Exhibit 10.5
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Contract No. YH14-0001
TABLE OF CONTENTS
SECTION A. CONTRACT AMENDMENT
1
SECTION B: CAPITATION RATES AND CONTRACTOR SPECIFIC REQUIREMENTS
5
SECTION C: DEFINITIONS
6
PART 1. DEFINITIONS PERTAINING TO ALL AHCCCS CONTRACTS
6
PART 2. DEFINITIONS PERTAINING TO ONE OR MORE AHCCCS CONTRACTS
20
SECTION D: ACUTE CARE PROGRAM REQUIREMENTS
28
1.
PURPOSE, APPLICABILITY, AND INTRODUCTION
28
2.
ELIGIBILITY CATEGORIES
29
3.
ENROLLMENT AND DISENROLLMENT
31
4.
ANNUAL AND OPEN ENROLLMENT CHOICE
33
5.
RESERVED
33
6.
AUTO-ASSIGNMENT ALGORITHM
33
7.
AHCCCS MEMBER IDENTIFICATION CARDS
34
8.
MAINSTREAMING OF AHCCCS MEMBERS
34
9.
TRANSITION ACTIVITIES
35
10.
SCOPE OF SERVICES
36
11.
SPECIAL HEALTH CARE NEEDS
46
12.
BEHAVIORAL HEALTH SERVICES
47
13.
AHCCCS GUIDELINES, POLICIES AND MANUALS
50
14.
MEDICAID SCHOOL BASED CLAIMING PROGRAM (MSB)
50
15.
PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM
51
16.
STAFF REQUIREMENTS AND SUPPORT SERVICES
51
17.
WRITTEN POLICIES AND PROCEDURES
56
18.
MEMBER INFORMATION
56
19.
SURVEYS
58
20.
CULTURAL COMPETENCY
58
21.
MEDICAL RECORDS
58
22.
ADVANCE DIRECTIVES
59
23.
QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT (QM/PI)
60
24.
MEDICAL MANAGEMENT (MM)
66
25.
TELEPHONE PERFORMANCE STANDARDS
68
26.
GRIEVANCE SYSTEM
68
27.
NETWORK DEVELOPMENT
69
28.
PROVIDER AFFILIATION TRANSMISSION
70
29.
NETWORK MANAGEMENT
70
30.
PRIMARY CARE PROVIDER STANDARDS
72
31.
MATERNITY CARE PROVIDER STANDARDS
73
32.
REFERRAL MANAGEMENT PROCEDURES AND STANDARDS
73
33.
APPOINTMENT STANDARDS
74
34.
FEDERALLY QUALIFIED HEALTH CENTERS (FQHCs) AND RURAL HEALTH CLINICS (RHCs)
75
35.
PROVIDER MANUAL
75
36.
PROVIDER REGISTRATION
76
37.
SUBCONTRACTS
76
38.
CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM
78
39.
SPECIALTY CONTRACTS
81
40.
HOSPITAL SUBCONTRACTING AND REIMBURSEMENT
82
41.
RESPONSIBILITY FOR NURSING FACILITY REIMBURSEMENT
82
42.
INCENTIVES/PAY FOR PERFORMANCE
83
2
Acute Care Contract
01/01/2014
Contract No. YH14-0001
43.
MANAGEMENT SERVICES AGREEMENT AND COST ALLOCATION PLAN
83
44.
MATERIAL CHANGE TO OPERATIONS
84
45.
MINIMUM CAPITALIZATION
84
46.
PERFORMANCE BOND OR BOND SUBSTITUTE
84
47.
AMOUNT OF PERFORMANCE BOND
85
48.
ACCUMULATED FUND DEFICIT
85
49.
ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS
85
50.
FINANCIAL VIABILITY STANDARDS
86
51.
SEPARATE INCORPORATION
87
52.
MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP
87
53.
COMPENSATION
87
54.
PAYMENTS TO CONTRACTORS
90
55.
CAPITATION ADJUSTMENTS
90
56.
MEMBER BILLING AND LIABILITY FOR PAYMENT
91
57.
REINSURANCE
92
58.
COORDINATION OF BENEFITS/THIRD PARTY LIABILITY
95
59.
COPAYMENTS
98
60.
MEDICARE SERVICES AND COST SHARING
98
61.
MARKETING
99
62.
CORPORATE COMPLIANCE
99
63.
RECORDS RETENTION
102
64.
SYSTEMS AND DATA EXCHANGE REQUIREMENTS
102
65.
ENCOUNTER DATA REPORTING
104
66.
ENROLLMENT AND CAPITATION TRANSACTION UPDATES
106
67.
PERIODIC REPORT REQUIREMENTS
107
68.
REQUESTS FOR INFORMATION
107
69.
DISSEMINATION OF INFORMATION
107
70.
OPERATIONAL AND FINANCIAL READINESS REVIEWS
108
71.
OPERATIONAL REVIEWS
108
72.
SANCTIONS
108
73.
BUSINESS CONTINUITY AND RECOVERY PLAN
109
74.
MEDICARE REQUIREMENTS
109
75.
PENDING LEGISLATION/OTHER ISSUES
110
SECTION E: CONTRACT TERMS AND CONDITIONS
113
1.
ADVERTISING AND PROMOTION OF CONTRACT
113
2.
APPLICABLE LAW
113
3.
ARBITRATION
113
4.
ASSIGNMENT AND DELEGATION
113
5.
ASSIGNMENT OF CONTRACT AND BANKRUPTCY