termination of a prescription), the pharmacy’s
name (and store number, if applicable), the date of the call, a
detailed explanation of the final resolution, and the name of
prescribed good or service.






	 	(2)	 	The Health Plan’s Enrollees are third party
beneficiaries for this Section of the Contract.






	 	(3)	 	The Health Plan shall conduct HSA surveys on an
annual basis, of no less than five percent (5%) of all participating
pharmacy locations to ensure compliance with the HSA.






	 	(a)	 	The Health Plan may survey less
than five percent (5%), with written approval from the Agency,
if the Health Plan can show that the number of participating
pharmacies it surveys is a statistically significant sample that
adequately represents the pharmacies that have contracted with
the Health Plan to provide pharmacy services.






	 	(b)	 	The Health Plan shall not include
in the HSA Survey any participating pharmacy location that the
Health Plan found to be in complete compliance with the HSA
requirements within the last twelve (12) months.






	 	(c)	 	The Health Plan shall require all
participating pharmacy locations that fail any aspect of the HSA
survey to undergo mandatory training within six (6) months and
then be re-evaluated within one (1) month of the Health Plan’s
HSA training to ensure that the participating pharmacy location
is in compliance with the HSA.






	 	(d)	 	The Health Plan shall ensure that
it complies with all aspects and surveying requirements set
forth in Policy Transmittal 06-01, Hernandez Settlement
Requirements, an electronic copy of which can be found at:





http://www.fdhc.state.fl.us/MCHQ/Managed_Health_Care/MHMO/med_prov.shtml





	 	(4)	 	The Health Plan shall offer to train all new
and existing participating pharmacy locations regarding the HSA
requirements.






	 	(5)	 	The Health Plan may delegate any or all
functions to one (1) or more Pharmacy Benefits Administrators (PBA).
Before entering into a Subcontract, the Health Plan shall:






	 	(a)	 	Provide a copy of the model
Subcontract between the Health Plan and the PBA to the Bureau of
Managed Health Care;






	 	(b)	 	Receive written approval from the
Bureau of Managed Health Care for the use of said model
Subcontract; and






	 	(c)	 	Work with the Fiscal Agent to
integrate the systems.






	 	e.	 	The Health Plan shall reimburse all pharmacies for the cost of
a brand name drug if:






	 	(1)	 	Writes in his/her own handwriting on the valid
prescription that the “Brand Name is Medically Necessary” (pursuant to
Section 465.025, F.S.); and






	 	(2)	 	Submits a completed “Multisource Drug and
Miscellaneous Prior Authorization” form to the Health Plan indicating
that the Enrollee has had an adverse reaction to a generic drug or has
had, in the prescriber’s medical opinion, better results when taking
the brand-name drug.






	 	f.	 	Effective September 1, 2006, hemophilia-related drugs
identified by the Agency for distribution through the Hemophilia Disease
Management Pilot Program will be reimbursed on a Fee-for-Service basis. Upon
implementation of the Hemophilia Disease Management Pilot Program, the Health
Plan shall coordinate the care of its’ Enrollees with Agency-approved
organizations and shall not be responsible for the distribution of
Hemophilia-related drugs.






	 	g.	 	Health Plans shall submit pharmacy encounter data in a format
supplied by the Agency on an ongoing quarterly payment schedule, as specified
in Section XII of this Contract. For example, data for all claims paid during
04/01/06 and 06/30/06 is due to the Agency by 07/31/06.






	 	17.	 	Quality Enhancements






	 	a.	 	In addition to the covered services specified in this Section,
the Health Plan shall offer Quality Enhancements (“QEs”) to Enrollees as
specified below.






	 	1.	 	The Health Plan shall offer QEs in community
settings that are accessible to Enrollees.






	 	2.	 	The Health Plan shall inform Enrollees and
Providers of the QEs, and how to access services related to QEs,
through the Enrollee and Provider Handbooks.






	 	3.	 	The Health Plan shall develop and maintain
written policies and procedures to implement QEs.






	 	4.	 	The Health Plan may cosponsor the annual
training of Providers, provided that the training meets the Provider
training requirements for the programs listed below. The Plan is
encouraged to actively collaborate with community agencies and
organizations, including CHD’s, local Early Intervention Programs,
Healthy Start Coalitions and local school districts in offering these
services.






	 	5.	 	If the Health Plan involves the Enrollee in an
existing community program for purposes of meeting the QE requirement,
the Health Plan shall document referrals to the community program,
shall follow-up on the Enrollee’s receipt of services from the
community program and record the Enrollee’s involvement in the
Enrollee’s Medical Record.






	 	6.	 	QE programs shall include, but not be limited
to, the following:






	 	(1)	 	Children’s Programs – The Health
Plan shall provide regular general wellness programs targeted
specifically toward Enrollees from birth to the age of five (5),
or the Health Plan shall make a good faith effort to involve
Enrollees in existing community Children’s Programs.






	 	(a)	 	Children’s
Programs shall promote increased utilization of
prevention and early intervention services for at-risk
Enrollees with Children/Adolescents in the target
population. The Health Plan shall approve claims for
services recommended by the Early Intervention Program
when they are Covered Services and Medically Necessary.






	 	(b)	 	The Health Plan
shall offer annual training to Providers that promote
proper nutrition, breast-feeding, immunizations, CHCUP,
wellness, prevention and early intervention services.






	 	(2)	 	Domestic Violence – The Health
Plan shall ensure that PCPs screen Enrollees for signs of
domestic violence and shall offer referral services to
applicable domestic violence prevention community agencies.






	 	(3)	 	Pregnancy Prevention – The Health
Plan shall conduct regularly scheduled Pregnancy Prevention
programs, or shall make a good faith effort to involve Enrollees
in existing community Pregnancy Prevention programs, such as the
Abstinence Education Program. The programs shall be targeted
towards teen Enrollees, but shall be open to all Enrollees,
regardless of age, gender, pregnancy status or parental consent.






	 	(4)	 	Prenatal/Postpartum Pregnancy
Programs – The Health Plan shall provide regular home visits,
conducted by a home health nurse or aide, and counseling and
educational materials to pregnant and postpartum Enrollees who
are not in compliance with the Health Plan’s prenatal and
postpartum programs. The Health Plan shall coordinate its
efforts with the local Healthy Start Care Coordinator to prevent
duplication of services.






	 	(5)	 	Smoking Cessation – The Health
Plan shall conduct regularly scheduled Smoking Cessation
programs as an option for all Enrollees, or the Health Plan
shall make a good faith effort to involve Enrollees in existing
community or Smoking Cessation programs. The Health Plan shall
provide Smoking Cessation counseling to Enrollees. The Health
Plan shall provide Participating PCPs with the Quick Reference
Guide to assist in identifying tobacco users and supporting and
delivering effective Smoking Cessation interventions (The Quick
Reference Guide is a distilled version of the Public Health
Service sponsored Clinical Practice Guideline, Treating Tobacco
Use & Dependence. The Plan can obtain copies of the Quick
Reference guide by contacting the DHHS, Agency for Health Care
Research & Quality (AHR) Publications Clearinghouse at (800)
358-9295 or P.O. Box 8547, Silver Spring, MD 20907).






	 	(6)	 	Substance Abuse – The Health Plan
shall offer Substance Abuse screening training to its Providers
on an annual basis.






	 	(a)	 	The Health Plan
shall have all PCPs screen Enrollees for signs of
Substance Abuse as part of prevention evaluation at the
following times:





	 	 	 
	(i)

	 	Initial contact with a new Enrollee;
	 
	 	 
	(ii)

	 	Routine physical examinations;
	 
	 	 
	(iii)

	 	Initial prenatal contact;







	 	 	 	(iv)
When the Enrollee evidences serious
over-utilization of medical, surgical, trauma or
emergency services; and






	 	 	 	(v)
When documentation of emergency room visits
suggests the need.






	 	(b)	 	The Health Plan
shall offer targeted Enrollees either community or
Health Plan sponsored Substance Abuse programs.






	 	18.	 	Protective Custody






	 	a.	 	The Health Plan shall provide a physical screening within
seventy-two (72) hours, or immediately if required, for all enrolled
Children/Adolescents taken into protective custody, emergency shelter or the
foster care program by DCF. See Rule 65C-12.002, F.A.C.






	 	b.	 	The Health Plan shall provide these required examinations, or,
if unable to do so within the required time frames, must approve the
out-of-network claim and forward it to the Agency and/or its Agent.






	 	c.	 	For all CHCUP screenings for Children/Adolescents whose
Enrollment and Medicaid eligibility are undetermined at the time of entry into
the care and custody of DCF, and who are later determined to be Enrollees at
the time the examinations took place, the Health Plan shall approve the claims
and forward them to the Agency and/or the Fiscal Agent.






	 	19.	 	Therapy Services






	 	a.	 	Medicaid therapy services or by physical, speech-language
(including augmentative and alternative communication systems), occupational
and respiratory therapies. Medicaid pays only for therapy services that are
Medically Necessary for the provision of therapy evaluations and individual
therapy treatment. Therapy services are limited to Children/Adolescents under
the age of twenty-one (21). Adults are covered for physical and respiratory
therapy services under the outpatient Hospital services program. The Agency
shall reimburse schools participating in the certified school match program for
school-based therapy services rendered to Enrollees. The provision of
school-based therapy services to an Enrollee does not replace, substitute or
fulfill a service prescription or doctors’ orders for therapy services external
to the Health Plan. The Health Plan shall:






	 	(1)	 	Refer Enrollees to appropriate Providers for
further assessment and treatment of conditions;






	 	(2)	 	Offer Enrollees scheduling assistance in making
treatment appointments and obtaining transportation; and






	 	(3)	 	Provide for care management in order to follow
the Enrollee’s progress from screening through his/her course of
treatment.






	 	20.	 	Transportation Services






	 	a.	 	Transportation services are an Optional Service (as described
in Section V.B., Optional Services, above). Transportation services include
the arrangement and provision of an appropriate mode of Transportation for
Enrollees to receive medical care services. The Health Plan shall
comply with the limitations and exclusions in the Medicaid Transportation
Coverage, Limitations & Reimbursement Handbook (the “Transportation Handbook”),
including Emergency Transportation Services. In any instance where compliance
conflicts with the terms of this Contract, the Contract terms shall take
precedence. In no instance may the limitations or exclusions imposed by
the Health Plan be more stringent than those specified in the Transportation
Handbook.






	 	b.	 	The Health Plan shall have the option to provide Transportation
services directly through the Health Plan’s network of Transportation
Providers, or through a Provider contract relationship, which may include the
CTD.






	 	c.	 	Regardless of whether the Health Plan chooses to coordinate
with a Transportation Provider or provide Transportation services directly, the
Health Plan shall be responsible for monitoring the provision of services. The
Health Plan:






	 	(1)	 	Shall assure that Transportation providers are
appropriately licensed and insured in accordance with the provisions of
the Transportation Handbook;






	 	(2)	 	Must provide Transportation Services for all
Enrollees seeking necessary Medicaid services;






	 	(3)	 	Is not obligated to follow the requirements of
the Commission for the Transportation Disadvantaged or the
Transportation Coordinating Boards as set forth in Chapter 427, F.S.,
unless the Health Plan has chosen to coordinate services with the CTD;






	 	(4)	 	Shall be responsible for the cost of
transporting an Enrollee from a nonparticipating facility or Hospital
to a participating facility or Hospital if the reason for transport is
solely for the Health Plan’s convenience; and






	 	(5)	 	Shall approve claims for Transportation
Providers in accordance with the requirements set forth in this
Contract.






	 	d.	 	The Health Plan may delegate the provision of Transportation
Services to a third party.






	 	(1)	 	The Health Plan shall provide a copy of the
model Participating Transportation Subcontract to the Bureau of Managed
Health Care.






	 	(2)	 	The Health Plan may subcontract with more than
one (1) Transportation Provider.






	 	(3)	 	The Health Plan shall maintain oversight of any
third party providing services on the Health Plan’s behalf.






	 	e.	 	The Health Plan shall provide the following non-emergency
Transportation, at a minimum, as part of its line of Transportation services
(as defined in the Transportation Handbook):






	 	(1)	 	Ambulatory Transportation;






	 	(2)	 	Long haul ambulatory Transportation;






	 	(3)	 	Wheelchair Transportation;






	 	(4)	 	Stretcher Transportation;






	 	(5)	 	Multiload Transportation;






	 	(6)	 	Mass transit Transportation;






	 	(7)	 	Over-the-road bus;






	 	(8)	 	Over-the-road train;






	 	(9)	 	Private volunteer Transportation;






	 	(10)	 	Escort services (including medical escort); and






	 	(11)	 	Commercial air carrier Transportation.






	 	f.	 	Before providing Transportation services, the Health Plan shall
provide to the Bureau of Managed Health Care a copy of its policies and
procedures relating to the following:






	 	(1)	 	How the Health Plan will determine eligibility
for each Enrollee;






	 	(2)	 	The Health Plan’s course of action as to how it
will determine what type of Transportation to provide to a particular
Enrollee;






	 	(3)	 	The Health Plan’s procedure for providing Prior
Authorization to Enrollees requesting Transportation services;






	 	(4)	 	The Health Plan’s comprehensive employee
training program to investigate potential Fraud;






	 	(5)	 	How the Health Plan will review Transportation
Providers who demonstrate a pattern or practice of:






	 	(a)	 	Falsified encounter or service
reports;






	 	(b)	 	Overstated reports or up-coded
levels of service; and/or






	 	(c)	 	Fraud or Abuse, as defined in
section 409.913, F.S.






	 	(6)	 	How the Health Plan will review Transportation
Providers that:






	 	(a)	 	Alter, falsify or destroy records
prior to the end of the five (5) year records retention
requirement;






	 	(b)	 	Make false statements about
credentials;






	 	(c)	 	Misrepresent medical information
to justify referrals;






	 	(d)	 	Fail to provide scheduled
Transportation for Enrollees;






	 	(e)	 	Charge Enrollees for Covered
Services; and/or






	 	(f)	 	Have committed, or been suspected
of committing, Fraud or Abuse, as defined in Section 409.913,
F.S.






	 	(7)	 	How the Health Plan will provide Transportation
Services outside of the Health Plan’s service area. The Health Plan
shall state clearly the guidelines it will use in order to control
costs when providing Transportation Services outside of the Health
Plan’s service area.






	 	g.	 	The Health Plan shall report immediately, in writing to the
Agency Contract Manager, the Bureau of Medicaid Program Integrity (MPI), and
Medicaid Fraud Control Unit (MFCU), any aspect of Transportation Service
delivery, by any Transportation services provider, or any adverse or untoward
incident (See section 641.55, F.S.). The Health Plan shall also report,
immediately upon identification, in writing to the Agency Contract Manager, the
MPI and the MFCU, all instances of suspected Enrollee or Transportation
Services Provider fraud or abuse (as defined in Section 409.913, F.S.)






	 	(1)	 	The Health Plan shall file a written report
with the Agency Contract Manager, the Bureau of Managed Health Care,
MPI and MFCU immediately upon the detection of a potentially or
suspected fraudulent or abusive action by a Transportation services
Provider. At a minimum, the report must contain the name, tax
identification number and contract information of the Transportation
services Provider and a description of the suspected fraudulent or
abusive act. The report shall be in the form of a narrative.






	 	h.	 	Insurance, Safety Requirements and Standards (including, but
not limited to, 41-2, F.A.C.)






	 	(1)	 	The Health Plan shall ensure compliance with
the minimum liability insurance requirement of $100,000 per person and
$200,000 per incident for all Transportation services purchased or
provided for the Transportation disadvantaged through the Health Plan.
See Section 768.28(5), F.S. The Health Plan shall indemnify and hold
harmless the local, State, and federal governments and their entities
and the Agency from any liabilities arising out of or due to an
accident or negligence on the part of the Health Plan and/or all
Transportation Providers under contract to the Health Plan. The Health
Plan may act as a Transportation Provider, in which case it must follow
all requirements set forth below for Transportation Providers.






	 	(2)	 	The Health Plan, and all Transportation
Providers, shall ensure that all operations and services are in
compliance with all federal and State safety requirements, including,
but not limited to, Section 341.061(2)(a), F.S., and Chapter 14-90,
F.A.C.






	 	(3)	 	The Health Plan, and all Transportation
Providers, shall ensure continuing compliance with all applicable State
or federal laws relating to drug testing, including, but not limited
to, to Section 112.0455, F.S., Rule 14-17.012, Chapters 59A-24 and
60L-19, F.A.C., 41 USC 701, 49 CFR, Parts 29 and 382, and 46 CFR, Parts
4, 5, 14, and 16.






	 	(4)	 	The Health Plan and all Transportation
Providers shall adhere to the following standards, including, but not
limited to:






	 	(a)	 	Drug and alcohol testing for
safety sensitive job positions relating to the provision of
Transportation services regarding pre-employment, randomization,
post-accident, and reasonable suspicion as required by the
Federal Highway Administration and the Federal Transit
Administration;






	 	(b)	 	Use of child safety restraint
devices, where the use of such devices would not interfere with
the safety of a child (for example, a child in a wheelchair);






	 	(c)	 	Enrollee property that can be
carried by the passenger and/or driver, and can be stowed safely
on the vehicle, shall be transported with the passenger at no
additional charge. The driver shall provide Transportation of
the following items, as applicable, within the capabilities of
the vehicle:





	 	 	 
	(i)

	 	Wheelchairs;
	 
	 	 
	(ii)

	 	Child seats;
	 
	 	 
	(iii)

	 	Stretchers;
	 
	 	 
	(iv)

	 	Secured oxygen;
	 
	 	 
	(v)

	 	Personal assistive devices; and/or
	 
	 	 
	(vi)

	 	Intravenous devices.







	 	(d)	 	Vehicle transfer points shall
provide shelter, security, and safety of Enrollees;






	 	(e)	 	Maintain inside all vehicles
copies of the Health Plan’s toll-free phone number for Enrollee
complaints;






	 	(f)	 	The interior of all vehicles
shall be free from dirt, grime, oil, trash, torn upholstery,
damaged or broken seats, protruding metal or other objects or
materials which could soil items placed in the vehicle or
provide discomfort for Enrollees;






	 	(g)	 	Maintain a passenger/trip
database for each Enrollee transported by the Health
Plan/Transportation Provider;






	 	(h)	 	Ensure adequate seating for
paratransit services for each Enrollee and escort, child, or
personal care attendant, and shall ensure that the vehicle does
not transport more passengers than the registered passenger
seating capacity in a vehicle at any time;






	 	(i)	 	Ensure adequate seating space for
transit services for each Enrollee and escort, child, or
personal care attendant, and shall ensure that transit vehicles
provide adequate seating or standing space to each rider, and
shall ensure that the vehicle does not transport more passengers
than the registered passenger seating or standing capacity in a
vehicle at any time;






	 	(j)	 	Drivers for paratransit services
shall identify themselves by name and company in a manner that
is conducive to communications with the specific passenger, upon
pickup of each Enrollee, group of Enrollees, or representative,
guardian, or associate of the Enrollee, except in situations
where the driver regularly transports the Enrollee on a
recurring basis;






	 	(k)	 	Each driver must have photo
identification that is viewable by the passenger. Name patches,
inscriptions or badges that affix to driver clothing are
acceptable. For transit services, the driver photo
identification shall be in a conspicuous location in the
vehicle;






	 	(l)	 	The paratransit driver shall
provide the Enrollee with boarding assistance, if necessary or
requested, to the seating portion of the vehicle. The boarding
assistance shall include, but not be limited to, opening the
vehicle door, fastening the seat belt or utilization of wheel
chair securement devices, storage of mobility assistive devices
and closing the vehicle door. In the door-through-door
paratransit service category, the driver shall open and close
doors to buildings, except in situations in which assistance in
opening and/or closing building doors would not be safe for
passengers remaining in the vehicle. The driver shall provide
assisted access in a dignified manner. Drivers may not assist
wheelchair passengers up or down more than one (1) step, unless
it can be performed safely as determined by the Enrollee,
guardian, and driver;






	 	(m)	 	Smoking, eating and drinking are
prohibited in any vehicle, except in cases in which, as a
Medical Necessity, the Enrollee requires fluids or sustenance
during transport;






	 	(n)	 	Ensure that all vehicles are
equipped with two-way communications, in good working order and
audible to the driver at all times, by which to communicate with
the Transportation services hub or base of operations;






	 	(o)	 	Ensure that all vehicles have
working air conditioners and heaters. The Health Plan shall
ensure that all vehicles that do not have a working air
conditioner or heater are removed from the vehicle pool and
scheduled for repair or replacement;






	 	(p)	 	Develop and implement a first aid
policy and cardiopulmonary resuscitation policy;






	 	(q)	 	Ensure that all drivers providing
Transportation services undergo a background screening;






	 	(r)	 	Establish Enrollee pick-up
windows and communicate these windows to Transportation
Providers and Enrollees;






	 	(s)	 	Establish a minimum 24-hour
advance notification policy to obtain Transportation Services.
The Health Plan shall communicate said policy to Transportation
Providers and Enrollees;






	 	(t)	 	Establish a performance measure
to evaluate the safety of the Transportation services provided
by Transportation Providers;






	 	(u)	 	Establish a performance measure
to evaluate the reliability of the vehicles utilized by
Transportation Providers;






	 	(v)	 	Establish a performance measure
to evaluate the quality of service provided by a Transportation
Provider;






	 	(w)	 	The Health Plan shall submit
these performance measures to the Agency for written approval by
the end of the first month of this contract term;






	 	(x)	 	The Health Plan shall report the
results of these evaluations to the Agency as described in
Section XII, Reporting Requirements; and






	 	(y)	 	Ensure that all drivers speak
English.






	 	i.	 	Operational Standards — Each Health Plan shall implement, or
ensure that each Transportation Provider has implemented, policies and
procedures that, at a minimum, comply with the following (for reference, see
14-90, F.A.C.):






	 	(1)	 	Address the following safety elements and
requirements:






	 	(a)	 	Safety policies and
responsibilities;






	 	(b)	 	Vehicle and equipment standards
and procurement criteria;






	 	(c)	 	Operational standards and
procedures;






	 	(d)	 	Vehicle driver and employee
selection;






	 	(e)	 	Driving requirements;






	 	(f)	 	Vehicle driver and employee
training;






	 	(g)	 	Vehicle maintenance;






	 	(h)	 	Investigations of events
described below;






	 	(i)	 	Hazard identification and
resolution;






	 	(j)	 	Equipment for transporting
wheelchairs;






	 	(k)	 	Safety data acquisition and
analysis;






	 	(l)	 	Safety standards for private
contract vehicle transit system(s) that provide(s)
Transportation services for compensation as a result of a
contractual agreement with the vehicle transit system.






	 	(2)	 	Shall submit an annual safety certification to
the Agency verifying the following:






	 	(a)	 	Adoption of policies and
procedures that, at a minimum, establish standard set forth in
this Section; and






	 	(b)	 	The Health Plan/Transportation
Provider is in full compliance with the policies and procedures
relating to Transportation services, and that it has performed
annual safety inspections on all vehicles operated by the Health
Plan/Transportation Provider, by persons meeting the
requirements set forth below.






	 	(3)	 	The Health Plan shall suspend immediately a
Transportation Provider if, in the sole discretion of the Health Plan,
and at any time, continued use of that Transportation Provider, is
unsafe for passenger service or poses a potential danger to public
safety.






	 	(4)	 	Address the following security requirements:






	 	(a)	 	Security policies, goals, and
objectives;






	 	(b)	 	Organization, roles, and
responsibilities;






	 	(c)	 	Emergency management processes
and procedures for mitigation, preparedness, response, and
recovery;






	 	(d)	 	Procedures for investigation of
any event involving a vehicle, or taking place on vehicle
transit system controlled property, resulting in a fatality,
injury, or property damage as discussed below;






	 	(e)	 	Procedures for the establishment
of interfaces with emergency response organizations;






	 	(f)	 	Employee security and threat
awareness training programs;






	 	(g)	 	Conduct and participate in
emergency preparedness drills and exercises; and






	 	(h)	 	Security requirements for
Transportation Providers that provide Transportation services
for compensation as a result of a contractual agreement with the
Health Plan/Transportation Provider.






	 	(5)	 	Shall establish criteria and procedures for
selection, qualification, and training of all drivers. The criteria
shall include, at a minimum, the following:






	 	(a)	 	Driver qualifications and
background checks with minimum hiring standards;






	 	(b)	 	Driving and criminal background
checks for all new drivers;






	 	(c)	 	Verification and documentation of
valid driver licenses for all employees who drive vehicles;






	 	(d)	 	Training and testing to
demonstrate and ensure adequate skills and capabilities to
safely operate each type of vehicle or vehicle combination
before driving unsupervised;






	 	(e)	 	At a minimum, drivers shall be
given explicit instructional and procedural training and testing
in the following areas:






	 	(i)	 	The Health
Plan’s/Transportation Provider’s safety and operational
policies and procedures;





	 	 	 
	(ii)

	 	Operational vehicle and equipment inspections;
	 
	 	 
	(iii)

	 	Vehicle equipment familiarization;
	 
	 	 
	(iv)

	 	Basic operations and maneuvering;
	 
	 	 
	(v)

	 	Boarding and alighting passengers;







	 	(vi)	 	Operation of
wheelchair lift and other special equipment and driving
conditions;





	 	 	 
	(vii)

	 	Defensive driving;
	 
	 	 
	(viii)

	 	Passenger assistance and securement;
	 
	 	 
	(ix)

	 	Handling of emergencies and security threats; and







	 	(x)	 	Security and
threat awareness.






	 	(f)	 	Shall provide written operational
and safety procedures to all vehicle drivers before the drivers
are allowed to drive unsupervised. These procedures and
instructions shall address, at a minimum, the following:






	 	(i)	 	Communication and
handling of unsafe conditions, security threats, and
emergencies;






	 	(ii)	 	Familiarization
and operation of safety and emergency equipment,
wheelchair lift equipment, and restraining devices; and






	 	(iii)	 	Application and
compliance with applicable federal and State rules and
regulations. The provisions in Sections V.E.20.i.(5)(e)
and (f), above, shall not apply to personnel licensed
and authorized by the Plan/Transportation Provider to
drive, move, or road test a vehicle in order to perform
repairs or maintenance services where it has been
determined that such temporary operation does not create
an unsafe operating condition or create a hazard to
public safety.






	 	(g)	 	Shall maintain the following
records for at least five (5) years:






	 	(i)	 	Records of
vehicle driver background checks and qualifications;






	 	(ii)	 	Detailed
descriptions of training administered and completed by
each vehicle driver;






	 	(iii)	 	A record of each
vehicle driver’s duty status, which shall include total
days worked, on-duty hours, driving hours and time of
reporting on- and off-duty each day; and






	 	(iv)	 	Any documents
required to be prepared by this Contract.






	 	(h)	 	Shall establish a drug-free
workplace policy statement, in accordance with 49 CFR Part 29
and a substance abuse management and testing program,
in accordance with 49 CFR Parts 40 and 655; and






	 	(i)	 	Shall require that drivers write
and submit a daily vehicle inspection report, pursuant to Rule
14-90.006, F.A.C.






	 	(6)	 	Shall establish a maintenance policy and
procedures for preventative and routine maintenance for all vehicles.
The maintenance policy and procedures shall ensure, at a minimum, that:






	 	(a)	 	All vehicles, all parts and
accessories on such vehicles, and any additional parts and
accessories which may affect the safety of vehicle operation,
including frame and frame assemblies, suspension systems, axles
and attaching parts, wheels and rims, and steering systems, are
regularly and systematically inspected, maintained and
lubricated in accordance with the standards developed and
established according to the vehicle manufacturer’s
recommendations and requirements;






	 	(b)	 	That a recording and tracking
system is established for the types of inspections, maintenance,
and lubrication intervals, including the date or mileage when
these services are due. Required maintenance inspections shall
be more comprehensive than daily inspections performed by the
driver;






	 	(c)	 	That proper preventive
maintenance is performed when on all vehicles; and






	 	(d)	 	That the Health
Plan/Transportation Provider maintains and provides written
documentation of preventive maintenance, regular maintenance,
inspections, lubrication, and repairs performed for each vehicle
under their control. Such records shall be maintained by the
Health Plan/Transportation Provider for at least five (5) years
and include, at a minimum, the following information:






	 	(i)	 	Identification of
the vehicle, including make, model, and license number
or other means of positive identification and ownership;






	 	(ii)	 	Date, mileage,
and type of inspection, maintenance, lubrication, or
repair performed;






	 	(iii)	 	Date, mileage,
and description of each inspection, maintenance, and
lubrication intervals performed;






	 	(iv)	 	If not owned by
the Health Plan/Transportation Provider, the name of any
person or lessor furnishing any vehicle; and






	 	(v)	 	The name and
address of any entity or contractor performing an
inspection, maintenance, lubrication, or repair.






	 	(7)	 	The Health Plan/Transportation Provider shall
investigate, or cause to be investigated, any event involving a vehicle
or taking place on Health Plan/Transportation Provider controlled
property resulting in a fatality, injury, or property damage as
follows:






	 	(a)	 	A fatality, where an individual
is confirmed dead, within three (3) days of a Transportation
services related event, excluding suicides and deaths from
illnesses. The Health Plan must file detailed report of the
incident with the Agency within ten (10) days of the event (see
Section 641.55(6), F.S.);






	 	(b)	 	Injuries requiring immediate
medical attention away from the scene for two (2) or more
individuals;






	 	(c)	 	Property damage to Health
Plan/Transportation Provider vehicles, other Health
Plan/Transportation Provider property or facilities, or any
other property, except the Health Plan/Transportation Provider
shall have the discretion to investigate events resulting in
property damage totaling less than $1,000;






	 	(d)	 	Evacuation of a vehicle due where
there is imminent danger to passengers on the vehicle, excluding
evacuations due to vehicle operation issues;






	 	(e)	 	Each investigation shall be
documented in a final report that includes a description of
investigation activities, identified causal factors and a
corrective action plan;






	 	(i)	 	Each corrective
action plan shall identify the action to be taken by the
Health Plan/Transportation Provider and the schedule for
its implementation; and






	 	(ii)	 	The Health
Plan/Transportation Provider must monitor and track the
implementation of each corrective action plan.






	 	(f)	 	The Health Plan/Transportation
Provider shall maintain all investigation reports, corrective
action plans, and related supporting documentation for a minimum
of five (5) years from the date of completion of the
investigation.






	 	j.	 	Medical Examinations for Drivers – The Health
Plan/Transportation Provider shall establish medical examination requirements
for all applicants for driver positions and for existing drivers. The medical
examination requirements shall include a pre-employment examination for
applicants, an examination at least once every two (2) years for existing
drivers, and a return to duty examination for any driver prior to returning to
duty after having been off duty for thirty (30) or more days due to an illness,
medical condition, or injury.






	 	(1)	 	Medical examinations may be performed and
recorded according to qualification standards adopted by the Health
Plan/Transportation Provider, provided the medical examination
qualification standards adopted by the Health Plan/Transportation
Provider meet or exceed those provided in Department Form Number
725-030-11, Medical Examination Report for Bus Transit System Driver,
Rev. 07/05, hereby incorporated by reference. Copies of Form Number
725-030-11 are available from the Florida Department of Transportation,
Public Transit Office, 605 Suwannee Street, Mail Station 26,
Tallahassee, Florida 32399-0450 or on-line at
www.dot.state.fl.us/transit.






	 	(2)	 	Medical examinations shall be performed by a
Doctor of Medicine or Osteopathy, a Physician Assistant (PA) or ARNP
licensed or certified by the State of Florida. The examination shall
be conducted in person, and not via the Internet. If medical
examinations are performed by a PA or ARNP, they must be performed
under the supervision or review of a Doctor of Medicine or Osteopathy.






	 	(a)	 	An ophthalmologist or optometrist
licensed by the State of Florida may perform as much of the
examination as pertains to visual acuity, field of vision and
color recognition.






	 	(b)	 	Upon completion of the
examination, the examining medical professional shall complete,
sign, and date the medical examination report.






	 	(3)	 	The Health Plan/Transportation Provider shall
have on file proof of medical examination, i.e., a completed and signed
medical examination report for each driver, dated within the past
twenty-four (24) months. Medical examination reports of employee
drivers shall be maintained by the Health Plan/Transportation Provider
for a minimum of five (5) years from the date of the examination.






	 	k.	 	Operational and Driving Requirements






	 	(1)	 	The Health Plan/Transportation Provider shall
not permit a driver to drive a vehicle when such driver’s license has
been suspended, canceled or revoked. The Health Plan/Transportation
Provider shall require a driver who receives a notice that his or her
license to operate a motor vehicle has been suspended, canceled, or
revoked notify his or her employer of the contents of the notice
immediately, and no later than the end of the business day following
the day he or she received the notice.






	 	(2)	 	At all times, the Health Plan/Transportation
Provider shall operate vehicles in compliance with applicable traffic
regulations, ordinances and laws of the jurisdiction in which they are
being operated.






	 	(3)	 	The Health Plan/Transportation Provider shall
not permit or require a driver to drive more than twelve (12) hours in
any one twenty-four (24) hour period, or drive after having been on
duty for sixteen (16) hours in any one twenty-four (24) hour period.
The Health Plan/Transportation Provider shall not permit a driver to
drive until the driver fulfills the requirement of a minimum eight (8)
consecutive hours off-duty. A driver’s work period shall begin from
the time he or she first reports for duty to his or her employer. A
driver is permitted to exceed his or her regulated hours in order to
reach a regularly established relief or dispatch point, provided the
additional driving time does not exceed one (1) hour.






	 	(4)	 	The Health Plan/Transportation Provider shall
not permit or require a driver to be on duty more than seventy-two (72)
hours in any period of seven (7) consecutive days; however, twenty-four
(24) consecutive hours off-duty shall constitute the end of any such
period of seven (7) consecutive days. The Health Plan/Transportation
Provider shall ensure that a driver who has reached the maximum 72
hours of on-duty time during the seven (7) consecutive days has a
minimum of twenty-four (24) consecutive hours off-duty before returning
to on-duty status.






	 	(5)	 	A driver is permitted to drive for more than
the regulated hours for safety and protection of the public due to
conditions such as adverse weather, disaster, security threat, a road
or traffic condition, medical emergency or an accident.






	 	(6)	 	The Health Plan/Transportation Provider shall
not permit or require any driver to drive when his or her ability is
impaired, or likely to be impaired, by fatigue, illness, or other
causes, as to make it unsafe for the driver to begin or continue
driving.






	 	(7)	 	The Health Plan/Transportation Provider shall
require pre-operational or daily inspection of all vehicles and
reporting of all defects and deficiencies likely to affect safe
operation or cause mechanical malfunctions.






	 	(a)	 	The Health Plan/Transportation
Provider shall maintain a log detailing a daily inspection or
test of the following parts and devices to ascertain that they
are in safe condition and in good working order:





	 	 	 
	(i)

	 	Service brakes;
	 
	 	 
	(ii)

	 	Parking brakes;
	 
	 	 
	(iii)

	 	Tires and wheels;
	 
	 	 
	(iv)

	 	Steering;
	 
	 	 
	(v)

	 	Horn;
	 
	 	 
	(vi)

	 	Lighting devices;
	 
	 	 
	(vii)

	 	Windshield wipers;
	 
	 	 
	(viii)

	 	Rear vision mirrors;
	 
	 	 
	(ix)

	 	Passenger doors and seats;







	 	(x)	 	Exhaust system;






	 	(xi)	 	Equipment for
transporting wheelchairs; and






	 	(xii)	 	Safety,
security, and emergency equipment.






	 	(b)	 	The Health Plan/Transportation
Provider shall review daily inspection reports and document
corrective actions taken as a result of any deficiencies
identified by any inspections.






	 	(c)	 	The Health Plan/Transportation
Provider shall retain records of all inspections and any
corrective action documentation for five (5) years.






	 	(8)	 	The driver shall not operate a vehicle with
passenger doors in the open position when passengers are aboard. The
driver shall not open the vehicle’s doors until the vehicle comes to a
complete stop. The Health Plan/Transportation Provider shall not
operate a vehicle with inoperable passenger doors with passengers
aboard, except to move the vehicle to a safe location.






	 	(9)	 	During darkness, interior lighting and lighting
in stepwells on vehicles shall be sufficient for passengers to enter
and exit safely.






	 	(10)	 	Passenger(s) shall not be permitted in the
stepwell(s) of any vehicle while the vehicle is in motion, or to occupy
an area forward of the standee line.






	 	(11)	 	Passenger(s) shall not be permitted to stand on
or in vehicles not designed and constructed for that purpose.






	 	(12)	 	The Health Plan/Transportation Provider shall
not refuel vehicles in a closed building. The Health
Plan/Transportation Provider shall minimize the number of times a
vehicle shall refuel when passengers are onboard.






	 	(13)	 	The Health Plan/Transportation Provider shall
require the driver to be properly secured to the driver’s seat with a
restraining belt at all times while the vehicle is in motion.






	 	(14)	 	The driver shall not leave vehicles unattended
with passenger(s) aboard for longer than five (5) minutes. The Health
Plan/Transportation Provider shall ensure that the driver sets the
parking or holding brake any time the vehicle is left unattended.






	 	(15)	 	The Health Plan/Transportation Provider shall
not leave vehicles unattended in an unsafe condition with passenger(s)
aboard at any time.






	 	l.	 	Vehicle Equipment Standards and Procurement Criteria






	 	(1)	 	The Health Plan/Transportation Provider shall
ensure that vehicles procured and operated meet the following
requirements, at a minimum:






	 	(a)	 	The capability and strength to
carry the maximum allowed load and not exceed the manufacturer’s
gross vehicle weight rating (GVWR), gross axle weighting, or
tire rating;






	 	(b)	 	Structural integrity that
mitigates or minimizes the adverse effects of collisions; and






	 	(c)	 	Federal Motor Vehicle Safety
Standards (FMVSS), 49 C.F.R. Part 571, Sections 102, 103, 104,
105, 108, 207, 209, 210, 217, 220, 221, 225, 302, 403, and 404,
October 1, 2004, are hereby incorporated by reference.






	 	(2)	 	Proof of strength and structural integrity
tests on new vehicles procured shall be submitted by manufacturers or
the Health Plan/Transportation Providers to the Department of
Transportation (See 14-90, F.A.C.).






	 	(3)	 	The Health Plan/Transportation Provider shall
ensure that every vehicle operated in the State in connection with this
Contract shall be equipped as follows:






	 	(a)	 	Mirrors — There must be at least
two (2) exterior rear vision mirrors, one (1) at each side. The
mirrors shall be firmly attached to the outside of the vehicle
and so located as to reflect to the driver a view to the rear
along both sides of the vehicle.






	 	(i)	 	Each exterior
rear vision mirror, on Type I buses shall have a minimum
reflective surface of fifty (50) square inches and the
right (curbside) mirror shall be located on the bus so
that the lowest part of the mirror and its mounting is a
minimum eighty (80) inches above the ground. All Type I
buses shall be equipped with an inside rear vision
mirror capable of giving the driver a clear view of
seated or standing passengers. Buses having a passenger
exit door that is located inconveniently for the
driver’s visual control shall be equipped with
additional interior mirror(s), enabling the driver to
view the passenger exit door. The exterior right
(curbside) rear vision mirror and its mounting on Type I
buses may be located lower than 80 inches from the
ground, provided such buses are used exclusively for
paratransit services. See Section 341.031, F.S.






	 	(ii)	 	In lieu of
interior mirrors, trailer buses and articulated buses
may be equipped with closed circuit video systems or
adult monitors in voice control with the driver.






	 	(b)	 	Wiring and Battery — Electrical
wiring shall be maintained so as not to come in contact with
moving parts, or heated surfaces, or be subject to chafing or
abrasion which may cause insulation to become worn.






	 	(i)	 	Every Type I bus
manufactured on or after February 7, 1988, shall be
equipped with a storage battery(ies) electrical power
main disconnect switch. The disconnect switch shall be
practicably located in an accessible location adjacent
to or near to the battery(ies) and be legibly and
permanently marked for identification.






	 	(ii)	 	Every storage
battery on each public-sector bus shall be mounted with
proper retainment devices in a compartment which
provides adequate ventilation and drainage.






	 	(c)	 	Brake Interlock Systems — All
Type I buses having a rear exit door shall be equipped with a
rear exit door/brake interlock that automatically applies the
brake(s) upon driver activation of the rear exit door to the
open position. Interlock brake application shall remain
activated until deactivation by the driver and the rear exit
door returns to the closed position. The rear exit door
interlock on such buses shall be equipped with an identified
override switch enabling emergency release of the interlock
function, which shall not be located within reach of the seated
driver. Air pressure application to the brake(s) during
interlock operation, on buses equipped with rear exit door/brake
interlock, shall be regulated at the original equipment
manufacturer’s specifications.






	 	(4)	 	Standee Line and Warning — Every vehicle
designed and constructed to allow standees shall be plainly marked with
a line of contrasting color at least two (2) inches wide or be equipped
with some other means to indicate that any passenger is prohibited from
occupying a space forward of a perpendicular plane drawn through the
rear of the driver’s seat and perpendicular to the longitudinal axis of
the vehicle. A sign shall be posted at or near the front of the vehicle
stating that it is a violation for a vehicle to be operated with
passengers occupying an area forward of the line.






	 	(5)	 	Handrails and Stanchions — Every vehicle
designed and constructed to allow standees shall be equipped with
overhead grab rails for standee passengers. Overhead grab rails shall
be continuous, except for a gap at the rear exit door, and terminate
into vertical stanchions or turn up into a ceiling fastener.






	 	(a)	 	Every Type I and Type II bus
designed for carrying more than sixteen (16) passengers shall be
equipped with grab handles, stanchions, or bars at least ten
(10) inches long and installed to permit safe on-board
circulation, seating and standing assistance, and boarding and
unloading by elderly and handicapped persons. Type I buses shall
be equipped with a safety bar and panel directly behind each
entry and exit stepwell.






	 	(6)	 	Flooring, Steps, and Thresholds — Flooring,
steps, and thresholds on all vehicles shall have slip resistant
surfaces without protruding or sharp edges, lips, or overhangs, to
prevent tripping hazards. All step edges and thresholds shall have a
band of color(s) running the full width of the step or edge which
contrasts with the step tread and riser, either light-on-dark or
dark-on-light.






	 	(7)	 	Doors — Power activated doors on all vehicles
shall be equipped with a manual device designed to release door closing
pressure.






	 	(8)	 	Emergency Exits — All vehicles shall have an
emergency exit door, or in lieu thereof, shall be provided with
emergency escape push-out windows. Each emergency escape window shall
be in a form of a parallelogram with dimensions of not less than 18” by
24”, and each shall contain an area of not less than 432 square inches.
There shall be a sufficient number of such push-out or kick-out
windows in each vehicle to provide a total escape area equivalent to 67
square inches per seat, including the driver’s seat.






	 	(a)	 	No less than forty percent (40%)
of the total escape area shall be on one (1) side of the
vehicle. Emergency escape kick-out or push-out windows and
emergency exit doors shall be conspicuously marked by a sign or
light and shall always be kept in good working order so that
they may be readily opened in an emergency.






	 	(b)	 	All such windows and doors shall
not be obstructed by bars or other such means located either
inside or outside so as to hinder escape. Vehicles equipped
with an auxiliary door for emergency exit shall be equipped with
an audible alarm and light indicating to the driver when a door
is ajar or opened while the engine is running.






	 	(c)	 	Supplemental security locks
operable by a key are prohibited on emergency exit doors unless
these security locks are equipped and connected with an ignition
interlock system or an audio visual alarm located in the
driver’s compartment. Any supplemental security lock system
used on emergency exits shall be kept unlocked whenever a
vehicle is in operation.






	 	(9)	 	Tires and Wheels — Tires shall be properly
inflated in accordance with manufacturer’s recommendations.






	 	(a)	 	No vehicle shall be operated with
a tread groove pattern depth:






	 	(i)	 	Less than 4/32
(1/8) of an inch, measured at any point on a major tread
groove for tires on the steering axle of all vehicles.
The measurements shall not be made where tie bars,
humps, or fillets are located.






	 	(ii)	 	Less than 2/32
(1/16) of an inch, measured at any point on a major
tread groove for all other tires of all vehicles. The
measurements shall not be made where tie bars, humps, or
fillets are located.






	 	(b)	 	The Health Plan/Transportation
Provider shall not operate any vehicle with recapped, regrooved
or retreaded tires on the steering axle.






	 	(c)	 	The Health Plan/Transportation
Provider shall ensure that all wheels are visibly free from
cracks and distortion and shall not have missing, cracked, or
broken mounting lugs.






	 	(10)	 	Suspension — The suspension system of all
vehicles, including springs, air bags, and all other suspension parts
as applicable, shall be free from cracks, leaks, or any other defect
which would or may cause its impairment or failure to function
properly.






	 	(11)	 	Steering and Front Axle — The steering system
of all vehicles shall have no indication of leaks which would or may
cause its impairment to function properly, and shall be free from
cracks and excessive wear of components that would or may cause
excessive free play or loose motion in the steering system or above
normal effort in steering control.






	 	(12)	 	Seat Belts — Every vehicle shall be equipped
with an adjustable driver’s restraining belt in compliance with the
requirements of FMVSS 209, “Seat Belt Assemblies” (see 49 CFR 571.209)
and FMVSS 210, “Seat Belt Assembly Anchorages” (49 CFR 571.210).







	 	(13)	 	Safety Equipment — Every vehicle shall be
equipped with one (1) fully charged dry chemical or carbon dioxide fire
extinguisher, having at least a 1A:BC rating and bearing the label of
Underwriter’s Laboratory, Inc.






	 	(a)	 	Each fire extinguisher shall be
securely mounted on the vehicle in a conspicuous place or a
clearly marked compartment and be readily accessible.






	 	(b)	 	Each fire extinguisher shall be
maintained in efficient operating condition and equipped with
some means of determining if it is fully charged.






	 	(c)	 	Every Type I bus shall be
equipped with portable red reflector warning devices (see
Section 316.300, F.S.).






	 	(14)	 	Vehicles used for the purpose of transporting
individuals with disabilities shall meet the requirements set forth in
49 CFR Part 38, hereby incorporated by reference, and the following:






	 	(a)	 	Installation of a wheelchair lift
or ramp shall not cause the manufacturer’s GVWR, gross axle
weight rating, or tire rating to be exceeded.






	 	(b)	 	Except in locations within 3 1/2
inches of the vehicle floor, all readily accessible exposed
edges or other hazardous protrusions of parts of wheelchair lift
assemblies or ramps that are located in the passenger
compartment shall be padded with energy absorbing material to
mitigate injury in normal use and in case of a collision. This
requirement shall also apply to parts of the vehicle associated
with the operation of the lift or ramp.






	 	(c)	 	The controls for operating the
lift shall be at a location where the driver or lift attendant
has a full view, unobstructed by passengers, of the lift
platform, its entrance and exit, and the wheelchair passenger,
either directly or with partial assistance of mirrors. Lifts
located entirely to the rear of the driver’s seat shall not be
operable from the driver’s seat, but shall have an override
control at the driver’s position that can be activated to
prevent the lift from being operated by the other controls
(except for emergency manual operation upon power failure).






	 	(d)	 	The installation of the
wheelchair lift or ramp and its controls and the method of
attachment in the vehicle body or chassis shall not diminish the
structural integrity of the vehicle nor cause a hazardous
imbalance of the vehicle. No part of the assembly, when
installed and stowed, shall extend laterally beyond the normal
side contour of the vehicle or vertically beyond the lowest part
of the rim of the wheel closest to the lift.






	 	(e)	 	Each wheelchair lift or ramp
assembly shall be legibly and permanently marked by the
manufacturer or installer with the following minimum
information:






	 	(i)	 	The
manufacturer’s name and address;






	 	(ii)	 	The month and
year of manufacture; and






	 	(iii)	 	A certificate
that the wheelchair lift or ramp securement devices, and
their installation, conform to State of Florida
requirements applicable to accessible vehicles.






	 	(15)	 	Wheelchair lifts, ramps, securement devices,
and restraints shall be inspected and maintained as specified above.
Instructions for normal and emergency operation of the lift or ramp
shall be carried or displayed in every vehicle.






	 	m.	 	Vehicle Safety Inspections






	 	(1)	 	The Health Plan/Transportation Provider shall
require that all vehicles be inspected in accordance with the vehicle
inspection procedures set forth above.






	 	(2)	 	It is the Health Plan’s/Transportation
Provider’s responsibility to ensure that each individual performing a
vehicle safety inspection is qualified as follows:






	 	(a)	 	Understands the requirements set
forth in 14-90, F.A.C., and can identify defective components;






	 	(b)	 	Is knowledgeable of, and has
mastered the methods, procedures, tools, and equipment used when
performing an inspection; and






	 	(c)	 	Has at least one (1) year of
training and/or experience as a mechanic or inspector in a
vehicle maintenance program and has sufficient general knowledge
of vehicles owned and operated by the Health Plan/Transportation
Provider to recognize deficiencies or mechanical defects.






	 	(3)	 	The Health Plan/Transportation Provider shall
ensure that each vehicle receiving a safety inspection is checked for
compliance with the safety devices and equipment requirements as
referenced or specified above. Specific operable equipment and devices
include the following:






	 	(a)	 	Horn;






	 	(b)	 	Windshield wipers;






	 	(c)	 	Mirrors;






	 	(d)	 	Wiring and battery(ies);






	 	(e)	 	Service and parking brakes;






	 	(f)	 	Warning devices;






	 	(g)	 	Directional signals;






	 	(h)	 	Hazard warning signals;






	 	(i)	 	Lighting systems and signaling
devices;






	 	(j)	 	Handrails and stanchions;






	 	(k)	 	Standee line and warning;






	 	(l)	 	Doors and interlock devices;






	 	(m)	 	Stepwells and flooring;






	 	(n)	 	Emergency exits;






	 	(o)	 	Tires and wheels;






	 	(p)	 	Suspension system;






	 	(q)	 	Steering system;






	 	(r)	 	Exhaust system;






	 	(s)	 	Seat belts;






	 	(t)	 	Safety equipment; and






	 	(u)	 	Equipment for transporting
wheelchairs.






	 	(4)	 	A safety inspection report shall be prepared by
the individual(s) performing the inspection which shall include the
following:






	 	(a)	 	Identification of the
individual(s) performing the inspection;






	 	(b)	 	Identification of the Health
Plan/Transportation Provider operating the vehicle;






	 	(c)	 	The date of the inspection;






	 	(d)	 	Identification of the vehicle
inspected;






	 	(e)	 	Identification of the equipment
and devices inspected including the identification of equipment
and devices found deficient or defective; and






	 	(f)	 	Identification of corrective
action(s) for deficient or defective items and date(s) of
completion of corrective action(s).






	 	(5)	 	Records of annual safety inspections and
documentation of any required corrective actions shall be retained for
compliance review a minimum of five (5) years by the Health
Plan/Transportation Provider.






	 	n.	 	Certification – Each Health Plan/Transportation Provider shall
submit an annual safety and security certification in accordance with 14-90.10,
F.A.C., and shall submit to any and all safety and security inspections and
reviews in accordance with 14-90.12, F.A.C.






	 	•	 	. The Health Plan shall report the following by August 15th of
each year:






	 	(1)	 	The estimated number of one-way passenger trips
to be provided in the following categories, as defined in the
Transportation Handbook:






	 	(a)	 	Ambulatory Transportation;






	 	(b)	 	Long haul ambulatory
Transportation;






	 	(c)	 	Wheelchair Transportation;






	 	(d)	 	Stretcher Transportation;






	 	(e)	 	Ambulatory multiload
Transportation;






	 	(f)	 	Wheelchair multiload
Transportation;






	 	(g)	 	Mass transit pending
Transportation;






	 	(h)	 	Mass transit Transportation;






	 	(i)	 	Mass transit Transportation
(Enrollee has pass); and






	 	(j)	 	Mass transit Transportation (sent
pass to Enrollee).






	 	(2)	 	The actual amount of funds expended and the
total number of trips provided during the previous fiscal year; and






	 	(3)	 	The operating financial statistics for the
previous fiscal year.






	 	 	 	p            The Health Plan shall provide the total number of vehicles in
each category, other than public Transportation, that will serve each county as
well as a provider directory for all Transportation Services.





26




REMAINDER OF PAGE INTENTIONALLY LEFT BLANKSection VI




Behavioral Health Care





	A.	 	General Provisions






	 	1.	 	The Health Plan shall provide Medically Necessary Behavioral Health Services
for all Enrollees pursuant to this Contract. The Health Plan shall provide a full range
of Behavioral Health Services authorized under the State Plan and specified by this
Contract.






	 	a.	 	Nothing in this contract shall be construed as preventing the
plan from substituting additional services supported by nationally recognized 
evidence based clinical guidelines for those provided in the Handbooks
described above, or from using different or alternative services, based on
nationally recognized evidence based practices, methods, or approaches to
assist individual enrollees, provided that the net effect of this substitution
and these alternatives is that the overall benefits available to the enrollee
are at least equivalent to those described in the applicable Handbooks. 
Provision of substitution or alternate services shall not supplant or relieve
the plan from providing covered services if needed.






	 	2.	 	The Health Plan shall provide the following services as described in the Mental
Health Targeted Case Management Coverage & Limitations Handbook, and the Community
Behavioral Health Services Coverage & Limitations Handbook (the Handbooks). The Health
Plan shall not alter the amount, duration and scope of such services from that
specified in the Handbooks. The Health Plan shall not establish service limitations
that are lower than, or inconsistent with the Handbooks.






	 	a.	 	Inpatient Hospital services for psychiatric conditions
(ICD-9-CM codes 290 through 290.43, 293.0 through 298.9, 300 through 301.9,
302.7, 306.51 through 312.4 and 312.81 through 314.9, 315.3, 315.31, 315.5,
315.8, and 315.9);






	 	b.	 	Outpatient Hospital services for psychiatric conditions
(ICD-9-CM codes 290 through 290.43, 293 through 298.9, 300 through 301.9,
302.7, 306.51 through 312.4 and 312.81 through 314.9, 315.3, 315.31, 315.5,
315.8, and 315.9);






	 	c.	 	Psychiatric physician services (for psychiatric specialty codes
42, 43, 44 and ICD-9-CM codes 290 through 290.43, 293.0 through 298.9, 300
through 301.9, 302.7, 306.51 through 312.4 and 312.81 through 314.9, 315.3,
315.31, 315.5, 315.8, and 315.9);






	 	d.	 	Community mental health services (ICD-9-CM codes 290 through
290.43, 293.0 through 298.9, 300 through 301.9, 302.7, 306.51 through 312.4 and
312.81 through 314.9, 315.3, 315.31, 315.5, 315.8, and 315.9); and for these
procedure codes H0001, H0001HN; H0001H0, H0001TS; H0031; H0031 HO; H0031HN;
H0031TS; H0032; H0032TS; H0046; H0047; H2000; H2000HO; H2000HP; H2010HO;
H2010HE; H2010HF; H2010HQ; H2012; H2012HF; H2017; H2019; H2019HM; M2019HN;
H2019HO; H2019HQ; H2019HR; H2030; T1007; T1007TS; T1015; T1015HE; T1015HF;
T1023HE; or T1023HF.






	 	e.	 	Mental Health Targeted Case Management (Children: T1017HA;
Adults: T1017); and






	 	f.	 	Mental Health Intensive Targeted Case Management (Adults:
T1017HK).






	 	3.	 	Non-Covered Services






	 	a.	 	The following services are not covered by the Health Plan.
Should the Health Plan determine the need for, or be advised of the need for,
these or other services not customarily covered by the Health Plan, the Health
Plan shall refer the Enrollee to the appropriate provider:






(1) Specialized Therapeutic Foster Care;




(2) Therapeutic Group Care Services;




(3) Behavioral Health Overlay Services;




	 	(4)	 	Community Substance Abuse Services, except as
required by this Contract;






(5) Residential Care;




(6) Sub-acute Inpatient Psychiatric Program (SIPP) Services;




(7) Clubhouse Services;




(8) Comprehensive Behavioral Assessment; and




(9) Florida Assertive Community Treatment Services (FACT).




	 	(1)	 	The Health Plan shall not be
responsible for the provision of Behavioral Health Services to
Enrollees assigned to a FACT team by the DCF Substance Abuse and
Mental Health Program (SAMH) Office. The Health Plan shall
disenroll these Enrollees from the Health Plan so that the
Enrollees can receive all Behavioral Health Services through the
funding mechanism developed by DCF/SAMH and AHCA.






	 	4.	 	The Health Plan shall provide Outpatient Medical Services in accordance with Section
V, Covered Services, of this Contract.






	 	5.	 	If an Enrollee makes a request for Behavioral Health Services to the Health
Plan, the Health Plan shall provide the Enrollee with the name (or names) of qualified
Behavioral Health Care Providers, and if requested, assist the Enrollee with making an
appointment with the Provider that is within the required access times indicated in
Section VII.D., Appointment Waiting Times and Geographic Access Standards, and Section
VII.E., Behavioral Health Services.






	 	6.	 	Services available under the Health Plan shall represent a comprehensive range
of appropriate services for both Children/Adolescents and adults who experience
impairments ranging from mild to severe and persistent. This Section outlines the
Agency’s expectations and requirements related to each of the categories of service.






	 	a.	 	The Health Plan may provide Expanded Services under the
Contract as a substitution of care or downward substitution.






	 	b.	 	When the Health Plan intends to provide a service as a downward
substitution, the provider must use clinical rationale for determining the
benefit of the service for the Enrollee.






	 	7.	 	The Health Plan must provide Covered Services to Enrollees as required by each
Enrollee without regard to the frequency or cost of services relative to the amount
paid pursuant to the Contract.






	B.	 	Service Requirements






	 	1.	 	Inpatient Hospital Services






	 	a.	 	Inpatient Hospital services are Medically Necessary Behavioral
Health Services provided in a Hospital setting (see Section V.7, Covered
Services, Hospital Services – Inpatient. Inpatient hospital services may be
provided in a general Hospital psychiatric unit or in a specialty Hospital.
The inpatient care and treatment services that an Enrollee receives must be
under the direction of a licensed physician with the appropriate Medicaid
specialty requirements.






	 	b.	 	A Hospital’s per diem (daily rate) for inpatient mental health
hospital care and treatment covers all services and items furnished during a
24-hour period. The facilities, supplies, appliances, and equipment furnished
by the Hospital during the inpatient stay are included in the per diem as well
as the related nursing, social, and other services furnished by the Hospital
during the inpatient stay.






	 	c.	 	For all Child/Adolescent Enrollees, the Health Plan shall be
responsible for the provision of up to 365 days of behavioral health-related
Hospital inpatient care for each year.






	 	d.	 	For all Enrollees, the Health Plan shall pay for inpatient
mental health-related Hospital days determined Medically Necessary by the
Health Plan’s medical director or designee, up to the maximum number of days
required under the Contract.






	 	e.	 	If an Enrollee is admitted to a Hospital for a non-psychiatric
diagnosis and during the same hospitalization transfers to a psychiatric unit
or receives treatment for a psychiatric diagnosis, the Health Plan is at risk
for the Medically Necessary behavioral health treatment inpatient days up to
the maximum number of days required under this Contract.






	 	f.	 	The Health Plan shall be responsible to cover the cost of all
Enrollees’ Medically Necessary stays resulting from a mental health emergency,
until such time as the Health Plan can safely transport the Enrollee to a
designated facility.






	 	g.	 	Crisis Stabilization Units may be used as a downward
substitution for inpatient psychiatric hospital care when determined medically
appropriate. These bed days are calculated on a two (2) for one (1)
basis. Beds funded by the Department of Children and Families, Substance
Abuse and Mental Health (SAMH) cannot be used for Enrollees if there are
non-funded clients in need of the beds. If CSU beds are at capacity, and some
of the beds are occupied by Enrollees, and a non-funded client presents in need
of services, the Enrollees must be transferred to an appropriate facility to
allow the admission of the non-funded client. Therefore, the Health Plan must
demonstrate adequate capacity for inpatient hospital care in anticipation of
such transfers.






	 	2.	 	Outpatient Hospital Services






	 	a.	 	Outpatient Hospital services are Medically Necessary Behavioral
Health Services provided in a Hospital setting. The outpatient care and
treatment services that an Enrollee receives must be under the direction of a
licensed physician with the appropriate specialty.






	 	3.	 	Physician Services






	 	a.	 	Physician services are those services rendered by a licensed
physician who possesses the appropriate Medicaid specialty requirements when
applicable. A psychiatrist must be certified as a psychiatrist by the American
Board of Psychiatry and Neurology or the American Osteopathic Board of
Neurology and Psychiatry, or have completed a psychiatry residency accredited
by the Accreditation Council for Graduate Medical Education (ACGME) or the
Royal College of Physicians and Surgeons of Canada.






	 	b.	 	Physician services include specialty consultations for
evaluations. A physician consultation shall include an examination and
evaluation of the Enrollee with information from family member(s) or
significant others as appropriate. The consultation shall include written
documentation on an exchange of information with the attending Provider. The
components of the evaluation and management procedure code and diagnosis code
must be documented in the Enrollee’s medical record. A Hospital visit to an
Enrollee in an acute care Hospital for a behavioral health diagnosis must be
documented with a behavioral health procedure code and behavioral health
diagnosis code. All procedures with a minimum time requirement shall be
documented in the Enrollee’s Medical Record to show the time spent providing
the service to the Enrollee. The Health Plan must be responsive to requests
for consultations made by the PCP.






	 	c.	 	Physicians are required to coordinate Medically Necessary
Behavioral Health Services with the PCP and other Providers involved with the
care of the Enrollee. The Health Plan shall draft and implement a set of
protocols that indicate when such coordination is required.






	 	4.	 	Community Mental Health Services






	 	a.	 	General Provisions






	 	(1)	 	Community mental health services include
Behavioral Health Services that are provided for the maximum reduction
of the Enrollee’s behavioral health disability and restoration to the
best possible functional level. Community mental health services are
those services that can reasonably be expected to improve the
Enrollee’s condition or prevent further regression so that the services
will no longer be needed. The Health Plan shall provide community
mental health services that are Medically Necessary and are rendered or
recommended by a physician or psychiatrist and included in a treatment
plan. Medically Necessary community mental health services must be
provided to Enrollees of all ages from very young children through the
geriatric population. Because the provision of community mental health
services at an early stage may reduce the provision of expensive
services later, the Health Plan is encouraged to expand the criteria
for some community mental health services and base the criteria upon
social necessity rather than strict Medical Necessity requirements.
Community mental health services should be age appropriate and
sensitive to the developmental level of the Enrollee. The term
“community mental health services” is not intended to suggest that the
following services must be provided by State funded “community mental
health centers” or to preclude State funded “community mental health
centers” from providing these services.






	 	(2)	 	The services provided must meet the intent of
the services covered in the Florida Medicaid Community Mental Health
Services Coverage and Limitations Handbook. Although the Health Plan
can provide flexible services, the service limits and medical necessity
criteria cannot be more restrictive than those in Medicaid policy as
stated in Medicaid handbooks and this Contract. Additionally, the
Health Plan may have available additional services, but must have the
core services available as outlined and discussed below.






	 	(3)	 	The health plan shall establish “Medical
Necessity” criteria, including admission criteria, continuing stay
criteria, and discharge criteria for all mandatory and optional
services.






	 	(a)	 	Criteria must be specific to
Enrollee ages and diagnoses and must account for orders for
involuntary outpatient placement pursuant to 394.4655, F.S.
These criteria must be submitted for review by the Agency and
approval.






	 	(4)	 	Treatment Plan Development and Modification:






	 	(a)	 	Treatment planning includes
working with the Enrollee, their natural support system, and all
involved treating Providers to develop an individualized plan
for addressing identified clinical needs. A Behavioral Health
Care Provider must complete a face-to-face interview with the
Enrollee during the development of the plan. The individualized
treatment plan should accurately reflect the presenting problems
of the Enrollee, identified strengths of the Enrollee, family,
and other natural support systems, and outcome-oriented
objectives for the Enrollee. The treatment plan shall also
include an outcome-oriented schedule of Behavioral Health
Services that will be provided to meet the Enrollee’s needs.
Behavioral Health Services and service frequency shall be
individualized and reflect the needs, goals, and abilities of
each Enrollee.






	 	(b)	 	The Individualized Treatment Plan
shall:






	 	(i)	 	Be
recovery-oriented and promote resiliency;






	 	(ii)	 	Be
Enrollee-directed;






	 	(iii)	 	Accurately
reflect the presenting problems of the Enrollee;






	 	(iv)	 	Be based on the
strengths of the Enrollee, family, and other natural
support systems;






	 	(v)	 	Provide
outcome-oriented objectives for the Enrollee;






	 	(vi)	 	Include an
outcome-oriented schedule of services that will be
provided to meet the Enrollee’s needs; and






	 	(vii)	 	Include the
coordination of services not covered by the Health Plan
such as school-based services, vocational
rehabilitation, housing supports, Medicaid
fee-for-service substance abuse treatment, and physical
health care.






	 	(c)	 	Individualized Treatment Plan
reviews shall be conducted at six (6) month intervals to assure
that the services being provided are effective and remain
appropriate for addressing individual Enrollee needs.
Additionally, a review is expected whenever clinically
significant events occur. The provider is expected to use the
Individualized Treatment Plan review process in the utilization
management of Medically Necessary services. For further guidance
see the most recent Community Behavioral Health Services and
Coverage Handbook.






	 	(d)	 	Treatment plan reviews shall be
conducted at appropriate time intervals to assure that the
services being provided are effective and remain appropriate for
addressing individual needs. A review is expected whenever a
clinically significant event occurs. The Health Plan is expected
to use the treatment plan review process in the Utilization
Management of Medically Necessary services.






(e) Assessment Services:




	 	(i)	 	Evaluation and
testing services include psychological testing
(standardized tests) and evaluations that assess the
Enrollee’s functioning in all areas. Evaluations
completed prior to provision of treatment must include a
holistic view of factors that underlie or may have
contributed to the Enrollee’s need for Behavioral Health
Services. Evaluations that are completed for diagnostic
purposes are included in this category. Diagnostic
evaluations must be comprehensive and when completed
must be used in the development of an individualized
treatment plan. All evaluations must be appropriate to
the age, developmental level and functioning of the
Enrollee. All evaluations must include a clinical
summary that integrates all the information gathered and
identifies the Enrollee’s needs. The evaluation should
prioritize the clinical needs, evaluate the
effectiveness of any prior treatment, and include
recommendations for interventions and mental health
services to be provided. All new Enrollees who appear
for treatment services should receive an evaluation
unless there is sufficient collateral information that a
new evaluation would not be necessary.






	 	(ii)	 	Evaluation
services, when determined Medically Necessary must
include assessment of mutual status, functional
capacity, strengths and service needs by trained mental
health staff. Also included in this category is the
administration of functional assessments that are
required by the Agency, DCF or the Florida Mental Health
Institute Independent Evaluation.






	 	(iii)	 	Prior to
receiving any community mental health services, children
ages 0-5 must have a current assessment (within one
year) of presenting symptoms and behaviors;
developmental and medical history; family psychosocial
and medical history; assessment of family functioning; a
clinical interview with the primary caretaker and an
observation of the child’s interaction with the
caretaker; and an observation of the child’s language,
cognitive, sensory, motor, self-care, and social
functioning.






	 	(3)	 	Medical and Psychiatric Services:






	 	(a)	 	These services include Medically
Necessary interventions that require the skills and expertise of
a psychiatrist, psychiatric ARNP, or physician.






	 	(b)	 	Medical psychiatric interventions
include the prescribing and management of medications,
monitoring side effects associated with prescribed medications,
individual or group medical psychotherapy, psychiatric
evaluation (for diagnostic purposes and for initiating
treatment), psychiatric review of treatment records for
diagnostic purposes, and psychiatric consultation with an
Enrollee’s family or significant others, PCPs, and other
treatment providers. Clinic visits are also a required service.






	 	(c)	 	Interventions related to specimen
collections, taking vital signs and administering injections are
also a Covered Service.






	 	(d)	 	Treatment services are
distinguished from the physician services outlined above in that
they are provided through a community mental health provider.
Psychiatric or physician services must be available at sites
where substantial amounts of community mental health services
are provided.






	 	(4)	 	Behavioral Health Therapy Services:






	 	(a)	 	Therapy services include
individual and family therapy, group therapy and behavioral
health day services. These services may include psychotherapy
or supportive counseling focused on assisting Enrollees with the
problems or symptoms identified in an assessment. The focus
should be on identifying and utilizing the strengths of the
Enrollee, family, and other natural support systems. Therapy
services should be geared to the individual needs of the
Enrollee and should be sensitive to the age, developmental
level, and functional level of the Enrollee.






	 	(b)	 	Family and marital therapy are
also included in this category. Examples of interventions
include those that focus on resolution of a life crisis or an
adjustment reaction to an external stressor or developmental
challenge.






	 	(c)	 	Behavioral day services are
designed to enable Enrollees to function successfully in the
community in the least restrictive environment and to restore or
enhance ability for social and prevocational life management
services. The primary functions of behavioral health day
services are stabilization of the symptoms related to a
behavioral health disorder to reduce or eliminate the need for
more intensive levels of care, to provide transitional treatment
after an acute episode, or to provide a level of therapeutic
intensity not possible in a traditional outpatient setting.






	 	(5)	 	Community Support and Rehabilitative services:






	 	(a)	 	These services include:
Psychosocial Rehabilitation Services and Clubhouse services.
Clubhouse services are excluded from the Health Plan’s Covered
Services. Psychosocial rehabilitation services may be provided
in a facility, home, or community setting. These services
assist Enrollees in functioning within the limits of a
disability or disabilities resulting from a mental illness.
Services focus on restoration of a previous level of functioning
or improving the level of functioning. Services must be
individualized and directly related to goals for improving
functioning within a major life domain.






	 	(b)	 	The coverage must include a range
of social, educational, vocational, behavioral, and cognitive
interventions to improve Enrollees’ potential for social
relationships, occupational/educational achievement and living
skills development. Skills training development is also
included in this category and includes activities aimed toward
restoration of Enrollees’ skills/abilities that are essential
for managing their illness, actively participating in treatment,
and conducting the requirements of daily independent living.
Providers must offer the services in a setting best suited for
desired outcomes, i.e., home or community-based settings.






	 	(c)	 	Psychosocial Rehabilitative
Services may also be provided to assist Enrollees in finding or
maintaining appropriate housing arrangements or to maintain
employment. Interventions should focus on the restoration of
skills/abilities that are adversely affected by the mental
health illness and supports required to manage the Enrollee’s
housing or employment needs. The provider must be knowledgeable
about the local TANF initiative and is responsible for Medically
Necessary mental health services that will assist the individual
in finding and maintaining employment.






	 	(6)	 	Therapeutic Behavioral On-Site Services for
Children and Adolescents (TBOS):






	 	(a)	 	Therapeutic Behavioral On-Site
Services are community services and natural supports for
Children/Adoloscents with serious emotional disturbances.
Clinical services include the provision of a professional level
therapeutic service that may include the teaching of problem
solving skills, behavioral strategies, normalization activities
and other treatment modalities that are determined to be
Medically Necessary. These services should be designed to
maximize strengths and reduce behavior problems or functional
deficits stemming from the existence of a mental health
disorder. Social services include interventions designed for
the restoration, modification, and maintenance of social,
personal adjustment and basic living skills.






	 	(b)	 	TBOS services are intended to
maintain the Child/Adolescent in the home and to prevent
reliance upon a more intensive, restrictive, and costly mental
health placement. They are also focused on helping the
Child/Adolescent possess the physical, emotional, and
intellectual skills to live, learn and work in their own
communities. Coverage must include the provision of these
services outside of the traditional office setting. The
services must be provided where they are needed, in the home,
school, childcare centers or other community sites.






	 	(7)	 	Day Treatment Services:






	 	(a)	 	Adult day treatment services
include therapy, rehabilitation, social interactions, and other
therapeutic services that are designed to redevelop, maintain,
or restore skills that are necessary for Enrollees to function
in the community. The Provider must have an array of available
services designed to meet the individualized needs of the
Enrollee, and which address the following primary functions:






	 	(i)	 	Stabilize
symptoms related to a behavioral health disorder to
reduce or eliminate the need for more intensive levels
of care;






	 	(ii)	 	Provide a level
of therapeutic intensity between traditional outpatient
and an inpatient or partial Hospital setting;






	 	(iii)	 	Provide a level
of treatment that will assist Enrollees in transitioning
from an acute care or institutional settings;






	 	(iv)	 	Assist Enrollees
in redeveloping the skills required to maintain a living
environment, use community resources, and conduct
activities of daily living; and






	 	(v)	 	Assist Enrollees
in redeveloping or restoring skills that are needed to
increase an Enrollee’s ability to live independently in
the community.






	 	(b)	 	Children/Adolescent’s day
treatment services include therapy, rehabilitation and social
interactions, and other therapeutic services that are designed
to redevelop, maintain, or restore skills that are necessary for
Children/Adolescents to function in their community. For
Children/Adolescents, the approach must take into consideration
their developmental levels and delays in development due to
emotional disorders. If the Child/Adolescent is school age, the
services must be coordinated with the school system. All
therapeutic day treatment interventions for Children/Adolescents
must have a component that addresses caregiver participation and
involvement. Services for all Children/Adolescents should be
coordinated with home care to the greatest extent possible. Day
treatment services must include an array of programs with the
following functions:






	 	(i)	 	Stabilize the
symptoms related to a behavioral health disorder to
reduce or eliminate the need for more intensive levels
of care;






	 	(ii)	 	Provide
transitional treatment after an acute episode, admission
to an inpatient program, or discharge from a residential
treatment setting;






	 	(iii)	 	Provide a
therapeutic intensity not possible in a traditional
outpatient setting; and






	 	(iv)	 	Assist the
Child/Adolescent in redeveloping the skills required to
conduct activities of everyday living in the community
that are age appropriate.






	 	(c)	 	Staff providing adult or
Children/Adolescent’s day treatment services must have
appropriate training and experience. Behavioral Health Care
Providers must be available to provide clinical services when
necessary.






	 	(8)	 	Additional Community Mental Health Services for
Children/Adolescents:






	 	(a)	 	All of the community mental
health services discussed above must be made available to
Children/Adolescents when Medically Necessary. The services
described in this section are two (2) additional core services
that must be available to Children/Adolescents when Medically
Necessary. This coverage is mandatory for Children/Adolescents
with a serious emotional disturbance. These services are
intended to maintain the Child/Adolescent in the home and to
prevent reliance upon a more intensive, restrictive, and costly
behavioral health placement. They are also focused on helping
the Child/Adolescent possess the physical, emotional, and
intellectual skills to live, learn and work in their own
communities. Coverage must include the provision of these
services outside of the traditional office setting. The services
must be provided where they are needed, in the home, school or
other community sites.






	 	(b)	 	Therapeutic behavioral on site
services include the provision of a professional level
therapeutic service that may include the teaching of problem
solving skills, behavioral strategies, normalization activities
and other treatment modalities that are determined to be
Medically Necessary. These services should be designed to
maximize strengths, reduce behavior problems or functional
deficits stemming from the existence of a behavioral health
disorder. These services shall not be office-based.






	 	(9)	 	Services for Children Ages 0 through 5-Years






	 	(a)	 	Services to these Enrollees
include behavioral health day services and Therapeutic
Behavioral On-Site Services for Children Ages 0 through 5 years.






	 	(b)	 	Prior to receiving these
services, the Enrollees in this age group must meet the criteria
as stated in the Medicaid Community Behavioral Health Service
Coverage and Limitations Handbook.






	 	(10)	 	Crisis Intervention Mental Health Services and
Post-Stabilization Care Services






	 	(a)	 	Crisis intervention services
include intervention activities of less than 24-hour duration
(within a 24-hour period) designed to stabilize an Enrollee in a
Psychiatric emergency.






	 	(b)	 	Post-stabilization care
services include any of the mandatory services that a treating
physician views as Medically Necessary, that are provided after
an Enrollee is stabilized from an emergency mental health
condition in order to maintain the stabilized condition, or
under the circumstances described in 42 CFR 438.114(e) to
improve or resolve the Enrollee’s condition.






	 	(11)	 	Substance Abuse Services






	 	(a)	 	Health Plan Enrollees will
receive Medicaid funded substance abuse services through the
fee-for-service system. The Health Plan shall develop methods of
coordinating and integrating mental health and substance abuse
services for Enrollees. The Health Plan shall be required to
use the Florida Supplement to the American Society of Addictions
Medicine Patient Placement Criteria for the coordination of
mental health treatment with substance abuse providers as part
of the integration effort (Second Edition ASAM PPC-2, July 1998)
the coordination shall be reflected in their individualized
Treatment Plan for Enrollees with co-occurring disorder. The
protocol for integrating mental health services with substance
abuse services shall be monitored through the Quality of Care
monitoring activities completed by the Agency’s EQRO contractor
and the Quality Improvement requirements in Section VIII.A.,
Quality Improvement.






	 	5.	 	Behavioral Health Targeted Case Management






	 	a.	 	The Health Plan must provide targeted Case Management services
to Children/Adolescents with serious emotional disturbances and adults with a
severe mental illness as defined below. The Health Plan shall meet the intent
of the services as outlined below and in the Medicaid Mental Health Targeted
Case Management Coverage and Limitations Handbook. The Health Plan shall set
criteria and clinical guidelines for Case Management services. Service limits
and criteria developed cannot be more restrictive than those in Medicaid policy
and as stated below.






	 	(1)	 	At a minimum, case management services are to
incorporate the principles of a strengths-based approach.
Strengths-based case management services are an alternative service
modality for working with individuals and families. This method
stresses building on the strengths of individuals that can be used to
resolve current problems and issues, countering more traditional
approaches that focus almost exclusively on individuals’ deficits or
needs.






	 	b.	 	Target Populations:






	 	(1)	 	The Health Plan shall have Case Management
services available to Children/Adolescents who have a serious emotional
disturbance, defined as: a Child/Adolescent with a defined mental
disorder; a level of functioning which requires two (2) or more
coordinated Behavioral Health Services to be able to live in the
community; and be at imminent risk of out of home behavioral health
treatment placement.






	 	(2)	 	The Health Plan shall also have Case Management
services available for adults who:






	 	(a)	 	Have been denied admission to a
long-term mental health institution or residential treatment
facility or have been discharged from a long-term mental health
institution or residential treatment facility;






	 	(b)	 	Require numerous services from
different providers and also require advocacy and coordination
to implement or access services;






	 	(c)	 	Would be unable to access or
maintain consistent care within the service delivery system
without case management services; and/or






	 	(d)	 	Do not possess the strengths,
skills, or support system to allow them to access or coordinate
services;






	 	(3)	 	The Health Plan will not be required to seek
approval from the Department of Children and Families, District
Substance Abuse and Mental Health (SAMH) Office for individual
eligibility or mental health targeted case management agency or
individual provider certification. The staffing requirements for case
management services are listed in Section VII.E.7.






	 	(4)	 	Behavioral health targeted Case Management
services shall be available to all Enrollees within the principles and
guidelines described as follows:






	 	(a)	 	Enrollees who require numerous
services from different providers and also require advocacy and
coordination to implement or access services are appropriate for
Case Management services;






	 	(b)	 	Enrollees who would be unable to
access or maintain consistent care within the service delivery
system without Case Management services are appropriate for the
service;






	 	(c)	 	Enrollees who do not possess the
strengths, skills, or support system to allow them to access or
coordinate services are appropriate for Case Management
services;






	 	(d)	 	Enrollees without the skills or
knowledge necessary to access services may benefit from Case
Management. Case Management provides support in gaining skills
and knowledge needed to access services and enhances the
Enrollee’s level of independence.






	 	c.	 	The Health Plan will not be required to seek approval from the
SAMH Program Office for client eligibility or behavioral health targeted Case
Management agency or individual provider certification. The staffing
requirements for Case Management services are found in Section VII.E.7,
Provider Network, Behavioral Health Services, in this Contract.






	 	d.	 	Required Services






	 	(1)	 	Behavioral health targeted Case Management
services include working with the Enrollee and the Enrollee’s natural
support system to develop and promote a needs assessment-based service
plan. The service plan reflects the services or supports needed to meet
the needs identified in an individualized assessment of the following
areas: education or employment, physical health, mental health,
substance abuse, social skills, independent living skills, and support
system status. The approach used should identify and utilize the
strengths, abilities, cultural characteristics, and informal supports
of the Enrollee, family, and other natural support systems. Targeted
case managers focus on overcoming barriers by collaborating and
coordinating with Providers and the Enrollee to assist in the
attainment of service plan goals. The targeted case manager takes the
lead in both coordinating services/treatment and assessing the
effectiveness of the services provided. A strengths-based approach to
providing services is consistent with the values of individuality and
uniqueness and promotes participant self-direction and choice. The
planning process is vital to achieving desired outcomes for the
Enrollee. The Enrollee must have a sense of ownership about his/her
goals, and the goals must have true meaning and vitality for him/her.






	 	(2)	 	When targeted case management recipients
enrolled in the Health Plan are hospitalized in an acute care setting
or held in a county jail or juvenile detention facility, the Health
Plan shall maintain contact with the Enrollee and shall participate
actively in the discharge planning processes.






	 	(3)	 	Case managers are also responsible for
coordination and collaboration with the parents or guardians of
Children/Adolescents who receive mental health targeted Case Management
services. The Health Plan shall make reasonable efforts to assure that
case managers include the parents or guardians of Enrollees in the
process of providing targeted Case Management services. Integration of
the parent’s input and involvement with the case manager and other
Providers shall be reflected in Medical Record documentation and
monitored through the Health Plan’s quality of care monitoring
activities. Involvement with the Child’s/Adolescent’s school and/or
childcare center must also be a component of case management with
Children/Adolescents.






	 	e.	 	Additional Requirements for Targeted Case Management






	 	(1)	 	The Health Plan shall have a Case Management
program, including clinical guidelines and protocol that addresses the
issues below:






	 	(a)	 	Caseloads shall be set to achieve
the desired results. Size limitations must clearly state the
ratio of Enrollees to each individual case manager. The limits
shall be specified for Children/Adolescents and adults, with a
description of the clinical rationale for determining each
limitation. If the Health Plan permits “mixed” caseloads, i.e.,
Children/Adolescents and adults, a separate limitation is
expected along with the rationale for the determination. Ratios
must be no greater than the requirements set forth in the
Medicaid Mental Health Targeted Case Management Coverage and
Limitations Handbook.






	 	(b)	 	A system shall be in place to
manage caseloads when positions become vacant.






	 	(c)	 	The modality of service
provision, and the location that services will be provided,
shall be described.






	 	(d)	 	Case Management protocol and
clinical practice guidelines, which outline the expected
frequency, duration and intensity of the service, shall be
available.






	 	(e)	 	Clinical guidelines shall address
issues related to recovery and self-care, including services
that will assist Enrollees in gaining independence from the
behavioral health and Case Management system.






	 	(2)	 	The Case Management program shall have services
available based on the individual needs of the Enrollees receiving the
service. The service should reflect a flexible system that allows
movement within a continuum of care that addresses the changing needs
and abilities of Enrollees.






	 	(a)	 	Case management staff must have
expertise and training necessary to competently and promptly
assist Enrollees in working with Social Security Administration
or Disability Determination in maintaining benefits from SSI and
SSDI. For Enrollees who wish to work, case management staff must
have the expertise and training necessary to assist Enrollees to
access Social Security Work Incentives including development of
Plans for Achieving Self-Support (PASS).






	 	(b)	 	At a minimum, case management
services are to incorporate the principles of a strengths-based
approach. Strengths-based case management services are a
preferred service modality for work with individuals and
families. This method stresses building on the strengths of
individuals and families that can be used to resolve current
problems and issues. This approach counters more traditional
approaches that focus almost exclusively on individuals’
deficits or needs. Service limits and criteria developed cannot
be more restrictive than those in Medicaid policy.






	 	6.	 	Intensive Case Management






	 	a.	 	Intensive Case Management is intended to provide intensive team
Case Management to highly recidivistic adults who have a severe and persistent
mental illness. The service is intended to help Enrollees remain in the
community and avoid institutional care. Clinical care criteria for this level
of Case Management shall address the same elements required above, as well as
expanded elements related to access and twenty-four (24) hour coverage as
described below. Additionally, the intensive Case Management team composition
shall be expanded to include members of the team selected specifically to
assist with the special needs of this population. The Health Plan shall
include the team composition and how it will assist with special needs in the
description of how this service will be provided.






	 	b.	 	The Health Plan shall provide this service for all Enrollees
for whom the service is determined to be Medically Necessary, to include
Enrollees who meet the following criteria:






	 	(1)	 	Has resided in a state mental health treatment
facility for at least six (6) months in the past 36 months;






	 	(2)	 	Resides in the community and has had two (2) or
more admissions to a state mental health treatment facility in the past
36 months;






	 	(3)	 	Resides in the community and has had three (3)
or more admissions to a crisis stabilization unit, short-term
residential facility, inpatient psychiatric unit, or any combination of
these facilities within the past twelve (12) months; or






	 	(4)	 	Resides in the community and, due to a mental
illness, exhibits behavior or symptoms that could result in long-term
hospitalization if frequent interventions for an extended period of
time were not provided.






	 	c.	 	Intensive Case Management provides services through the use of
a team of case managers. The team can be expanded to include other specialists
that are qualified to address identified needs of the Enrollees receiving
intensive Case Management. This level of care for Case Management is the most
intensive and serves Enrollees with the most severe and disabling mental
conditions. Services are frequent and intense with a focus on assisting the
Enrollee with attaining the skills and supports needed to gain independent
living skills. Case Management services are provided primarily in the
Enrollee’s residence and include community-based interventions.






	 	d.	 	The Health Plan shall provide this service in the least
restrictive setting with the goal of improving the Enrollee’s level of
functioning, and providing ample opportunities for rehabilitation, recovery,
and self-sufficiency. Intensive Case Management services shall be accessible
twenty-four (24) hours per day, seven (7) days per week. The Health Plan shall
demonstrate adequate capacity to provide this service for the targeted
population within the guidelines outlined.






	 	e.	 	Intensive Case Management teams shall provide the same
coordination and Case Management services for Enrollees admitted to inpatient
facilities, State mental Hospitals, and forensic or corrections facilities as
those listed above for behavioral health targeted Case Management services.






	 	7.	 	Community Treatment of Patients Discharged from State Mental Hospitals






	 	a.	 	The Health Plan shall provide Medically Necessary Behavioral
Health Services to Enrollees who have been discharged from any State mental
Hospital, including, but not limited to, follow-up services and care. All
Enrollees who have previously received services at the State mental Hospital
must receive follow up care.






	 	b.	 	The plan of care shall be aimed at encouraging Enrollees to
achieve a high quality of life while living in the community in the least
restrictive environment that is medically appropriate and reducing the
likelihood that the Enrollees will be readmitted to a State mental Hospital.






	 	c.	 	The Health Plan shall follow the progress of all Enrollees
enrolled in the Health Plan prior to admission to a State mental Hospital until
the one hundred eightieth (180th) day after Disenrollment from the Health Plan.
The Health Plan shall use behavioral health targeted case managers to follow
the progress of Enrollees. The behavioral health targeted case manager must
attend and participate in the discharge planning activities at the facility.
Targeted case managers are responsible for working with the former Enrollee
before discharge from the State facility to assure that Benefits are reinstated
as soon as possible, and that the Enrollee receives community Behavioral Health
Services within twenty-four (24) hours of his/her discharge from the State
facility.






	 	d.	 	If the Enrollee remains in the State facility more than one
hundred eighty (180) days after Disenrollment, the Health Plan shall cooperate
with DCF and the Enrollee to ensure that the Enrollee is assigned a DCF funded
Case Management provider who will bear the responsibility of ongoing monthly
follow-up care and discharge planning until such time that the Enrollee is
again eligible for, and enrolled in, a Health Plan.






	 	e.	 	The Health Plan shall develop a cooperative agreement with the
behavioral health care facility to enable the Health Plan to anticipate those
Medicaid Recipients who were Enrollees of the Health Plan prior to admission to
the Facility, and will be soon discharged from the Facility. The cooperative
agreement must address arrangements for Medicaid Recipients, whom the Facility
is discharging, but who are not eligible for immediate re-enrollment.






	 	8.	 	Community Services for Medicaid Recipients Involved with the Corrections System






	 	a.	 	The Health Plan shall provide Medically Necessary
community-based services for Health Plan Enrollees who have corrections
involvement as follows:






	 	(1)	 	Establish a linkage to pre-booking sites for
assessment, screening or diversion related to Behavioral Health
Services;






	 	(2)	 	Provide immediate access (within twenty-four
(24) hours of release) for psychiatric services upon release from jail,
prison, juvenile detention facility, or other corrections facility to
assure that prescribed medications are available for all Enrollees.






	 	(3)	 	Establish a linkage to post-booking sites for
discharge planning and assuring that prior Health Plan Enrollees
receive necessary services upon release from the facility. Health Plan
Enrollees must be linked to services and receive routine care within
seven (7) days from the date they are released.






	 	(4)	 	Provide outreach to homeless and other
populations of Health Plan Enrollees at risk of corrections
involvement, as well as those Health Plan Enrollees currently involved
in this system, to assure that services are accessible and provided
when necessary. This activity should be oriented toward preventive
measures to assess behavioral health needs and provide services that
can potentially prevent the need for future inpatient services or
possible deeper involvement in the forensic or corrections system.






	 	(5)	 	The Health Plan shall develop a cooperative
agreement with corrections facilities to enable the Health Plan to
anticipate Enrollees who were Health Plan Enrollees prior to
incarceration who will be released from these institutions. The
cooperative agreement must address arrangement for persons who are to
be released, but for whom re-Enrollment may not take effect
immediately. All Enrollees who were Health Plan Enrollees prior to
incarceration and Medicaid Recipients who are likely to enroll in the
Health Plan upon return to the community must receive a community
Behavioral Health Service within twenty-four (24) hours of discharge
from the corrections facility.






	 	9.	 	Treatment and Coordination of Care for Enrollees with Medically Complex
Conditions






	 	a.	 	The Health Plan shall ensure that there are appropriate
treatment resources available to address the treatment of complex conditions
that reflect both mental health and physical health involvement. The following
conditions must be addressed:






	 	(1)	 	Mental health disorders due to or involving a
general medical condition, specifically -9-CM Diagnoses 293.0 through
294.1, 294.9, 307.89, and 310.1; and






	 	(2)	 	Eating disorders – ICD-9-CM Diagnoses 307.1,
307.50, 307.51, and 307.52.






	 	b.	 	The Health Plan shall provide medically necessary community
mental health services to enrollees who exhibit the above diagnoses and shall
develop a plan of care that includes all appropriate collateral providers
necessary to address the complex medical issues involved. Clinical care
criteria shall address modalities of treatment that are effective for each
diagnosis. The Health Plan’s provider network must include appropriate
treatment resources necessary for effective treatment of each diagnosis within
the required access time periods.






	 	10.	 	Monitoring of Enrollees admitted to Children’s Residential Treatment (Level I –
IV)






	 	a.	 	The Health Plan shall maintain contact with
Children/Adolescents who are disenrolled from the Health Plan due to placement
in a residential treatment facility (Statewide Inpatient Psychiatric Program
(SIPP), Therapeutic Group Care Services (TGCS), or Behavioral Health Overlay
Services (BHOS)). The Health Plan shall participate in discharge planning,
assist the Enrollee and their caregiver to locate community-based services, and
notify Medicaid when the enrollee is discharged from the facility. The Health
Plan’s contract manager or designee shall re-enroll the Enrollee in the Health
Plan upon notification of discharge into the community.






	 	b.	 	Children placed in SIPP, TGCS, or BHOS facilities will be
disenrolled from the Health Plan and then covered under Medicaid
Fee-for-Service for mental health services. The Medicaid contract manager or
designee will be responsible for the disenrollment process. The Department of
Juvenile Justice, residential providers, and/or the assigned Mental Health
Targeted Case Management providers will be responsible for notifying Medicaid
of all admissions and discharges. A specific agreement regarding the
disenrollment and re-enrollment process will be developed between the Agency,
residential providers, and the departments.






	 	c.	 	Upon notification of the Enrollee’s discharge from the facility
the Health Plan shall notify the Choice Counselor/Enrollment Broker for
re-Enrollment into the Health Plan, if it is within six (6) months (180 days)
from the disenrollment.






	 	11.	 	Coordination of Children’s Services






	 	a.	 	General Principles






	 	(1)	 	The delivery and coordination of
Children’s/Adolescent’s mental health services shall be provided for
all Children/Adolescents who exhibit the symptoms and behaviors of an
emotional disturbance. The delivery of services must address the needs
of any Child/Adolescent served in an SED or EH school program.
Developmentally appropriate early childhood mental health services must
be available to children age birth to five (5) years old and their
families.






	 	(2)	 	The Health Plan shall deliver services for all
Children/Adolescents within a strengths-based, culturally competent
service design. The service design shall recognize and ensure that
services are family-driven and include the participation of family,
significant others, informal support systems, school personnel, and any
State entities or other service providers involved in the
Child’s/Adolescent’s life.






	 	(3)	 	For all Children/Adolescents receiving services
from the Health Plan, the Provider shall work with the parents,
guardians, or other responsible parties to monitor the results of
services and determine whether progress is occurring. Active monitoring
of the Child/Adolescent’s status shall occur to detect potential risk
situations and emerging needs or problems.






	 	(4)	 	When the court mandates a parental behavioral
health assessment, and the parent is an Enrollee, the Provider must
complete an assessment of the parent’s mental health status and the
effects on the child. Time frames for completion of this service shall
be determined by the mandates issued by the courts.






	 	b.	 	Targeted Case Management






	 	(1)	 	The Health Plan shall provide behavioral case
management services to Children/Adolescents in the care or custody of
the State who need behavioral health targeted Case Management services,
as defined in the Health Plan’s approved clinical protocols. These
children shall not be transferred to the new Medicaid Child Welfare
Targeted Case Management program. The Health Plan shall develop a
cooperative agreement with DCF or their provider of community based
services, to address how to minimize duplication of case management
services and to promote the establishment of one case manager for the
Child/Adolescent and family whenever possible.






	 	c.	 	Community Based Care Programs






	 	(1)	 	If the community in which the Health Plan
operates has a community-based care program contracted by DCF for the
provision of children’s protective services, the Health Plan shall
determine how to provide services to Enrollees served by the
community-based care program. The Health Plan shall develop, during the
implementation phase of the Contract, or upon notification that the
department has contracted with a Health Plan, a cooperative agreement
between the Health Plan and the community-based care program. Medicaid
and DCF shall approve the agreement. The Health Plan shall be prepared
to provide services in a collaborative manner in each county covered by
the Health Plan.






	 	12.	 	Evaluation and Treatment Services for Enrolled Children/Adolescents






	 	a.	 	The Health Plan shall provide all Medically Necessary
evaluation and treatment services for Children/Adolescents referred to the
Health Plan by DCF, DJJ and by schools (elementary, middle, and secondary
schools).






	 	b.	 	The Health Plan shall provide Medically Necessary
Children/Adolescent Behavioral Health Services in such a way as to minimize
disruption of services available to high-risk populations served by DCF.






	 	c.	 	The Health Plan shall promptly evaluate, provide psychological
testing, and deliver Behavioral Health Services to Children/Adolescents
(including delinquent and dependent Children/Adolescent) referred by DCF in
accordance with Medical Necessity. As well, the Health Plan shall adhere to the
minimum staffing, availability and access standards described in this Contract.






	 	d.	 	The Health Plan shall provide court ordered evaluation and
treatment required for Children/Adolescents who are Enrollees. See
specifications in the Medicaid Community Behavioral Health Services Coverage &
Limitations Handbook.






	 	e.	 	The Health Plan must participate in all DCF or school staffings
that may result in the provision of Behavioral Health Services to an Enrolled
Child/Adolescent.






	 	f.	 	The Health Plan shall refer Children/Adolescents to DCF when
residential treatment is Medically Necessary. The Health Plan shall not be
responsible for providing any residential treatment for Children/Adolescents.
The SAMH or DJJ district office shall coordinate the placement of the Enrolled
Child/Adolescent with the Health Plan.






	 	g.	 	The Health Plan’s Case Management of Children/Adolescents shall
include those persons, schools, programs, networks and agencies that figure
importantly in the Child’s/Adolescent’s life.






	 	h.	 	The Health Plan shall make determinations about care based on a
comprehensive evaluation, consultation with those persons, schools, programs,
networks and agencies that figure importantly in the Child’s/Adolescent’s life,
and appropriate protocols for admission and retention.






	 	i.	 	The Health Plan shall monitor services for adequacy in
conformity with the cooperative agreement between the Health Plan and the
facility.






	 	13.	 	Assessment and Treatment of Mental Health Residents Who Reside in Assisted
Living Facilities (ALF) that hold a Limited Mental Health License






	 	a.	 	The provider must develop and implement a plan to ensure
compliance with Section 394.4574, F.S., related to services provided to
residents of licensed assisted living facilities that hold a limited mental
health license. A cooperative agreement, as defined in Section 400.402, F.S.,
must be developed by the ALF if an Enrollee is a resident of an ALF. The
provider must ensure that appropriate assessment services are provided to
Enrollees and that Medically Necessary Behavioral Health Services are available
to all Enrollees who reside in this type of setting.






	 	b.	 	A Community Living Support Plan, as defined in Section I,
Definitions and Acronyms, must be developed for each Enrollee who is a resident
of an ALF, and it must be updated annually. The Health Plan case manager is
responsible for ensuring that the community living support plan is implemented
as written.






	 	14.	 	Psychiatric Evaluations for Enrollees Applying for Nursing Home Admission






	 	a.	 	The Health Plan, upon request from the SAMH district office,
shall promptly arrange for and authorize psychiatric evaluations for Enrollees
applying for admission to a Nursing Facility, and who, on the basis of a
screening conducted by CARES, are thought to need Behavioral Health Services,
pursuant to OBRA, 1987. The examination shall be adequate to determine the need
for “specialized treatment” under the Act. Any of the Mental Health
Professionals listed in section 394.455, F.S., and make the observations as
part of the evaluation, although a psychiatrist must sign all evaluations. The
examination shall be adequate to determine the need for “specialized treatment”
under the Act. Evaluations must be completed within five (5) Business Days
from the receipt of the request from the DCF SAMH Program Office. The State
has interpreted regulations to permit any of the “mental health professionals”
listed in Section 394.455, F.S. to make observations preparatory to the
evaluation, although a psychiatrist must sign such evaluations.






	 	b.	 	The Health Plan shall not be responsible for annual resident
reviews or for providing services as a result of a Preadmission Screening
Assessment Annual Resident Review (“PASSAR”) evaluation.






	 	15.	 	Individuals with Special Health Care Needs






	 	a.	 	The Health Plan shall implement mechanisms for identifying,
assessing and ensuring the existence of an Individualized Treatment Plan for
Enrollees with Special Health Care Needs, as defined in Section I, Definitions
and Acronyms. Mechanisms shall include evaluation of risk assessments, claims
data, and CPT/ICD-9 codes. Additionally, the Health Plan shall implement a
process for receiving and considering provider and Enrollee input.






	 	b.	 	In accordance with this Contract and 42 CFR 438.208(c)(3), an
Individualized Treatment Plan for an Enrollee determined to need a course of
treatment or regular care monitoring must be:






	 	(1)	 	Developed by the Enrollee’s direct service
mental health care professional with Enrollee participation and in
consultation with any specialists caring for the Enrollee;






	 	(2)	 	Approved by the Health Plan in a timely manner
if this approval is required; and






	 	(3)	 	Developed in accordance with any applicable
Agency quality assurance and utilization review standards.






	 	c.	 	Pursuant to 42 CFR 438.208(c)(4), for Enrollees with Special
Health Care Needs determined through an assessment by appropriate mental health
care professionals (consistent with 42 CFR 438.208(c)(2)) to need a course of
treatment or regular care monitoring, the Health Plan must have a mechanism in
place to allow Enrollees to directly access a mental health care specialist
(for example, through a standing referral or an approved number of visits) as
appropriate for the Enrollee’s condition and identified needs.






	 	16.	 	Crisis Support/Emergency Services






	 	a.	 	The Health Plan shall operate, as part of its Crisis
Support/Emergency Services, a crisis emergency hotline available to all
Enrollees twenty-four (24) hours a day, seven (7) days a week.






	 	17.	 	Provision of Behavioral Health Services When Not Covered by the Health Plan






	 	a.	 	If the Health Plan determines that an Enrollee is in need of
Behavioral Health Services that are not covered under the Contract, the Health
Plan shall refer the Enrollee to the appropriate provider. The Health Plan may
request the assistance of the Agency’s local field office or the local DCF
District ADM Office for referral to the appropriate service setting.






	 	b.	 	Long term care institutional services in a nursing facility, an
institution for persons with developmental disabilities, specialized
therapeutic foster care, children’s residential treatment services or State
hospital services are not covered by the Health Plan. For Enrollees requiring
those services, the Health Plan shall consult the Medicaid Field Office and/or
the DCF District ADM Office to identify appropriate methods of assessment and
referral.






	 	c.	 	The Health Plan is responsible for transition and referral of
the Enrollee to appropriate providers. The Health Plan shall request
Disenrollment of all Enrollees receiving the services described in this
Section.






	 	18.	 	Behavioral Health Services Care Coordination and Management






	 	a.	 	The Health Plan shall be responsible for the coordination and
management of Behavioral Health Services and continuity of care for all
Enrollees. At a minimum, the Health Plan shall provide the following services
to its Enrollees:






	 	(1)	 	Minimize disruption to the Enrollee as a result
of any change in Behavioral Health Care Providers or Behavioral Health
Care Case Managers that occur as a result of this Contract. For new
Enrollees who had been receiving Behavioral Health Services, the Health
Plan shall continue to authorize all valid claims for services until
the Health Plan has:





	 	 	 
	(a)

	 	Reviewed the Enrollee’s treatment plan;
	 
	 	 
	(b)

	 	Developed an appropriate written transition plan; and
	 
	 	 
	(c)

	 	Implemented the written transition plan.







	 	(2)	 	If the previous Behavioral Health Care Provider
is unable to allow the Health Plan access to the Enrollee’s Medical
Records because the Enrollee refuses to release his/her records, then
the Health Plan shall provide:





	 	 	 
	(a)

	 	Up to four (4) sessions of individual or group therapy;
	 
	 	 
	(b)

	 	One (1) psychiatric medical session;
	 
	 	 
	(c)

	 	Two (2) one-hour intensive therapeutic on-site sessions; or
	 
	 	 
	(d)

	 	Six (6) days of day treatment services.







	 	(3)	 	Document all Emergency Behavioral Health
Services received by an Enrollee, along with any follow-up services, in
the Enrollee’s behavioral health Medical Records. The Health Plan shall
also assure the PCP receives the information about the Emergency
Behavioral Health Services for filing in the PCP’s Medical Record.






	 	(4)	 	Document all referral services in the
Enrollees’ behavioral health Medical Records.






	 	(5)	 	Monitor Enrollees admitted to State mental
health institutions by participating in discharge planning and
community placement of Enrollees who are discharged within sixty (60)
days of losing their Health Plan enrollment due to State
institutionalization. The Agency shall sanction the Health Plan, as
described in Section XIV, Sanctions, for any inappropriate
over-utilization of State mental hospital services for its Enrollees.






	 	(6)	 	Coordinate Hospital and institutional discharge
planning for psychiatric admissions and substance abuse detoxification
to ensure inclusion of appropriate post-discharge care.






	 	(a)	 	Enrollees admitted to an acute
care facility (inpatient Hospital or CSU) shall receive
appropriate services upon discharge from the acute care
facility.






	 	(b)	 	The Health Plan shall have
follow-up services available to Enrollees within twenty-four
(24) hours of discharge from an acute care facility, provided
the acute care facility notified the Health Plan that it had
provided services to the Enrollee.






	 	(c)	 	The Health Plan shall continue
the medication prescribed by a State mental health facility to
the Enrollee for at least ninety (90) days after the State
mental health facility discharges the Enrollee, unless the
Health Plan’s prescribing psychiatrist, in consultation and
agreement with the State mental health facility’s prescribing
physician, determines that the medications:






	 	(i)	 	Are not Medically
Necessary; or






	 	(ii)	 	Are potentially
harmful to the Enrollee.






	 	g.	 	Provide appropriate referral of the Enrollee for non-covered
services to the appropriate service setting. The Health Plan shall request
referral assistance, as needed, from the Medicaid Field Office. The Health
Plan is encouraged to use the Florida Supplement to the American Society of
Addictions Medicine Patient Placement Criteria for coordination and treatment
of substance abuse related disorders with substance abuse providers. The
Health Plan is encouraged to use the Florida Supplement to the American Society
of Addictions Medicine Placement Criteria for coordination and treatment of
substance-related disorders with substance abuse Providers. The Health Plan
shall provide coordination of care with community-based substance abuse
agencies as part of its policies and procedures developed for continuity of
care for Enrollees who are diagnosed with mental illness and substance abuse or
dependency.






	 	h.	 	Provide court ordered mental health evaluations for Enrollees.
The Health Plan shall also provide expert behavioral health testimony for
Enrollees.






	 	i.	 	Provide appropriate screening, assessment, and crisis
intervention in support of Enrollees who are in the care and custody of the
State. See Specifications listed in the Medicaid Community Mental Health
Services Coverage & Limitations Handbook.






	 	 	 	j.. Upon request from an ALF, the Health Plan shall provide
procedures for the ALF to follow should an emergent condition arise with an
Enrollee that resides at the ALF (see Section 409.912, F.S.).






	 	k.	 	The Health Plan shall participate in the SAMH planning process
in each DCF district (see Section 394.75, F.S.).






	 	l.	 	The Health Plan shall design and implement a Drug Utilization
Review (“DUR”) program. Once the Health Plan’s pharmacy utilization indicates
that an Enrollee is receiving an antipsychotic medication from a PCP or
prescribing non-psychiatrist physician, the Health Plan shall request a
consultation with the PCP or prescribing non-psychiatrist physician. Once the
Health Plan’s pharmacy utilization indicates that an Enrollee, who is being
treated by a Behavioral Health Care Provider, receives medication for certain
physical conditions (such as hypertension, diabetes, neurological disorders,
cardiac problems, or any other serious medical condition) the Health Plan shall
schedule a consultation with the PCP or prescribing physician to discuss
coordination of care and concerns related to drug interactions. The Health Plan
shall ensure coordination with the PCP or prescribing physician with regards to
drug utilization and potential contraindications.






	 	19.	 	Discharge Planning






	 	a.	 	Discharge Planning is the evaluation of an Enrollee’s medical
care needs, including Behavioral Health Service needs, substance abuse service
needs, or both, in order to arrange for appropriate care after discharge from
one level of care to another level of care. The Health Plan shall:






	 	(1)	 	Monitor all Enrollee discharge plans from
behavioral health inpatient admissions to ensure that they incorporate
the Enrollees’ needs for continuity in existing behavioral health
therapeutic relationships.






	 	(2)	 	Ensure that Enrollees’ family members,
guardians, outpatient individual practitioners and other identified
supports are given the opportunity to participate in Enrollee treatment
to the maximum extent practicable and appropriate, including behavioral
health treatment team meetings and developing the discharge plan. For
adult Enrollees, family members and other identified supports may be
involved in the development of the Discharge Plan only if the Enrollee
consents to their involvement.






	 	(3)	 	Designate staff members who are responsible for
identifying Enrollees who remain in the Hospital for non-clinical
reasons (i.e., absence of appropriate treatment setting availability,
high demand for appropriate treatment setting, high-risk Enrollees and
Enrollees with multiple agency involvement).






	 	(4)	 	Develop and implement a plan that monitors and
ensures that clinically indicated Behavioral Health Services are
offered and available to Enrollees within twenty-four (24) hours of
discharge from an inpatient setting.






	 	(5)	 	Ensure that a behavioral health program
clinician provides medication management to Enrollees requiring
medication monitoring within twenty-four (24) hours of discharge from a
behavioral health program inpatient setting. The Health Plan shall
ensure that the behavioral health program clinician is duly qualified
and licensed to provide medication management.






	 	(6)	 	Upon the admission of an Enrollee, the Health
Plan shall make its best efforts to ensure the Enrollee’s smooth
transition to the next service or to the community; and shall require
that Behavioral Health Care Providers:






	 	(a)	 	Assign a Behavioral Health Care
Case Manager to oversee the care given to the Enrollee;






	 	(b)	 	Develop an individualized
discharge plan, in collaboration with the Enrollee where
appropriate, for the next service or program or the Enrollee’s
discharge, anticipating the Enrollee’s movement along a
continuum of services; and






	 	(c)	 	Make best efforts to ensure a
smooth transition to the next service or community;






	 	(d)	 	Document all significant efforts
related to these activities, including the Enrollee’s active
participation in discharge planning.






	 	20.	 	Transition Plan






	 	a.	 	A transition plan is a detailed description of the process of
transferring Enrollees from non-participating providers to the Health Plan’s
Behavioral Health Care Provider network to ensure optimal continuity of care.
The transition plan shall include, but not be limited to, a timeline for
transferring Enrollees, description of provider medical record transfers,
scheduling of appointments, and propose prescription drug protocols and claims
approval for existing providers during the transition period. The Health Plan
shall document its efforts relating to the transition plan in the Enrollee’s
Medical Records.






	 	b.	 	The Health Plan shall minimize the disruption of treatment by
an Enrollee’s current behavioral health care provider by arranging for Enrollee
use of services outside of the Health Plan’s network. For Enrollees who have
received Behavioral Health Services for at least six (6) months from a
behavioral health care provider, whether the provider is in the Health Plan’s
network or not, the Health Plan shall continue to authorize all valid claims
until the Health Plan reviews the Enrollee’s treatment plan and implements an
appropriate written transition plan.






	 	c.	 	During the first three (3) months that the Enrollee receives
Behavioral Health Services under this Contract, the Health Plan shall not deny
requests for Behavioral Health Services outside the network under the following
conditions:






	 	(1)	 	The Enrollee is a patient at a community
behavioral health center and the center has discussed the Enrollee’s
care with the Health Plan.






	 	(2)	 	If, following contact with the Health Plan,
there is no Behavioral Health Care Provider readily available and the
Enrollee’s condition would not permit a delay in treatment.






	 	d.	 	If the previous treating provider is unable to allow the Health
Plan access to the Enrollee’s Medical Records because the Enrollee refuses to
release the records, then the Health Plan shall approve the provider’s claims
for:






	 	(1)	 	Four (4) sessions of outpatient behavioral
health counseling or therapy;






	 	(2)	 	One (1) outpatient psychiatric physician
session;






	 	(3)	 	Two (2) one-hour intensive therapeutic on-site
sessions; or






	 	(4)	 	Six (6) days of day treatment services.






	 	e.	 	Any disputes related to coverage of services necessary for the
transition of Enrollees from their current behavioral health care provider to a
Behavioral Health Care Provider shall follow the process set forth in Section
IX, Grievance System.






	 	f.	 	The Health Plan shall approve claims from providers for
authorized out-of-plan non-emergency services, provided such claims are
submitted within twelve (12) months of the date of service. The Health Plan
must process such claims within the time period specified in Section 641.3155,
F.S.






	 	21.	 	Functional Assessments






	 	a.	 	The Health Plan shall ensure that all Behavioral Health Care
Providers administer functional assessments using the Functional Assessment
Rating Scales (FARS) for all Enrollees over the age of eighteen (18) and Child
Functional Assessment Rating Scale (CFARS) for all Enrollees age eighteen (18)
and under.






	 	b.	 	The Health Plan shall ensure that all Behavioral Health Care
Providers administer and maintain the FARS and CFARS, according to the FARS and
CFARS manuals, to all Enrollees receiving Behavioral Health Services and upon
termination of providing such services.






	 	c.	 	The results of the FARS and CFARS assessments shall be
maintained in each Enrollee’s Medical Record, including a chart trending the
results of the functional assessments.






	 	d.	 	The Health Plan shall submit the FARS/CFARS reports as required
in Section XII, Reporting Requirements.






	 	22.	 	Outreach Program






	 	a.	 	The Health Plan shall have an outreach program designed to
encourage Enrollees to seek Behavioral Health Services through the Health Plan
when the Health Plan, or Providers, perceive a need for Behavioral Health
Services. In addition, the outreach program, at a minimum, shall provide for
the following:






	 	(1)	 	Make available, by mail or at the request of an
Enrollee/provider (participating or non-participating), outreach
program documentation that is written at the fourth (4th)
grade reading level and written in the primary language spoken by the
Enrollee;






	 	(2)	 	A program to identify and manage Enrollees who
are homeless.






	 	(3)	 	A program, including referral and other
resources, designed to assist PCP’s in the identification, management
and treatment of:





	 	 	 
	
 
	 	(a)Enrollees with severe and persistent mental illness;
	 
	 	 
	
 
	 	(b)Children/Adolescents with severe emotional disturbances; and
	 
	 	 
	
 
	 	(c)Enrollees with clinical depression.
	 
	 	 
	23.

	 	Behavioral Health Provider Contracts







	 	a.	 	If the Health Plan subcontracts with a Managed Behavioral
Health Organization (MBHO) for the provision of Behavioral Health Services, the
MBHO must be accredited by at least one (1) of the recognized national
accreditation organizations.






	 	a.	 	The Health Plan shall submit to the Agency the staff
psychiatrist employment contract, if any, and the model Provider Contracts for
each Behavioral Health Services specialist type or facility.






	 	b.	 	All subcontracts and Provider Contracts must adhere to the
requirements set forth in this Contract.






	 	24.	 	Optional Services






	 	a.	 	The Health Plan is encouraged to provide additional services
that will enhance the Health Plan’s Covered Services for Enrollees. To the
degree possible, the Health Plan should use existing community resources. Below
is a list of possible optional services that could be provided with the savings
achieved or as downward substitutions. This list is not intended to be
all-inclusive and the Health Plan is encouraged to use creativity in developing
new and innovative services to expand the array of services and meet the needs
of Enrollees.






	 	(1)	 	Respite Care Services;






	 	(2)	 	Prevention Services in the Community;






	 	(3)	 	Supportive Living Services;






	 	(4)	 	Supported Employment Services;






	 	(5)	 	Foster Homes for Adults;






	 	(6)	 	Parental Education Programs;






	 	(7)	 	Drop-In Centers and other consumer operated
programs (beyond the elements provided under the Opportunities for
Recovery and Reintegration component);






	 	(8)	 	Intensive Therapeutic On-Site Services for
Adults;






	 	(9)	 	Home and Community Based Rehabilitation
Services for Adults; and






	 	(10)	 	Any other new and innovative interventions or
services designed to benefit Enrollees.






	 	25.	 	Community Coordination and Collaboration






	 	a.	 	The Health Plan must be or become a vital part of the community
services and support system. It must actively participate with and support
community programs and coalitions that promote school readiness, that assist
persons to return to work and provide for prevention programs. The Health Plan
must have linkages with numerous community programs that will assist Enrollees
in obtaining housing, economic assistance and other supports.






	C.	 	Behavioral Health Managed Care Local Advisory Group






	 	1.	 	There will be a local advisory group for the Health Plan that convenes
quarterly and reports to the Agency on advocacy and programmatic concerns. The local
advisory group is responsible for providing technical and policy advice to the Agency
regarding the Health Plan’s provision of services. The local advisory group does not
have access to Enrollee Medical Records.






	 	2.	 	The role of the local advisory group is to report to the Agency information
related to practical and real events that occur related to the activities of Medicaid
health plans. Concerns about services, program changes, quality of care, difficulties,
advocacy issues, and reports about positive outcomes are presented by members of the
local advisory group and are addressed by the Agency as part of the ongoing monitoring
of the Health Plan. The Agency presents information about actions taken related to
issues presented by the group. If the local advisory group determines that it is
appropriate, the local advisory group members also vote to present their issues to the
Agency in writing.






	 	3.	 	The local advisory group may request information to be presented at each
meeting that will keep the local advisory group up-to-date regarding the Contract and
activities of each Health Plan. Minutes of the meetings are kept and distributed to all
members and attendees. The voting membership of the local advisory group is updated
periodically. This is a public meeting and may be attended by anyone in the community.






	 	4.	 	The local advisory group is coordinated by Agency area staff (who are not part
of the voting membership) and consists of providers, consumer representatives, advocacy
groups, and other relevant groups as identified by the Agency, which represent the
counties within the Service Area. Such relevant groups include the Agency’s Medicaid
Office, including Health Plan representatives; SAMH and Family Safety representatives;
representatives from any community based care Providers contracted with DCF; the
Florida Drop-In Center Association; the Human Rights Advocacy Committee; the Alliance
for the Mentally Ill; the Florida Consumer Action Council; and the Substance Abuse and
Mental Health Planning Council. In addition, the Health Plan provides representation to
the local advisory group. The local advisory group elects a chairperson and
vice-chairperson from the voting membership, who facilitates the meetings and prepares
any written correspondence on behalf of the group.






	 	5.	 	The Health Plan’s responsibility related to the local advisory group is as
follows:





	 	 	 
	a.

	 	Assure representation at all scheduled meetings;
	 
	 	 
	b.

	 	Provide information requested by local advisory group members;







	 	c.	 	Follow up on identified issues of concern related to the
provision of services or administration of the Health Plan; and






	 	d.	 	Share pertinent information about Quality Improvement findings
and outreach activities with the local advisory group.






	D.	 	Community Behavioral Health Services Annual 80/20 Expenditure Report






	 	1.	 	By April 1 of each year, Health Plans shall provide a breakdown of expenditures
related to the provision of community behavioral health services, using the spreadsheet
template provided by the Agency (see Section XII, Reporting Requirements).  In
accordance with Section 409.912, F.S., eighty percent (80%) of the Capitation Rate paid
to the Health Plan by the Agency shall be expended for the provision of community
behavioral health services.  In the event the Health Plan expends less than eighty
percent (80%) of the Capitation Rate, the Health Plan shall return the difference to
the Agency no later than May 1 of each year.






	 	 	 	a.   For reporting purposes in accordance with this Section,
‘community behavioral health services’ are defined as those services that the
Health Plan is required to provide as listed in the Community Mental Health
Services Coverage and Limitations Handbook and the Mental Health Targeted Case
Management Coverage and Limitations handbook.






	 	 	 	b.   For reporting purposes in accordance with this Section
‘expended’ means the total amount, in dollars, paid directly or indirectly to
community behavioral health services providers solely for the provision of
community behavioral health services, not including administrative expenses or
overhead of the plan.  If the report indicates that a portion of the capitation
payment is to be returned to the Agency, the Health Plan shall submit a check
for that amount with the Behavioral Health Services Annual 80/20 Expenditure
Report that the Health Plan provides to the Agency.





27




REMAINDER OF PAGE INTENTIONALLY LEFT BLANKSection VII




Provider Network





	A.	 	General Provisions






	 	1.	 	The Health Plan shall have sufficient facilities, service locations, service
sites and personnel to provide the Covered Services described in Section V, above, and
Behavioral Health Care described in Section VI, above.






	 	2.	 	The Health Plan shall provide the Agency with adequate assurances that the
Health Plan has the capacity to provide Covered Services to all Enrollees up to the
maximum enrollment level in each county, including assurances that the Health Plan:






	 	a.	 	Offers an appropriate range of services and accessible
preventive and primary care services such that the Health Plan can meet the
needs of the maximum enrollment level in each county, and






	 	b.	 	Maintains a sufficient number, mix and geographic distribution
of Providers, including Providers who are accepting new Medicaid patients as
specified in Section 1932(b)(7) of the Social Security Act, as enacted by
Section 4704(a) of the Balanced Budget Act of 1997.






	 	3.	 	By November 30, 2006, the Health Maintenance Organizations and other licensed
managed care organizations shall register all network providers with the Agency’s
Fiscal Agent, in the manner, and format determined by the Agency.






	 	4.	 	Each Provider shall maintain Hospital privileges if Hospital privileges are
required for the delivery of Covered Services. The Health Plan may use admitting
panels to comply with this requirement.






	 	5.	 	When designing the Provider network, the Health Plan shall take the following
into consideration as required by 42 CFR 438.206:






	 	a.	 	The anticipated number of Enrollees;






	 	b.	 	The expected utilization of services, taking into consideration
the characteristics and health care needs of specific Medicaid populations
represented;






	 	c.	 	The numbers and types (in terms of training, experience, and
specialization) of providers required to furnish the Covered Services;






	 	d.	 	The numbers of network providers who are not accepting new
Enrollees;






	 	e.	 	The geographic location of providers and Enrollees, considering
distance, travel time, the means of transportation ordinarily used by Enrollees
and whether the location provides physical access for Medicaid enrollees with
disabilities; and






	 	f.	 	There is to be no discrimination against particular providers
that serve high-risk populations or specialize in conditions that require
costly treatments.






	 	6.	 	If the Health Plan is unable to provide Medically Necessary services to an
Enrollee, the Health Plan must cover these services by using providers and services
that are not providers in the Health Plan’s network, in an adequate and timely manner,
for as long as the Health Plan is unable to provide the Medically Necessary services
within the Health Plan’s network.






	 	7.	 	The Health Plan shall allow each Enrollee to choose his or her Providers to the
extent possible and appropriate.






	 	8.	 	The Health Plan shall require each Provider to have a unique Florida Medicaid
Provider number, in accordance with the requirement of Section X.C.jj., of this
Contract. By May 2007, the Health Plan shall require each Provider to have a National
Provider Identifier (NPI) in accordance with section 1173(b) of the Social Security
Act, as enacted by section 4707(a) of the Balanced Budget Act of 1997.






	 	a.	 	The Health Plan need not obtain an NPI from the following
Providers:






	 	(1)	 	Individuals or organizations that furnish
atypical or nontraditional services that are only indirectly related to
the provision of health care (examples include taxis, home and vehicle
modifications, insect control, habilitation and respite services); and






	 	(2)	 	Individuals ore businesses that only bill or
receive payment for, but do not furnish, health care services or
supplies (examples includes billing services, repricers and value-added
networks).






	 	9.	 	The Health Plan shall provide the Agency with documentation of compliance with
access requirements:






	 	a.	 	Upon the effective date of the Contract; and






	 	b.	 	At any time there has been a significant change in the Health
Plan’s operations that would affect adequate capacity and services, including,
but not limited to, the following:






	 	(1)	 	Changes in Health Plan services or Service
Area; and






	 	(2)	 	Enrollment of a new population in the Health
Plan.






	 	10.	 	The Health Plan shall have procedures to inform Potential Enrollees and
Enrollees of any changes to service delivery and/or the Provider network including the
following:






	 	a.	 	Inform Potential Enrollees and Enrollees of any restrictions to
access to Providers, including Providers who are not taking new patients, upon
request and, for Enrollees, at least on a six (6) month basis.






	 	b.	 	An explanation to all Potential Enrollees that an enrolled
family may choose to have all family members served by the same PCP or they may
choose different PCPs based on each family member’s needs.






	 	c.	 	Inform Potential Enrollees and Enrollees of objections to
providing counseling and referral services based on moral or religious grounds
within ninety (90) days after adopting the policy with respect to any service.






	 	11.	 	The Health Plan shall not discriminate with respect to participation,
reimbursement, or indemnification as to any provider, whether participating or
nonparticipating, who is acting within the scope of the provider’s license or
certification under applicable State law, solely on the basis of such license or
certification, in accordance with Section 1932(b) (7) of the Social Security Act (as
enacted by section 4704(a) of the Balanced Budget Act of 1997). The Health Plan is not
prohibited from including providers only to the extent necessary to meet the needs of
the Health Plan’s Enrollees or from establishing any measure designed to maintain
quality and control costs consistent with the responsibilities of the Health Plan. If
the Health Plan declines to include individual providers or groups of providers in its
network, it must give the affected providers written notice of the reason for its
decision.






	B.	 	Primary Care Providers






	 	1.	 	The Health Plan shall enter into Provider Contracts with a sufficient number of
PCPs to ensure adequate accessibility for Enrollees of all ages. The Health Plan shall
select and approve its PCPs. The Health Plan shall ensure its PCP Provider Contracts
provide for the following:






	 	a.	 	The PCP shall accept all associated Case Management
responsibilities;






	 	b.	 	The PCP shall provide, or arrange for coverage of services,
consultation or approval for referrals twenty four (24) hours per day, seven
(7) days per week by Medicaid enrolled providers who will accept Medicaid
reimbursement. This coverage must consist of an answering service, call
forwarding, provider call coverage or other customary means approved by the
Agency. The chosen method of twenty four (24) hour coverage must connect the
caller to someone who can render a clinical decision or reach the PCP for a
clinical decision. The after hours coverage must be accessible using the
medical office’s daytime telephone number. The PCP or covering medical
professional must return the call within thirty (30) minutes of the initial
contact; and






	 	c.	 	The PCP shall arrange for coverage of primary care services
during absences due to vacation, illness or other situations which require the
PCP to be unable to provide services. Coverage must be provided by a Medicaid
eligible PCP.






	 	2.	 	The Health Plan shall provide the following:






	 	a.	 	At least one (1) FTE PCP per Service Area including, but not
limited to, the following specialties:






	 	(1)	 	Family Practice;






	 	(2)	 	General Practice;






	 	(3)	 	Obstetrics or Gynecology;






	 	(4)	 	Pediatrics; and






	 	(5)	 	Internal Medicine.






	 	b.	 	At least one (1) FTE PCP per 1,500 Enrollees. The Health Plan
may increase the ratio by 750 Enrollees for each FTE ARNP or FTE PA affiliated
with a PCP.






	 	c.	 	The Health Plan shall allow pregnant Enrollees to choose the
Health Plan’s obstetricians as their PCPs to the extent that the obstetrician
is willing to participate as a PCP.






	 	3.	 	At least annually, the Health Plan shall review each PCP’s average wait times
to ensure services are in compliance with Section VII.D., Appointment Waiting Times and
Geographic Access Standards.






	 	4.	 	The Health Plan shall assign a pediatrician or other appropriate PCP to all
pregnant Enrollees for the care of their newborn babies no later than the beginning of
the last trimester of gestation. If the Health Plan was not aware that the Enrollee
was pregnant until she presented for delivery, the Health Plan shall assign a
pediatrician or a PCP to the newborn baby within one (1) Business Day after birth. The
Health Plan shall advise all Enrollees of the Enrollees’ responsibility to notify their
Health Plan and their DCF public assistance specialists (case workers) of their
pregnancies and the births of their babies.






	C.	 	Minimum Standards






	 	1.	 	Emergency Services and Emergency Services Facilities  — The
Health Plan shall ensure the availability of Emergency Services and Care
twenty-four (24) hours a day, seven (7) days a week.






	 	2.	 	General Acute Care Hospital — The Health Plan shall provide at
least one (1) fully accredited general acute care Hospital bed per 275
Enrollees. The Agency may waive this accreditation requirement, in writing,
for Rural areas.






	 	3.	 	Birth Delivery Facility — The Health Plan shall provide at
least one (1) birth delivery facility, licensed under Chapter 383, F.S.,
or a Hospital with birth delivery facilities, licensed under Chapter 383,
F.S. The birth delivery facility may be part of a Hospital or a freestanding
facility.






	 	4.	 	Birthing Center — The Health Plan shall provide a birthing
center, licensed under Chapter 383, F.S. that is accessible to low risk
Enrollees.






	 	5.	 	Regional Perinatal Intensive Care Centers (RPICC) — The
Health Plan shall assure access for Enrollees in one (1) or more of Florida’s
Regional Perinatal Intensive Care Centers (RPICC), see Sections 383.15 through
383.21, F.S., or a Hospital licensed by the Agency for Neonatal Intensive Care
Unit (NICU) Level III beds.






	 	6.	 	Neonatal Intensive Care Unit (NICU) — The Health Plan shall
ensure that care for medically high risk perinatal Enrollees is provided in a
facility with a NICU sufficient to meet the appropriate level of need for the
Enrollee.






	 	7.	 	Certified Nurse Midwife Services — The Health Plan shall ensure
access to certified nurse midwife services or licensed midwife services for low
risk Enrollees, licensed in accordance with Section 641.31, F.S.






	 	8.	 	Pharmacy — If the Health Plan elects to use a more restrictive
pharmacy network than the non-Medicaid Reform fee-for-service network, the
Health Plan shall provide at least one (1) licensed pharmacy per 2,500
Enrollees. The Health Plan shall ensure that its contracted pharmacies comply
with the Settlement Agreement to Hernandez et al. v. Medows (case number
02-20964 Civ-Gold/Simonton) (HSA).






	 	9.	 	Access for Persons with Disabilities — The Health Plan shall
ensure that all facilities have access for persons with disabilities.






	 	10.	 	Health, Cleanliness and Safety — The Health Plan shall ensure
adequate space, supplies, proper sanitation, and smoke-free facilities with
proper fire and safety procedures in operation.






	D.	 	Appointment Waiting Times and Geographic Access Standards






	 	1.	 	The Health Plans must assure that PCP services and referrals to Participating
Specialists are available on a timely basis, as follows:






	 	a.	 	Urgent Care — within one (1) day,






	 	b.	 	Routine Sick Patient Care — within one (1) week, and






	 	c.	 	Well Care Visit — within one (1) month.






	 	2.	 	All PCP’s and Hospital services must be available within an average of thirty
(30) minutes travel time from an Enrollee’s residence. All Participating Specialists
and Ancillary Providers must be within an average of sixty (60) minutes travel time
from an Enrollee’s residence. The Agency may waive this requirement, in writing, for
Rural Areas and for areas where there are no PCPs or Hospitals within a thirty (30)
minute average travel time.






	 	3.	 	The Health Plan shall provide a designated emergency services facility within
an average of thirty (30) minutes travel time from an Enrollee’s residence, that
provides care on a twenty-four (24) hours a day, seven (7) days a week basis. Each
designated emergency service facility shall have one (1) or more physicians and one (1)
or more nurses on duty in the facility at all times. The Agency may waive the travel
time requirement, in writing, in Rural areas.






	 	4.	 	For Rural areas, if the Health Plan is unable to enter into an agreement with
specialty or ancillary service providers within the required sixty (60) minute average
travel time, the Agency may waive, in writing, the requirement.






	 	5.	 	At least one (1) pediatrician or one (1) CHD, FQHC or RHC within an average of
thirty (30) minutes travel time from an Enrollee’s residence, provided that this
requirement remains consistent with the other minimum time requirements of this
Contract. In order to meet this requirement, the pediatrician(s), CHD, FQHC, and/or
RHC must provide access to care on a twenty-four (24) hours a day, seven (7) days a
week basis. The Agency may waive this requirement, in writing, for Rural areas and
where there are no pediatricians, CHDs, FQHCs or RHCs within the thirty (30) minute
average travel time.






	E.	 	Behavioral Health Services






	 	1.	 	The Health Plan shall have at least one (1) certified adult psychiatrist and at
least one (1) board certified child psychiatrist (or one (1) child psychiatrist who
meets all education and training criteria for Board Certification) that is available
within thirty (30) minutes average travel time for Urban areas and sixty (60) minutes
average travel time for Rural areas of all Enrollees.






	 	2.	 	For Rural areas, if the Health Plan does not have a Provider with the necessary
experience, the Agency may waive, in writing, the requirements in Section VII.E.1,
above.






	 	3.	 	The Health Plan shall ensure that outpatient staff includes at least one (1)
FTE Direct Service Behavioral Health Provider per 1,500 Enrollees. The Agency expects
the Health Plan’s staffing pattern for direct service Providers to reflect the ethnic
and racial composition of the community.






	 	4.	 	The Health Plan’s array of Direct Service Behavioral Health Providers for
adults and Children/Adolescents shall include Providers that are licensed or eligible
for licensure, and demonstrate two (2) years of clinical experience in the following
specialty areas or with the following populations:






	 	a.	 	Adoption;






	 	b.	 	Child protection or foster care;






	 	c.	 	Dual diagnosis (mental illness and substance abuse);






	 	d.	 	Dual diagnosis (mental illness and developmental disability);






	 	e.	 	Developmental disabilities;






	 	f.	 	Behavior analysis;






	 	g.	 	Behavior management and alternative therapies for
children/Adolescents;






	 	h.	 	Separation and loss;






	 	i.	 	Victims and perpetrators of sexual abuse (Children/Adolescents
and adults);






	 	j.	 	Victims and perpetrators of violence and violent crimes
(Children/Adolescents and adults);






	 	k.	 	Court ordered mental health evaluations including assessment of
parental mental health issues and parental competency as it relates to mental
health; and






	 	l.	 	Expert witness testimony.






	 	5.	 	All Direct Service Behavioral Health Providers and mental health targeted case
managers serving the Children/Adolescent population shall be certified by DCF to
administer CFARS (or other rating scale required by DCF or the Agency).






	 	6.	 	The Health Plan shall not count Behavioral Health targeted case managers shall
not be counted as direct service Behavioral Health Providers.






	 	7.	 	For Case Management services, the Health Plan shall provide staff that meets
the following minimum requirements:






	 	a.	 	Have a baccalaureate degree from an accredited university, with
major course work in the areas of psychology, social work, health education or
a related human service field and, if working with Children/Adolescents, have a
minimum of one-(1) year full-time experience, or equivalent experience, working
with the target population. Prior experience is not required if working with
the adult population; or






	 	b.	 	Have a baccalaureate degree from an accredited university and
if working with Children/Adolescents, have at least three (3) years full-time
or equivalent experience, working with the target population. If working with
adults, the case manager must have two (2) years of experience. (Note: case
managers who were certified by the Department prior to July 1, 1999, who do not
meet the degree requirements, may provide Case Management services if they meet
the other requirements; and






	 	c.	 	Have completed a training program within six (6) months of
employment. The training program must be prior approved in writing by the
Agency. The training must include a review of the local resources and a
thorough presentation of the applicable State and federal statutes and promote
the knowledge, skills, and competency of all case managers through the
presentation of key core elements relevant to the target population. The case
manager must also be able to demonstrate an understanding of the Health Plan’s
Case Management policies and procedures.






	 	8.	 	Case Management supervision must be provided by a person who has a master’s
degree in a human services field and three (3) years of professional full time
experience serving this target population or a person with a bachelor’s degree and five
(5) years of full time or equivalent Case Management experience. For supervising case
managers who work only with adults, two (2) years of full time experience is required.
The supervisors must have had the approved Health Plan training in Case Management or
have documentation that they have prior equivalent training.






	 	9.	 	The Health Plan shall have access to no less than one (1) fully accredited
psychiatric community Hospital bed per 2,000 Enrollees, as appropriate, for both
Children/Adolescents and adults. Specialty psychiatric Hospital beds may be used to
count toward this requirement when psychiatric community Hospital beds are not
available within a particular community. Additionally, the Health Plan shall have
access to sufficient numbers of accredited Hospital beds on a medical/surgical unit to
meet the need for medical detoxification treatment.






	 	10.	 	The Health Plan’s facilities must be licensed, as required by law and rule,
accessible to the handicapped, in compliance with federal Americans with Disabilities
Act guidelines, and have adequate space, supplies, good sanitation, and fire, safety,
and disaster preparedness and recovery procedures in operation.






	 	11.	 	The Health Plan shall ensure that it has Providers that are qualified to serve
Enrollees and experienced in serving severely emotionally disturbed
Children/Adolescents and severely and persistent mentally ill adults. The Health Plan
shall maintain documentation of its Providers’ experience in the Providers’
credentialing file.






	 	12.	 	The Health Plan shall adhere to the staffing ratio of at least one (1) FTE
Behavioral Health Care Case Manager for twenty (20) Children/Adolescents and at least
one (1) FTE Behavioral Health Care Case Manager per forty (40) adults. Direct Service
Behavioral Health Care Providers shall not count as Behavioral Health Care Case
Managers.






	 	13.	 	Prior to commencement of Behavioral Health Services, the Health Plan shall
enter into agreements for coordination of care and treatment of Enrollees, jointly or
sequentially served, with county community mental health care center(s) that are not a
part of the Health Plan’s Provider network. The Health Plan shall enter into similar
agreements with agencies funded pursuant to Chapter 394, F.S. The Agency shall approve
all model agreements between the Health Plan and county community mental health
center(s)/agencies before the Health Plan enters into the agreement. This requirement
shall not apply if the Health Plan provides the Agency with documentation that shows
the Health Plan has made a good faith effort to contract with county community mental
health center(s)/agencies, but could not reach an agreement.






	 	14.	 	The Health Plan shall request current behavioral health care provider
information from all new Enrollees upon enrollment. The Health Plan shall solicit
these behavioral health services providers to participate in the Health Plan’s network.
The Health Plan may request in writing that the Agency grant exemption to a Health
Plan from soliciting a specific behavioral health services provider on a case-by-case
basis.






	 	15.	 	To the maximum extent possible, the Health Plan shall contract for the
provision of Behavioral Health Services with the State’s community mental health
centers designated by the Agency and DCF.






	F.	 	Specialists and Other Providers






	 	1.	 	In addition to the above requirements, the Health Plan shall assure the
availability of the following specialists, as appropriate for both adults and pediatric
Enrollees, on at least a referral basis. The Health Plan shall use Participating
Specialists with pediatric expertise for Children/Adolescents when the need for
pediatric specialty care is significantly different from the need for adult specialty
care (for example a pediatric cardiologist for Children/Adolescents with congenital
heart defects).






a. Allergist,




b. Cardiologist,




c. Endocrinologist,




d. General Surgeon,




e. Obstetrical/Gynecology (OB/GYN),




f. Neurologist,




g. Nephrologist,




h. Orthopedist,




i. Urologist,




j. Dermatologist,




k. Otolaryngologist,




l. Pulmonologist,




m. Chiropractic Physician,




n. Podiatrist,




o. Ophthalmologist,



	 	 	 
	p.

	 	Optometrist,
	 
	 	 
	q.

	 	Neurosurgeon,
	 
	 	 
	r.

	 	Gastroenterologist,
	 
	 	 
	s.

	 	Oncologist,
	 
	 	 
	t.

	 	Radiologist,
	 
	 	 
	u.

	 	Pathologist,
	 
	 	 
	v.

	 	Anesthesiologist,
	 
	 	 
	w.

	 	Psychiatrist,







x. Oral surgeon,




y. Physical, respiratory, speech and occupational therapists, and




z. Infectious disease specialist.




	 	2.	 	If the infectious disease specialist does not have expertise in HIV and its
treatment and care, then the Health Plan must have another Provider with such
expertise.






	 	3.	 	The Health Plan shall make a good faith effort to execute memoranda of
agreement with the local CHDs to provide services which may include, but are not
limited to, family planning services, services for the treatment of sexually
transmitted diseases, other public health related diseases, tuberculosis,
immunizations, foster care emergency shelter medical screenings, and services related
to Healthy Start prenatal and post-natal screenings. The Health Plan shall provide
documentation of its good faith effort upon the Agency’s request.






	 	4.	 	Notwithstanding Section VIII.B.2, Certain Public Providers, of this Contract,
the Health Plan shall pay, without prior authorization, at the contracted rate or the
Medicaid fee-for-service rate, all valid claims initiated by any CHD for office visits,
prescribed drugs, laboratory services directly related to DCF emergency shelter medical
screening, and tuberculosis. The Health Plan must reimburse the CHD when the CHD
notifies the Health Plan and provides the Health Plan with copies of the appropriate
Medical Records and provides the Enrollee’s PCP with the results of any tests and
associated office visits.






	 	5.	 	The Health Plan shall make a good faith effort to execute a contract with a
Federally Qualified Health Center (FQHC) and, if applicable, a Rural Health Clinic
(RHC). The Health Plan shall reimburse FQHCs and RHCs at rates comparable to those
rates paid for similar services in the FQHC’s or RHC’s community. The Health Plan
shall report to the Agency, on a quarterly basis, the payment rates and the payment
amounts made to FQHCs and RHCs for contractual services provided by these entities.






	 	6.	 	The Health Plan shall permit female Enrollees to have direct access to a
women’s health specialist within the network for Covered Services necessary to provide
women’s routine and preventive health care services. This is in addition to an
Enrollee’s designated PCP, if that Provider is not a women’s health specialist.






	G.	 	Continuity of Care






	 	1.	 	The Health Plan shall allow Enrollees in active treatment to continue care with
a terminated treating provider when such care is Medically Necessary, through
completion of treatment of a condition for which the Enrollee was receiving care at the
time of the termination, until the Enrollee selects another treating Provider, or
during the next Open Enrollment period. None of the above may exceed six (6) months
after the termination of the Provider’s contract.






	 	2.	 	The Health Plan shall allow pregnant Enrollees who have initiated a course of
prenatal care, regardless of the trimester in which care was initiated, to continue
care with a terminated treating provider until completion of postpartum care.






	 	3.	 	Notwithstanding the provisions in this subsection, a terminated provider may
refuse to continue to provide care to an Enrollee who is abusive or noncompliant.






	 	4.	 	For continued care under this subsection, the Health Plan and the terminated
provider shall continue to abide by the same terms and conditions as existed in the
terminated contract.






	 	5.	 	The requirements set forth in this subsection shall not apply to providers who
have been terminated from the Health Plan for Cause.






	 	6.	 	The Health Plan shall develop and maintain policies and procedures for the
above requirements.






	H.	 	Network Changes






	 	1.	 	The Health Plan shall notify the Agency within seven (7) Business Days of any
significant changes to the Health Plan network. A significant change is defined as:






	 	a.	 	A decrease in the total number of PCPs by more than five
percent (5%);






	 	b.	 	A loss of all Participating Specialists in a specific specialty
where another Participating Specialist in that specialty is not available
within sixty (60) minutes;






	 	c.	 	A loss of a Hospital in an area where another Health Plan
Hospital of equal service ability is not available within thirty (30) minutes;
or






	 	d.	 	Other adverse changes to the composition of the network which
impair or deny the Enrollee’s adequate access to Providers.






	 	2.	 	The Health Plan shall have procedures to address changes in the Health Plan
network that negatively affect the ability of Enrollees to access services, including
access to a culturally diverse Provider network. Significant changes in network
composition that negatively impact Enrollee access to services may be grounds for
Contract termination or Agency determined sanctions.






	 	3.	 	The Health Plan shall make a good faith effort to give written notice of
termination within fifteen (15) days after receipt of a termination notice to each
Enrollee who received his or her primary care from, or was seen on a regular basis by,
a terminated provider.






	 	a.	 	If an Enrollee is in a Prior Authorized ongoing course of
treatment with any other Provider who becomes unavailable to continue to
provide services, the Health Plan shall notify the Enrollee in writing within
ten (10) Calendar Days from the date the Health Plan becomes aware of such
unavailability.






	 	b.	 	These requirements to provide notice prior to the effective
dates of termination shall be waived in instances where a Provider becomes
physically unable to care for Enrollees due to illness, a Provider dies, the
Provider moves from the Service Area and fails to notify the Health Plan, or
when a Provider fails credentialing. Under these circumstances, notice shall
be issued immediately upon the Health Plan becoming aware of the circumstances.





28




REMAINDER OF PAGE INTENTIONALLY LEFT BLANKSection VIII




Quality Management





	A.	 	Quality Improvement






	 	1.	 	General Requirements






	 	a.	 	The Health Plan shall have an ongoing Quality Improvement
Program (QIP) that objectively and systematically monitors and evaluates the
quality and appropriateness of care and services rendered, thereby promoting
quality of care and quality patient outcomes in service performance to its
Enrollees.






	 	b.	 	The Health Plan’s written policies and procedures shall address
components of effective health care management including, but not limited to
anticipation, identification, monitoring, measurement, evaluation of Enrollee’s
health care needs, and effective action to promote quality of care.






	 	c.	 	The Health Plan shall define and implement improvements in
processes that enhance clinical efficiency, provide effective utilization, and
focus on improved outcome management achieving the highest level of success.






	 	d.	 	The Health Plan and its QIP shall demonstrate in its care
management, specific interventions to better manage the care and promote
healthier Enrollee outcomes.






	 	e.	 	The Health Plan shall cooperate with the Agency and the
External Quality Review Organization (EQRO). The Agency will set methodology
and standards for Quality Improvement (QI) with advice from the EQRO.






	 	f.	 	Prior to implementation, the Agency and/or the EQRO shall
review the Health Plan’s QIP.






	 	g.	 	The Health Plan must submit its QIP to the Agency no later than
the execution date of the Contract. The QIP must be approved, in writing, by
the Agency no later than three (3) months following the execution of this
Contract.






	 	2.	 	Specific Required Components of the QIP






	 	a.	 	The Health Plan’s governing body shall oversee and evaluate the
QIP. The role of the Health Plan’s governing body shall include providing
strategic direction to the QIP, as well as ensuring the QIP is incorporated
into the operations throughout the Health Plan.






	 	b.	 	The Health Plan shall have a QIP Committee. The Health Plan’s
Medical Director shall serve as either the Chairman or Co-Chairman of the QIP
Committee. Appropriate Health Plan staff representing the various departments
of the organization shall have membership on the Committee. The Committee shall
meet on a regular periodic basis. Its responsibilities shall include the
following:






	 	(1)	 	Development and implementation of a written QI
plan, which incorporates the strategic direction provided by the
governing body.






	 	(2)	 	The QI plan shall reflect a coordinated
strategy to implement the QIP including planning, decision making,
intervention, and assessment of results.






	 	(3)	 	The QI plan shall include a description of the
Health Plan staff assigned to the QIP; their specific training
regarding Medicaid; how they are organized; and their responsibilities.






	 	(4)	 	The QI plan shall describe the role of its
Providers in giving input to the QIP, whether that is by membership on
the Committee, its Sub-Committees, or other means.






	 	(5)	 	The Health Plan is encouraged to include an
advocate representative on the QIP Committee.






	 	(6)	 	The Health Plan shall submit its written QI
plan to the Agency for written approval within thirty (30) days of the
execution of the Contract.






	 	c.	 	Direct and review QI activities, including, but not limited to:






	 	(1)	 	Assure that QIP activities take place
throughout the Health Plan;






	 	(2)	 	Review and suggest new and/or improved QI
activities;






	 	(3)	 	Direct task forces/committees to review areas
of concern in the provision of health care services to Enrollees;






	 	(4)	 	Designate evaluation and study design
procedures;






	 	(5)	 	Report findings to appropriate executive
authority, staff, and departments within the Health Plan; and






	 	(6)	 	Direct and analyze periodic reviews of
Enrollees’ service utilization patterns.






	 	d.	 	Maintain minutes of all Committee and Sub-Committee meetings.






	 	3.	 	Health Plan QI Activities






The Health Plan shall monitor and evaluate the quality and appropriateness of care
and service delivery (or the failure to provide care or deliver services) to
Enrollees through performance improvement projects (PIPs), medical record audits,
performance measures, surveys, and related activities.




	 	a.	 	PIPs






The Health Plan shall perform no less than six (6) Agency approved
performance improvement projects.




	 	(1)	 	Each PIP must include a statistically
significant sample of Enrollees.






	 	(2)	 	At least one (1) of the PIPs must focus on
Language and Culture, Clinical Health Care Disparities, or Culturally
and Linguistically Appropriate Services.






	 	(3)	 	At least two (2) of the PIPs must relate to
Behavioral Health Services.






	 	(4)	 	All PIPs by the Health Plan must achieve,
through ongoing measurements and intervention, significant improvement
to the quality of care and service delivery, sustained over time, in
both clinical care and non-clinical care areas that are expected to
have a favorable effect on health outcomes and Enrollee satisfaction.






	 	(5)	 	The PIPs must be completed in a reasonable time
period so as to allow the Health Plan to evaluate the information drawn
from them and to use the results of the analysis to improve quality of
care and service delivery every year.






	 	(6)	 	Within three (3) months of the execution of
this Contract, the Health Plan shall submit, in writing, a description
of each of the PIPs to the Agency for written approval. The detailed
description shall include:






	 	(a)	 	An overview explaining how and
why the project was selected, as well as its relevance to the
Health Plan’s Enrollees and Providers;






(b) The study question;




(c) The study population;




	 	(d)	 	The quantifiable measures to be
used, including a goal or benchmark;






(e) Baseline methodology;




(f) Data sources;




(g) Data collection methodology;




(h) Data collection cycle;




(i) Data analysis cycle;




(j) Results with quantifiable measures;




(k) Analysis with time period and the measures covered;




	 	(l)	 	Analysis and identification of
opportunities for improvement; and






(m) An explanation of all interventions to be taken.




	 	b.	 	Behavioral Health QI Requirements






	 	(1)	 	The Health Plan’s QIP shall include a
Behavioral Health component in order to monitor and assure that the
Health Plan’s Behavioral Health Services are sufficient in quantity, of
acceptable quality and meet the needs of the Enrollees.






	 	(2)	 	Treatment plans must:






(a) Identify reasonable and appropriate objectives;




(b) Provide necessary services to meet the identified objectives; and




	 	(c)	 	Include retrospective reviews
that confirm that the care provided, and its outcomes, were
consistent with the approved treatment plans and appropriate for
the Enrollees’ needs.






	 	(3)	 	In determining if Behavioral Health Services
are acceptable according to current treatment standards, the Health
Plan shall:






	 	(a)	 	Perform a quarterly review of a
random selection of ten percent (10%) or fifty (50) Medical
Records, whichever is more, of Enrollees who received Behavioral
Health Services during the previous quarter; and






(b) Elements of these reviews shall include, but not be limited to:




	 	(i)	 	Management of
specific diagnoses;






	 	(ii)	 	Appropriateness
and timeliness of care;






	 	 	 	(iii)
Comprehensiveness of, and compliance with, the plan of
care;






	 	(iv)	 	Evidence of
special screening for high risk Enrollees and/or
conditions; and






	 	(v)	 	Evidence of
appropriate coordination of care.






	 	(4)	 	In areas in which there is not an established
local advisory group, the Health Plan is responsible for the
development of local advisory group meetings within sixty (60) days of
the effective date of the Contract.






	 	(5)	 	In areas where there is more than one (1)
Health Plan authorized to provide Behavioral Health Services, the
Health Plans shall work together in establishing an area local advisory
group.






	 	(6)	 	Composition of local advisory groups shall
follow the requirements set forth in Section VI.C., Behavioral Health
Managed Care Local Advisory Group.






	 	(7)	 	The Health Plan shall send representation to
the local advisory group’s meetings that convene quarterly and report
to the Agency on the behavioral health advocacy and programmatic
concerns.






	 	(8)	 	Local advisory groups shall provide technical
and policy advice to the Agency regarding Behavioral Health Services.






	 	c.	 	Performance Measures (PMs)






	 	(1)	 	Quality and performance measures shall be
evaluated at least once annually at dates to be determined by the
Agency, or as otherwise specified by this Contract. The Health Plan
will implement an enhanced quality improvement and performance
measurement system to provide for the delivery of quality care with the
primary goal of improving the health status of Enrollees.






	 	(2)	 	The Health Plan, in conjunction with the
Agency, will participate in workgroups to plan further quality
improvement strategies and learning to use best practice methods for
enhancing quality of health care.






	 	(3)	 	If CAHPS, the AHCA quality indicators, the
annual medical record audit or the EQR indicate that the Health Plan’s
performance is not acceptable, then the Agency may restrict the Health
Plan’s Enrollment activities, including, but not limited to,
termination of Automatic Assignments.






	 	(4)	 	For Health Plan performance that is not
acceptable, the Agency shall require the Health Plan to submit a
corrective action plan (CAP). Failure to provide a CAP within the time
specified shall be cause for the Agency to immediately terminate all
Enrollment activities and Automatic Assignments. When considering
whether to impose a limitation on Enrollment activities or Automatic
Assignments, the Agency may consider the Health Plan’s cumulative
performance on all quality and performance measures.






	 	(5)	 	The Health Plan shall collect data on patient
outcome PMs, as defined by the Health Plan Employee Data and
Information Set (HEDIS) or otherwise defined by the Agency and report
the results of the measures to the Agency annually. The Agency may add
or remove reporting requirements with thirty (30) days advance notice.






(6) At a minimum, the following PMs shall be measured by the Health Plan:



	 	 	 
	(a)

	 	Breast Cancer Screening;
	 
	 	 
	(b)

	 	Cervical Cancer Screening;
	 
	 	 
	(c)

	 	Colorectal Cancer Screening;
	 
	 	 
	(d)

	 	Well Child Visits in the First 15 Months of Life;







	 	(e)	 	Well Child Visits in the Third,
Fourth, Fifth and Sixth Years of Life;





	 	 	 
	(f)

	 	Adolescent Well Care Visits;
	 
	 	 
	(g)

	 	Childhood Immunization Status;
	 
	 	 
	(h)

	 	Adolescent Immunization Status;







	 	(i)	 	Preventive and Total Dental
Visits for Children/Adolescents Between Three Years and Eleven
Years and for Children/Adolescents Between Twelve Years and
Twenty Years of Age;






	 	(j)	 	Average number of days spent in
the community by all Enrollees receiving behavioral health
intensive case management services;






	 	(k)	 	Number of Enrollees admitted to a
State Mental Hospital;






	 	(l)	 	Amount of time between discharge
from a State Mental Hospital and first date of service received
from a Provider; and






	 	(m)	 	Number of Enrollees who receive a
psychiatric evaluation within the required time frames prior to
admission to a nursing facility.






	 	d.	 	Consumer Assessment of Health Plans Survey (CAHPS)






	 	(1)	 	At the end of the first (1st) year under this
Contract, the Agency shall conduct an annual Consumer Assessment of
Health Plans Survey (CAHPS). The CAHPS survey shall be done on an
annual basis thereafter. The Health Plan shall provide an action plan
to address the results of the CAHPS Survey within two (2) months of
receipt of the written request from the Agency.






	 	e.	 	Medical Record Review






	 	(1)	 	If the Health Plan is not accredited, or if the
Health Plan is accredited by an entity, that does not review the
Medical Records of the Health Plan’s PCPs, then the Health Plan shall
conduct reviews of Enrollees’ Medical Records to ensure that PCPs
provide high quality health care that is documented according to
established standards.






	 	(2)	 	The standards, which must include all Medical
Record documentation requirements addressed in this Contract, must be
distributed to all Providers.






	 	(3)	 	The Health Plan must conduct these reviews at
all PCP sites that serve fifty (50) or more Enrollees.






	 	(4)	 	Practice sites include both individual offices
and large group facilities.






	 	(5)	 	The Health Plan must review each practice site
at least one (1) time during each two (2) year period.






	 	(6)	 	The Health Plan must review a reasonable number
of records at each site to determine compliance. Five (5) to ten (10)
records per site is a generally-accepted target, though additional
reviews must be completed for large group practices or when additional
data is necessary in specific instances.






	 	(7)	 	The Health Plan shall report the results of all
Medical Record reviews to the Agency within thirty (30) Calendar Days
of the review.






	 	(8)	 	The Health Plan must submit to the Agency for
written approval and maintain a written strategy for conducting Medical
Record reviews. The strategy must include, at a minimum, the following:






	 	(a)	 	Designated staff to perform this
duty;






	 	(b)	 	The method of case selection;






	 	(c)	 	The anticipated number of reviews
by practice site;






	 	(d)	 	The tool that the Health Plan
will use to review each site; and






	 	(e)	 	How the Health Plan will link the
information compiled during the review to other Health Plan
functions (e.g., QI, credentialing, Peer Review, etc.).






	 	f.	 	Peer Review






	 	(1)	 	The Health Plan shall have a Peer Review
process which:






	 	(a)	 	Reviews a Provider’s practice
methods and patterns, morbidity/mortality rates, and all
Grievances filed against the Provider relating to medical
treatment.






	 	(b)	 	Evaluates the appropriateness of
care rendered by Providers.






	 	(c)	 	Implements corrective action(s)
when the Health Plan deems it necessary to do so.






	 	(d)	 	Develops policy recommendations
to maintain or enhance the Quality of care provided to
Enrollees.






	 	(e)	 	Conducts reviews which include
the appropriateness of diagnosis and subsequent treatment,
maintenance of a Provider’s Medical Records, adherence to
standards generally accepted by a Provider’s peers and the
process and outcome of a Provider’s care.






	 	(f)	 	Appoints a Peer Review Committee,
as a Sub-Committee to the QIP Committee, to review provider
performance when appropriate. The Medical Director or his/her
designee shall chair the Peer Review Committee, and its
membership shall be drawn from the Provider Network and include
peers of the Provider being reviewed.






	 	(g)	 	Receive and review all written
and oral allegations of inappropriate or aberrant service by a
Provider.






	 	(h)	 	Educate Enrollees and Health Plan
staff about the Peer Review process, so that Enrollees and the
Health Plan staff can notify the Peer Review authority of
situations or problems relating to Providers.






	 	g.	 	Credentialing and Recredentialing






	 	(1)	 	The Health Plan shall be responsible for the
credentialing and recredentialing of its Provider network. Hospital
ancillary Providers are not required to be independently credentialed
if those Providers only provide services to the Health Plan Enrollees
through the Hospital.






	 	(2)	 	The Health Plan shall establish and verify
credentialing and recredentialing criteria for all professional
Providers that, at a minimum, meet the Agency’s Medicaid participation
standards. The Agency’s criteria includes:






	 	(a)	 	A copy of each Provider’s current
medical license pursuant to Section 641.495, F.S






	 	(b)	 	No receipt of revocation or
suspension of the Provider’s State License by the Division of
Medical Quality Assurance, Department of Health.






	 	(c)	 	No ongoing investigation(s) by
Medicaid Program Integrity, other governmental entities.






	 	(d)	 	Conduct a background check with
the Florida Department of Law Enforcement (FDLE) for all
treating providers not currently enrolled in Medicaid’s
Fee-for-Service program.






	 	(i)	 	If exempt from
the criminal background screening requirements, a copy
of the screen print of the Provider’s current Department
of Health licensure status and exemption reason must be
included.






	 	(ii)	 	The Health Plan
shall not contract with any Provider who has a record of
illegal conduct; i.e., found guilty of, regardless of
adjudication, or who entered a plea of nolo contendere
or guilty to any of the offenses listed in Section
435.03, F.S.






	 	(e)	 	Proof of the Provider’s medical
school graduation, completion of residency and other
postgraduate training. Evidence of board certification shall
suffice in lieu of proof of medical school graduation, residency
and other postgraduate training.






(f) Evidence of specialty board certification, if applicable.




(g) Evidence of the Provider’s professional liability claims history.




	 	(h)	 	Any sanctions imposed on the
Provider by Medicare or Medicaid.






	 	(3)	 	The Health Plan’s credentialing and
recredentialing files must document the education, experience, prior
training and ongoing service training for each staff member or Provider
rendering Behavioral Health Services.






	 	(4)	 	The Health Plan’s credentialing and
recredentialing policies and procedures shall be in writing and include
the following:






(a) Formal delegations and approvals of the credentialing process.




(b) A designated credentialing committee.




(c) Identification of Providers who fall under its scope of
authority.




	 	(d)	 	A process which provides for the
verification of the credentialing and recredentialing criteria
required under this Contract.






	 	(e)	 	Approval of new Providers and
imposition of sanctions, termination, suspension and
restrictions on existing Providers.






	 	(f)	 	Identification of quality
deficiencies which result in the Health Plan’s restriction,
suspension, termination or sanctioning of a Provider.






	 	(5)	 	The credentialing and recredentialing processes
must also include verification of the following additional requirements
for physicians and must ensure compliance with 42 CFR 438.214:






	 	(a)	 	Good standing of privileges at
the Hospital designated as the primary admitting facility by the
PCP or if the PCP does not have admitting privileges, good
standing of privileges at the Hospital by another Provider with
whom the PCP has entered into an arrangement for Hospital
coverage.






	 	(b)	 	Valid Drug Enforcement
Administration (DEA) certificates, where applicable.






	 	(c)	 	Attestation that the total active
patient load (all populations with Medicaid FFS, CMS Network,
HMO, Health Plan, Medicare and commercial coverage) is no more
than 3,000 patients per PCP. An active patient is one that is
seen by the Provider a minimum of three (3) times per year.






	 	(d)	 	A good standing report on a site
visit survey. For each PCP and OB/GYN Provider, documentation
in the Health Plan’s credentialing files regarding the site
survey shall include the following:






	 	(i)	 	Evidence that the
Health Plan has evaluated the Provider’s facilities
using the Health Plan’s organizational standards.






	 	(ii)	 	Evidence that the
Health Plan has evaluated the Provider’s medical record
keeping practices at each site to ensure conformity with
the Health Plan’s organizational standards.






	 	(iii)	 	Evidence that
the Health Plan has determined that the following
documents are posted in the Provider’s waiting
room/reception area: the Agency’s statewide consumer
call center telephone number, including hours of
operation and a copy of the summary of Florida’s
Patient’s Bill of Rights and Responsibilities, in
accordance with Section 381.026, F.S.; the Provider has
a complete copy of the Florida Patient’s Bill of Rights
and Responsibilities, available upon request by an
Enrollee, at each of the Provider’s offices.






	 	(iv)	 	The Provider’s
waiting room/reception area has a consumer assistance
notice prominently displayed in the reception area in
accordance with Section 641.511, F.S.






	 	(e)	 	Attestation to the
correctness/completeness of the Provider’s application.






	 	(f)	 	Statement regarding any history
of loss or limitation of privileges or disciplinary activity as
described in Section 456.039, F.S.






	 	(g)	 	A statement from each Provider
applicant regarding the following:






	 	(i)	 	Any physical or
mental health problems that may affect the Provider’s
ability to provide health care;






(ii) Any history of chemical dependency/substance abuse;




	 	(iii)	 	Any history of
loss of license and/or felony convictions; and






(iv) The Provider is eligible to become a Medicaid provider.




	 	(h)	 	Current curriculum vitae, which
includes at least five (5) years of work history.






	 	(6)	 	The Health Plan shall recredential its
Providers at least every three (3) years.






	 	(7)	 	The Health Plan shall develop and implement an
appeal procedure for Providers against whom the Health Plan has imposed
sanctions, restrictions, suspensions and/or terminations.






	 	(8)	 	The Health Plan shall submit a Provider Network
for initial or expansion review to the Agency for approval only when
the Health Plan has satisfactorily completed the minimum standards
required in Section VII, Provider Network and the minimum credentialing
steps required in Section VIII.A.3.h(2), and i.(5) and (6).






	 	4.	 	Agency Oversight






	 	a.	 	The Agency shall evaluate the Health Plan’s QIP and PMs at
least one (1) time per year at dates to be determined by the Agency, or as
otherwise specified by this Contract.






	 	b.	 	The Health Plan, in conjunction with the Agency, shall
participate in workgroups to design additional QI strategies and to learn to
use the best practice methods for enhancing the quality of health care provided
to Enrollees.






	 	c.	 	If the PIPs, CAHPS, the PMs, the annual Medical Record audit or
the EQRO indicate that the Health Plan’s performance is not acceptable, then
the Agency may restrict the Health Plan’s Enrollment activities including, but
not limited to, termination of Mandatory Assignments.






	 	d.	 	If the Agency determines that the Health Plan’s performance is
not acceptable, the Agency shall require the Health Plan to submit a corrective
action plan (CAP). If the Health Plan fails to provide a CAP within the time
specified by the Agency, the Agency shall sanction the Health Plan, in
accordance with the provisions of Section XIV, Sanctions, and may immediately
terminate all Enrollment activities and Mandatory Assignments. When considering
whether to impose a limitation on Enrollment activities or Mandatory
Assignments, the Agency may take into account the Health Plan’s cumulative
performance on all QI activities.






	 	e.	 	Annual Medical Record Audit






	 	(1)	 	The Health Plan shall furnish specific data
requested by the Agency in order to conduct the Medical Record audit.






	 	(2)	 	If the Medical Record audit indicates that
quality of care is not acceptable, pursuant to contractual
requirements, the Agency shall sanction the Health Plan, in accordance
with the provisions of Section XIV, Sanctions, and may immediately
terminate all Enrollment activities and Mandatory Assignments, until
the Health Plan attains an acceptable level of quality of care as
determined by the Agency.






	 	f.	 	Independent Medical Record Review by an EQRO






	 	(1)	 	The Health Plan shall provide all information
requested by the EQRO and/or the Agency, including, but not limited to
quality outcomes concerning timeliness of, and Enrollee access to,
Covered Services.






	 	(2)	 	The Health Plan shall cooperate with the EQRO
during the Medical Record review, which will be done at least one (1)
time per year.






	 	(3)	 	If the EQRO indicates that the Quality of care
is not within acceptable limits set forth in this Contract, the Agency
shall sanction the Health Plan, in accordance with the provisions of
Section XIV, Sanctions and may immediately terminate all Enrollment
activities and Mandatory Assignments until the Health Plan attains a
satisfactory level of Quality of care as determined by the EQRO.






	B.	 	Utilization Management (UM)






	 	1.	 	General Requirements






The UM program shall be consistent with 42 CFR 456 and include, but not be limited
to:




	 	a.	 	Procedures for identifying patterns of over-utilization and
under-utilization by Enrollees and for addressing potential problems identified
as a result of these analyses.






	 	b.	 	The Health Plan shall report Fraud and Abuse information
identified through the Utilization Management program to the Agency’s contract
manager, MPI and MFCU as described in Section X, and referenced in 42 CFR
455.1(a)(1).






	 	c.	 	A procedure for Enrollees to obtain a second medical opinion
and that the Health Plan shall be responsible for authorizing claims for such
services in accordance with Section 641.51, F.S.






	 	d.	 	Service Authorization protocols for Prior Authorization and
denial of services; the process used to evaluate prior and con-current
authorization; mechanisms to ensure consistent application of review criteria
for authorization decisions; consultation with the requesting Provider when
appropriate, Hospital discharge planning, physician profiling; and a
retrospective review of both inpatient and ambulatory claims, meeting the
predefined criteria below. The Health Plan shall be responsible for ensuring
the consistent application of review criteria for authorization decisions and
consulting with the requesting Provider when appropriate.






	 	(1)	 	The Health Plan must have written approval from
the Agency for its Service Authorization protocols and for any changes
to the original protocols.






	 	(2)	 	The Health Plan’s Service Authorization systems
shall provide the authorization number and effective dates for
authorization to Providers and non-participating providers.






	 	(3)	 	The Health Plan’s Service Authorization systems
shall provide written confirmation of all denials of authorization to
providers (See 42 CFR 438.210(c)).






	 	(a)	 	The Health Plan may request to be
notified, but shall not deny claims payment based solely on lack
of notification, for the following:






	 	(i)	 	Inpatient
emergency admissions (within ten (10) days);






	 	(ii)	 	Obstetrical care
(at first visit);






	 	(iii)	 	Obstetrical
admissions exceeding forty-eight (48) hours for vaginal
delivery and ninety-six (96) hours for caesarean
section; and






	 	(iv)	 	Transplants.






	 	(b)	 	The Health Plan shall ensure that
all decisions to deny a Service Authorization request, or limit
a service in amount, duration, or scope that is less than
requested, are made by Health Care Professionals who have the
appropriate clinical expertise in treating the Enrollee’s
condition or disease (see 42 CFR 438.210(b)(3)).






	 	(4)	 	Only a licensed psychiatrist may authorize a
denial for an initial or concurrent authorization of any request for
Behavioral Health Services. The psychiatrist’s review shall be part of
the UM process and not part of the clinical review, which may be
requested by a Provider or the Enrollee, after the issuance of a
denial.






	 	(5)	 	The Health Plan shall provide post
authorization to CHDs for the provision of emergency shelter medical
screenings provided for clients of DCF.






	 	(6)	 	Health Plans with automated authorization
systems may not require paper authorization as a condition of receiving
treatment.






	 	2.	 	Certain Public Providers






	 	a.	 	The Health Plan shall authorize all claims, from a CHD, a
migrant health center funded under Section 329 of the Public Health Services
Act or a community health center funded under Section 330 of the Public Health
Services Act, without Prior Authorization for the following:






	 	(1)	 	The diagnosis and treatment of sexually
transmitted diseases and other communicable diseases, such as
tuberculosis and human immunodeficiency syndrome;






	 	(2)	 	The provision of immunizations;






	 	(3)	 	Family planning services and related
pharmaceuticals;






	 	(4)	 	School health services listed in (1), (2) and
(3) above, and for services rendered on an urgent basis by such
providers; and,






	 	(5)	 	In the event that a vaccine-preventable disease
emergency is declared, the Health Plan shall authorize claims from the
CHD for the cost of the administration of vaccines.






	 	b.	 	The providers specified in Section VIII.B.2.a., above, shall
attempt to contact the Health Plan before providing health care services to
Enrollees. Such providers shall provide the Health Plan with the results of the
office visit, including test results.






	 	c.	 	The Health Plan shall not deny claims for services delivered by
the providers specified in Section VIII.B.2.a., above solely based on the
period between the date of service and the date of clean claim submission,
unless that period exceeds 365 Calendar Days, and shall be reimbursed by the
Health Plan at the rate negotiated between the Health Plan and the public
provider or the Medicaid Fee-for-Service rate.






	 	3.	 	Notice of Action






	 	a.	 	The Health Plan shall notify the Enrollee, in writing, using
language at, or below the fourth (4th) grade reading level, of any Action taken
by the Health Plan to deny a Service Authorization request, or limit a service
in an amount, duration, or scope that is less than requested.






	 	b.	 	The Health Plan must provide notice to the Enrollee as set
forth below (see 42 CFR 438.404(a) and (c) and 42 CFR 438.210(b) and (c)):






	 	(1)	 	The Action the Health Plan has taken or intends
to take;






	 	(2)	 	The reasons for the Action, customized for the
circumstances of the Enrollee;






	 	(3)	 	The Enrollee’s or the Provider’s (with written
permission of the Enrollee) right to file an Appeal;






	 	(4)	 	The procedures for filing an Appeal;






	 	(5)	 	The circumstances under which expedited
resolution is available and how to request it; and






	 	(6)	 	The Enrollee’s rights to request that Benefits
continue pending the resolution of the Appeal, how to request that
Benefits be continued, and the circumstances under which the Enrollee
may be required to pay the costs of these services.






	 	c.	 	The Health Plan must provide the notice of Action within the
following time frames:






	 	(1)	 	At least ten (10) Calendar Days before the date
of the Action or fifteen (15) Calendar Days if the notice is sent by
Surface Mail (five [5] Calendar Days if the Health Plan suspects Fraud
on the part of the Enrollee). See 42 CFR 431.211, 42 CFR 431.213 and
42 CFR 431.214.






	 	(2)	 	For denial of the claim, at the time of any
Action affecting the claim.






	 	(3)	 	For standard Service Authorization decisions
that deny or limit services, as quickly as the Enrollee’s health
condition requires, but no later than fourteen (14) Calendar Days
following receipt of the request for service (see 42 CFR
438.201(d)(1)).






	 	(4)	 	If the Health Plan extends the time frame for
notification, it must:






	 	(a)	 	Give the Enrollee written notice
of the reason for the extension and inform the Enrollee of the
right to file a Grievance if the Enrollee disagrees with the
Health Plan’s decision to extend the time frame; and






	 	(b)	 	Carry out its determination as
quickly as the Enrollee’s health condition requires, but in no
case later than the date upon which the fourteen (14) Calendar
Day extension period expires (see 42 CFR 438.210(d)(1)).






	 	(5)	 	If the Health Plan fails to reach a decision
within the time frames described above, the failure on the part of the
Health Plan shall be considered a denial and is an Action adverse to
the Enrollee (See 42 CFR 438.210(d)).






	 	(6)	 	For expedited Service Authorization decisions,
within three (3) Business Days (with the possibility of a fourteen (14)
Calendar Day extension). See 42 CFR 438.210(d)(2).






	 	(7)	 	The Health Plan shall provide timely approval
or denial of authorization of out-of-network use through the assignment
of a Prior Authorization number, which refers to and documents the
approval. The Health Plan shall provide written follow-up documentation
of the approval or the denial to the out-of-network provider within
five (5) Business Days from the request for approval.






	 	(8)	 	The Health Plan shall determine when
exceptional referrals to out-of-network specially qualified providers
are needed to address the unique medical needs of an Enrollee (e.g.,
when an Enrollee’s medical condition requires testing by a geneticist).
The Health Plan shall develop and maintain policies and procedures for
such referrals.






	 	4.	 	Care Management






	 	a.	 	The Health Plan shall be responsible for the management of
medical care and continuity of care for all Enrollees. The Health Plan shall
maintain written Case Management and continuity of care protocols that include
the following minimum functions:






	 	(1)	 	Appropriate referral and scheduling assistance
of Enrollees needing specialty health care/Transportation Services,
including those identified through Child Health Check-Up Program
(CHCUP) Screenings;






	 	(2)	 	Determination of the need for Non-Covered
Services and referral of the Enrollee for assessment and referral to
the appropriate service setting (to include referral to WIC and Healthy
Start) utilizing assistance as needed by the area Medicaid office;






	 	(3)	 	Case Management follow-up services for
Children/Adolescents, who the Health Plan identifies through blood
Screenings as having abnormal levels of lead;






	 	(4)	 	Coordinated Hospital/institutional discharge
planning that includes post-discharge care, including skilled,
short-term, skilled nursing facility care, as appropriate; and






	 	(5)	 	A mechanism for direct access to specialists
for Enrollees identified as having special health care needs, as is
appropriate for their condition and identified needs.






	 	(6)	 	The Health Plan shall have an outreach program
and other strategies for identifying every pregnant Enrollee. This
shall include case management, claims analysis, and use of health risk
assessment, etc. The Health Plan shall require its participating
Providers to notify the Health Plans of any Medicaid Enrollee who is
identified as being pregnant.






	 	(7)	 	Documentation of referral services in
Enrollees’ Medical Records, including results.






	 	(8)	 	Monitoring of Enrollees with ongoing medical
conditions and coordination of services for high utilizers such that
the following functions are addressed as appropriate: acting as a
liaison between the Enrollee and Providers, ensuring the Enrollee is
receiving routine medical care, ensuring that the Enrollee has adequate
support at home, assisting Enrollees who are unable to access necessary
care due to their medical or emotional conditions or who do not have
adequate community resources to comply with their care, and assisting
the Enrollee in developing community resources to manage the Enrollee’s
medical condition.






	 	(9)	 	Documentation of emergency care encounters in
Enrollees’ Medical Records with appropriate medically indicated
follow-up.






	 	(10)	 	Coordination of hospital/institutional
discharge planning that includes post-discharge care, including skilled
short-term rehabilitation, and skilled nursing facility care, as
appropriate.






	 	(11)	 	Share with other MCOs, PIHPs, and PAHPs serving
the Enrollee the results of its identification and assessment of any
Enrollee with special health care needs so that those activities need
not be duplicated.






	 	(12)	 	Ensure that in the process of coordinating
care, each Enrollee’s privacy is protected consistent with the
confidentiality requirements in 45 CFR parts 160 and 164. 45 CFR Part
164 specifically describes the requirements regarding the privacy of
individually identifiable health information.






	 	5.	 	New Enrollee Procedures






	 	a.	 	The Health Plan shall not delay Service Authorization if
written documentation is not available in a timely manner.






	 	b.	 	The Health Plan shall contact each new Enrollee at least two
(2) times, if necessary, within ninety (90) Calendar Days of the Enrollee’s
Enrollment to schedule the Enrollee’s initial appointment with his/her PCP for
the purpose of obtaining a health risk assessment and/or CHCUP Screening. For
this subsection, “contact” is defined as mailing a notice to, or telephoning,
an Enrollee at the most recent address or telephone number available.






	 	c.	 	The Health Plan shall urge Enrollees to see their PCPs within
180 Calendar Days of Enrollment.






	 	d.	 	The Health Plan shall contact each new Enrollee within thirty
(30) Calendar Days of Enrollment to request that the Enrollee authorize the
release of his or her Medical Records (including those related to Behavioral
Health Services) to the Health Plan, or the Health Plan’s health services
Subcontractor, from those providers who treated the Enrollee prior to the
Enrollee’s Enrollment with the Health Plan. Also, the Health Plan shall request
or assist the Enrollee’s new PCP by requesting the Enrollee’s Medical Records
from the Enrollee’s previous providers.






	 	e.	 	The Health Plan shall use the Enrollee’s health risk
assessments and/or released Medical Records to identify Enrollees who have not
received CHCUP Screenings in accordance with the Agency approved periodicity
schedule.






	 	f.	 	The Health Plan shall contact, up to two (2) times if
necessary, any Enrollee more than two (2) months behind in the Agency approved
periodicity Screening schedule to urge those Enrollees, or their legal
representatives, to make an appointment with the Enrollees’ PCPs for a
Screening visit.






	 	g.	 	Within thirty (30) Calendar Days of Enrollment, the Health Plan
shall notify Enrollees of, and ensure the availability of, a Screening for all
Enrollees known to be pregnant or who advise the Health Plan that they may be
pregnant. The Health Plan shall refer Enrollees who are, or may be, pregnant to
the appropriate Provider stating that the Enrollee can obtain appropriate
prenatal care.






	 	h.	 	The Health Plan shall honor any written documentation of Prior
Authorization of ongoing Covered Services for a period of thirty (30) Business
Days after the effective date of Enrollment, or until the Enrollee’s PCP
reviews the Enrollee’s treatment plan for the following types of Enrollees:






	 	(1)	 	Enrollees who voluntarily enrolled; and






	 	(2)	 	Those Enrollees who were automatically
reenrolled after regaining Medicaid eligibility.






	 	i.	 	For Mandatory Assignment Enrollees, the Health Plan shall honor
any written documentation of Prior Authorization of ongoing services for a
period of one (1) month after the effective date of Enrollment or until the
Mandatory Assignment Enrollee’s PCP reviews the Enrollee’s treatment plan,
whichever comes first.






	 	j.	 	For all Enrollees, written documentation of Prior Authorization
of ongoing services includes the following, provided that the services were
prearranged prior to Enrollment with the Health Plan:






	 	(1)	 	Prior existing orders;






	 	(2)	 	Provider appointments, e.g. dental
appointments, surgeries, etc.; and






	 	(3)	 	Prescriptions (including prescriptions at
non-participating pharmacies).






	 	k.	 	The Health Plan shall not delay Service Authorization if
written documentation is not available in a timely manner. The Health Plan is
not required to approve claims for which it has received no written
documentation.






	 	l.	 	The Health Plan shall not deny claims submitted by an
out-of-network provider solely based on the period between the date of service
and the date of clean claim submission, unless that period exceeds 365 days.






	 	m.	 	The Enrollee’s guardian, next of kin or legally authorized
responsible person is permitted to act on the Enrollee’s behalf in matters
relating to the Enrollee’s Enrollment, plan of care, and/or provision of
services, if the Enrollee:






	 	(1)	 	Was adjudicated incompetent in accordance with
the law;






	 	(2)	 	Is found by his or her Provider to be medically
incapable of understanding his or her rights; or






	 	(3)	 	Exhibits a significant communication barrier.






	 	n.	 	The Health Plan shall take immediate action to address any
identified urgent medical needs. “Urgent medical needs” means any sudden or
unforeseen situation which requires immediate action to prevent hospitalization
or nursing home placement. Examples include hospitalization of spouse or
caregiver or increased impairment of an Enrollee living alone who suddenly
cannot manage basic needs without immediate help, hospitalization or nursing
home placement.






	 	6.	 	Incentive Programs






	 	a.	 	The Health Plan may offer incentives for Enrollees to receive
preventive care services. The Health Plan shall receive written approval from
the Agency before offering any incentives. The Health Plan shall make all
incentives available to all Enrollees. The Health Plan shall not use incentives
to direct individuals to select a particular Provider.






	 	b.	 	The Health Plan may inform Enrollees, once they are enrolled,
about the specific incentives available.






	 	c.	 	The Health Plan shall not include the provision of gambling,
alcohol, tobacco or drugs in any of the Health Plan’s incentives.






	 	d.	 	The Health Plan’s incentives shall have some health or child
development related function (e.g., clothing, food, books, safety devices,
infant care items, magazine subscriptions to publications which devote at least
ten percent (10%) of their copy to health related subjects, membership in clubs
advocating educational advancement and healthy lifestyles, etc.). Incentive
dollar values shall be in proportion to the importance of the health service to
be utilized (e.g., a T-shirt for attending one (1) prenatal class, but a car
seat for completion of a series of classes).






	 	e.	 	Incentives shall be limited to a dollar value of ten dollars
($10.00), except in the case of incentives for the completion of a series of
services, health education classes or other educational activities, in which
case the incentive shall be limited to a dollar value of fifty dollars
($50.00). The Agency will allow a special exception to the dollar value
relating to infant car seats, strollers, and cloth baby carriers or slings.






	 	f.	 	The Health Plan shall not include in the dollar limits on
incentives any money spent on the transportation of Enrollees to services or
child care provided during the provision of services.






	 	g.	 	The Health Plan may offer an Agency approved program for
pregnant women in order to encourage the commencement of prenatal care visits
in the first (1st) trimester of pregnancy. The Health Plan’s
prenatal and postpartum care Incentive Program must be aimed at promoting early
intervention and prenatal care to decrease infant mortality and low birth
weight and to enhance healthy birth outcomes. The prenatal and postpartum
incentives may include the provision of maternity and health related items and
education.






	 	h.	 	The Health Plan’s request for approval of all incentives shall
contain a detailed description of the incentive and its mission.






	 	7.	 	Practice Guidelines






	 	a.	 	The Health Plan shall adopt practice guidelines that meet the
following requirements:






	 	(1)	 	Are based on valid and reliable clinical
evidence or a consensus of Health Care Professionals in a particular
field;






	 	(2)	 	Consider the needs of the Enrollees;






	 	(3)	 	Are adopted in consultation with Providers; and






	 	(4)	 	Are reviewed and updated periodically, as
appropriate (See 42 CFR 438.236(b)).






	 	b.	 	The Health Plan shall disseminate any revised practice
guidelines to all affected Providers and, upon request, to Enrollees and
Potential Enrollees.






	 	c.	 	The Health Plan shall ensure consistency with regard to all
decisions relating to UM, Enrollee education, Covered Services and other areas
to which the practice guidelines apply.






	 	9.	 	Changes to Utilization Management Components






	 	a.	 	The Health Plan shall provide no less than thirty (30) Calendar
Days written notice before making any changes to the administration and/or
management procedures and/or authorization, denial or review procedures,
including any delegations, as described in this section.






	 	10.	 	Out-of-Plan Use of Non-Emergency Services






	 	a.	 	Unless otherwise specified in this Contract, where an Enrollee
utilizes services available under the Health Plan other than Emergency Services
from a non-participating provider, the Health Plan shall not be liable for the
cost of such utilization unless the Health Plan referred the Enrollee to the
non-participating provider or authorized such out-of-network utilization. The
Health Plan shall provide timely approval or denial of authorization of
out-of-network use through the assignment of a prior authorization number,
which refers to and documents the approval. The Health Plan may not require
paper authorization as a condition of receiving treatment if the Health Plan
has an automated authorization system. Written follow up documentation of the
approval must be provided to the out-of-network provider within one (1)
Business Day from the request for approval. The Enrollee shall be liable for
the cost of such unauthorized use of Covered Services from non-participating
providers.






	 	b.	 	In accordance with Section 409.912, F.S., the Health Plan shall
reimburse any hospital or physician that is outside the Health Plan’s
authorized Service Area for Health Plan authorized services provided by the
hospital or physician to Enrollees at a rate negotiated with the hospital or
physician for the provision of services or according to the lesser of the
following:






	 	(1)	 	The usual and customary charge made to the
general public by the hospital or physician; or






	 	(2)	 	The Florida Medicaid reimbursement rate
established for the hospital or physician.






	 	c.	 	The Health Plan shall reimburse all out-of-network providers
pursuant to Section 641.3155, F.S.





29




REMAINDER OF PAGE INTENTIONALLY LEFT BLANKSection IX

Grievance System





	A.	 	General Requirements






	 	1.	 	The Health Plan shall have a Grievance System in place that includes a
Grievance process, an Appeal process and access to the Medicaid Fair Hearing system.
The Health Plan’s Grievance System shall comply with the requirements set forth in
Section 641.511, F.S., if applicable and with all applicable federal and State laws and
regulations, including 42 CFR 431.200 and 42 CFR 438, Subpart F, “Grievance System.”






	 	2.	 	The Health Plan must develop and maintain written policies and procedures
relating to the Grievance System and must provide its Grievance Procedures to the
Agency for approval. Before implementation, the Agency must give the Health Plan
written approval of the Health Plan’s Grievance System policies and procedures.






	 	3.	 	The Health Plan shall refer all Enrollees and/or providers, on behalf of the
Enrollee, (whether the provider is a participating Provider or a nonparticipating
provider) who are dissatisfied with the Health Plan or its Actions to the Health Plan’s
Grievance/Appeal Coordinator for processing and documentation in accordance with this
Contract and the Health Plan’s Agency-approved policies and procedures.






	 	4.	 	The Health Plan’s Grievance System must include an additional grievance
resolution process, as set forth in Section 408.7056, F.S., and referred to in this
Contract as the Subscriber Assistance Program (SAP).






	 	5.	 	The Health Plan must give Enrollees reasonable assistance in completing forms
and other procedural steps, including, but not limited to, providing interpreter
services and toll-free numbers with TTY/TDD and interpreter capability.






	 	6.	 	The Health Plan must acknowledge, in writing, receipt of Appeal, unless the
Enrollee or provider requests an expedited resolution.






	 	7.	 	The Health Plan shall ensure that none of the decision makers on a Grievance or
Appeal were involved in any of the previous levels of review or decision-making and
that all decision makers are health care professionals with clinical expertise in
treating the Enrollee’s condition or disease when deciding any of the following:





a. An Appeal of a denial that is based on lack of Medical Necessity;




	 	b.	 	A Grievance regarding the denial of an expedited resolution of
an Appeal; and






c. A Grievance or Appeal that involves clinical issues.




	 	8.	 	The Health Plan shall allow the Enrollee, and/or the Enrollee’s representative,
an opportunity to examine the Enrollee’s case file before and during the Appeal
process, including all medical records and any other documents and records.






	 	9.	 	The Health Plan shall consider the Enrollee, the Enrollee’s representative or
the representative of a deceased Enrollee’s estate as parties to the Grievance/Appeal.






	 	10.	 	The Health Plan shall include information (including all related policies,
procedures and time frames) regarding Grievances, Appeals and Medicaid Fair Hearings in
the Health Plan’s Provider Manual. The Health Plan shall provide a copy of the
Provider Manual to all Providers/Subcontractors at the time the Plan enters into
agreements with said Providers/Subcontractors.






	 	11.	 	The Enrollee Handbook and the Provider Manual must clearly specify all
necessary procedural steps for filing Grievances, Appeals and Medicaid Fair Hearings,
as set forth in Section IV.A.2. and 4., above, including:






	 	a.	 	Enrollee rights to file Grievances and Appeals and all
requirements and time frames for filing Grievances and Appeals.






	 	b.	 	The Health Plan’s Grievances and Appeals Coordinator’s address,
toll-free telephone number and office hours.






	 	c.	 	The availability of assistance to Enrollees in filing
Grievances, Appeals and Medicaid Fair Hearings.






	 	d.	 	Enrollee rights to a Medicaid Fair Hearing and the method for
obtaining a Medicaid Fair Hearing, including the address for pursuing a
Medicaid Fair Hearing:





Office of Public Assistance Appeals Hearings

1317 Winewood Boulevard, Building 5, Room 203

Tallahassee, FL 32399-0700





	 	e.	 	The rules that govern representation at the Medicaid Fair
Hearing.






	 	f.	 	A statement explaining the Enrollee’s right to request a
continuation of benefits during an Appeal and/or Medicaid Fair Hearing and a
statement that if the Health Plan’s Action is upheld in any Medicaid Fair
Hearing, the Health Plan may hold the Enrollee liable for the cost of any
continued Benefits.






	 	g.	 	A detailed explanation of the proper procedure for an Enrollee
to request a continuation of benefits during an Appeal and/or Medicaid Fair
Hearing.






	 	h.	 	An explanation regarding the Enrollee’s rights to appeal to the
Agency and the SAP after exhausting the Health Plan’s Appeal/Grievance process,
with the following exception: pursuant to Sections 408.7056 and 641.511, F.S.,
the SAP will not consider a Grievance or Appeal taken to a Medicaid Fair
Hearing.






	 	i.	 	The information set forth in the Enrollee Handbook and the
Provider Manual must explain that an Enrollee must request a review by the SAP
within one (1) year of receipt of the final decision letter from the Health
Plan, must explain how to initiate a review by the SAP and must include the
SAP’s address and telephone number:





Agency for Health Care Administration

Subscriber Assistance Program

Building 1, MS #26

2727 Mahan Drive, Tallahassee, Florida 32308

(850) 921-5458

(888) 419-3456 (toll-free)





	 	12.	 	The Health Plan shall maintain a record/log of all Grievances, Appeals and
Medicaid Fair Hearings in accordance with the terms of this Contract and to fulfill the
reporting requirements as set forth in Section XII, Reporting Requirements.






	B.	 	The Grievance Process






	 	1.	 	The Grievance process is the Health Plan’s procedure for addressing Enrollee
Grievances, which are expressions of dissatisfaction about any matter other than
Action.






	 	2.	 	An Enrollee may file a Grievance, or a provider (whether a participating
Provider or a nonparticipating provider), acting on behalf of the Enrollee and with the
Enrollee’s written consent, may file a Grievance.






	 	3.	 	The Health Plan must complete the Grievance process in time to permit the
Enrollee’s disenrollment to be effective in accordance with the time frames specified
in 42 CFR 438.56(e)(1).






	 	4.	 	General Health Plan Duties






a. The Health Plan must:




	 	(1)	 	Resolve each Grievance within State-established
time frames not to exceed ninety (90) Calendar Days from the day the
Health Plan received the initial Grievance request, be it oral or in
writing;






	 	(2)	 	Notify the Enrollee, in writing, within ninety
(90) Calendar Days of the resolution of the Grievance. The notice of
disposition shall include the results and date of the resolution of the
Grievance, and for decisions not wholly in the Enrollee’s favor, the
notice of disposition shall include:






	 	(a)	 	Notice of the right to request a
Medicaid Fair Hearing if applicable;






	 	(b)	 	Information necessary to allow
the Enrollee/provider to request a Medicaid Fair Hearing,
including the contact information necessary to pursue a Medicaid
Fair Hearing (see Section IX.D., below);






	 	(3)	 	Provide the Agency with a copy of the written
notice of disposition upon request; and






	 	(4)	 	Ensure that no punitive action is taken against
a provider who files a Grievance on behalf of an Enrollee, or supports
an Enrollee’s Grievance.






	 	b.	 	The Health Plan may extend the Grievance resolution time frame
by up to fourteen (14) Calendar Days if the Enrollee requests an extension, or
the Health Plan documents that there is a need for additional
information and that the delay is in the Enrollee’s best interest.






	 	(1)	 	If the extension is not requested by the
Enrollee, the Health Plan must give the Enrollee written notice of the
reason for the delay.






c. Filing Requirements




	 	(1)	 	The Enrollee or provider may file a Grievance
within one (1) year after the date of occurrence that initiated the
Grievance.






	 	(2)	 	The Enrollee or provider may file a Grievance
either orally or in writing. An oral request may be followed up with a
written request, however the timeframe for resolution begins the date
the plan receives the oral request.






	C.	 	The Appeal Process






	 	1.	 	The Appeal process is the Health Plan’s procedure for addressing Enrollee
Appeals, which are requests for review of an Action.






	 	2.	 	An Enrollee, or a provider (whether a participating Provider or a
nonparticipating provider) acting on behalf of an Enrollee and with the Enrollee’s
written consent, may file an Appeal.






	 	3.	 	The Appeal procedure must be the same for all Enrollees.






	 	4.	 	General Health Plan Duties






a. The Health Plan shall:




	 	(1)	 	Confirm in writing all oral inquiries seeking
an Appeal, unless the Enrollee or provider requests an expedited
resolution;






	 	(2)	 	If the resolution is in favor of the Enrollee,
provide the services as quickly as the Enrollee’s health condition
requires;






	 	(3)	 	Provide the Enrollee or provider with a
reasonable opportunity to present to evidence and allegations of fact
or law, in person and/or in writing;






	 	(4)	 	Allow the Enrollee, and/or the Enrollee’s
representative, an opportunity, before and during the Appeal process,
to examine the Enrollee’s case file, including all Medical Records and
any other documents and records;






	 	(5)	 	Consider the Enrollee, the Enrollee’s
representative or the representative of a deceased Enrollee’s estate as
parties to the Appeal;






	 	(6)	 	Continue the Enrollee’s Benefits if:






	 	(a)	 	The Enrollee files the Appeal in
a timely manner, meaning on or before the later of the
following:






	 	(i)	 	Within ten (10) Business Days of the date on the
notice of Action (add five [5] Business Days if the
notice is sent via Surface Mail); or






	 	(ii)	 	The intended
effective date of the Health Plan’s proposed Action.






	 	(b)	 	The Appeal involves the
termination, suspension or reduction of a previously authorized
course of treatment;






	 	(c)	 	The services were ordered by an
authorized provider;






	 	(d)	 	The authorization period has not
expired; and/or






	 	(e)	 	The Enrollee requests extension
of Benefits.






	 	(7)	 	Provide written notice of the resolution of the
Appeal, including the results and date of the resolution within
two (2) business days after the resolution. For decisions not
wholly in the Enrollee’s favor, the notice of resolution shall include:






	 	(a)	 	Notice of the right to request a
Medicaid Fair Hearing;






	 	(b)	 	Information about how to request
a Medicaid Fair Hearing, including the DCF address necessary for
pursuing a Medicaid Fair Hearing, as set forth in Section IX.D.,
below;






	 	(c)	 	Notice of the right to continue
to receive Benefits pending a Medicaid Fair Hearing;






	 	(d)	 	Information about how to request
the continuation of Benefits;






	 	(e)	 	Notice that if the Health Plan’s
Action is upheld in a Medicaid Fair Hearing, the Enrollee may be
liable for the cost of any continued Benefits; and






	 	(f)	 	Pursuant to Section
408.7056, F.S., the Health Plan must notify the
Enrollee/provider that if the Appeal is not resolved to the
satisfaction of the Enrollee/provider, the Enrollee/provider has
one (1) year from the date of the occurrence that initiated the
Appeal in which to request review of the Health Plan’s decision
concerning the Appeal by the SAP. The notice must explain how
to initiate such a review and include the address and toll-free
telephone numbers of the Agency and the SAP, as provided in
Section IX.A.11(i), above.






	 	(8)	 	Provide the Agency with a copy of the written
notice of disposition upon request; and






	 	(9)	 	Ensure that punitive action is not taken
against a provider who files an Appeal on behalf of an Enrollee or
supports an Enrollee’s Appeal.






	 	b.	 	If the Health Plan continues or reinstates the Enrollee’s
Benefits while the Appeal is pending, the Health Plan must continue providing
the Benefits until one (1) of the following occurs:





(1) The Enrollee withdraws the Appeal;




	 	(2)	 	Ten (10) Business Days pass from the date of
the Health Plan’s notice of resolution of the appeal if the resolution
is adverse to the enrollee and if the Enrollee has not requested a
Medicaid Fair Hearing with continuation of Benefits until a Medicaid
Fair Hearing decision is reached.






(3) The Medicaid Fair Hearing panel’s decision is adverse to the Enrollee;
or




	 	(4)	 	The authorization to provide services expires,
or the Enrollee meets the authorized service limits.






	 	c.	 	If the final resolution of the Appeal is adverse to the
Enrollee, the Health Plan may recover the costs of the services furnished from
the Enrollee while the Appeal was pending, to the extent that the services were
furnished solely because of the requirements of this Section.






	 	d.	 	If services were not furnished while the Appeal was pending and
the Appeal panel reverses the Plan’s decision to deny, limit or delay services,
the Health Plan must authorize or provide the disputed services promptly and as
quickly as the Enrollee’s health condition requires.






	 	e.	 	If the services were furnished while the Appeal was pending and
the Appeal panel reverses the Plan’s decision to deny, limit or delay services,
the Health Plan must pay for disputed services in accordance with State policy
and regulations.






5. Filing Requirements




	 	a.	 	The Enrollee/provider must file an Appeal within thirty (30)
Calendar Days of receipt of the notice of the Health Plan’s Action






	 	b.	 	The Enrollee/provider may file an Appeal either orally or in
writing. If the filing is oral, the Enrollee/provider must also file a
written, signed Appeal within thirty (30) Calendar Days of the oral filing.
The Health Plan shall notify the requesting party that it must file the written
request within ten (10) Business Days after receipt of the oral request. For
oral filings, time frames for resolution of the Appeal begin on the date the
Health Plan receives the oral filing.






	 	c.	 	The Health Plan shall resolve each Appeal within
State-established time frames not to exceed forty-five (45) Calendar Days from
the day the Plan received the initial Appeal request, whether oral or in
writing.






	 	d.	 	If the resolution is in favor of the Enrollee, the Health Plan
shall provide the services as quickly as the Enrollee’s health condition
requires.






	 	e.	 	The Health Plan may extend the resolution time frames by up to
fourteen (14) Calendar Days if the Enrollee requests an extension, or the
Health Plan documents that there is a need for additional information and that
the delay is in the Enrollee’s best interest.






	 	(1)	 	If the extension is not requested by the
Enrollee, the Health Plan must give the Enrollee written notice of the
reason for the delay.






	 	(2)	 	The Health Plan must provide written notice of
the extension to the Enrollee within five (5) Business Days of
determining the need for an extension.





6. Expedited Process




	 	a.	 	The Health Plan shall establish and maintain an expedited
review process for Appeals when the Health Plan determines, the Enrollee
requests or the provider indicates (in making the request on the Enrollee’s
behalf or supporting the Enrollee’s request) that taking the time for a
standard resolution could seriously jeopardize the Enrollee’s life, health or
ability to attain, maintain or regain maximum function.






	 	b.	 	The Enrollee/provider may file an expedited Appeal either
orally or in writing. No additional written follow-up on the part of the
Enrollee/provider is required for an oral request for an expedited Appeal.





c. The Health Plan must:




	 	(1)	 	Inform the Enrollee of the limited time
available for the Enrollee to present evidence and allegations of fact
or law, in person and in writing;






	 	(2)	 	Resolve each expedited Appeal and provide
notice to the Enrollee, as quickly as the Enrollee’s health condition
requires, within State established time frames not to exceed
seventy-two (72) hours after the Health Plan receives the Appeal
request, whether the Appeal was made orally or in writing;






	 	(3)	 	Provide written notice of the resolution in
accordance with Section IX. C.7. of the expedited Appeal to the
Enrollee;






	 	(4)	 	Make reasonable efforts to provide oral notice
of disposition to the Enrollee immediately after the Appeal panel
renders a decision; and






	 	(5)	 	Ensure that punitive action is not taken
against a provider who requests an expedited resolution on the
Enrollee’s behalf or supports an Enrollee’s request for expedited
resolution of an Appeal.






	 	d.	 	If the Health Plan denies a request for an expedited resolution
of an Appeal, the Health Plan must:






	 	(1)	 	Transfer the Appeal to the standard time frame
of no longer than forty-five (45) Calendar Days from the day the Health
Plan received the request for Appeal (with a possible fourteen [14] day
extension);






	 	(2)	 	Make all reasonable efforts to provide
immediate oral notification of the Health Plan’s denial for expedited
resolution of the Appeal;






	 	(3)	 	Provide written notice of the denial of the
expedited Appeal within two (2) Calendar Days; and






(4) Fulfill all requirements set forth in Section IX.C.1 – 5, above.




	 	7.	 	Submission to the Subscriber Assistance Program (SAP)






	 	(1)	 	Before filing with the SAP, the
Enrollee/provider must complete the Health Plan’s Appeal process.






	 	(2)	 	The Enrollee/provider must submit the Appeal to
the SAP within one (1) year of the date of the occurrence that
initiated the Appeal.






	 	(3)	 	The SAP will not consider a Grievance or Appeal
taken to a Medicaid Fair Hearing.






	D.	 	Medicaid Fair Hearing System






	 	1.	 	As set forth in Rule 65-2.042, FAC, the Health Plan’s Grievance Procedure and
Appeal and Grievance processes shall state that the Enrollee has the right to request a
Medicaid Fair Hearing, in addition to, and at the same time as, pursuing resolution
through the Health Plan’s Grievance and Appeal processes.






	 	a.	 	A provider must have an Enrollee’s written consent before
requesting a Medicaid Fair Hearing on behalf of an Enrollee.






	 	b.	 	The parties to a Medicaid Fair Hearing include the Health Plan,
as well as the Enrollee, his/her representative or the representative of a
deceased Enrollee’s estate.





2. Filing Requirements




	 	a.	 	The Enrollee/provider may request a Medicaid Fair Hearing
within ninety (90) days of the date of the notice of the Health Plan’s
resolution of the Enrollee’s Grievance/Appeal by contacting DCF at:





The Office of Appeal Hearings

1317 Winewood Boulevard, Building 5, Room 203

Tallahassee, Florida 32399-0700




3. General Health Plan Duties



a. The Health Plan must:




	 	(1)	 	Continue the Enrollee’s Benefits while the
Medicaid Fair Hearing is pending if:






	 	(a)	 	The Medicaid Fair Hearing is
filed timely, meaning on or before the later of the following:






	 	(i)	 	Within ten (10)
Business Days of the date on the notice of Action (add
five [5] Business Days if the notice is sent via Surface
Mail);






	 	(ii)	 	The intended
effective date of the Health Plan’s proposed Action.






	 	(b)	 	The Medicaid Fair Hearing
involves the termination, suspension or reduction of a
previously authorized course of treatment;






(c) The services were ordered by an authorized provider;




(d) The authorization period has not expired; and/or




(e) The Enrollee requests extension of Benefits.




	 	(2)	 	Ensure that punitive action is not taken
against a provider who requests a Medicaid Fair Hearing on an
Enrollee’s behalf or supports an Enrollee’s request for a Medicaid Fair
Hearing.






	 	b.	 	If the Health Plan continues or reinstates Enrollee Benefits
while the Medicaid Fair Hearing is pending, the Health Plan must continue said
Benefits until one (1) of the following occurs:






	 	(1)	 	The Enrollee withdraws the request for a
Medicaid Fair Hearing;






	 	(2)	 	Ten (10) Business Days pass from the date of
the Health Plan’s notice of resolution of the appeal if the resolution
is adverse to the enrollee and the Enrollee has not requested a
Medicaid Fair Hearing with continuation of benefits until a Medicaid
Fair Hearing decision is reached (add five [5] Business Days if the
Health Plan sends the notice of Action by Surface Mail);






	 	(3)	 	The Medicaid Fair Hearing officer renders a
decision that is adverse to the Enrollee; and/or






	 	(4)	 	The Enrollee’s authorization expires or the
Enrollee reaches his/her authorized service limits.






	 	4.	 	If the final resolution of the Medicaid Fair Hearing is adverse to the
Enrollee, the Health Plan may recover the costs of the services furnished while the
Medicaid Fair Hearing was pending, to the extent that the services were furnished
solely because of the requirements of this Section.






	 	5.	 	If services were not furnished while the Medicaid Fair Hearing was pending, and
the Medicaid Fair Hearing resolution reverses the Health Plan’s decision to deny, limit
or delay services, the Health Plan must authorize or provide the disputed services as
quickly as the Enrollee’s health condition requires.






	 	6.	 	If the services were furnished while the Medicaid Fair Hearing was pending, and
the Medicaid Fair Hearing resolution reverses the Plan’s decision to deny, limit or
delay services, the Health Plan must pay for disputed services in accordance with State
policy and regulations.





30




REMAINDER OF PAGE INTENTIONALLY LEFT BLANKSection X




Administration and Management





	A.	 	General Provisions






	 	1.	 	The Health Plan’s governing body shall set forth policy and has overall
responsibility for the organization of the Health Plan. The Health Plan shall be
responsible for the administration and management of all aspects of this Contract,
including all Subcontracts, employees, agents and services performed by anyone acting
for or on behalf of the Health Plan. The Health Plan shall have a centralized executive
administration, which shall serve as the contact point for the Agency, except as
otherwise specified in this Contract.






	 	2.	 	The Health Plan shall be responsible for the administration and management of
all aspects of this Contract, such as, but not limited to, the delivery of services,
Provider network, Provider education, and claims resolution and assistance.






	 	3.	 	The Health Plan must provide that compensation to individuals or entities that
conduct utilization management activities is not structured so as to provide incentives
for the individual or entity to deny, limit, or discontinue Medically Necessary
services to any Enrollee.






	B.	 	Staffing






	 	1.	 	Minimum Staffing Requirements






	 	a.	 	Contract Manager: The Health Plan shall designate a
Contract Manager to work directly with the Agency. The Contract Manager shall
be a full-time employee of the Health Plan with the authority to revise
processes or procedures and assign additional resources as needed to maximize
the efficiency and effectiveness of services required under the Contract. The
Health Plan shall meet in person, or by telephone, at the request of Agency
representatives, but at least monthly, to discuss the status of the Contract,
Health Plan performance, benefits to the State, necessary revisions, reviews,
reports and planning. Summary reports shall be developed and presented to the
Agency, or its Agent, as specified.






	 	b.	 	Full-Time Administrator: The Health Plan shall have a
Full-Time Administrator specifically identified to administer the day-to-day
business activities of this Contract. The Health Plan may designate the same
person as the Contract Manager, the Full-time Administrator, or the Medical
Director, The Health Plan may designate the same person as the
Contract Manager, the Full-time Administrator, or the Medical Director, but
such person cannot be designated to any other position in this section,
including in other lines of business within the Health Plan, unless otherwise
approved by the Agency.






	 	c.	 	Medical and Professional Support Staff: The Health
Plan shall have Medical and Professional Support Staff sufficient to conduct
daily business in an orderly manner, including having Enrollee services staff
directly available during business hours for Enrollee services consultation, as
determined through management and medical reviews. The Health Plan shall
maintain sufficient medical staff, available twenty-four (24) hours per day,
seven (7) days per week, to handle Emergency Services and Care inquiries. The
Health Plan shall maintain sufficient Medical and Professional Support Staff
during non-business hours, unless the Health Plan’s computer system
automatically approves all Emergency Services and Care claims relating to
Screening and treatment.






	 	d.	 	Medical Director: The Health Plan shall have a
full-time licensed physician to serve as Medical Director to oversee and be
responsible for the proper provision of Covered Services to Enrollees, the
Quality Management Program and the Grievance System. The Medical Director
shall be licensed in accordance with Chapter 458 or 459, F.S. The Medical
Director cannot be designated to serve in any other non-administrative
position. The Medical Director cannot be designated to serve in any other
non-administrative position.






	 	e.	 	Medical Records Review Coordinator: A designated
person, qualified by training and experience, to ensure compliance with the
Medical Records requirements as described in this Contract. The Medical
Records Review Coordinator shall maintain Medical Record standards and conduct
Medical Record reviews according to the terms of this Contract.






	 	f.	 	Data Processing and Data Reporting Coordinator: The
Health Plan shall have a person trained and experienced in data processing,
data reporting, and claims resolution, as required, to ensure that computer
system reports that that the Health Plan provides to the Agency and its Agents
are accurate, and that computer systems operate in an accurate and timely
manner.






	 	g.	 	Marketing Oversight Coordinator: If the Health Plan
engages in Marketing, the Health Plan shall have a designated person, qualified
by training and experience, to assure the Health Plan adheres to the marketing
requirements of this Contract.






	 	h.	 	QI and UM Professional: The Health Plan shall have a
designated person, qualified by training and experience in QI and UM and who
holds the appropriate clinical certification and/or license.






	 	i.	 	Grievance System Coordinator: The Health Plan shall
have a designated person, qualified by training and experience, to process and
resolve Appeals and Grievances and to be responsible for the Grievance System.






	 	j.	 	Compliance Officer: The Health Plan shall have a
designated person qualified by training and experience, to oversee a Fraud and
Abuse program to prevent and detect potential Fraud and Abuse activities
pursuant to State and federal rules and regulations.






	 	k.	 	Case Management Staff: The Health Plan shall have
sufficient Case Management Staff, qualified by training, experience and
certification/licensure to conduct the Health Plan’s Case Management functions.






	 	l.	 	Claims/Encounter Manager: The Health Plan shall have a
designated person qualified by training and experience to oversee claims and
encounter submittal and processing and to ensure the accuracy, timeliness and
completeness of processing payment and reporting.






	 	2.	 	Behavioral Health Staff Requirements






	 	a.	 	The Health Plan must name a staff member to maintain oversight
responsibility for Behavioral Health Services and to act as a liaison to the
Agency.






	 	b.	 	The Health Plan’s Medical Director shall appoint a board
certified, or board eligible, licensed psychiatrist (staff psychiatrist) to
oversee the provision of Behavioral Health Services to Enrollees. The Health
Plan may delegate this duty, by way of a written Subcontract, to a third party.






	 	c.	 	The Agency shall review and approve the Health Plan’s
Behavioral Health Services staff and any Subcontracted Behavioral Health Care
Providers in order to determine the Health Plan’s compliance with all licensure
requirements.






	C.	 	Provider Contract Requirements






	 	1.	 	The Health Plan shall comply with all Agency procedures for Provider Contract
review and approval submission.






	 	a.	 	All Provider Contracts must comply with 42 CFR 438.230.






	 	b.	 	If the Health Plan is a capitated health plan, it shall ensure
that all Providers are eligible for participation in the Medicaid program. If
a Provider was involuntarily terminated from the Florida Medicaid program,
other than for purposes of inactivity, that Provider is not considered an
eligible Medicaid provider.






	 	c.	 	The Health Plan shall not employ or contract with individuals
on the State or federal exclusions list.






	 	d.	 	No Provider Contract which the Health Plan enters into with
respect to performance under Contract shall in any way relieve the Health Plan
of any responsibility for the provision of services duties under this Contract.
The Health Plan shall assure that all services and tasks related to the
Provider Contract are performed in accordance with the terms of this Contract.
The Health Plan shall identify in its Provider Contract any aspect of service
that may be subcontracted by the Provider.






	 	e.	 	All model Provider Contracts and amendments must be submitted
by the Health Plan to the Agency for approval and the Health Plan must receive
written approval by the Agency prior to use.






	 	2.	 	All Provider Contracts and amendments executed by the Health Plan must be in
writing, signed, and dated by the Health Plan and the Provider. All model and executed
Provider Contracts and amendments shall meet the following requirements:






	 	a.	 	Prohibit the Provider from seeking payment from the Enrollee
for any Covered Services provided to the Enrollee within the terms of the
Contract;






	 	b.	 	Require the Provider to look solely to the Health Plan for
compensation for services rendered, with the exception of nominal cost sharing,
pursuant to the State Medicaid Plan and the Florida Coverages and Limitations
Handbooks,






	 	c.	 	If there is a Health Plan physician incentive plan, include a
statement that the Health Plan shall make no specific payment directly or
indirectly under a physician incentive plan to a Provider as an inducement to
reduce or limit Medically Necessary services to an Enrollee, and that all
incentive plans shall not contain provisions which provide incentives, monetary
or otherwise, for the withholding of Medically Necessary care;






	 	d.	 	Specify that any contracts, agreements, or subcontracts entered
into by the Provider for the purposes of carrying out any aspect of this
Contract must include assurances that the individuals who are signing the
contract, agreement or subcontract are so authorized and that it includes all
the requirements of this Contract;






	 	e.	 	Require the Provider to cooperate with the Health Plan’s peer
review, grievance, QIP and UM activities, and provide for monitoring and
oversight, including monitoring of services rendered to Enrollees, by the
Health Plan (or its Subcontractor) and for the Provider to provide assurance
that all licensed Providers are Credentialed in accordance with the Health
Plan’s and the Agency’s Credentialing requirements as found in Section
VIII.A.3.h Credentialing and Recredentialing, of this Contract, if the Health
Plan has delegated the Credentialing to a Subcontractor;






	 	f.	 	Include provisions for the immediate transfer to another PCP or
Health Plan if the Enrollee’s health or safety is in jeopardy;






	 	g.	 	Not prohibit a Provider from discussing treatment or
non-treatment options with Enrollees that may not reflect the Health Plan’s
position or may not be covered by the Health Plan;






	 	h.	 	Not prohibit a Provider from acting within the lawful scope of
practice, from advising or advocating on behalf of an Enrollee for the
Enrollee’s health status, medical care, or treatment or non-treatment options,
including any alternative treatments that might be self-administered;






	 	i.	 	Not prohibit a Provider from advocating on behalf of the
Enrollee in any Grievance System or UM process, or individual authorization
process to obtain necessary health care services;






	 	j.	 	Require Providers to meet appointment waiting time standards
pursuant to this Contract;






	 	k.	 	Provide for continuity of treatment in the event a Provider
Contract terminates during the course of an Enrollee’s treatment by that
Provider;






	 	l.	 	Prohibit discrimination with respect to participation,
reimbursement, or indemnification of any Provider who is acting within the
scope of his or her license or certification under applicable State law, solely
on the basis of such license or certification. This provision should not be
construed as a willing Provider law, as it does not prohibit the Health Plan
from limiting provider participation to the extent necessary to meet the needs
of the Enrollees. This provision does not interfere with measures established
by the Health Plan that are designed to maintain quality and control costs;






	 	m.	 	Prohibit discrimination against Providers serving high-risk
populations or those that specialize in conditions requiring costly treatments;






	 	n.	 	Require an adequate record system be maintained for recording
services, charges, dates and all other commonly accepted information elements
for services rendered to the Health Plan.






	 	•	 	. Require that records be maintained for a period not less than
five (5) years from the close of the Contract, and retained further if the
records are under review or audit until the review or audit is complete.
(Prior approval for the disposition of records must be requested and approved
by the Health Plan if the Provider Contract is continuous.)






	 	p.	 	Specify that DHHS, the Agency, MPI and MFCU, shall have the
right to inspect, evaluate, and audit all of the following related to this
Contract:






	 	(1)	 	Pertinent books,






	 	(2)	 	Financial records,






	 	(3)	 	Medical Records, and






	 	(4)	 	Documents, papers, and records of any Provider
involving financial transactions;






	 	q.	 	Specify Covered Services and populations to be served under the
Provider Contract;






	 	r.	 	Require that Providers comply with the Health Plan’s cultural
competency plan;






	 	s.	 	Require that any marketing materials related to this Contract
that are distributed by the Provider be submitted to the Agency for written
approval before use;






	 	t.	 	Provide for submission of all reports and clinical information
required by the Health Plan, including Child Health Check-Up reporting (if
applicable);






	 	u.	 	Require Providers of transitioning Enrollees to cooperate in
all respects with providers of other Health Plans to assure maximum health
outcomes for Enrollees;






	 	v.	 	Require Providers to submit notice of withdrawal from the
network at least ninety (90) Calendar Days prior to the effective date of such
withdrawal;






	 	w.	 	Require that all Providers agreeing to participate in the
network as PCPs fully accept and agree to perform the Case Management
responsibilities and duties associated with the PCP designation;






	 	x.	 	Require all Providers to notify the Health Plan in the event of
a lapse in general liability or medical malpractice insurance, or if assets
fall below the amount necessary for licensure under Florida Statutes;






	 	y.	 	Require Providers to offer hours of operation that are no less
than the hours of operation offered to commercial HMO members or comparable
Medicaid FFS Recipients if the Provider serves only Medicaid Recipients.






	 	z.	 	Require safeguarding of information about Enrollees according
to 42 CFR, Part 438.224.






	 	aa.	 	Require compliance with HIPAA privacy and security provisions.






	 	bb.	 	Require an exculpatory clause, which survives Provider
agreement termination, including breach of Provider Contract due to insolvency,
that assures that Medicaid Recipients nor the Agency shall be held liable for
any debts of the Provider.






	 	cc.	 	Contain a clause indemnifying, defending and holding the Agency
and the Health Plan’s Enrollees harmless from and against all claims, damages,
causes of action, costs or expense, including court costs and reasonable
attorney fees to the extent proximately caused by any negligent act or other
wrongful conduct arising from the Provider Contract:






	 	(1)	 	This clause must survive the termination of the
Provider Contract, including breach due to Insolvency, and






	 	(2)	 	The Agency may waive this requirement for
itself, but not Health Plan Enrollees, for damages in excess of the
statutory cap on damages for public entities if the Provider is a
public health entity with statutory immunity (all such waivers must be
approved in writing by the Agency);






	 	dd.	 	Require that the Provider secure and maintain during the life
of the Provider Contract worker’s compensation insurance (complying with the
Florida’s Worker’s Compensation Law) for all of its employees connected with
the work under this Contract unless such employees are covered by the
protection afforded by the Health Plan;






	 	ee.	 	Make provisions for a waiver of those terms of the Provider
Contract, which, as they pertain to Medicaid Recipients, are in conflict with
the specifications of this Contract;






	 	ff.	 	Contain no provision that in any way prohibits or restricts the
Provider from entering into a commercial contract with any other health plan
(see Section 641.315, F.S.);






	 	gg.	 	Contain no provision requiring the Provider to contract for
more than one (1) HMO product or otherwise be excluded (see Section 641.315,
F.S.); and






	 	hh.	 	Contain no provision that prohibits the Provider from providing
inpatient services in a contracted Hospital to an Enrollee if such services are
determined to be Medically Necessary and Covered Services under this Contract;






	 	ii.	 	Require all Providers to apply for a National Provider
Identification number (NPI) no later than May 1, 2007. Providers can obtain
their NPIs through the National Plan and Provider Enumerator System located at:
https://nppes.cms.hhs.gov/NPPES/Welcome.do. Additionally, the Provider
Contract shall require the Provider to submit all NPIs for its physicians and
other health care providers to the Health Plan within fifteen (15) Business
Days of receipt. The Health Plan shall report the Providers’ NPIs as part of
its Provider Network Report, in a manner to be determined by the Agency, and in
its Provider Directory, to the Agency or its Choice Counselor/Enrollment
Broker, as set forth in Section XII, Reporting Requirements.






(1) The Health Plan need not obtain an NPI from the following Providers:




	 	(a)	 	Individuals or organizations that
furnish atypical or nontraditional services that are only
indirectly related to the provision of health care (examples
include taxis, home and vehicle modifications, insect control,
habilitation and respite services); and






	 	(b)	 	Individuals or businesses that
only bill or receive payment for, but do not furnish, health
care services or supplies (examples include billing services,
repricers and value-added networks).






	 	jj.	 	Require Providers to cooperate fully in any investigation by
the Agency, Medicaid Program Integrity (MPI), or Medicaid Fraud Control Unit
(MFCU), or any subsequent legal action that may result from such an
investigation.






	D.	 	Provider Termination






	 	1.	 	The Health Plan shall comply with all State and federal laws regarding Provider
termination. In its Provider contracts, the Health Plan shall:






	 	a.	 	Specify that in addition to any other right to terminate the
Provider contract, and not withstanding any other provision of this Contract,
the Agency or the Health Plan may request immediate termination of a Provider
contract if, as determined by the Agency, a Provider fails to abide by the
terms and conditions of the Provider contract, or in the sole discretion of the
Agency, the Provider fails to come into compliance with the Provider contract
within fifteen (15) Calendar Days after receipt of notice from the Health Plan
specifying such failure and requesting such Provider abide by the terms and
conditions thereof; and






	 	b.	 	Specify that any Provider whose participation is terminated
pursuant to the Provider Contract for any reason shall utilize the applicable
appeals procedures outlined in the Provider Contract. No additional or separate
right of appeal to the Agency or the Health Plan is created as a result of the
Health Plan’s act of terminating, or decision to terminate any Provider under
this Contract. Notwithstanding the termination of the Provider Contract with
respect to any particular Provider, this Contract shall remain in full force
and effect with respect to all other Providers; and






	 	2.	 	The Health Plan shall notify the Agency at least ninety (90) Calendar Days
prior to the effective date of the suspension, termination, or withdrawal of a Provider
from participation in the Health Plan network. If the termination was for “Cause” the
Health Plan shall provide to the Agency the reasons for termination; and






	 	3.	 	The Health Plan shall notify Enrollees in accordance with the provisions of
this Contract; and






	 	4.	 	The Health Plan shall provide sixty (60) Calendar Days’ advance written notice
to the Provider before canceling, without cause, the Contract with the Provider, except
in a case in which a patient’s health is subject to imminent danger or a physician’s
ability to practice medicine is effectively impaired by an action by the Board of
Medicine or other governmental Agency, in which case notification shall be provided to
the Agency immediately. A copy of the notice shall be submitted simultaneously to the
Agency.






	E.	 	Provider Services






	 	1.	 	General Provisions






	 	a.	 	The Health Plan shall provide sufficient information to all
Providers in order to operate in full compliance with this Contract and all
applicable federal and State laws and regulations.






	 	b.	 	The Health Plan shall monitor Provider knowledge and
understanding of Provider requirements, and take corrective actions to ensure
compliance with such requirements.






	 	c.	 	The Health Plan shall submit to the Agency for written approval
all materials and information to be distributed and/or made available to
Providers.






	 	2.	 	Provider Handbooks






	 	a.	 	The Health Plan shall develop and issue a Provider Handbook to
all Providers at the time the Provider Contract is signed. The Health Plan may
choose not to distribute the Provider Handbook via Surface Mail, provided it
submits a written notification to all Providers that explains how to obtain the
Provider Handbook from the Health Plan’s website. This notification shall also
detail how the Provider can request a hard-copy from the Health Plan at no
charge to the Provider. All Provider Handbooks and bulletins shall be in
compliance with State and federal laws. The Provider Handbook shall serve as a
source of information regarding Health Plan Covered Services, policies and
procedures, statutes, regulations, telephone access and special requirements to
ensure all Contract requirements are met. At a minimum, the Provider Handbook
shall include the following information:






	 	(1)	 	Description of the program;






	 	(2)	 	Covered Services;






	 	(3)	 	Emergency Service responsibilities;






	 	(4)	 	Child Health Check-Up program services and
standards;






	 	(5)	 	Policies and procedures that cover the Provider
complaint system. This information shall include, but not be limited
to, specific instructions regarding how to contact the Health Plan’s
Provider services to file a Provider complaint and which individual(s)
has/have the authority to review a Provider complaint;






	 	(6)	 	Information about the Grievance System, the
timeframes and requirements, the availability of assistance in filing,
the toll-free numbers and the Enrollee’s right to request continuation
of Benefits while utilizing the Grievance System;






	 	(7)	 	Medical Necessity standards and practice
guidelines;






	 	(8)	 	Practice protocols, including guidelines
pertaining to the treatment of chronic and complex conditions;






	 	(9)	 	PCP responsibilities;






	 	(10)	 	Other Provider or Subcontractor
responsibilities;






	 	(11)	 	Prior Authorization and referral procedures;






	 	(12)	 	Medical Records standards;






	 	(13)	 	Claims submission protocols and standards,
including instructions and all information necessary for a clean or
complete claim;






	 	(14)	 	Notice that Provider complaints regarding
claims payment should be sent to the Health Plan;






	 	(15)	 	The Health Plan’s cultural competency plan;






	 	(16)	 	Enrollee rights and responsibilities (see 42
CFR 438.100); and






	 	(17)	 	The Health Plan shall disseminate bulletins as
needed to incorporate any needed changes to the Provider Handbook.






	 	3.	 	Education and Training






	 	a.	 	The Health Plan shall offer training to all Providers and their
staff regarding the requirements of this Contract and special needs of
Enrollees. The Health Plan shall conduct initial training within thirty (30)
Calendar Days of placing a newly contracted Provider, or Provider group, on
active status. The Health Plan shall also conduct ongoing training, as deemed
necessary by the Health Plan or the Agency, in order to ensure compliance with
program standards and this Contract.






	 	b.	 	The Health Plan shall submit the Provider training manual and
training schedule to the Agency for written approval.






	 	4.	 	Provider Relations






The Health Plan shall establish and maintain a formal Provider relations function to
timely and adequately respond to inquiries, questions and concerns from network
Providers. The Health Plan shall implement policies addressing the compliance of
Providers with the requirements of this Contract, institute a mechanism for Provider
dispute resolution and execute a formal system of terminating Providers from the
Health Plan’s network.




	 	5.	 	Toll-free Provider Telephone Help Line






	 	a.	 	The Health Plan shall operate a toll-free telephone help line
to respond to Provider questions, comments and inquiries.






	 	b.	 	The Health Plan shall develop telephone help line policies and
procedures that address staffing, personnel, hours of operation, access and
response standards, monitoring of calls via recording or other means, and
compliance with standards.






	 	c.	 	The Health Plan shall submit these telephone help line policies
and procedures, including performance standards, to the Agency for written
approval.






	 	d.	 	The Health Plan’s call center systems shall have the capability
to track call management metrics identified in Section IV.A.7., Toll-free
Enrollee Help Line.






	 	e.	 	The Health Plan shall staff the telephone help line twenty-four
(24) hours a day, seven (7) days a week to respond to Prior Authorization
requests. The Health Plan shall staff the telephone help line so that the
Health Plan can respond to Provider questions in all other areas, including the
Provider complaint system, Provider responsibilities, etc., between the hours
of 8:00 am and 7:00 pm EST or EDT as appropriate, Monday through Friday,
excluding State holidays.






	 	f.	 	The Health Plan shall develop performance standards and monitor
telephone help line performance by recording calls and employing other
monitoring activities. All performance standards shall be submitted to the
Agency for written approval.






	 	g.	 	The Health Plan shall ensure that after regular business hours
the Provider services line (not the Prior Authorization line) is answered by an
automated system with the capability to provide callers with information about
operating hours and instructions about how to verify Enrollment for an Enrollee
with an Emergency or Urgent Medical Condition. The requirement that the Health
Plan shall provide information to providers about how to verify Enrollment for
an Enrollee with an Emergency or Urgent Medical Condition shall not be
construed to mean that the provider must obtain verification before providing
Emergency Services and Care.






	 	6.	 	Provider Complaint System






	 	a.	 	The Health Plan shall establish a Provider complaint system
that permits a Provider to dispute the Health Plan’s policies, procedures, or
any aspect of a Health Plan’s administrative functions, including proposed
Actions.






	 	b.	 	The Health Plan shall submit its Provider complaint system
policies and procedures to the Agency for written approval.






	 	c.	 	The Health Plan shall include its Provider complaint system
policies and procedures in its Provider handbook as described above.






	 	d.	 	The Health Plan shall also distribute the Provider complaint
system policies and procedures to out of network providers upon written or oral
request. The Health Plan may distribute a summary of these policies and
procedures, if the summary includes information about how the provider may
access the full policies and procedures on the Health Plan’s Web site. This
summary shall also detail how the provider can request a hard-copy from the
Health Plan at no charge to the provider.






	 	e.	 	As a part of the Provider complaint system, the Health Plan
shall:






	 	(1)	 	Allow providers forty-five (45) Calendar Days
to file a written complaint;






	 	(2)	 	Have dedicated staff for providers to contact
via telephone, electronic mail, or in person, to ask questions, file a
provider complaint and resolve problems;






	 	(3)	 	Identify a staff person specifically designated
to receive and process provider complaints;






	 	(4)	 	Thoroughly investigate each provider complaint
using applicable statutory, regulatory, Contractual and Provider
contract provisions, collecting all pertinent facts from all parties
and applying the Health Plan’s written policies and procedures; and






	 	(5)	 	Ensure that Health Plan executives with the
authority to require corrective action are involved in the provider
complaint process.






	 	f.	 	In the event the outcome of the review of the provider
complaint is adverse to the provider, the Health Plan shall provide a written
notice of adverse action to the provider.






	 	g.	 	The Health Plan shall ensure that claims are processed and
comply with the federal and State requirements set forth in 42 CFR 447.45 and
447.46 and Chapter 641, F.S., whichever is more stringent.






	F.	 	Medical Records Requirements






	 	1.	 	The Health Plan shall maintain Medical Records for each Enrollee in accordance
with this Section. Medical Records shall include the quality, quantity,
appropriateness, and timeliness of services performed under this Contract.






	 	a.	 	The Health Plan must include/follow the Medical Record
standards set forth below for each Enrollee’s Medical Records, as appropriate:






	 	(1)	 	The Enrollee’s identifying information,
including name, Enrollee identification number, date of birth, sex and
legal guardianship (if any);






	 	(2)	 	Each record must be legible and maintained in
detail;






	 	(3)	 	A summary of significant surgical procedures,
past and current diagnoses or problems, allergies, untoward reactions
to drugs and current medications;






	 	(4)	 	All entries must be dated and signed by the
appropriate party;






	 	(5)	 	All entries must indicate the chief complaint
or purpose of the visit, the objective, diagnoses, medical findings or
impression of the provider;






	 	(6)	 	All entries must indicate studies ordered
(e.g., laboratory, x-ray, EKG) and referral reports;






	 	(7)	 	All entries must indicate therapies
administered and prescribed;






	 	(8)	 	All entries must include the name and
profession of the provider rendering services (e.g., MD, DO, OD),
including the signature or initials of the provider;






	 	(9)	 	All entries must include the disposition,
recommendations, instructions to the Enrollee, evidence of whether
there was follow-up and outcome of services;






	 	(10)	 	All records must contain an immunization
history;






	 	(11)	 	All records must contain information relating
to the Enrollee’s use of tobacco products and alcohol/substance abuse;






	 	(12)	 	All records must contain summaries of all
Emergency Services and Care and Hospital discharges with appropriate
medically indicated follow up;






	 	(13)	 	Documentation of referral services in
Enrollees’ Medical Records;






	 	(14)	 	All services provided by providers. Such
services must include, but not necessarily be limited to, family
planning services, preventive services and services for the treatment
of sexually transmitted diseases;






	 	(15)	 	All records must reflect the primary language
spoken by the Enrollee and any translation needs of the Enrollee;






	 	(16)	 	All records must identify Enrollees needing
communication assistance in the delivery of health care services; and






	 	(17)	 	All records must contain documentation that the
Enrollee was provided with written information concerning the
Enrollee’s rights regarding Advance Directives (written instructions
for living will or power of attorney) and whether or not the Enrollee
has executed an Advance Directive. Neither the Health Plan, nor any of
its Providers shall, as a condition of treatment, require the Enrollee
to execute or waive an Advance Directive. The Health Plan must maintain
written policies and procedures for Advance Directives.






	 	b.	 	Confidentiality of Medical Records






	 	(1)	 	The Health Plan shall have a policy to ensure
the confidentiality of Medical Records in accordance with 42 CFR, Part
431, Subpart F. This policy shall also include confidentiality of a
minor’s consultation, examination, and treatment for a sexually
transmissible disease in accordance with section 384.30(2), F.S.






	 	(2)	 	The Health Plan shall have a policy to ensure
compliance with the Privacy and Security provisions of the Health
Insurance Portability and Accountability Act (HIPAA).






	 	2.	 	The Health Plan shall maintain a behavioral health Medical Record for each
Enrollee. Each Enrollee’s behavioral health Medical Record shall include:






	 	a.	 	Documentation sufficient to disclose the quality, quantity,
appropriateness and timeliness of Behavioral Health Services performed;






	 	b.	 	Must be legible and maintained in detail consistent with the
clinical and professional practice which facilitates effective internal and
external peer review, medical audit and adequate follow-up treatment; and






	 	c.	 	For each service provided, clear identification as to:






	 	(1)	 	The physician or other service provider;






	 	(2)	 	Date of service;






	 	(3)	 	The units of service provided; and






	 	(4)	 	The type of service provided.






	G.	 	Claims Payment






	 	1.	 	The Health Plan shall reimburse providers for the delivery of authorized
services pursuant to Section 641.3155 F.S., including, but not limited to:






	 	a.	 	Claims are considered received on the date the claims are
received by the Health Plan at its designated claims receipt location.






	 	b.	 	The provider must mail or electronically transfer (submit) the
claim to the Health Plan within six (6) months of:






	 	(1)	 	The date of service or discharge from an
inpatient setting; or






	 	(2)	 	The provider has been furnished with the
correct name and address of the Enrollee’s Health Plan.






	 	c.	 	When the Health Plan is the secondary payor, the provider must
submit the claim to the Health Plan within ninety (90) days of the final
determination of the primary payor.






	 	2.	 	The Health Plan shall reimburse providers for Medicare deductibles and
co-insurance payments for Medicare dually eligible members according to the lesser of
the following:






	 	a.	 	The rate negotiated with the provider; or






	 	b.	 	The reimbursement amount as stipulated in Section 409.908 F.S.






	 	3.	 	In accordance with Section 409.912 F.S., the Health Plan shall reimburse any
Hospital or physician that is outside the Health Plan’s authorized geographic service
area for Health Plan authorized services provided by the Hospital or physician to
Enrollees:






	 	a.	 	At a rate negotiated with the Hospital or physician; or






	 	b.	 	The lesser of the following:






	 	(1)	 	The usual and customary charge made to the
general public by the Hospital or physician; or






	 	(2)	 	The Florida Medicaid reimbursement rate
established for the Hospital or physician.






	 	4.	 	The Health Plan shall have a process for handling and addressing the resolution
of provider complaints concerning claims issues. The process shall be in compliance
with Section 641 .3155 F.S.






	 	5.	 	The Health Plan shall have claims processing and payment performance metrics
including those for quality, accuracy and timeliness and include a process for
measurement and monitoring, and for the development and implementation of interventions
for improvement. These metrics must be approved in writing by the Agency.






	 	6.	 	The Health Plan shall ensure that claims are processed and payment
systems comply with the federal and State requirements set forth in 42 CFR 447.45, 42
CFR 447.46, and Chapter 641, F.S., as applicable.






	H.	 	Encounter Data






	 	1.	 	The Agency is developing a Medicaid Encounter Data System (MEDS) to collect all
encounter data from health plans reimbursed on a capitated basis. Encounter data
collection will be required from all Florida capitated health plans for all health care
services rendered to its members.






	 	2.	 	The information required to support encounter reporting and submission will be
defined by the Agency in the MEDS Companion Guide and MEDS Operations Manual. Other
information contained within the MEDS Companion Guide and MEDS Operations Manual will
be Managed Care Organization testing requirements for SFY 06-07 and thereafter. The
Companion Guide and Operations Manual will be distributed to Health Plans in a manner
that makes them easily accessible.






	 	3.	 	Upon the request of the Agency, Health Plans shall be prepared to submit
encounter data to the Agency or its designee. Health Plans shall have a comprehensive
automated and integrated Encounter Data System that is capable of meeting the
requirements listed below:






	 	a.	 	All encounters shall be submitted in the standard HIPAA
transaction formats, namely the ANSI X12N 837 Transaction formats (P -
Professional, I — Institutional, and D – Dental), and the National Council for
Prescription Drug Programs NCPDP format (for Pharmacy services).






	 	b.	 	Health Plans shall collect and submit to the Agency or its
designee, enrollee service level encounter data for all covered services.
Health Plans will be held responsible for errors or noncompliance resulting
from their own actions or the actions of an agent authorized to act on their
behalf.






	 	c.	 	Health Plans shall have the capability to convert all
information that enters their claims systems via hard copy paper claims to
encounter data to be submitted in the appropriate HIPAA compliant formats.






	 	d.	 	Complete and accurate encounters shall be provided to the
Agency. Health Plans will implement review procedures to validate encounter
data submitted by providers. The historical encounter data submission shall be
retained for a period not less than five years following generally accepted
retention guidelines.






	 	e.	 	Health Plans shall require each Provider to have a unique
Florida Medicaid Provider number, in accordance with the requirement of Section
X, C. jj. of this Contract.






	 	f.	 	Health Plans will designate sufficient IT and staffing
resources to perform these encounter functions as determined by generally
accepted best industry practices.






	I.	 	Fraud Prevention






	 	1.	 	The Health Plan shall establish functions and activities governing program
integrity in order to reduce the incidence of Fraud and Abuse and shall comply with all
State and federal program integrity requirements, including the applicable provisions
of 42 CFR 438.608, 42 CFR 455(a)(2), Chapters 358, 414, 641 and 932, F.S. and Sections
409.912 (21) and (22), F.S.






	 	2.	 	The Health Plan shall designate a compliance officer with sufficient experience
in health care, who shall have the responsibility and authority for carrying out the
provisions of the Fraud and Abuse policies and procedures. The Health Plan shall have
adequate staffing and resources to investigate unusual incidents and develop and
implement corrective action plans to assist the Health Plan in preventing and detecting
potential Fraud and Abuse activities.






	 	3.	 	The Health Plan shall have internal controls and policies and procedures in
place that are designed to prevent, detect and report known or suspected Fraud and
Abuse activities.






	 	4.	 	The Health Plan shall submit its Fraud and Abuse policies and procedures to the
Bureau of Managed Health Care (BMHC) for written approval before implementation. At a
minimum, the Health Plan’s Fraud and Abuse policies and procedures shall:






	 	a.	 	Ensure that all officers, directors, managers and employees
know and understand the provisions of the Health Plan’s Fraud and Abuse
policies and procedures;






	 	b.	 	Include procedures designed to prevent and detect potential or
suspected abuse and fraud in the administration and delivery of services under
this Contract. Nothing in this Contract shall require that the Health Plan
assure that non-participating providers are compliant with this Contract or
State and/or federal law, but the Health Plan is responsible for reporting
suspected abuse and fraud by non-participating providers when detected, in
accordance with the Health Plan’s policies and procedures.






	 	c.	 	Incorporate a description of the specific controls in place for
prevention and detection of potential or suspected Fraud and Abuse, including,
but not limited to:






	 	(1)	 	Claims edits;






	 	(2)	 	Post-processing review of claims;






	 	(3)	 	Provider profiling and credentialing, including
a review process for claims that shall include Providers and
non-participating providers:






	 	(a)	 	Who consistently demonstrate a
pattern of submitting falsified encounter or service reports;






	 	(b)	 	Who consistently demonstrate a
pattern of overstated reports or up-coded levels of service;






	 	(c)	 	Who alter, falsify or destroy
clinical record documentation;






	 	(d)	 	Who make false statements
relating to credentials;






	 	(e)	 	Who misrepresent medical
information to justify Enrollee referrals;






	 	(f)	 	Who fail to render Medically
Necessary Covered Services that they are obligated to provide
according to their Provider contracts; and






	 	(g)	 	Who charge Enrollees for Covered
Services.






	 	(4)	 	Prior Authorization;






	 	(5)	 	Utilization Management;






	 	(6)	 	Relevant Subcontract and Provider contract
provisions; and






	 	(7)	 	Pertinent provisions from the Provider handbook
and the Enrollee handbook.






	 	d.	 	Contain provisions for the confidential reporting of Health
Plan violations to the Health Plan’s analyst with the Bureau of Managed Health
Care, MPI and MFCU;






	 	e.	 	Include provisions for the investigation and follow-up of any
reports;






	 	f.	 	Ensure that the identities of individuals reporting acts of
Fraud and Abuse are protected;






	 	g.	 	Require all instances of provider or Enrollee Fraud and Abuse
under State and/or federal law be reported to the Health Plan’s analyst with
the Bureau of Managed Health Care and MPI. The Health Plan shall not cease an
investigation or resolve the suspicion, knowledge or action without first
informing the Agency and MPI. Additionally, any final resolution must include
a written statement that provides notice to the provider or enrollee that the
resolution in no way binds the State of Florida nor precludes the State of
Florida from taking further action for the circumstances that brought rise to
the matter;






	 	h.	 	The Health Plan and all Providers, upon request, and as
required by State and/or federal law, shall:






	 	(1)	 	Make available to the Agency, MPI and/or MFCU
any and all administrative, financial and Medical Records relating to
the delivery of items or services for which Medicaid monies are
expended; and






	 	(2)	 	Allow access to the Agency, MPI and/or MFCU to
any place of business and all Medical Records, as required by State
and/or federal law. The Agency, MPI and MFCU shall have access during
normal business hours, except under special circumstances when the
Agency, MPI and MFCU shall have after hour admission. The Agency, MPI
and/or MFCU shall determine the need for special circumstances.






	 	i.	 	The Health Plan shall cooperate fully in any investigation by
the Agency, MPI, MFCU or any subsequent legal action that may result from such
an investigation.






	 	j.	 	Ensure that the Health Plan does not retaliate against any
individual who reports violations of the Health Plan’s Fraud and Abuse policies
and procedures or suspected Fraud and Abuse.






	 	k.	 	The Health Plan shall provide for the use of the List of
Excluded Individuals and Entities (LEIE), or its equivalent, to identify
excluded parties during the process of an engaging the services of new
Providers to ensure that the Providers are not in a nonpayment status or
sanctioned from participation in federal health care programs. The Health Plan
shall not engage the services of a provider if that provider is in nonpayment
status or is excluded from participation in federal health care programs under
Sections 1128 and 1128A of the Social Security Act. The Health Plan shall not
employ or contract the services of excluded Providers and must terminate the
Provider contract immediately between the Health Plan and a Provider that
becomes an excluded provider.






	 	5.	 	The Health Plan shall comply with all reporting requirements as set forth in
Section XII., Reporting Requirements.






	 	6.	 	The Health Plan shall meet with the Agency periodically, at the Agency’s
request, to discuss Fraud, Abuse, Neglect and Overpayment issues. For purpose of this
Section, the Health Plan Compliance Officer shall be the point of contact for the
Health Plan and the Agency’s Medicaid Fraud and Abuse Liaison shall be the point of
contact for the Agency.





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Section XI




Information Management and Systems





	A.	 	General Provisions






	 	1.	 	Systems Functions. The Health Plan shall have Information management processes
and Information Systems that enable it to meet Agency and federal reporting
requirements and other Contract requirements and that are in compliance with this
Contract and all applicable State and federal laws, rules and regulations, including
HIPAA.






	 	2.	 	Systems Capacity. The Health Plan’s Systems shall possess capacity sufficient
to handle the workload projected for the begin date of operations and will be scaleable
and flexible so they can be adapted as needed, within negotiated timeframes, in
response to changes in Contract requirements, increases in Enrollment estimates, etc.






	 	3.	 	E-Mail System. The Health Plan shall provide a continuously available
electronic mail communication link (E-mail system) with the Agency. This system shall
be:






	 	a.	 	Available from the workstations of the designated Health Plan
contacts; and






	 	b.	 	Capable of attaching and sending documents created using
software products other than Health Plan’s systems, including the Agency’s
currently installed version of Microsoft Office and any subsequent upgrades as
adopted.






	 	4.	 	Participation in Information Systems Work Groups/Committees. The Health Plan
shall meet as requested by the Agency, to coordinate activities and develop cohesive
systems strategies across vendors and agencies.






	 	5.	 	Connectivity to the Agency/State Network and Systems. The Health Plan shall be
responsible for establishing connectivity to the Agency’s/State’s wide area data
communications network, and the relevant information systems attached to this network,
in accordance with all applicable Agency and/or State policies, standards and
guidelines.






	B.	 	Data and Document Management Requirements






	 	1.	 	Adherence to Data and Document Management Standards






	 	a.	 	The Health Plan’s Systems shall conform to the standard
transaction code sets specified in Section XI.I.






	 	b.	 	The Health Plan’s Systems shall conform to HIPAA standards for
data and document management that are currently under development within one
hundred twenty (120) Calendar Days of the standard’s effective date or, if
earlier, the date stipulated by CMS or the Agency.






	 	c.	 	The Health Plan shall partner with the Agency in the management
of standard transaction code sets specific to the Agency. Furthermore, the
Health Plan shall partner with the Agency in the development and implementation
planning of future standard code sets not specific to HIPAA or other federal
efforts and shall conform to these standards as stipulated in the plan to
implement the standards.






	 	2.	 	Data Model and Accessibility. Health Plan Systems shall be Structured Query
Language (SQL) and/or Open Database Connectivity (ODBC) compliant. Alternatively, the
Health’s Plan Systems shall employ a relational data model in the architecture of its
databases in addition to a relational database management system (RDBMS) to operate and
maintain them.






	 	3.	 	Data and Document Relationships. The Health Plan shall house indexed images of
documents used by Enrollees and providers to transact with the Health Plan in the
appropriate database(s) and document management systems so as to maintain the logical
relationships between certain documents and certain data.






	 	4.	 	Information Retention. Information in the Health Plan’s Systems shall be
maintained in electronic form for three (3) years in live Systems and, for audit and
reporting purposes, for five (5) years in live and/or archival Systems.






	 	5.	 	Information Ownership. All Information, whether data or documents, and reports
that contain or make references to said Information, involving or arising out of this
Contract is owned by the Agency. The Health Plan is expressly prohibited from sharing
or publishing the Agency information and reports without the prior written consent of
the Agency. In the event of a dispute regarding the sharing or publishing of
information and reports, the Agency’s decision on this matter shall be final and not
subject to change.






	C.	 	System and Data Integration Requirements






	 	1.	 	Adherence to Standards for Data Exchange






	 	a.	 	The Health Plan’s Systems shall be able to transmit, receive
and process data in HIPAA-compliant formats that are in use as of the Contract
execution date; these formats are detailed in Section XI.J.






	 	b.	 	The Health Plan’s Systems shall be able to transmit, receive
and process data in the Agency-specific formats and/or methods that are in use
on the Contract execution date, as specified in Section XI.J.






	 	c.	 	Health Plan Systems shall conform to future federal and/or
Agency specific standards for data exchange within one hundred twenty (120)
Calendar Days of the standard’s effective date or, if earlier, the date
stipulated by CMS or the Agency. The Health Plan shall partner with the Agency
in the management of current and future data exchange formats and methods and
in the development and implementation planning of future data exchange methods
not specific to HIPAA or other Federal effort. Furthermore, the Health Plan
shall conform to these standards as stipulated in the plan to implement such
standards.






	 	2.	 	HIPAA Compliance Checker






All HIPAA-conforming exchanges of data between the Agency and the Health Plan shall
be subjected to the highest level of compliance as measured using an
industry-standard HIPAA compliance checker application.




	 	3.	 	Data and Report Validity and Completeness






The Health Plan shall institute processes to ensure the validity and completeness of
the data, including reports, it submits to the Agency. At its discretion, the
Agency will conduct general data validity and completeness audits using
industry-accepted statistical sampling methods. Data elements that will be audited
include but are not limited to: Enrollee ID, date of service, assigned Medicaid
Provider ID, category and sub category (if applicable) of service, diagnosis codes,
procedure codes, revenue codes, date of claim processing, and (if and when
applicable) date of claim payment. Control totals shall also be reviewed and
verified.




	 	4.	 	State/Agency Website/Portal Integration






Where deemed that the Health Plan’s Web presence will be incorporated to any degree
to the Agency’s or the State’s Web presence (also known as a portal), the Health
Plan shall conform to any applicable Agency or State standard for Website structure,
coding and presentation.




	 	5.	 	Connectivity to and Compatibility/Interoperability with Agency Systems and IT
Infrastructure.






The Health Plan shall be responsible for establishing connectivity to the
Agency’s/State’s wide area data communications network, and the relevant information
systems attached to this network, in accordance with all applicable Agency and/or
State policies, standards and guidelines.




	 	6.	 	Functional Redundancy with FMMIS.






The Health Plan’s Systems shall be able to transmit and receive transaction data to
and from FMMIS as required for the appropriate processing of claims and any other
transaction that could be performed by either System.




	 	7.	 	Data Exchange in Support of the Agency’s Program Integrity and Compliance
Functions.






The Health Plan’s System(s) shall be capable of generating files in the prescribed
formats for upload into Agency Systems used specifically for program integrity and
compliance purposes.




	 	8.	 	Address Standardization.






The Health Plan’s System(s) shall possess mailing address standardization
functionality in accordance with US Postal Service conventions.



9. Eligibility and Enrollment Data Exchange Requirements




	 	a.	 	The Health Plan shall receive, process and update enrollment
files sent daily by the Agency or its Agent.






	 	b.	 	The Health Plan shall update its eligibility/Enrollment
databases within twenty-four (24) hours of receipt of said files.






	 	c.	 	The Health Plan shall transmit to the Agency or its Agent, in a
periodicity schedule, format and data exchange method to be determined by the
Agency, specific data it may garner from an Enrollee including third party
liability data.






	 	d.	 	The Health Plan shall be capable of uniquely identifying a
distinct Medicaid Recipient across multiple Systems within its Span of Control.






	D.	 	Systems Availability, Performance and Problem Management Requirements






1. Availability of Critical Systems Functions




The Health Plan shall ensure that critical systems functions available to Enrollees
and providers, functions that if unavailable would have an immediate detrimental
impact on Enrollees and providers, are available twenty-four (24) hours a day, seven
(7) days a week, except during periods of scheduled System Unavailability agreed
upon by the Agency and the Health Plan. Unavailability caused by events outside of
a Health Plan’s Span of Control is outside the scope of this requirement. The
Health Plan shall make the Agency aware of the nature and availability of these
functions prior to extending access to these functions to Enrollees and/or
providers.




2. Availability of Data Exchange Functions




The Health Plan shall ensure that the systems and processes within its Span of
Control associated with its data exchanges with the Agency and/or its Agent(s) are
available and operational according to specifications and the data exchange
schedule.




3. Availability of Other Systems Functions




The Health Plan shall ensure that at a minimum all other System functions and
Information are available to the applicable System users between the hours of 7:00
a.m. and 7:00 p.m., EST or EDT as appropriate, Monday through Friday.




4. Problem Notification




	 	a.	 	Upon discovery of any problem within its Span of Control that
may jeopardize or is jeopardizing the availability and performance of all
Systems functions and the availability of information in said Systems,
including any problems impacting scheduled exchanges of data between the Health
Plan and the Agency and/or its Agent(s), the Health Plan shall notify the
applicable Agency staff via phone, fax and/or electronic mail within fifteen
(15) minutes of such discovery. In its notification the Health Plan shall
explain in detail the impact to critical path processes such as enrollment
management and claims submission processes.






	 	b.	 	The Health Plan shall provide to appropriate Agency staff
information on System Unavailability events, as well as status updates on
problem resolution. At a minimum these up-dates shall be provided on an hourly
basis and made available via electronic mail and/or telephone.






5. Recovery from Unscheduled System Unavailability




Unscheduled System unavailability caused by the failure of systems and
telecommunications technologies within the Health Plan’s Span of Control will be
resolved, and the restoration of services implemented, within forty-eight (48) hours
of the official declaration of System Unavailability.




6. Exceptions to System Availability Requirement




The Health Plan shall not be responsible for the availability and performance of
systems and IT infrastructure technologies outside of the Health Plan’s Span of
Control.




7. Corrective Action Plan




Full written documentation, that includes a Corrective Action Plan, that describes
how problems with critical Systems functions will be prevented from occurring again,
shall be delivered within five (5) Business Days of the System
Unavailability/problem’s occurrence.




8. Business Continuity-Disaster Recovery (BC-DR) Plan




	 	a.	 	Regardless of the architecture of its Systems, the Health Plan
shall develop, and be continually ready to invoke, a business continuity and
disaster recovery (BC-DR) plan that is reviewed and prior-approved by the
Agency.






	 	b.	 	At a minimum the Health Plan’s BC-DR plan shall address the
following scenarios: (1) the central computer installation and resident
software are destroyed or damaged; (2) System interruption or failure resulting
from network, operating hardware, software, or operational errors that
compromise the integrity of transactions that are active in a live system at
the time of the outage; (3) System interruption or failure resulting from
network, operating hardware, software or operational errors that compromise the
integrity of data maintained in a live or archival system; (4) System
interruption or failure resulting from network, operating hardware, software or
operational errors that do not compromise the integrity of transactions or data
maintained in a live or archival system, but does prevent access to the System,
i.e. causes unscheduled System Unavailability.






	 	c.	 	The Health Plan shall periodically, but no less than annually,
perform comprehensive tests of its BC-DR plan through simulated disasters and
lower level failures in order to demonstrate to the Agency that it can restore
System functions per the standards outlined elsewhere in this Section of the
Contract.






	 	d.	 	In the event that the Health Plan fails to demonstrate in the
tests of its BC-DR plan that it can restore system functions per the standards
outlined in this Contract, the Health Plan shall be required to submit to the
Agency a Corrective Action Plan in accordance with Section XIV, Sanctions, that
describes how the failure will be resolved. The Corrective Action Plan shall
be delivered within ten (10) Business Days of the conclusion of the test.






	E.	 	System Testing and Change Management Requirements






1. Notification and Discussion of Potential System Changes.




The Health Plan shall notify the applicable Agency staff person of the following
changes to Systems within its Span of Control within at least ninety (90) Calendar
Days of the projected date of the change; if so directed by the Agency, the Health
Plan shall discuss the proposed change with the applicable Agency staff: (1)
software release updates of core transaction Systems: claims processing, eligibility
and Enrollment processing, service authorization management, Provider enrollment and
data management; (2) conversions of core transaction management Systems.




	 	2.	 	Response to Agency Reports of Systems Problems not Resulting in System
Unavailability.






	 	a.	 	The Health Plan shall respond to Agency reports of System
problems not resulting in System Unavailability according to the following
timeframes:






	 	(1)	 	Within seven (7) Calendar Days of receipt, the
Health Plan shall respond in writing to notices of system problems.






	 	(2)	 	Within twenty (20) Calendar Days, the
correction will be made or a Requirements Analysis and Specifications
document will be due.






	 	(3)	 	The Health Plan will correct the deficiency by
an effective date to be determined by the Agency.






3. Valid Window for Certain System Changes.




Unless otherwise agreed to in advance by the Agency as part of the activities
described in this Section, scheduled System Unavailability to perform System
maintenance, repair and/or upgrade activities shall not take place during hours that
could compromise or prevent critical business operations.




4. Testing




	 	a.	 	The Health Plan shall work with the Agency pertaining to any
testing initiative as required by the Agency.






	 	b.	 	Upon the Agency’s written request, the Health Plan shall
provide details of the test regions and environments of its core production
Information Systems, including a live demonstration, to enable the Agency to
corroborate the readiness of the Health Plan’s Information Systems.






	F.	 	Information Systems Documentation Requirements






1. Types of Documentation




The Health Plan shall develop, prepare, print, maintain, produce, and distribute
distinct System Process and Procedure Manuals, User Manuals and Quick/Reference
Guides, and any updates thereafter, for the Agency and other applicable Agency
staff.




2. Content of System Process and Procedure Manuals




The Health Plan shall ensure that written System Process and Procedure Manuals
document and describe all manual and automated system procedures for its information
management processes and Information Systems.




	 	3.	 	Content of System User Manuals






The System User Manuals shall contain information about, and instructions for, using
applicable System functions and accessing applicable system data.




	 	4.	 	Changes to Manuals






	 	a.	 	When a System change is subject to the Agency’s written
approval, the Health Plan shall draft revisions to the appropriate manuals
prior to Agency approval of the change.






	 	b.	 	Updates to the electronic version of these manuals shall occur
in real time; updates to the printed version of these manuals shall occur
within ten (10) Business Days of the update taking effect.






	 	5.	 	Availability of/Access to Documentation






All of the aforementioned manuals and reference guides shall be available in printed
form and/or on-line. If so prescribed, the manuals will be published in accordance
with the appropriate Agency and/or State standard.




	G.	 	Reporting Requirements — Specific to Information Management and Systems Functions and
Capabilities — and Technological Capabilities






	 	1.	 	Reporting Requirements.






If the Health Plan is extending access to “critical systems functions” to providers
and Enrollees as described in Section XI.D.1., above, it shall submit a monthly
Systems Availability and Performance Report to the Agency as described in Section
XII, Reporting Requirements, otherwise this reporting requirement is not applicable.



2. Reporting Capabilities.




The Health Plan shall provide Systems-based capabilities, such as a data warehouse,
that enables authorized Agency personnel, or the Agency’s Agent, on a secure and
read-only basis, to build and generate reports for management use.




	H.	 	Other Requirements






	 	1.	 	Community Health Record/Electronic Medical Record and Related Efforts






	 	a.	 	At such times that the Agency requires, the Health Plan shall
participate and cooperate with the Agency to implement, within a reasonable
timeframe, a secure, Web-accessible, Community Health Records for Enrollees.






	 	b.	 	The design of the vehicle(s) for accessing the Community Health
Record, the health record format and design shall comply with all HIPAA and
related regulations.






	 	c.	 	The Health Plan shall also cooperate with the Agency in the
continuing development of the State’s health care data site
(FloridaHealthStat).






	I.	 	Compliance with Standard Coding Schemes






1. Compliance with HIPAA-Based Code Sets.




	 	a.	 	A Health Plan System that is required to or otherwise contain
the applicable data type shall conform to the following HIPAA-based standard
code sets; the processes through which the data are generated should conform to
the same standards as needed:






	 	(1)	 	Logical Observation Identifier Names and Codes
(LOINC);






	 	(2)	 	Health Care Financing Administration Common
Procedural Coding System (HCPCS);






	 	(3)	 	Home Infusion EDI Coalition (HEIC) Product
Codes;






	 	(4)	 	National Drug Code (NDC);






	 	(5)	 	National Council for Prescription Drug Programs
(NCPDP);






	 	(6)	 	International Classification of Diseases
(ICD-9);






	 	(7)	 	Diagnosis Related Group (DRG);






	 	(8)	 	Claim Adjustment Reason Codes; and






	 	(9)	 	Remittance Remarks Codes.






	 	2.	 	Compliance with Other Code Sets






	 	a.	 	A Health Plan System that is required to or otherwise contains
the applicable data type shall conform to the following non-HIPAA-based
standard code sets:






	 	(1)	 	As described in all AHCA Medicaid Reimbursement
Handbooks, for all “Covered Entities”, as defined under HIPAA, and
which submit transactions in paper format (non-electronic format).






	 	(2)	 	As described in all AHCA Medicaid Reimbursement
Handbooks for all “Non-covered Entities”, as defined under HIPAA.






	J.	 	Data Exchange and Formats and Methods Applicable to Health Plans






	 	1.	 	HIPAA-Based Formatting Standards






	 	a.	 	Health Plan Systems shall conform to the following
HIPAA-compliant standards for information exchange effective the first day of
operations in the applicable service region:






	 	(1)	 	Batch transaction types






	 	(a)	 	ASC X12N 834 Enrollment and Audit
Transaction






	 	(b)	 	ASC X12N 835 Claims Payment
Remittance Advice Transaction






	 	(c)	 	ASC X12N 837I Institutional
Claim/Encounter Transaction






	 	(d)	 	ASC X12N 837P Professional
Claim/Encounter Transaction






	 	(e)	 	ASC X12N 837D Dental
Claim/Encounter Transaction






	 	(f)	 	NCPDP 1.1 Pharmacy
Claim/Encounter Transaction






	 	(2)	 	Online transaction types






	 	(a)	 	ASC X12N 270/271
Eligibility/Benefit Inquiry/Response






	 	(b)	 	ASC X12N 276 Claims Status
Inquiry






	 	(c)	 	ASC X12N 277 Claims Status
Response






	 	(d)	 	ASC X12N 278/279 Utilization
Review Inquiry/Response






	 	(e)	 	NCPDP 5.1 Pharmacy
Claim/Encounter Transaction






	 	2.	 	Methods for Data Exchange






The Health Plan and the Agency and/or its Agent shall made predominant use of Secure
File Transfer Protocol (SFTP) and Electronic Data Interchange (EDI) in their
exchanges of data.




	 	3.	 	Agency-Based Formatting Standards and Methods






	 	a.	 	Health Plan Systems shall exchange the following data with the
Agency and/or its Agent in a format to be jointly agreed upon by the Health
Plan and the Agency:






	 	(1)	 	Provider network data;






	 	(2)	 	Case Management fees; and






	 	(3)	 	Administrative payments.





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32




Section XII




Reporting Requirements





	A.	 	Health Plan Reporting Requirements






	 	1.	 	The Health Plan shall comply with all Reporting Requirements set forth by the
Agency in this Contract.






	 	a.	 	The Health Plan is responsible for assuring the accuracy,
completeness, and timely submission of each report.






	 	b.	 	The Health Plan’s chief executive officer (CEO), chief
financial officer (CFO), or an individual who reports to the CEO or CFO and who
has delegated authority to certify the Health Plan’s reports, must attest,
based on his/her best knowledge, information, and belief, that all data
submitted in conjunction with the reports and all documents requested by the
Agency are accurate, truthful, and complete (see 42 CFR 438.606(a) and (b)).






	 	c.	 	The Health Plan must submit its certification at the same time
it submits the certified data reports (see 42 CFR 438.606(c)). The
certification page should be scanned and submitted it electronically.






	 	d.	 	Before October 1 of each year, the Health Plan shall deliver to
the Agency a certification by an Agency-approved independent auditor that the
Performance Measure data reported for the previous calendar year are fairly and
accurately presented.






	 	e.	 	Deadlines for report submission referred to in this Contract
specify the actual time of receipt at the Agency, not the date the file was
postmarked or transmitted.






	 	f.	 	If a reporting due date falls on a weekend, the report shall be
due to the Agency on the following Business Day.






	 	g.	 	All reports filed on a quarterly basis shall be filed on a
calendar year quarter.






	 	2.	 	The Agency shall furnish the Health Plan with the appropriate reporting
formats, templates, instructions, submission timetables, and technical assistance, as
required.






	 	3.	 	The Agency reserves the right to modify the Reporting Requirements, with a
ninety (90) Calendar Day notice to allow the Health Plan to complete implementation,
unless otherwise required by law.






	 	4.	 	The Agency shall provide the Health Plan with written notification of any
modifications to the Reporting Requirements.





5. The Reporting Requirements specifications are outlined in detail below.




	 	6.	 	If the Health Plan fails to submit the required reports accurately and within
the timeframes specified below, the Agency shall fine or otherwise sanction the Health
Plan in accordance with Section XIV, Sanctions.






	 	7.	 	The Health Plan must use the following naming convention for all submitted
reports. Unless otherwise noted, each report will have an 8-digit file name,
constructed as follows:





Digit 1 Report Identifier Indicates the report type. See Digit 1 Report Identifiers table below.


Digits 2, 3, and 4 Plan Identifier Indicates the specific Health Plan submitting the data by the
use of three (3) unique alpha digits. Comports to the Health Plan identifier used in exchanging
data with the Choice Counselor/Enrollment Broker.



Digits 5 and 6 Year Indicates the year. For example, reports submitted in 2006 should indicate 06.



Digits 7 and 8 Time Period For reports submitted on a quarterly basis, use Q1, Q2, Q3 or Q4. For
reports submitted monthly, use the appropriate month, such as 01, 02, 03, etc.



Digit 1 Report Identifiers




	 	 	 
	R

I

G

F

C

T

S

E

B

P

O

	 	Marketing Representative

Information Systems Availability

Grievance System Reporting

Financial Reporting

Claims Inventory

Transportation

Critical Incident Summary

Behavioral Health Encounter Data

Behavioral Health Pharmacy Encounter Data

Behavioral Health Required Staff/Providers

FARS/CFARS







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33




8. Unless otherwise specified, these files can be:



a. Mailed to the following address:



Agency for Health Care Administration



Bureau of Managed Health Care



2727 Mahan Drive, MS #26



Tallahassee, FL 32308



or




	 	b.	 	Transmitted electronically to the Agency at the following
address:





MMCDATA@ahca.myflorida.com





	 	c.	 	PHI information has to be submitted to the AHCA SFTP site.






	 	9.	 	For financial reporting, the Health Plan shall complete the spreadsheets and
mail the CD or DVD to the address indicated above or transmit it electronically to the
Agency at the email address noted below:





MMCFIN@ahca.myflorida.com





	 	10.	 	For Claims Inventory Summary reporting, the Health Plan shall complete the
template and mail the CD or DVD to the address indicated above or transmit it
electronically to the Agency at the e-mail address noted below:





MMCCLMS@ahca.myflorida.com




34




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S.NEXTSection XIII




Method of Payment





	A.	 	Fixed Price Unit Contract






This is a fixed price unit cost contract. The Agency or its appointed Fiscal Agent shall
make payment to the Health Plan on a monthly basis for the Health Plan’s satisfactory
performance of its duties and responsibilities as set forth in this Contract. To
accommodate payments, the Health Plan is a capitated health plan with the Fiscal Agent.
Section XII, Reporting Requirements, details the enrollment reports, the monthly payment
request processing and service utilization procedures.




	B.	 	Child Health Check-Up Incentive Program






Health Plans will be eligible to participate in the Child Health Check-Up (CHCUP) incentive
program when the Health Plan has exceeded both the sixty percent (60%) State screening rate
and the federal eighty percent (80%) participation and screening ratio goals as outlined in
Section V, Covered Services, E.2. The Agency will determine which Health Plans will
participate based upon the audited CHCUP reports submitted each October as set forth in
Section XII.M., above.




	 	1.	 	The amount of the incentive payment shall be calculated as follows: the ratio
of a qualified Health Plan’s screenings to the total of all Health Plans’ screenings
will be multiplied by the total amount in the fund for the incentive payment. The
ratios will be based on the Health Plans’ audited CHCUP reports. The total amount in
the fund will be determined at the discretion of the Agency. In no event shall the
total monies allotted to the incentive program be in excess of the incentive payment
fund.






	 	2.	 	Pursuant to 42 CFR 438.6, I(1)(iv) and (5)(iii), the payment to any one (1)
Health Plan shall not be in excess of five percent (5%) of the capitation amount paid
to all Health Plans for CHCUP services provided pursuant to this Contract.






	C.	 	Capitation Rate






The Agency shall pay the applicable Capitation Rate for each Enrollee whose name appears on
the ONGOING REPORT (FLMR 8200-R004) and the REINSTATEMENT REPORT (FLMR 8200-R009) for each
month, except that the Agency shall not pay for, and shall recoup, any part of the total
Enrollment that exceeds the maximum authorized Enrollment level(s) expressed in Attachment
I. The total payment amount to the Health Plan shall depend upon the number of Enrollees in
each eligibility category and each rate group, as provided for by this Contract, or as
adjusted pursuant to the Contract when necessary. The Health Plan is obligated to provide
services pursuant to the terms of this Contract for all Enrollees for whom the Health Plan
has received capitation payment and for whom the Agency has assured the Health Plan that
capitation payment is forthcoming.




	 	1.	 	The Agency’s Capitation Rates are developed using historical rates paid by
Medicaid fee-for-service for similar services in the same Service Area, adjusted for
inflation, where applicable, in accordance with 42 CFR 438.6(c).






	 	2.	 	The Capitation Rates to be paid specific to the Health Plan shall be as
indicated in Attachment I, which indicates the initial and maximum authorized
Enrollment levels and Capitation Rates applicable to each authorized eligibility
category.






	 	3.	 	At such time as the Agency receives legislative direction to assess Health
Plans for Enrollment and Disenrollment Services costs, the Agency shall apply
assessments, in quarterly installments each Contract Year, against the Health Plan’s
next capitation payment to pay for the Enrollment and Disenrollment Services Contractor
as follows:






	 	a.	 	July 1, for costs estimated for the Agency’s Enrollment and
Disenrollment Services Contractor system and contract for July and the
following two (2) months.






	 	b.	 	October 1, for costs related to the third party Enrollment and
Disenrollment Services contract for October and the following two (2) months.






	 	c.	 	January 1, for costs related to maintaining the third party
Enrollment and Services contract for January and the following two (2) months.






	 	d.	 	April 1, for costs related to maintaining the third party
Enrollment and Disenrollment Services contract for April and the following two
(2) months.






	 	4.	 	Unless otherwise specified in this Contract, the Health Plan shall accept the
capitation payment received each month as payment in full by the Agency for all
services provided to Enrollees covered under this Contract and the administrative costs
incurred by the Health Plan in providing or arranging for such services. Any and all
costs incurred by the Health Plan in excess of the capitation payment shall be borne in
total by the Health Plan.






	 	5.	 	The Agency shall pay a retroactive Capitation Rate for each Newborn enrolled in
the Health Plan for up to the first (1st) three (3) months of life, provided
the Newborn was enrolled through the Unborn Activation Process.






	 	a.	 	The Health Plan shall use the Unborn Activation Process to
enroll all babies born to pregnant Enrollees as specified in Section III.B.3,
Newborn Enrollment.






	 	 	 	b. The Health Plan is responsible for payment of all Covered Services
provided to Newborns enrolled through the Unborn Activation Process.






	 	6.	 	Because the HomeSafeNet program covers the cost of Behavioral Health Services
provided to members of the HomeSafeNet program, the Agency shall not pay the Health
Plan the behavioral health component of the Capitation Rate for Enrollees that are part
of the HomeSafeNet program, even if the Health Plan provides Behavioral Health Services
in the county in which the Enrollee resides.






	D.	 	Errors






	 	1.	 	The Agency expects the Health Plan to prepare all reports and monthly payment
requests for submission to the Agency. If after preparation and electronic submission,
the Health Plan discovers an error, including, but not limited to, errors resulting in
capitated payments above the Health Plan’s authorized levels, either by the Health Plan
or the Agency, the Health Plan has thirty (30) Business Days from its discovery of the
error, or thirty (30) Business Days after receipt of notice by the Agency, to correct
the error and re-submit accurate reports and/or invoices. Failure to respond within
the thirty (30) Business Day period shall result in a loss of any money due to the
Health Plan for such errors and/or sanctions against the Health Plan pursuant to
Section XIV of this Contract.






	E.	 	Member Payment Liability Protection






	 	1.	 	Pursuant to Section 1932 (b)(6), Social Security Act (as enacted by
section 4704 of the Balanced Budget Act of 1997), the Health Plan shall not hold
members liable for the following:






	 	a.	 	For debts of the Health Plan, in the event of the Health Plan’s
insolvency;






	 	b.	 	For payment of Covered Services provided by the Health Plan if
the Health Plan has not received payment from the Agency for the Covered
Services, or if the provider, under contract or other arrangement with the
Health Plan, fails to receive payment from the Agency or the Health Plan;
and/or






	 	c.	 	For payments to a provider, including referral providers, that
furnished Covered Services under a contract, or other arrangement with the
Health Plan, that are in excess of the amount that normally would be paid by
the Enrollee if the Covered Services had been received directly from the Health
Plan.






	F.	 	Co-payments






	 	1.	 	The Health Plan shall not require any co-payment or cost sharing for Covered
Services, expanded services and/or optional services listed in Section V, Covered
Services or Section VI, Behavioral Health Care, nor may the Health Plan charge
Enrollees for missed appointments.






	G.	 	Enrollment Levels






	 	1.	 	The Health Plan is assigned an authorized maximum Enrollment level for each
operational county. The authorized maximum Enrollment level is in effect on September
1, 2006, or upon Contract execution, whichever is later.






	 	2.	 	The Agency must approve in writing any increase in the Health Plan’s maximum
Enrollment level for each operational county and subpopulation to be served, as
applicable. Such approval shall not be unreasonably withheld, and shall be based on
the Health Plan’s satisfactory performance of terms of the Contract and approval of the
Health Plan’s administrative and service resources, as specified in this Contract, in
support of each Enrollment level.






	 	 	 	3. Authorized Enrollment Levels in Attachment I indicate the Health Plan’s maximum
authorized Enrollment levels for each Medicaid Reform county and each applicable
authorized eligibility category.






	 	4.	 	Attachment I sets forth the total Contract amount.






	 	5.	 	Attachment I, Exhibit I sets forth the Health Plan’s authorized Service Areas
and maximum enrollment levels.






	 	6.	 	Attachment I, Exhibit II sets forth the Health Plan’s Capitation Rates for each
County in which it is authorized to provide services.






	 	7.	 	Attachment I, Exhibit III lists the Capitation Rates for the Health Plan’s
authorized Service Areas.






	H.	 	Transition to Medicaid Reform






	 	1.	 	The Health Plan understands that the State is commencing Medicaid Reform that
shall start in Broward County and Duval County on September 1, 2006, with other
counties added as authorized by the State. As a result, in all areas in which the
State implements Medicaid Reform, the Health Plan’s Enrollment will transition from
coverage under this Contract to the Medicaid Reform Contract in accordance with the
Agency’s implementation schedule. By April 1, 2007, the Health Plan’s total maximum
Enrollment in Broward County and Duval County, if any, will be zero (0).






	 	2.	 	When the State authorizes expansion of Medicaid Reform into a new county in
which the Health Plan is currently providing, or will provide, Medicaid services, the
Health Plan acknowledges that it must request an amendment for an expansion of service
under the Medicaid Reform Contract in order to continue to provide Benefits in the new
Medicaid Reform county. Upon implementation of Medicaid Reform, the Health Plan shall
not:






	 	a.	 	Engage in Marketing activities with regard to the services
and/or Benefits provided under this Contract;






	 	b.	 	Receive voluntary or mandatory Enrollees for the Medicaid
Reform county under this Contract; and must






	I.	 	Cost Effectiveness






	 	1.	 	The Agency shall ensure that the Health Plan is cost-effective (see Section
409.912(44), F.S.). The Agency may not renew this Contract if it is not
cost-effective.





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REMAINDER OF PAGE INTENTIONALLY LEFT BLANKSection XIV




Sanctions





	A.	 	General Provisions






	 	1.	 	The Health Plan shall comply with all requirements and performance standards
set forth in this Contract. In the event the Agency identifies a violation of this
Contract, or other non-compliance with this Contract, the Health Plan shall submit a
corrective action plan (CAP) within three (3) Calendar Days of the date of receiving
notification of the violation or non-compliance from the Agency.






	 	2.	 	Within five (5) Business Days of receiving the CAP the Agency will either
approve or disapprove the CAP. If disapproved, the Health Plan shall resubmit, within
ten (10) Business Days, a new CAP that addresses the concerns identified by the Agency.






	 	3.	 	Upon approval of the CAP, whether the initial CAP or the revised CAP, the
Health Plan shall implement the CAP within the time frames specified by the Agency.






	 	4.	 	Except where specified below, the Agency shall impose a monetary sanction of
$100 per day on the Health Plan for each Calendar Day that the approved CAP is not
implemented to the satisfaction of the Agency.






	B.	 	Specific Sanctions






	 	1.	 	As described in 42 CFR 438.700, the Agency may impose any of the following
sanctions against a Health Plan if it determines that a Health Plan has violated any
provision of this Contract, or any applicable statutes:






	 	a.	 	Suspension of the Health Plan’s Voluntary Enrollments and
participation in the Mandatory Assignment process for Enrollment






	 	b.	 	Suspension or revocation of payments to the Health Plan for
Enrollees during the sanction period;






	 	c.	 	For any nonwillful violation of the Contract, the Agency shall
impose a fine, not to exceed $2,500 per Violation. In no event shall such fine
exceed an aggregate amount of $10,000 for all nonwillful Violations arising out
of the same action;






	 	d.	 	With respect to any knowing and willful violation of the
Contract the Agency shall impose a fine upon the Health Plan in an amount not
to exceed $20,000 for each such violation. In no event shall such fine exceed
an aggregate amount of $100,000 for all knowing and willful violations arising
out of the same action;






	 	e.	 	If the Health Plan fails to carry out substantive terms of the
Contract or fails to meet all applicable requirements in 42 CFR 438.700, the
Agency shall terminate the Contract. After the Agency notifies the Health Plan
that it intends to terminate the Contract, the Agency shall give the Health
Plan’s Enrollees written notice of the State’s intent to terminate the Contract
and allow the Enrollees to disenroll immediately without Cause.






	 	f.	 	The Agency may impose intermediate sanctions in accordance with
42 CFR 438.702, including, but not limited to:






	 	(1)	 	Civil monetary penalties in the amounts
specified in this Contract.






	 	(2)	 	Appointment of temporary management for the
Health Plan. Rules for temporary management pursuant to 42 CFR 438.706
are as follows:






	 	(a)	 	The State may impose temporary
management only if it finds (through on-site survey, Enrollee
Grievances, financial audits, or any other means) that:






	 	(i)	 	There is
continued egregious behavior by the Health Plan,
including but not limited to behavior that is described
in 42 CFR 438.700;






	 	(ii)	 	There is
substantial risk to Enrollees’ health;






	 	(iii)	 	The sanction is
necessary to ensure the health of the Health Plan’s
Enrollees;






	 	(iv)	 	While
improvements are made to remedy the Health Plan’s
violation(s) under 42 CFR 438.700; and/or






	 	(v)	 	Until there is an
orderly termination or reorganization of the Health
Plan.






	 	(3)	 	The State must impose temporary management
(regardless of any other sanction that may be imposed) if it finds that
the Health Plan has repeatedly failed to meet substantive requirements
in 42 CFR 438.706. The State must also grant Enrollees the right to
terminate Enrollment without Cause, as described in 42 CFR
438.702(a)(3), and must notify the affected Enrollees of their right to
terminate Enrollment.






	 	(4)	 	The State shall not delay imposition of
temporary management to provide a hearing before imposing this
sanction.






	 	(5)	 	The State shall not terminate temporary
management until it determines that the Health Plan can ensure that the
sanctioned behavior will not recur.






	 	g.	 	Granting Enrollees the right to terminate Enrollment without
Cause and notifying affected Enrollees of their right to disenroll;






	 	h.	 	Suspension or limitation of all new Enrollment, including
Mandatory Enrollment, after the effective date of the sanction;






	 	i.	 	Suspension of payment for Enrollees after the effective date of
the sanction and until CMS or the Agency is satisfied that the reason for
imposition of the sanction no longer exists and is not likely to recur; and/or






	 	j.	 	Before imposing any intermediate sanctions, the State must give
the Health Plan timely notice according to 42 CFR 438.710.






	 	7.	 	If the Health Plan’s CHCUP Screening compliance rate is below sixty percent
(60%), it must submit to the Agency, and implement, an Agency accepted CAP. If the
Health Plan does not meet the standard established in the CAP during the time period
indicated in the plan, the Agency has the authority to impose sanctions in accordance
with this Section;






	 	8.	 	Unless the duration of a sanction is specified, a sanction shall remain in
effect until the Agency is satisfied that the basis for imposing the sanction has been
corrected and is not likely to recur; and/or





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Section XV




Financial Requirements





	A.	 	Insolvency Protection






	 	1.	 	The Health Plan shall establish a restricted Insolvency protection account with
a federally guaranteed financial institution licensed to do business in Florida (See
Section 1903(m)(1) of the Social Security Act as amended by Section 4706 of the
Balanced Budget Act of 1997, and Section 409.912, F.S.). The Health Plan shall deposit
into that account five percent (5%) of the capitation payments made by the Agency each
month until a maximum total of two percent (2%) of the total current Contract amount is
reached. No interest may be withdrawn from this account until the maximum Contract
amount is reached. This provision shall remain in effect as long as the Health Plan
continues to contract with the Agency. The restricted Insolvency protection account
may be drawn upon with the authorized signatures of two (2) persons designated by the
Health Plan and two (2) representatives of the Agency. The signature card shall be
resubmitted when a change in authorized personnel occurs. If the authorized persons
remain the same, the Health Plan shall submit an attestation to this effect annually.
The Health Plan may obtain a sample Multiple Signature Verification Agreement form from
the Agency or its Agent. All such agreements or other signature cards must be approved
in advance by the Agency.






	 	2.	 	In the event that a determination is made by the Agency that the Health Plan is
insolvent, as defined in Section I Definitions, of this Contract, the Agency may draw
upon the amount solely with the two (2) authorized signatures of representatives of the
Agency and funds may be disbursed to meet financial obligations incurred by the Health
Plan under this Contract. A statement of account balance shall be provided by the
Health Plan within fifteen (15) Calendar Days of request of the Agency.






	 	3.	 	If the Contract is terminated, expired, or not continued, the account balance
shall be released by the Agency to the Health Plan upon receipt of proof of
satisfaction of all outstanding obligations incurred under this Contract.






	 	4.	 	In the event the Contract is terminated or not renewed and the Health Plan is
Insolvent, the Agency may draw upon the Insolvency protection account to pay any
outstanding debts the Health Plan owes the Agency including, but not limited to,
overpayments made to the Health Plan and fines imposed under the Contract or Section
641.52, F.S., for which a final order has been issued. In addition, if the Contract is
terminated or not renewed and the Health Plan is unable to pay all of its outstanding
debts to health care providers, the Agency and the Health Plan agree to the court
appointment of an impartial receiver for the purpose of administering and distributing
the funds contained in the Insolvency protection account. Should a receiver be
appointed, he or she shall give outstanding debts owed to the Agency priority over
other claims.






	B.	 	Insolvency Protection Account Waiver






Pursuant to Section 409.912, the Agency may waive the Insolvency protection account
requirement, in writing, when evidence of adequate Insolvency insurance and reinsurance are
on file with the Agency which shall protect Enrollees in the event the Health Plan is unable
to meet its obligations.




	C.	 	Surplus Start Up Account






All new Health Plans, after initial Contract execution, but prior to initial Enrollee
Enrollment, shall submit to the Agency, if a private entity, proof of working capital in the
form of cash or liquid assets, excluding revenues from Medicaid premium payments, equal to
at least the first three (3) months of operating expenses or $200,000, whichever is greater.
This provision shall not apply to Health Plans that have been providing services to
Enrollees for a period exceeding three (3) continuous months.




	D.	 	Surplus Requirement






	 	1.	 	In accordance with Section 409.912, F.S., the Health Plan shall maintain at all
times in the form of cash, investments that mature in less than 180 Calendar Days and
allowable as admitted assets by the Department of Financial Services, and restricted
funds of deposits controlled by the Agency (including the Health Plan’s Insolvency
protection account) or the Department of Financial Services, a Surplus amount equal to
one and one half (11/2) times the Health Plan’s monthly Medicaid prepaid revenues. In
the event that the Health Plan’s Surplus falls below an amount equal to one and one
half (11/2) times the Health Plan’s monthly Medicaid prepaid revenues, the Agency shall:






	 	a.	 	Prohibit the Health Plan from engaging in Marketing and Request
for Benefit Information activities;






	 	b.	 	Shall cease to process new Enrollments until the required
balance is achieved; and/or






c. May terminate the Health Plan’s Contract.




	E.	 	Interest






	 	1.	 	Interest generated through investments made by the Health Plan under this
Contract shall be the property of the Health Plan and shall be used at the Health
Plan’s discretion.






	F.	 	Inspection and Audit of Financial Records






	 	1.	 	The State and DHHS may inspect and audit any financial records of the Health
Plan or its Subcontractors. Pursuant to section 1903(m)(4)(A) of the Social Security
Act and State Medicaid Manual 2087.6(A-B), non-federally qualified health plans must
report to the State, upon request, and to the Secretary and the Inspector General of
DHHS, a description of certain transactions with parties of interest as defined in
Section 1318(b) of the Social Security Act.






	G.	 	Physician Incentive Plans






	 	1.	 	Physician incentive plans shall comply with 42 CFR 417.479, 42 CFR 438.6(h), 42
CFR 422.208 and 42 CFR 422.210. The Health Plan shall make no specific payment,
directly or indirectly, under a physician incentive plan to a physician or physician
group as an inducement to reduce or limit Medically Necessary services furnished to an
individual Enrollee. Physician incentive plans must not contain provisions which
provide incentives, monetary or otherwise, for the withholding of Medically Necessary
care.






	 	2.	 	The Health Plan shall disclose information on physician incentive plans listed
in 42 CFR 417.479(h)(1) and 42 CFR 417.479(i) at the times indicated in 42 CFR
417.479(d)-(g). All such arrangements must be submitted to the Agency for approval, in
writing, prior to use. If any other type of withhold arrangement currently exists, it
must be omitted from all Provider contracts.






	H.	 	Third Party Resources






	 	1.	 	The Health Plan must specify whether it will assume full responsibility for
third party collections in accordance with this Section.






	 	2.	 	The Health Plan shall be responsible for making every reasonable effort to
determine the legal liability of third parties to pay for services rendered to
Enrollees under this Contract. The Health Plan has the same rights to recovery of the
full value of services as the Agency (see Section 409.910, F.S.). The following
standards govern recovery:






	 	a.	 	If the Health Plan has determined that third party liability
exists for part or all of the services provided directly by the Health Plan to
an Enrollee, the Health Plan shall make all reasonable efforts to recover from
third party liable sources the value of services rendered.






	 	b.	 	If the Health Plan determines that third party liability exists
for part or all of the services provided to an Enrollee by a Subcontractor or
referral Provider, and the third party is reasonably expected to make payment
within 120 Calendar Days, the Health Plan may pay the Subcontractor or referral
Provider only the amount, if any, by which the Subcontractor’s or referral
Provider’s allowable claim exceeds the amount of the anticipated third party
payment; or, the Health Plan may assume full responsibility for third party
collections for services provided through the Subcontractor or referral
Provider.






	 	c.	 	The Health Plan may not withhold payment for services provided
to an Enrollee if third party liability or the amount of liability cannot be
determined, or if payment shall not be available within a reasonable time,
beyond 120 Calendar Days from the date of receipt.






	 	d.	 	When both the Agency and the Health Plan have liens against the
proceeds of a third party resource, the Agency shall prorate the amount due to
Medicaid to satisfy such liens between the Agency and the Health Plan (see
Section 409.910, F.S.). This prorated amount shall satisfy both liens in full.






	 	e.	 	The Agency may, at its sole discretion, offer to provide third
party recovery services to the Health Plan. If the Health Plan elects to
authorize the Agency to recover on its behalf, the Health Plan shall be
required to provide the necessary data for recovery in the format prescribed by
the Agency. All recoveries, less the Agency’s cost to recover shall be income
to the Health Plan. The Health Plan shall express the cost to recover as a
percentage of recoveries and shall be fixed at the time the Health Plan elects
to authorize the Agency to recover on its behalf.






	 	f.	 	All funds recovered from third parties shall be treated as
income for the Health Plan.






	I.	 	Fidelity Bonds






	 	1.	 	The Health Plan shall secure and maintain during the life of this Contract a
blanket fidelity bond from a company doing business in the State of Florida on all
personnel in its employment. The bond shall be issued in the amount of at least
$250,000 per occurrence. Said bond shall protect the Agency from any losses sustained
through any fraudulent or dishonest act or acts committed by any employees of the
Health Plan and Subcontractors, if any. Proof of coverage must be submitted to the
Agency’s contract manager within sixty (60) Calendar Days after execution of the
Contract and prior to the delivery of health care. To be acceptable to the Agency for
fidelity bonds, a surety company shall comply with the provisions of Chapter 624, F.S.





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Terms and Conditions





	A.	 	Agency Contract Management






	 	1.	 	The Division of Medicaid within the Agency shall be responsible for management
of the Contract. The Division of Medicaid shall make all statewide policy
decision-making or Contract interpretation. In addition, the Division of Medicaid
shall be responsible for the interpretation of all federal and State laws, rules and
regulations governing, or in any way affecting, this Contract. Management shall be
conducted in good faith, with the best interest of the State and the Medicaid
Recipients it serves being the prime consideration. The Agency shall provide final
interpretation of general Medicaid policy. When interpretations are required, the
Health Plan shall submit written requests to the Agency’s contract manager.






	 	2.	 	The terms of this Contract do not limit or waive the ability, authority or
obligation of the Office of Inspector General, the Bureau of Medicaid Program
Integrity, its contractors, or other duly constituted government units (State or
federal) to audit or investigate matters related to, or arising out of this Contract.






	 	3.	 	The Contract shall only be amended as follows:






	 	a.	 	The parties cannot amend or alter the terms of this Contract
without a written amendment.






	 	b.	 	The Agency and the Health Plan understand that any such written
amendment to amend or alter the terms of this Contract shall be executed by an
officer of both parties, who is duly authorized to bind the Agency and the
Health Plan.






	 	c.	 	Only a person authorized by the Agency and a person authorized
by the Health Plan may amend or alter the terms of this Contract.






	B.	 	Applicable Laws and Regulations






	 	1.	 	The Health Plan agrees to comply with all applicable federal and State laws,
rules and regulations including but not limited to: Title 42 CFR Chapter IV,
Subchapter C; Title 45 CFR Part 74, General Grants Administration Requirements;
Chapters 409 and 641, F.S.; all applicable standards, orders, or regulations issued
pursuant to the Clean Air Act of 1970 as amended (42 USC 1857, et seq.); Title VI of
the Civil Rights Act of 1964 (42 USC 2000d) in regard to persons served; Title IX of
the education amendments of 1972 (regarding education programs and activities); 42 CFR
431, Subpart F; Section 409.907(3)(d), F.S., and Rule 59G-8.100 (24)(b), F.A.C. in
regard to the contractor safeguarding information about Enrollees; Title VII of the
Civil Rights Act of 1964 (42 USC 2000e) in regard to employees or applicants for
employment; Rule 59G-8.100, F.A.C.; Section 504 of the Rehabilitation Act of 1973, as
amended, 29 USC 794 (which prohibits discrimination on the basis of handicap in
programs and activities receiving or benefiting from federal financial assistance); the
Age Discrimination Act of 1975, as amended, 42 USC 6101 et. seq. (which prohibits
discrimination on the basis of age in programs or activities receiving or benefiting
from federal financial assistance); the Omnibus Budget Reconciliation Act of 1981, P.L.
97-35, which prohibits discrimination on the basis of sex and religion in programs and
activities receiving or benefiting from federal financial assistance; Medicare -
Medicaid Fraud and Abuse Act of 1978; the federal Omnibus Budget Reconciliation Acts;
Americans with Disabilities Act (42 USC 12101, et seq.); the Newborns’ and Mothers’
Health Protection Act of 1996, the Balanced Budget Act of 1997, and the Health
Insurance Portability and Accountability Act of 1996. The Health Plan is subject to
any changes in federal and state law, rules, or regulations.






	C.	 	Assignment






	 	1.	 	Except as provided below, or with the prior written approval of the Agency,
which approval shall not be unreasonably withheld, this Contract and the monies which
may become due are not to be assigned, transferred, pledged or hypothecated in any way
by the Health Plan, including by way of an asset or stock purchase of the Health Plan,
and shall not be subject to execution, attachment or similar process by the Health
Plan.






	 	a.	 	When a merger or acquisition of a health plan has been approved
by the Department of Financial Services (see Section 628.4615, F.S.), the
Agency shall approve the assignment or transfer of the appropriate Medicaid
health plan contract upon the request of the surviving entity of the merger or
acquisition if the health plan and the surviving entity have been in good
standing with the Agency for the most recent twelve (12) month period, unless
the Agency determines that the assignment or transfer would be detrimental to
Medicaid Recipients or the Medicaid program (see Section 409.912, F.S.). The
entity requesting the assignment or transfer shall notify the Agency of the
request ninety (90) days prior to the anticipated effective date.






	 	b.	 	To be in good standing, a Health Plan must not have failed
accreditation or committed any material violation of the requirements of
Section 641.52, F.S., and must meet the Medicaid contract requirements.






	 	c.	 	For the purposes of this section, a merger or acquisition means
a change in controlling interest of a health plan, including an asset or stock
purchase.






	D.	 	Attorney’s Fees






	 	1.	 	In the event of a dispute, each party to the Contract shall be responsible for
its own attorneys’ fees, except as otherwise provided by law.






	E.	 	Conflict of Interest






	 	1.	 	This Contract is subject to the provisions of Chapter 112, F.S. The Health
Plan shall disclose the name of any officer, director, or agent who is an employee of
the State of Florida, or any of its agencies. Further, the Health Plan shall disclose
the name of any State employee who owns, directly or indirectly, an interest of five
percent (5%) or more in the offerer’s firm or any of its branches. The Health Plan
covenants that it presently has no interest and shall not acquire any interest, direct
or indirect, which would conflict in any manner or degree with the performance of the
services hereunder. The Health Plan further covenants that in the performance of the
Contract no person having any such known interest shall be employed. No official or
employee of the Agency and no other public official of the State of Florida or the
federal government who exercises any functions or responsibilities in the review or
approval of the undertaking of carrying out the Contract shall, prior to completion of
this Contract, voluntarily acquire any personal interest, direct or indirect, in this
Contract or proposed Contract.






	F.	 	Contract Variation






	 	1.	 	If any provision of the Contract (including items incorporated by reference) is
declared or found to be illegal, unenforceable, or void, then both the Agency and the
Health Plan shall be relieved of all obligations arising under such provisions. If the
remainder of the Contract is capable of performance, it shall not be affected by such
declaration or finding and shall be fully performed. In addition, if the laws or
regulations governing this Contract should be amended or judicially interpreted as to
render the fulfillment of the Contract impossible or economically infeasible, both the
Agency and the Health Plan shall be discharged from further obligations created under
the terms of the Contract. However, such declaration or finding shall not affect any
rights or obligations of either party to the extent that such rights or obligations
arise from acts performed or events occurring prior to the effective date of such
declaration or finding.






	G.	 	Court of Jurisdiction or Venue






	 	1.	 	For purposes of any legal action occurring as a result of, or under, this
Contract, between the Health Plan and the Agency, the place of proper venue shall be
Leon County.






	H.	 	Damages for Failure to Meet Contract Requirements






	 	1.	 	In addition to any remedies available through this Contract, in law or equity,
the Health Plan shall reimburse the Agency for any federal disallowances or sanctions
imposed on the Agency as a result of the Health Plan’s failure to abide by the terms of
this Contract.






	I.	 	Disputes






	 	1.	 	The Health Plan may request in writing an interpretation of the Contract from
the contract manager. In the event the Health Plan disputes this interpretation, the
Health Plan may request that the dispute be decided by the Division of Medicaid. The
ability to dispute an interpretation does not apply to issues that are a matter of law
or fact. Any disputes shall be decided by the Agency’s Division of Medicaid which
shall reduce the decision to writing and serve a copy on the Health Plan. The written
decision of the Agency’s Division of Medicaid shall be final and conclusive. The
division will render its final decision based upon the written submission of the Health
Plan and the Agency, unless, at the sole discretion of the Division director, the
division allows an oral presentation by the Health Plan and the Agency. If such a
presentation is allowed, the information presented will be considered in rendering the
division’s decision. Should the Health Plan challenge an Agency decision through
arbitration as provided below, the Agency action shall not be stayed except by order of
an arbitrator. Thereafter, a Health Plan shall resolve any controversy or claim
arising out of, or relating to, the Contract, or the breach thereof, by arbitration.
Said arbitration shall be held in the City of Tallahassee, Florida, and administered by
the American Arbitration Association in accordance with its applicable rules and the
Florida Arbitration Code (chapter 682, F.S.). Judgment upon any award rendered by the
arbitrator may be entered by the Circuit Court in and for the Second Judicial Circuit,
Leon County, Florida. The chosen arbitrator must be a member of the Florida Bar
actively engaged in the practice of law with expertise in the process of deciding
disputes and interpreting contracts in the health care field. Any arbitration award
shall be in writing and shall specify the factual and legal bases for the award.
Either party may appeal a judgment entered pursuant to an arbitration award to the
First District Court of Appeal. The parties shall bear their own costs and expenses
relating to the preparation and presentation of a case in arbitration. The arbitrator
shall award to the prevailing party all administrative fees and expenses of the
arbitration, including the arbitrator’s fee. This Contract with numbered attachments
represents the entire agreement between the Health Plan and the Agency with respect to
the subject matter in it and supersedes all other contracts between the parties when it
is duly signed and authorized by the Health Plan and the Agency. Correspondence and
memoranda of understanding do not constitute part of this Contract. In the event of a
conflict of language between the Contract and the attachments, the provisions of the
Contract shall govern. However, the Agency reserves the right to clarify any
contractual relationship in writing with the concurrence of the Health Plan and such
clarification shall govern. Pending final determination of any dispute over an Agency
decision, the Health Plan shall proceed diligently with the performance of the Contract
and in accordance with the Agency’s Division of Medicaid direction.






	J.	 	Force Majeure






	 	1.	 	The Agency shall not be liable for any excess cost to the Health Plan if the
Agency’s failure to perform the Contract arises out of causes beyond the control and
without the result of fault or negligence on the part of the Agency. In all cases, the
failure to perform must be beyond the control without the fault or negligence of the
Agency. The Health Plan shall not be liable for performance of the duties and
responsibilities of the Contract when its ability to perform is prevented by causes
beyond its control. These acts must occur without the fault or negligence of the
Health Plan. These include destruction to the facilities due to hurricanes, fires,
war, riots, and other similar acts. Annually by May 31, the Health Plan shall submit
to the Agency for approval an emergency management plan specifying what actions the
Health Plan shall conduct to ensure the ongoing provisions of health services in a
disaster or man-made emergency.






	K.	 	Legal Action Notification






	 	1.	 	The Health Plan shall give the Agency, by certified mail, immediate written
notification (no later than thirty (30) Calendar Days after service of process) of any
action or suit filed or of any claim made against the Health Plan by any Subcontractor,
vendor, or other party which results in litigation related to this Contract for
disputes or damages exceeding the amount of $50,000. In addition, the Health Plan
shall immediately advise the Agency of the Insolvency of a Subcontractor or of the
filing of a petition in bankruptcy by or against a principal Subcontractor.






	L.	 	Licensing






	 	1.	 	In accordance with Section 409.912, F.S., all entities that provide Medicaid
prepaid health care services must be commercially licensed in accordance with the
provisions of Part I and Part III of Chapter 641, F.S.






	M.	 	Misuse of Symbols, Emblems, or Names in Reference to Medicaid






	 	1.	 	No person or Health Plan may use, in connection with any item constituting an
advertisement, solicitation, circular, book, pamphlet or other communication, or a
broadcast, telecast, or other production, alone or with other words, letters, symbols
or emblems the words “Medicaid,” or “Agency for Health Care Administration,” except as
required in the Agency’s Standard Contract, page two (2), unless prior written approval
is obtained from the Agency. Specific written authorization from the Agency is
required to reproduce, reprint, or distribute any Agency form, application, or
publication for a fee. State and local governments are exempt from this prohibition.
A disclaimer that accompanies the inappropriate use of program or Agency terms does not
provide a defense. Each piece of mail or information constitutes a violation.






	N.	 	Offer of Gratuities






	 	1.	 	By signing this agreement, the Health Plan signifies that no member of, or a
delegate of, Congress, nor any elected or appointed official or employee of the State
of Florida, the General Accounting Office, Department of Health and Human Services,
CMS, or any other federal agency has or shall benefit financially or materially from
this procurement. The Agency may terminate this Contract may be terminated by the
Agency if it is determined that gratuities of any kind were offered to, or received by,
any officials or employees from the State, its agents, or employees.






	O.	 	Subcontracts






	 	1.	 	The Health Plan is responsible for all work performed under this Contract, but
may, with the prior written approval of the Agency, enter into Subcontracts for the
performance of work required under this Contract. All Subcontracts must comply with 42
CFR 438.230. All Subcontracts and amendments executed by the Health Plan shall meet
the following requirements. All Subcontractors must be eligible for participation in
the Medicaid program; however, the Subcontractor is not required to participate in the
Medicaid program as a provider. The Agency encourages use of minority business
enterprise Subcontractors. See Section X.C., Provider Contract Requirements, above of
this Contract, for provisions and requirements specific to Provider contracts.






	 	2.	 	No Subcontract that the Health Plan enter into with respect to performance
under the Contract shall, in any way, relieve the Health Plan of any responsibility for
the performance of duties under this Contract. The Health Plan shall assure that all
tasks related to the Subcontract are performed in accordance with the terms of this
Contract. The Health Plan shall identify in its Subcontracts any aspect of service
that may be further subcontracted by the Subcontractor.






	 	3.	 	All model and executed Subcontracts and amendments used by the Health Plan
under this Contract must be in writing, signed, and dated by the Health Plan and the
Subcontractor and meet the following requirements:






	 	a.	 	Identification of conditions and method of payment:






	 	(1)	 	The Health Plan agrees to make payment to all
Subcontractors pursuant to all State and federal laws, rules and
regulations, specifically, Section 641.3155, F.S., 42 CFR 447.46, and
42 CFR 447.45(d)(2), (3), (d)(5) and (d)(6);






	 	(2)	 	Provide for prompt submission of information
needed to make payment;






	 	(3)	 	Make full disclosure of the method and amount
of compensation or other consideration to be received from the Health
Plan;






	 	(4)	 	Require an adequate record system be maintained
for recording services, charges, dates and all other commonly accepted
information elements for services rendered to the Health Plan; and






	 	(5)	 	Specify that the Health Plan shall assume
responsibility for cost avoidance measures for third party collections
in accordance with Section XV., Financial Requirements.






	 	b.	 	Provisions for monitoring and inspections:






	 	(1)	 	Provide that the Agency and DHHS may evaluate
through inspection or other means the quality, appropriateness and
timeliness of services performed;






	 	(2)	 	Provide for inspections of any records
pertinent to the Contract by the Agency and DHHS;






	 	(3)	 	Require that records be maintained for a period
not less than five (5) years from the close of the Contract and
retained further if the records are under review or audit until the
review or audit is complete. (Prior approval for the disposition of
records must be requested and approved by the Health Plan if the
Subcontract is continuous.)






	 	(4)	 	Provide for monitoring and oversight by the
Health Plan and the Subcontractor to provide assurance that all
licensed medical professionals are Credentialed in accordance with the
Health Plan’s and the Agency’s Credentialing requirements as found in
Section VIII.A.3.h Credentialing and Recredentialing, above, if the
Health Plan has delegated the Credentialing to a Subcontractor; and






	 	(5)	 	Provide for monitoring of services rendered to
Enrollees sponsored by the Provider.






	 	c.	 	Specification of functions of the Subcontractor:






	 	(1)	 	Identify the population covered by the
Subcontract;






	 	(2)	 	Provide for submission of all reports and
clinical information required by the Health Plan, including Child
Health Check-Up reporting (if applicable); and






	 	(3)	 	Provide for the participation in any internal
and external quality improvement, utilization review, peer review, and
grievance procedures established by the Health Plan.






	 	d.	 	Protective clauses:






	 	(1)	 	Require safeguarding of information about
Enrollees according to 42 CFR, Part 438.224;






	 	(2)	 	Require compliance with HIPAA privacy and
security provisions;






	 	(3)	 	Require an exculpatory clause, which survives
Subcontract termination, including breach of Subcontract due to
insolvency, which assures that Medicaid Recipients or the Agency will
not be held liable for any debts of the Subcontractor; and






	 	(4)	 	If there is a Health Plan physician incentive
plan, include a statement that the Health Plan shall make no specific
payment directly or indirectly under a physician incentive plan to a
Subcontractor as an inducement to reduce or limit Medically Necessary
services to an Enrollee, and affirmatively state that all incentive
plans do not provide incentives, monetary or otherwise, for the
withholding of Medically Necessary care.






	 	4.	 	Contain a clause indemnifying, defending and holding the Agency and the Health
Plan’s Enrollees harmless from and against all claims, damages, causes of action, costs
or expenses, including court costs and reasonable attorney fees, to the extent
proximately caused by any negligent act or other wrongful conduct arising from the
Subcontract agreement. This clause must survive the termination of the Subcontract,
including breach due to Insolvency. The Agency may waive this requirement for itself,
but not Health Plan Enrollees, for damages in excess of the statutory cap on damages
for public entities, if the Subcontractor is a public health entity with statutory
immunity. All such waivers must be approved in writing by the Agency.






	 	5.	 	Require that the Subcontractor secure and maintain, during the life of the
Subcontract, worker’s compensation insurance for all of its employees connected with
the work under this Contract unless such employees are covered by the protection
afforded by the Health Plan. Such insurance shall comply with Florida’s Worker’s
Compensation Law.






	 	6.	 	Specify that if the Subcontractor delegates or Subcontracts any functions of
the Health Plan, that the Subcontract or delegation includes all the requirements of
this Contract.






	 	7.	 	Make provisions for a waiver of those terms of the Subcontract, which, as they
pertain to Medicaid Recipients, are in conflict with the specifications of this
Contract.






	 	8.	 	Provide for revoking delegation, or imposing other sanctions, if the
Subcontractor’s performance is inadequate.






	P.	 	Hospital Provider Contracts






All Hospital Provider Contracts must meet the requirements outlined in Section X.C.,
Provider Contract Requirements, above. In addition, Hospital Provider Contracts shall
require that the Hospitals notify the Health Plan of births where the mother is a Health
Plan Enrollee. The Hospital Provider Contract must also specify which entity (Health Plan
or Hospital) is responsible for completing form DCF-ES 2039 and submitting it to the local
DCF Economic Self-Sufficiency Services office. The Hospital Provider Contract must also
indicate that the Health Plan’s name must be indicated as the referring Agency when the form
DCF-ES 2039 is completed.




	Q.	 	Termination Procedures






	 	1.	 	In conjunction with Section III.B., Termination, on page eight (8) of the
Standard Contract, all Provider Contracts and Subcontracts shall contain termination
procedures. The Health Plan agrees to extend the thirty (30) Calendar Days notice
found in Section III.B.1., Termination at Will, on page eight (8) of the Standard
Contract to ninety (90) Calendar Days notice. The party initiating the termination
shall render written notice of termination to the other party by certified mail, return
receipt requested, or in person with proof of delivery, or by facsimile letter followed
by certified mail, return receipt requested. The notice of termination shall specify
the nature of termination, the extent to which performance of work under the Contract
is terminated, and the date on which such termination shall become effective. In
accordance with 1932(e)(4), Social Security Act, the Agency shall provide the Health
Plan with an opportunity for a hearing prior to termination for Cause. This does not
preclude the Agency from terminating without Cause.






	 	2.	 	Upon receipt of final notice of termination, on the date and to the extent
specified in the notice of termination, the Health Plan shall:






	 	a.	 	Stop work under the Contract, but not before the termination
date.






	 	b.	 	Cease enrollment of new Enrollees under the Contract.






	 	c.	 	Terminate all Marketing activities and Subcontracts relating to
Marketing.






	 	d.	 	Assign to the State those Subcontracts as directed by the
Agency’s contracting officer including all the rights, title and interest of
the Health Plan for performance of those Subcontracts.






	 	e.	 	In the event the Agency has terminated this Contract in one or
more Agency areas of the State, complete the performance of this Contract in
all other areas in which the Health Plan’s Contract was not terminated.






	 	f.	 	Take such action as may be necessary, or as the Agency’s
contracting officer may direct, for the protection of property related to the
Contract that is in the possession of the Health Plan and in which the Agency
has been granted or may acquire an interest.






	 	g.	 	Not accept any payment after the Contract ends, unless the
payment is for the time period covered under the Contract. Any payments due
under the terms of this Contract may be withheld until the Agency receives from
the Health Plan all written and properly executed documents as required by the
written instructions of the Agency.






	 	h.	 	At least sixty (60) Calendar Days prior to the termination
effective date, provide written notification to all Enrollees of the following
information: the date on which the Health Plan will no longer participate in
the State’s Medicaid program and instructions on contacting the Agency’s Choice
Counselor/Enrollment Broker help line to obtain information on the Enrollee’s
enrollment options and to request a change in Health Plans.






	R.	 	Waiver






	 	1.	 	No covenant, condition, duty, obligation, or undertaking contained in or made a
part of the Contract shall be waived except by written agreement of the parties, and
forbearance or indulgence in any other form or manner by either party in any regard
whatsoever shall not constitute a waiver of the covenant, condition, duty, obligation,
or undertaking to be kept, performed, or discharged by the party to which the same may
apply. Until complete performance or satisfaction of all such covenants, conditions,
duties, obligations, or undertakings, the other party shall have the right to invoke
any remedy available under law or equity not withstanding any such forbearance or
indulgence.






	S.	 	Withdrawing Services from a County






	 	1.	 	If the Health Plan intends to withdraw services from a county, it shall provide
written notice to all Enrollees in that county at least sixty (60) Calendar Days before
the last day of service. The notice shall contain the same information as required for
a notice of termination according to Section XVI.Q., Terms and Conditions, Termination
Procedures, of this Contract. The Health Plan shall also provide written notice of the
withdrawal to all Providers and Subcontractors in the county.






	T.	 	MyFloridaMarketPlace Vendor Registration






	 	1.	 	The Health Plan is exempt under Rule 60A-1.030(3)d(ii), Florida Administrative
Code, from being required to register in MyFloridaMarketPlace for this Contract.






	U.	 	MyFloridaMarketplace Vendor Registration and Transaction Fee Exemption






	 	1.	 	The Health Plan is exempted from paying the 1% transaction fee per
60A-1.032(1)(g) of the Florida Administrative Code for this Contract.






	V.	 	Ownership and Management Disclosure






	 	1.	 	Federal and State laws require full disclosure of ownership, management and
control of Disclosing Entities.






	 	a.	 	Disclosure shall be made on forms prescribed by the Agency for
the areas of ownership and control interest (42 CFR 455.104, Form CMS 1513),
business transactions (42 CFR 455.105), public entity crimes (Section
287.133(3)(a), F.S.), and disbarment and suspension (52 Fed. Reg., pages
20360-20369, and Section 4707 of the Balanced Budget Act of 1997). The forms
are available through the Agency and are to be submitted to the Agency with the
initial application for a Medicaid Health Plan and then submitted on an annual
basis. The Health Plan shall disclose any changes in management as soon as
those occur. In addition, the Health Plan shall submit to the Agency full
disclosure of ownership and control of the Health Plan at least sixty (60)
Calendar Days before any change in the Health Plan’s ownership or control
occurs.






	 	b.	 	The following definitions apply to ownership disclosure:






	 	(1)	 	A person with an ownership interest or control
interest means a person or corporation that:






	 	(a)	 	Owns, indirectly or directly,
five percent (5%) or more of the Health Plan’s capital or
stock, or receives five percent (5%) or more of its profits;






	 	(b)	 	Has an interest in any
mortgage, deed of trust, note, or other obligation secured in
whole or in part by the Health Plan or by its property or
assets and that interest is equal to or exceeds five percent
(5%) of the total property or assets; or






	 	(c)	 	Is an officer or director of
the Health Plan, if organized as a corporation, or is a partner
in the Health Plan, if organized as a partnership.






	 	(2)	 	The percentage of direct ownership or control
is calculated by multiplying the percent of interest which a person
owns, by the percent of the Health Plan’s assets used to secure the
obligation. Thus, if a person owns ten percent (10%) of a note secured
by sixty percent (60%) of the Health Plan’s assets, the person owns six
percent (6%) of the Health Plan.






	 	(3)	 	The percent of indirect ownership or control is
calculated by multiplying the percentage of ownership in each
organization. Thus, if a person owns ten percent (10%) of the stock in
a corporation, which owns eighty percent (80%) of the Health Plan’s
stock, the person owns eight percent (8%) of the Health Plan.






	 	c.	 	The following definitions apply to management disclosure:






	 	(1)	 	Changes in management are defined as any change
in the management control of the Health Plan. Examples of such changes
are those listed below or equivalent positions by another title.






	 	(a)	 	Changes in the board of
directors or officers of the Health Plan, medical director,
chief executive officer, administrator, and chief financial
officer.






	 	(b)	 	Changes in the management of
the Health Plan where the Health Plan has decided to contract
out the operation of the Health Plan to a management
corporation. The Health Plan shall disclose such changes in
management control and provide a copy of the contract to the
Agency for approval at least sixty (60) Calendar Days prior to
the management contract start date.






	 	d.	 	The Health Plan shall conduct an annual background check with
the Florida Department of Law Enforcement on all persons with five percent (5%)
or more ownership interest in the Health Plan, or who have executive management
responsibility for the Health Plan, or have the ability to exercise effective
control of the Health Plan (see Section 409.912, F.S.). The Health Plan shall
submit information to the Agency for such persons who have a record of illegal
conduct according to the background check. The Health Plan shall keep a record
of all background checks to be available for Agency review upon request.






	 	(1)	 	The Health Plan shall submit, prior to
execution of a contract, complete sets of fingerprints of principals of
the Health Plan to the Agency for the purpose of conducting a criminal
history record check (see Section 409.907, F.S.).






	 	(2)	 	Principals of the Health Plan shall be as
defined in Section 409.907, F.S.






	 	e.	 	The Health Plan shall submit to the Agency, within five (5)
Business Days, any information on any officer, director, agent, managing
employee, or owner of stock or beneficial interest in excess of five percent
(5%) of the Health Plan who has been found guilty of, regardless of
adjudication, or who entered a plea of nolo contendere or guilty to, any of the
offenses listed in Section 435.03, F.S.






	 	f.	 	The Agency shall not contract with a Health Plan that has an
officer, director, agent, managing employee, or owner of stock or beneficial
interest in excess of five percent (5%) of the Health Plan, who has committed
any of the above listed offenses (see Section 409.912, F.S.). In order to
avoid termination, the Health Plan must submit a corrective action plan,
acceptable to the Agency, which ensures that such person is divested of all
interest and/or control and has no role in the operation and/or management of
the Health Plan.






	W.	 	Minority Recruitment and Retention Plan






	 	1.	 	The Health Plan shall implement and maintain a minority recruitment and
retention plan in accordance with section 641.217, F.S. The Health Plan shall have
policies and procedures for the implementation and maintenance of such a plan. The
minority recruitment and retention plan may be company-wide for all product lines.






	X.	 	Independent Provider






	 	1.	 	It is expressly agreed that the Health Plan and any Subcontractors, and any
agents, officers, and/or employees of the Health Plan or any Subcontractors, in the
performance of this Contract shall act in an independent capacity and not as officers
and employees of the Agency or the State of Florida. It is further expressly agreed
that this Contract shall not be construed as a partnership or joint venture between the
Health Plan or any Subcontractor and the Agency and the State of Florida.






	Y.	 	General Insurance Requirements






	 	1.	 	The Health Plan shall obtain and maintain the same adequate insurance coverage
including general liability insurance, professional liability and malpractice
insurance, fire and property insurance, and directors’ omission and error insurance.
All insurance coverage must comply with the provisions set forth for HMOs in Rule
69O-191.069, F.A.C.; excepting that the reporting, administrative, and approval
requirements shall be to the Agency rather than to the Department of Financial
Services. All insurance policies must be written by insurers licensed to do business
in the State of Florida and in good standing with the Department of Financial Services.
All policy declaration pages must be submitted to the Agency annually. Each
certificate of insurance shall provide for notification to the Agency in the event of
termination of the policy.






	Z.	 	Worker’s Compensation Insurance






	 	1.	 	The Health Plan shall secure and maintain during the life of the Contract,
worker’s compensation insurance for all of its employees connected with the work under
this Contract. Such insurance shall comply with the Florida Worker’s Compensation Law
(see Chapter 440, F.S.). Policy declaration pages must be submitted to the Agency
annually.






	AA.	 	State Ownership






	 	1.	 	The Agency shall have the right to use, disclose, or duplicate all information
and data developed, derived, documented, or furnished by the Health Plan resulting from
this Contract. Nothing herein shall entitle the Agency to disclose to third parties
data or information which would otherwise be protected from disclosure by State or
federal law.






	BB.	 	Disaster Plan






	 	1.	 	The Health Plan shall submit a plan describing procedures guaranteeing the
continuation of services during an emergency, including but not limited to localized
acts of nature, accidents, and technological and/or attack-related emergencies.





REMAINDER OF PAGE INTENTIONALLY LEFT BLANK




38




ATTACHMENT III

BUSINESS ASSOCIATE AGREEMENT




The parties to this Attachment agree that the following provisions constitute a business
associate agreement for purposes of complying with the requirements of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA). This Attachment is applicable if the Vendor is
a business associate within the meaning of the Privacy and Security Regulations, 45 C.F.R. 160 and
164.



The Vendor certifies and agrees as to abide by the following:




	1.	 	Definitions. Unless specifically stated in this Attachment, the definition of the
terms contained herein shall have the same meaning and effect as defined in 45 C.F.R. 160 and
164.






	 	 	 	1.a. Protected Health Information. For purposes of this Attachment, protected
health information shall have the same meaning and effect as defined in 45 C.F.R. 160 and
164, limited to the information created, received, maintained or transmitted by the Vendor
from, or on behalf of, the Agency.






	 	 	 	1.b. Security Incident. For purposes of this Attachment, security incident shall
mean any event resulting in computer systems, networks, or data being viewed, manipulated,
damaged, destroyed or made inaccessible by an unauthorized activity. See National
Institute of Standards and Technology (NIST) Special Publication 800-61, “Computer
Security Incident Handling Guide,” for more information.






	2.	 	Use and Disclosure of Protected Health Information. The Vendor shall not use or
disclose protected health information other than as permitted by this Contract or by federal
and state law. The Vendor will use appropriate safeguards to prevent the use or disclosure of
protected health information for any purpose not in conformity with this Contract and federal
and state law. The Vendor will implement administrative, physical, and technical safeguards
that reasonably and appropriately protect the confidentiality, integrity, and availability of
electronic protected health information the Vendor creates, receives, maintains, or transmits
on behalf of the Agency.






	3.	 	Use and Disclosure of Information for Management, Administration, and
Legal Responsibilities. The Vendor is permitted to use and disclose protected
health information received from the Agency for the proper management and administration of
the Vendor or to carry out the legal responsibilities of the Vendor, in accordance with 45
C.F.R. 164.504(e)(4). Such disclosure is only permissible where required by law, or where the
Vendor obtains reasonable assurances from the person to whom the protected health information
is disclosed that: (1) the protected health information will be held confidentially, (2) the
protected health information will be used or further disclosed only as required by law or for
the purposes for which it was disclosed to the person, and (3) the person notifies the Vendor
of any instance of which it is aware in which the confidentiality of the protected health
information has been breached.





AHCA Contract No. FA614, Attachment III, Page 1 of 3




AHCA Form 2100-0017 (Rev. JAN 05)








39




	4.	 	Disclosure to Third Parties. The Vendor will not divulge, disclose, or
communicate protected health information to any third party for any purpose not in conformity
with this Contract without prior written approval from the Agency. The Vendor shall ensure
that any agent, including a subcontractor, to whom it provides protected health information
received from, or created or received by the Vendor on behalf of, the Agency agrees to the
same terms, conditions, and restrictions that apply to the Vendor with respect to protected
health information.






	5.	 	Access to Information. The Vendor shall make protected health information available
in accordance with federal and state law, including providing a right of access to persons
who are the subjects of the protected health information in accordance with 45 C.F.R.
164.524.






	6.	 	Amendment and Incorporation of Amendments. The Vendor shall make protected health
information available for amendment and to incorporate any amendments to the protected health
information in accordance with 45 C.F.R. § 164.526.






	7.	 	Accounting for Disclosures. The Vendor shall make protected health information
available as required to provide an accounting of disclosures in accordance with 45 C.F.R. §
164.528. The Vendor shall document all disclosures of protected health information as needed
for the Agency to respond to a request for an accounting of disclosures in accordance with 45
C.F.R. § 164.528.






	8.	 	Access to Books and Records. The Vendor shall make its internal practices, books,
and records relating to the use and disclosure of protected health information received from,
or created or received by the Vendor on behalf of the Agency, available to the Secretary of
the Department of Health and Human Services or the Secretary’s designee for purposes of
determining compliance with the Department of Health and Human Services Privacy Regulations.






	9.	 	Reporting. The Vendor shall make a good faith effort to identify any use or
disclosure of protected health information not provided for in this Contract. The Vendor will
report to the Agency, within ten (10) business days of discovery, any use or disclosure of
protected health information not provided for in this Contract of which the Vendor is aware.
The Vendor will report to the Agency, within twenty-four (24) hours of discovery, any
security incident of which the Vendor is aware. A violation of this paragraph shall be a
material violation of this Contract.






	10.	 	Termination. Upon the Agency’s discovery of a material breach of this Attachment,
the Agency shall have the right to terminate this Contract.






	 	 	 	10.a. Effect of Termination. At the termination of this Contract, the Vendor shall
return all protected health information that the Vendor still maintains in any form,
including any copies or hybrid or merged databases made by the Vendor; or with prior
written approval of the Agency, the protected health information may be destroyed by the
Vendor after its use. If the protected health information is destroyed pursuant to the
Agency’s prior written approval, the Vendor must provide a written confirmation of





AHCA Contract No. FA614, Attachment III, Page 2 of 3




AHCA Form 2100-0017 (Rev. JAN 05)



40





such destruction to the Agency. If return or destruction of the protected
health information is determined not feasible by the Agency, the Vendor agrees to protect
the protected health information and treat it as strictly confidential.



The Vendor has caused this Attachment to be signed and delivered by its duly authorized
representative, as of the date set forth below.



	 	 	 
	Vendor Name:

	 	

	Signature

	 	Date






Name and Title of Authorized Signer




REMAINDER OF PAGE INTENTIONALLY LEFT BLANK



AHCA Contract No. FA614, Attachment III, Page 3 of 3




AHCA Form 2100-0017 (Rev. JAN 05)





41





AHCA Form 2100-0010 (Rev. OCT02)



ATTACHMENT IV




CERTIFICATION REGARDING LOBBYING




CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS




The undersigned certifies, to the best of his or her knowledge and belief, that:




	(1)	 	No federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or employee
of any agency, a member of congress, an officer or employee of congress, or an employee of a
member of congress in connection with the awarding of any federal contract, the making of any
federal grant, the making of any federal loan, the entering into of any cooperative
agreement, and the extension, continuation, renewal, amendment, or modification of any
federal contract, grant, loan, or cooperative agreement.






	(2)	 	If any funds other than federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency, a
member of congress, an officer or employee of congress, or an employee of a member of
congress in connection with this federal contract, grant, loan, or cooperative agreement, the
undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report
Lobbying,” in accordance with its instructions.






	(3)	 	The undersigned shall require that the language of this certification be included in the
award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and
contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall
certify and disclose accordingly.





This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for
making or entering into this transaction imposed by section 1352, Title 31, U.S. Code. Any person
who fails to file the required certification shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.



	 	 	 
	Signature

Name of Authorized Individual

	 	Date

Application or Contract Number






Name and Address of Organization




AHCA Contract No. FA614, Attachment IV, Page 1 of 1



42




AHCA Form 2100-0009 (JAN 03)



ATTACHMENT V




CERTIFICATION REGARDING




DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION




CONTRACTS/SUBCONTRACTS




This certification is required by the regulations implementing Executive Order 12549,

Debarment and




Suspension, signed February 18, 1986. The guidelines were published in the May 29, 1987, Federal
Register (52 Fed. Reg., pages 20360-20369).



INSTRUCTIONS





	1.	 	Each Vendor whose contract/subcontract equals or exceeds $25,000 in federal monies must sign
this certification prior to execution of each contract/subcontract. Additionally, Vendors who
audit federal programs must also sign, regardless of the contract amount. The Agency for
Health Care Administration cannot contract with these types of Vendors if they are
debarred or suspended by the federal government.






	2.	 	This certification is a material representation of fact upon which reliance is placed when
this contract/subcontract is entered into. If it is later determined that the signer
knowingly rendered an erroneous certification, the Federal Government may pursue available
remedies, including suspension and/or debarment.






	3.	 	The Vendor shall provide immediate written notice to the contract manager at any time the
Vendor learns that its certification was erroneous when submitted or has become erroneous by
reason of changed circumstances.






	4.	 	The terms “debarred,” “suspended,” “ineligible,” “person,” “principal,” and “voluntarily
excluded,” as used in this certification, have the meanings set out in the Definitions and
Coverage sections of rules implementing Executive Order 12549. You may contact the contract
manager for assistance in obtaining a copy of those regulations.






	5.	 	The Vendor agrees by submitting this certification that, it shall not knowingly enter into
any subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily
excluded from participation in this contract/subcontract unless authorized by the Federal
Government.






	6.	 	The Vendor further agrees by submitting this certification that it will require each
subcontractor of this contract/subcontract, whose payment will equal or exceed $25,000 in
federal monies, to submit a signed copy of this certification.






	7.	 	The Agency for Health Care Administration may rely upon a certification of a Vendor that it
is not debarred, suspended, ineligible, or voluntarily excluded from
contracting/subcontracting unless it knows that the certification is erroneous.






	8.	 	This signed certification must be kept in the contract manager’s contract file.
Subcontractor’s certifications must be kept at the contractor’s business location.





CERTIFICATION





	(1)	 	The prospective Vendor certifies, by signing this certification, that neither he nor
his principals is presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded from participation in this contract/subcontract by any federal
department or agency.






	(2)	 	Where the prospective Vendor is unable to certify to any of the statements in this
certification, such prospective Vendor shall attach an explanation to this certification.






Signature Date




Name and Title of Authorized Signer



AHCA Contract No. FA614, Attachment V, Page 1 of I





43