Document:

CONTRACT

    Exhibit
      10.4(a)

     

     

    
      
        	
                 

                Part
                  1: Parties to the Contract: 

                 

              
	
                 

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

                 

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

                 

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

                 

              
	
                 

                Part
                  2: Effective Date of Amendment: 

                 

              	
                 

                Part
                  3: Contract Expiration Date 

              	
                 

                Part
                  4: Operational Start Date: 

              
	
                 

                February
                  1, 2007 

                 

              	
                 

                August
                  31, 2008 

                 

              	
                 

                STAR
                  and CHIP HMOs: September 1, 2006 

                 

                STAR+PLUS
                  HMOs: February 1, 2007 

                 

                CHIP
                  Perinatal HMOs: January 1, 2007 

                 

              
	
                 

                Part
                  5: Project Managers: 

                 

              
	
                 

                HHSC:
                  

                 

                Cindy
                  Jorgensen 

                Director
                  of Medicaid/CHIP Health Plan Operations 

                11209
                  Metric Boulevard, Building H 

                Austin,
                  Texas 78758 

                Phone:
                  512-491-1302 

                Fax:
                  512-491-1966 

              	
                 

                HMO:
                  

                 

                Stacey
                  Hull 

                Vice
                  President of Regulatory Affairs 

                2100
                  South IH-35, Suite 202 

                Austin,
                  Texas 78704 

                Phone:
                  512-692-1465 

                Fax:
                  512-692-1474 

                E-mail:
                  shull@centene.com

              
	
                 

                Part
                  6: Deliver Legal Notices to: 

                 

              
	
                 

                HHSC:
                  

                 

                General
                  Counsel 

                4900
                  North Lamar Boulevard, 4th
                  Floor 

                Austin,
                  Texas 78751 

                Fax:
                  512-424-6586 

                 

              	
                 

                HMO:
                  

                 

                Superior
                  HealthPlan 

                2100
                  South IH-35, Suite 202 

                Austin,
                  Texas 78704 

                Fax:
                  512-692-1435 

                 

              

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      

      
        	
                 

                Part
                  7: HMO Programs and Service Areas: 

                 

              
	
                 

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

                 

              
	
                 

                 Medicaid
                  STAR HMO Program 

                 

              
	
                 

                Service
                  Areas: 

                 

              	
                 

                
                  T
                    Bexar 

                

                
                  £
                    Dallas 

                

                T
El
                  Paso 

                £
Harris

              	
                 

                T
Lubbock

                T
Nueces

                £
Tarrant

                T
Travis

                 

              
	
                 

                See
                  Attachment B-6, “Map of Counties with HMO Program Service Areas,” for
                  listing of counties included within the STAR Service Areas. 

                 

              
	
                 

                Medicaid
                  STAR+PLUS HMO Program 

                 

              
	
                 

                Service
                  Areas: 

                 

              	
                 

                T
Bexar

                £
Harris

                 

              	
                 

                T
Nueces

                £
Travis

                 

              
	
                 

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

                 

              
	
                 

                 CHIP
                  HMO Program 

                 

              
	
                 

                Core
                  Service Areas: 

                 

              	
                 

                T
Bexar

                £
Dallas

                T
El
                  Paso 

                £
Harris

                T
Lubbock

              	
                 

                T
Nueces 

                £
Tarrant

                T
Travis

                £
Webb

              
	
                 

                Optional
                  Service Areas: 

                 

              	
                 

                T
Bexar

                T
El
                  Paso 

                £
Harris

                 

              	
                 

                T
Lubbock 

                T
Nueces 

                T
Travis 

                 

              
	
                 

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

                 

              
	
                 

                CHIP
                  Perinatal Program 

                 

              
	
                 

                Core
                  Service Areas: 

                 

                 

                 

                 

              	
                 

                T
Bexar

                £
Dallas

                T
El
                  Paso 

                £
Harris

                   
  T
Lubbock 

                 

              	
                 

                T
Nueces

                £
Tarrant

                T
Travis

                £
Webb
 

                 

              
	
                 

                Optional
                  Service Areas: 

                 

              	
                 

                T
Bexar

                T
El
                  Paso 

                £
Harris

                 

              	
                 

                T
Lubbock 

                T
Nueces 

                T
Travis

                 

              
	
                 

                See
                  Attachment B-6.2, “Map of Counties with CHIP Perinatal HMO Program Service
                  Areas,” for a list of counties included within the CHIP Perinatal Service
                  Areas. 

                 

              

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      

      
        	
                 

                Part
                  8: Payment 

                 

              
	 

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

                 

                Medicaid
                  STAR HMO PROGRAM 

                 

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

              

      

       

      

        

         

        
          	
                   

                	
                   Service
                    Area: BEXAR

                
	
                   

                    

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  Capitation
                    Rates 

                
	
                   1
                    

                	
                   TANF
                    Adult 

                	
                   $
                    261.68

                
	
                   2
                    

                	
                   TANF
                    Child >12 months 

                	
                   $
                    87.11

                
	
                   3
                    

                	
                   Expansion
                    Child >12 months 

                	
                   $
                    87.41

                
	
                   4
                    

                	
                   Newborn
                    <
                    12 months 

                	
                   $
                    650.47

                
	
                   5
                    

                	
                   TANF
                    child <
                    12 months 

                	
                   $
                    280.34

                
	
                   6
                    

                	
                   Expansion
                    child <
                    12 months 

                	
                   $
                    184.41

                
	
                   7
                    

                	
                   Federal
                    Mandate child 

                	
                   $
                    67.40

                
	
                   8
                    

                	
                   Pregnant
                    Woman 

                	
                   $
                    399.99

                
	
                   9
                    

                	
                   Delivery
                    Supplemental Payment 

                	
                   $3,166.59

                

        

         

        
          	
                   

                	
                   Service
                    Area: EL
                    PASO 

                
	
                   

                   

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  Capitation
                    Rates 

                
	
                   1
                    

                	
                   TANF
                    Adult

                	
                   $
                    219.32

                
	
                   2
                    

                	
                   TANF
                    Child >12 months 

                	
                   $
                    75.90

                
	
                   3
                    

                	
                   Expansion
                    Child >12 months 

                	
                   $
                    90.95

                
	
                   4
                    

                	
                   Newborn
                    <
                    12 months 

                	
                   $
                    556.63

                
	
                   5
                    

                	
                   TANF
                    child <
                    12 months 

                	
                   $
                    238.42

                
	
                   6
                    

                	
                   Expansion
                    child <
                    12 months 

                	
                   $
                    181.32

                
	
                   7
                    

                	
                   Federal
                    Mandate child 

                	
                   $
                    66.95

                
	
                   8
                    

                	
                   Pregnant
                    Woman 

                	
                   $
                    380.91

                
	
                   9
                    

                	
                   Delivery
                    Supplemental Payment 

                	
                   $3,343.04

                

        

      

       

      
        
          	
                   

                	
                   Service
                    Area: LUBBOCK 

                
	
                   

                   

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  Capitation
                    Rates 

                
	
                   1
                    

                	
                   TANF
                    Adult 

                	
                   $
                    253.16

                
	
                   2
                    

                	
                   TANF
                    Child >12 months 

                	
                   $
                    86.38

                
	
                   3
                    

                	
                   Expansion
                    Child >12 months 

                	
                   $
                    88.21

                
	
                   4
                    

                	
                   Newborn
                    <
                    12 months 

                	
                   $
                    416.38

                
	
                   5
                    

                	
                   TANF
                    child <
                    12 months 

                	
                   $
                    207.08

                
	
                   6
                    

                	
                   Expansion
                    child <
                    12 months 

                	
                   $
                    238.86

                
	
                   7
                    

                	
                   Federal
                    Mandate child 

                	
                   $
                    76.09

                
	
                   8
                    

                	
                   Pregnant
                    Woman 

                	
                   $
                    510.74

                
	
                   9
                    

                	
                   Delivery
                    Supplemental Payment 

                	
                   $3,130.39

                

        

         

        
          	
                   

                	
                   Service
                    Area: NUECES

                
	
                   

                    

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  Capitation
                    Rates 

                
	
                   1
                    

                	
                   TANF
                    Adult 

                	
                   $
                    230.50

                
	
                   2
                    

                	
                   TANF
                    Child >12 months 

                	
                   $
                    88.46

                
	
                   3
                    

                	
                   Expansion
                    Child >12 months 

                	
                   $
                    92.31

                
	
                   4
                    

                	
                   Newborn
                    <
                    12 months 

                	
                   $
                    670.99

                
	
                   5
                    

                	
                   TANF
                    child <
                    12 months 

                	
                   $
                    322.76

                
	
                   6
                    

                	
                   Expansion
                    child <
                    12 months 

                	
                   $
                    322.76

                
	
                   7
                    

                	
                   Federal
                    Mandate child 

                	
                   $
                    67.25

                
	
                   8
                    

                	
                   Pregnant
                    Woman 

                	
                   $
                    292.08

                
	
                   9
                    

                	
                   Delivery
                    Supplemental Payment 

                	
                   $3,103.82

                

        

         

        
          	
                   

                	
                   Service
                    Area: TRAVIS 

                
	
                   

                    

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  Capitation
                    Rates 

                
	
                   1
                    

                	
                   TANF
                    Adult 

                	
                   $
                    195.85

                
	
                   2
                    

                	
                   TANF
                    Child >12 months 

                	
                   $
                    73.05

                
	
                   3
                    

                	
                   Expansion
                    Child >12 months 

                	
                   $
                    86.18

                
	
                   4
                    

                	
                   Newborn
                    <
                    12 months 

                	
                   $
                    740.08

                
	
                   5
                    

                	
                   TANF
                    child <
                    12 months 

                	
                   $
                    213.76

                
	
                   6
                    

                	
                   Expansion
                    child <
                    12 months 

                	
                   $
                    215.26

                
	
                   7
                    

                	
                   Federal
                    Mandate child 

                	
                   $
                    64.06

                
	
                   8
                    

                	
                   Pregnant
                    Woman 

                	
                   $
                    417.81

                
	
                   9
                    

                	
                   Delivery
                    Supplemental Payment 

                	
                   $3,147.49

                

        

      

       

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

                 

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

                 

              

      

       

       

       

      
        	
                 Medicaid
                  STAR+PLUS HMO Program 

                 

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

              

      

       

      

        
          	
                  STAR+PLUS
                    Service Area: BEXAR 

                
	
                   

                    

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  Capitation
                    Rates 

                	
                  Rate
                    Period 2 

                  Capitation
                    Rates 

                
	
                   1.
                    

                	
                  Medicaid
                    Only Standard Rate 

                	
                  $
                    388.93

                	
                  $
                    403.69

                
	
                   2.
                    

                	
                  Medicaid
                    Only 1915(C) Nursing Facility Waiver Rate 

                	
                  $
                    2,755.92

                	
                  $
                    2,873.79

                
	
                   3.
                    

                	
                  Dual
                    Eligible Standard Rate 

                	
                  $
                    251.00

                	
                  $
                    259.76

                
	
                   4.
                    

                	
                  Dual
                    Eligible 1915(C) Nursing Facility Waiver Rate 

                	
                  $
                    1,704.75

                	
                  $
                    1,776.84

                
	
                   5.
                    

                	
                  Nursing
                    Facility - Medicaid Only 

                	
                  $
                    388.93

                	
                  $
                    403.69

                
	
                   6.
                    

                	
                  Nursing
                    Facility - Dual Eligible 

                	
                  $
                    251.00

                	
                  $
                    259.76

                

        

         

        
          	
                  STAR+PLUS
                    Service Area: NUECES 

                
	
                   

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  Capitation
                    Rates 

                	
                   Rate
                    Period 2 

                  Capitation
                    Rates 

                
	
                   1.
                    

                	
                  Medicaid
                    Only Standard Rate 

                	
                  $
                    453.61

                	
                  $
                    471.19

                
	
                   2.
                    

                	
                  Medicaid
                    Only 1915(C) Nursing Facility Waiver Rate 

                	
                  $
                    2,689.23

                	
                  $
                    2,804.20

                
	
                   3.
                    

                	
                  Dual
                    Eligible Standard Rate 

                	
                  $
                    311.35

                	
                  $
                    322.73

                
	
                   4.
                    

                	
                  Dual
                    Eligible 1915(C) Nursing Facility Waiver Rate 

                	
                  $
                    1,666.27

                	
                  $
                    1,736.68

                
	
                   5.
                    

                	
                  Nursing
                    Facility - Medicaid Only 

                	
                  $
                    453.61

                	
                  $
                    471.19

                
	
                   6.
                    

                	
                  Nursing
                    Facility - Dual Eligible 

                	
                  $
                    311.35

                	
                  $
                    322.73

                

        

      

       

      
        	
                CHIP
                  HMO PROGRAM 

                 

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

              

      

       

      

        
          	
                  Service
                    Area: BEXAR 

                
	
                   

                   

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  Capitation
                    Rates 

                
	
                   1
                    

                	
                   <
                    Age 1 

                	
                   $
                    100.58

                
	
                   2
                    

                	
                   Ages
                    1 through 5 

                	
                   $
                    78.71

                
	
                   3
                    

                	
                   Ages
                    6 through 14 

                	
                   $
                    61.06

                
	
                   4
                    

                	
                   Ages
                    15 through 18 

                	
                   $
                    84.70

                

        

         

        
          	
                  Service
                    Area: EL PASO 

                
	
                   

                   

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  Capitation
                    Rates 

                
	
                   1
                    

                	
                   <
                    Age 1 

                	
                   $
                    61.24

                
	
                   2
                    

                	
                   Ages
                    1 through 5 

                	
                   $
                    73.74

                
	
                   3
                    

                	
                   Ages
                    6 through 14 

                	
                   $
                    57.09

                
	
                   4
                    

                	
                   Ages
                    15 through 18 

                	
                   $
                    67.88

                

        

         

        
          	
                  Service
                    Area: LUBBOCK 

                
	
                   

                    

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  Capitation
                    Rates 

                
	
                   1
                    

                	
                   <
                    Age 1 

                	
                   $
                    56.26

                
	
                   2
                    

                	
                   Ages
                    1 through 5 

                	
                   $
                    76.79

                
	
                   3
                    

                	
                   Ages
                    6 through 14 

                	
                   $
                    68.04

                
	
                   4
                    

                	
                   Ages
                    15 through 18 

                	
                   $
                    93.75

                

        

         

        
          	
                  Service
                    Area: NUECES 

                
	
                    

                   

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  Capitation
                    Rates 

                
	
                   1
                    

                	
                   <
                    Age 1 

                	
                   $
                    89.40

                
	
                   2
                    

                	
                   Ages
                    1 through 5 

                	
                   $
                    93.77

                
	
                   3
                    

                	
                   Ages
                    6 through 14 

                	
                   $
                    78.78

                
	
                   4
                    

                	
                   Ages
                    15 through 18 

                	
                   $
                    97.60

                

        

         

        
          	Service
                  Area: TRAVIS 
	
                   

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  Capitation
                    Rates 

                
	
                   1
                    

                	
                   <
                    Age 1 

                	
                   $
                    63.15

                
	
                   2
                    

                	
                   Ages
                    1 through 5 

                	
                   $
                    90.64

                
	
                   3
                    

                	
                   Ages
                    6 through 14 

                	
                   $
                    83.08

                
	
                   4
                    

                	
                   Ages
                    15 through 18 

                	
                   $
                    124.32

                

        

      

       

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

              

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      

      
        	
                 CHIP
                  Perinatal Program 

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

              

      

       

       

      

        
          	
                  Service
                    Area: BEXAR 

                
	
                    

                   

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  CapitationRates

                
	
                   1
                    

                	
                   
                    Perinate 0% - 185% 

                	
                   $
                    152.35

                
	
                   2
                    

                	
                   Perinate
                    186% - 200% 

                	
                   $
                    152.35

                
	
                   3
                    

                	
                   Perinate
                    Newborn 0% - 185% 

                	
                   $
                    335.90

                
	
                   4
                    

                	
                   Perinate
                    Newborn 186% - 200% 

                	
                   $
                    683.52

                

        

         

        
          	
                  Service
                    Area: EL PASO 

                
	
                    

                   

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  Capitation
                    Rates 

                
	
                   1
                    

                	
                   
                    Perinate 0% - 185% 

                	
                   $
                    152.35

                
	
                   2
                    

                	
                   Perinate
                    186% - 200% 

                	
                   $
                    152.35

                
	
                   3
                    

                	
                   Perinate
                    Newborn 0% - 185% 

                	
                   $
                    287.45

                
	
                   4
                    

                	
                   Perinate
                    Newborn 186% - 200% 

                	
                   $
                    584.91

                

        

         

        
          	
                  Service
                    Area: LUBBOCK 

                
	
                    

                   

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  Capitation
                    Rates 

                
	
                   1
                    

                	
                   
                    Perinate 0% - 185% 

                	
                   $
                    152.35

                
	
                   2
                    

                	
                   Perinate
                    186% - 200% 

                	
                   $
                    152.35

                
	
                   3
                    

                	
                   Perinate
                    Newborn 0% - 185% 

                	
                   $
                    215.02

                
	
                   4
                    

                	
                   Perinate
                    Newborn 186% - 200% 

                	
                   $
                    437.53

                

        

         

        
          	
                  Service
                    Area: NUECES 

                
	
                   

                    

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  Capitation
                    Rates 

                
	
                   1
                    

                	
                   
                    Perinate 0% - 185% 

                	
                   $
                    152.35

                
	
                   2
                    

                	
                   Perinate
                    186% - 200% 

                	
                   $
                    152.35

                
	
                   3
                    

                	
                   Perinate
                    Newborn 0% - 185% 

                	
                   $
                    346.50

                
	
                   4
                    

                	
                   Perinate
                    Newborn 186% - 200% 

                	
                   $
                    705.08

                

        

         

        
          	
                  Service
                    Area: TRAVIS 

                
	
                   

                    

                   

                	
                   Rate
                    Cell 

                	
                   Rate
                    Period 1 

                  Capitation
                    Rates 

                
	
                   1
                    

                	
                   Perinate
                    0% - 185% 

                	
                   $
                    152.35

                
	
                   2
                    

                	
                   Perinate
                    186% - 200% 

                	
                   $
                    152.35

                
	
                   3
                    

                	
                   Perinate
                    Newborn 0% - 185% 

                	
                   $
                    380.66

                
	
                   4
                    

                	
                   Perinate
                    Newborn 186% - 200% 

                	
                   $
                    774.58

                

        

      

       

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

                 

              

      

       

       

      
        	
                 

                Part
                  9: Contract Attachments: 

                 

              
	
                 

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

                 

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

                 

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

                 

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

                B-2:
                  Covered Services 

                B-2.1
                  STAR+PLUS Covered Services 

                B-2.2
                  CHIP Perinatal Program Covered Services   

                B-3:
                  Value-added Services 

                B-3.1
                  STAR+PLUS Value-added Services 

                B-3.2
                  CHIP Perinatal Program Value-added Services   

                B-4:
                  Performance Improvement Goals  

                B-4.1
                  SFY 2008 Performance Improvement Goals  

                B-5:
                  Deliverables/Liquidated Damages Matrix  

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

                B-6.1
                  STAR+PLUS Service Areas 

                B-6.2
                  CHIP Perinatal Program Service Areas 

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

                 

                C:
                  HMO’s Proposal and Related Documents 

                 

                C-1:
                  HMO’s Proposal 

                C-2:
                  HMO Supplemental Responses 

                C-3:
                  Agreed Modifications to HMO’s Proposal 

                 

                 

              
	
                 

                Part
                  10: Signatures: 

                 

              
	
                 

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

                 

              
	
                 

                Texas
                  Health and Human Services Commission 

                 

                Charles
                  E. Bell, M.D. 

                 

                Deputy
                  Executive Commissioner for Health Services 

                 

                Date:
                  ________________________________ 

                 

              	
                 

                Superior
                  HealthPlan, Inc. 

                 

                By: 
                  /s/ Christopher Bowers 

                 

                Title:
                  President and CEO 

                 

                Date:
                  _January 29, 2007_______________________________ 

                 

              

      

      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      

 

      
        Texas
          Health & Human Services Commission 

         

         

        Uniform
          Managed Care Contract Terms & Conditions 

         

        Version
          1.6 

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

         

        
          	
                  DOCUMENT
                    HISTORY LOG 

                
	
                  STATUS1

                	
                  DOCUMENT
                    

                  REVISION2

                	
                  EFFECTIVE
                    

                  DATE
                    

                	
                  DESCRIPTION3

                
	
                   

                  Baseline
                    

                   

                	
                   

                  n/a
                    

                   

                	
                   

                   

                   

                	
                   

                  Initial
                    version of the Uniform Managed Care Contract Terms & Conditions
                    

                   

                
	
                   

                  Revision
                    

                	
                   

                  1.1
                    

                	
                   

                  June
                    30, 2006 

                	
                   

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

                   

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

                   

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

                   

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

                   

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

                   

                
	
                   

                  Revision
                    

                	
                   

                  1.2
                    

                	
                   

                  September
                    1, 2006 

                	
                   

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

                   

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

                   

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

                   

                  Article
                    10 is amended to clarify the following sections: 10.01(d), regarding
                    the
                    fixed monthly Capitation Rate components; 10.10(c), regarding
                    updating the
                    state system for Members who become eligible for SSI. Section
                    10.17 is
                    added regarding recoupment for federal disallowance. 

                   

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

                   

                
	
                   

                  Revision
                    

                	
                   

                  1.3
                    

                	
                   

                  September
                    1, 2006 

                	
                   

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

                   

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

                   

                   

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

                
	
                   

                  Revision
                    

                	
                   

                  1.4
                    

                	
                   

                  September,
                    1 2006 

                	
                   

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

                   

                   

                
	
                   

                  Revision
                    

                	
                   

                  1.5
                    

                	
                   

                  January
                    1, 2007 

                	
                   

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

                   

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

                   

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

                   

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

                   

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

                   

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

                   

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

                
	
                   

                  Revision
                    

                	
                   

                  1.6
                    

                	
                   

                  February
                    1, 2007 

                	
                   

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

                   

                   

                
	
                   

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

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

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

                

        

        

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

         

        TABLE
          OF CONTENTS 

         

        

         

        Article
          1. Introduction...................................................................................................................................2 

         

        Section
          1.01 Purpose......................................................................................................................................2 

        Section
          1.02 Risk-based contract...................................................................................................................2 

        Section
          1.03 Inducements...............................................................................................................................2 

        Section
          1.04 Construction of the Contract......................................................................................................2 

        Section
          1.05 No implied authority...................................................................................................................3 

        Section
          1.06 Legal Authority...........................................................................................................................3 

         

        Article
          2. Definitions.....................................................................................................................................3 

         

         

        Article
          3. General Terms & Conditions.......................................................................................................15 

         

        Section
          3.01 Contract elements.....................................................................................................................15 

        Section
          3.02 Term of the Contract.................................................................................................................15 

        Section
          3.03 Funding.....................................................................................................................................15 

        Section
          3.04 Delegation of authority..............................................................................................................15 

        Section
          3.05 No waiver of sovereign immunity..............................................................................................15 

        Section
          3.06 Force majeure...........................................................................................................................15 

        Section
          3.07 Publicity.....................................................................................................................................15 

        Section
          3.08 Assignment...............................................................................................................................16 

        Section
          3.09 Cooperation with other vendors and prospective vendors........................................................16 

        Section
          3.10 Renegotiation and reprocurement rights...................................................................................16 

        Section
          3.11 RFP errors and omissions.........................................................................................................16 

        Section
          3.12 Attorneys’ fees..........................................................................................................................16 

        Section
          3.13 Preferences under service contracts.........................................................................................16 

        Section
          3.14 Time of the essence..................................................................................................................16 

        Section
          3.15 Notice........................................................................................................................................17 

         

        Article
          4. Contract Administration & Management..................................................................................17 

         

        Section
          4.01 Qualifications, retention and replacement of HMO employees.................................................17 

        Section
          4.02 HMO’s Key Personnel...............................................................................................................17 

        Section
          4.03 Executive Director.....................................................................................................................17 

        Section
          4.04 Medical Director........................................................................................................................18 

        Section
          4.04.1 STAR+PLUS Service Coordinator.........................................................................................18 

        Section
          4.05 Responsibility for HMO personnel and Subcontractors.............................................................18 

        Section
          4.06 Cooperation with HHSC and state administrative agencies......................................................19 

        Section
          4.07 Conduct of HMO personnel.......................................................................................................19 

        Section
          4.08 Subcontractors..........................................................................................................................20 

        Section
          4.09 HHSC’s ability to contract with Subcontractors.........................................................................21 

        Section
          4.10 HMO Agreements with Third Parties.........................................................................................21 

         

        Article
          5. Member Eligibility & Enrollment.................................................................................................21 

         

        Section
          5.01 Eligibility Determination.............................................................................................................21 

        Section
          5.02 Member Enrollment & Disenrollment.........................................................................................21 

        Section
          5.03 STAR enrollment for pregnant women and infants....................................................................22 

        Section
          5.04 CHIP eligibility and enrollment..................................................................................................22 

        Section
          5.05 Span of Coverage.....................................................................................................................23 

        Section
          5.06 Verification of Member Eligibility...............................................................................................23 

        Section
          5.07 Special Temporary STAR Default Process...............................................................................23 

        Section
          5.08 Special
          Temporary STAR+PLUS Default Process....................................................................23 

         

        Article
          6. Service Levels & Performance Measurement...........................................................................24 

         

        Section
          6.01 Performance measurement.......................................................................................................24 

         

        Article
          7. Governing Law & Regulations....................................................................................................24 

         

        Section
          7.01 Governing law and venue.........................................................................................................24 

        Section
          7.02 HMO responsibility for compliance with laws and
          regulations...................................................24 

        Section
          7.03 TDI licensure/ANHC certification and solvency.........................................................................25 

        Section
          7.04 Immigration Reform and Control Act of 1986............................................................................25 

        Section
          7.05 Compliance with state and federal anti-discrimination laws......................................................25 

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        Section
          7.06 Environmental protection laws..................................................................................................25 

        Section
          7.07 HIPAA.......................................................................................................................................26 

         

        Article
          8. Amendments & Modifications.....................................................................................................26 

         

        Section
          8.01 Mutual agreement.....................................................................................................................26 

        Section
          8.02 Changes in law or contract........................................................................................................26 

        Section
          8.03 Modifications as a remedy........................................................................................................26 

        Section
          8.04 Modifications upon renewal or extension of Contract................................................................26 

        Section
          8.05 Modification of HHSC Uniform Managed Care Manual.............................................................26 

        Section
          8.06 CMS
          approval of Medicaid amendments..................................................................................26 

        Section
          8.07 Required compliance with amendment and modification
          procedures.......................................26 

         

        Article
          9. Audit & Financial Compliance....................................................................................................27 

         

        Section
          9.01 Financial record retention and audit..........................................................................................27 

        Section
          9.02 Access to records, books, and documents................................................................................27 

        Section
          9.03 Audits of Services, Deliverables and inspections......................................................................27 

        Section
          9.04 SAO Audit.................................................................................................................................28 

        Section
          9.05 Response/compliance with audit or inspection findings............................................................28 

         

        Article
          10. Terms & Conditions of Payment...............................................................................................28 

         

        Section
          10.01 Calculation of monthly Capitation Payment.............................................................................28 

        Section
          10.02 Time and Manner of Payment.................................................................................................28 

        Section
          10.03 Certification of Capitation Rates..............................................................................................29 

        Section
          10.04 Modification of Capitation Rates..............................................................................................29 

        Section
          10.05 STAR Capitation Structure......................................................................................................29 

        Section
          10.05.1STAR+PLUS Capitation Structure........................................................................................30 

        Section
          10.06 CHIP Capitation Rates Structure.............................................................................................30 

        Section
          10.07 HMO input during rate setting process....................................................................................30 

        Section
          10.08 Adjustments to Capitation Payments......................................................................................31 

        Section
          10.09 Delivery Supplemental Payment for CHIP, CHIP Perinatal and STAR
          HMOs........................31 

        Section
          10.10 Administrative Fee for SSI Members.......................................................................................31 

        Section
          10.11 STAR, CHIP, and CHIP Perinatal Experience Rebate............................................................32 

        Section
          10.11.1 STAR+PLUS Experience Rebate.........................................................................................33 

        Section
          10.12 Payment by Members.............................................................................................................34 

        Section
          10.13 Restriction on assignment of fees...........................................................................................35 

        Section
          10.14 Liability for taxes.....................................................................................................................35 

        Section
          10.15 Liability for employment-related charges and benefits............................................................35 

        Section
          10.16 No additional consideration.....................................................................................................35 

        Section
          10.17 Federal Disallowance..............................................................................................................35 

         

        Article
          11. Disclosure & Confidentiality of Information...........................................................................35 

         

        Section
          11.01 Confidentiality..........................................................................................................................35 

        Section
          11.02 Disclosure of HHSC’s Confidential Information.......................................................................36 

        Section
          11.03 Member Records.....................................................................................................................36 

        Section
          11.04 Requests for public information...............................................................................................36 

        Section
          11.05 Privileged Work Product..........................................................................................................36 

        Section
          11.06 Unauthorized acts...................................................................................................................37 

        Section
          11.07 Legal action.............................................................................................................................37 

         

        Article
          12. Remedies & Disputes................................................................................................................37 

         

        Section
          12.01 Understanding and expectations.............................................................................................37 

        Section
          12.02 Tailored remedies...................................................................................................................37 

        Section
          12.03 Termination by HHSC.............................................................................................................39 

        Section
          12.04 Termination by HMO...............................................................................................................41 

        Section
          12.05 Termination by mutual agreement...........................................................................................41 

        Section
          12.06 Effective date of termination....................................................................................................41 

        Section
          12.07 Extension of termination effective date...................................................................................41 

        Section
          12.08 Payment and other provisions at Contract termination............................................................42 

        Section
          12.09 Modification of Contract in the event of remedies...................................................................42 

        Section
          12.10 Turnover assistance................................................................................................................42 

        Section
          12.11 Rights upon termination or expiration of Contract...................................................................42 

        Section
          12.12 HMO responsibility for associated costs.................................................................................42 

        Section
          12.13 Dispute resolution...................................................................................................................42 

        Section
          12.14 Liability of HMO.......................................................................................................................43 

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        Article
          13. Assurances & Certifications.....................................................................................................43 

        Section
          13.01 Proposal certifications.............................................................................................................43 

        Section
          13.02 Conflicts of interest..................................................................................................................43 

        Section
          13.03 Organizational conflicts of interest..........................................................................................43 

        Section
          13.04 HHSC personnel recruitment prohibition.................................................................................44 

        Section
          13.05 Anti-kickback provision............................................................................................................44 

        Section
          13.06 Debt or back taxes owed to State of Texas.............................................................................44 

        Section
          13.07 Certification regarding status of license, certificate, or
          permit.................................................44 

        Section
          13.08 Outstanding debts and judgments...........................................................................................44 

         

        Article
          14. Representations & Warranties..................................................................................................44 

         

        Section
          14.01 Authorization...........................................................................................................................44 

        Section
          14.02 Ability to perform.....................................................................................................................44 

        Section
          14.03 Minimum Net Worth................................................................................................................45 

        Section
          14.04 Insurer solvency......................................................................................................................45 

        Section
          14.05 Workmanship and performance..............................................................................................45 

        Section
          14.06 Warranty of deliverables.........................................................................................................45 

        Section
          14.07 Compliance with Contract.......................................................................................................45 

        Section
          14.08 Technology Access.................................................................................................................45 

         

        Article
          15. Intellectual Property..................................................................................................................46 

         

        Section
          15.01 Infringement and misappropriation..........................................................................................46 

        Section
          15.02 Exceptions...............................................................................................................................46 

        Section
          15.03 Ownership and Licenses.........................................................................................................46 

         

        Article
          16. Liability.......................................................................................................................................47 

         

        Section
          16.01 Property damage.....................................................................................................................47 

        Section
          16.02 Risk of Loss.............................................................................................................................47 

        Section
          16.03 Limitation of HHSC’s Liability..................................................................................................47 

         

        Article
          17. 
          Insurance & Bonding................................................................................................................48 

         

        Section
          17.01 Insurance Coverage................................................................................................................48 

        Section
          17.02 Performance Bond..................................................................................................................49 

        Section
          17.03 TDI Fidelity Bond.....................................................................................................................49 

        

        
          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

Article
          1. Introduction 

         

        Section
          1.01 Purpose.
          

         

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

         

        Section
          1.02 Risk-based
          contract. 

         

        This
          is a
          Risk-based contract. 

         

        Section
          1.03 Inducements.
          

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

        Section
          1.04 Construction
          of the Contract. 

         

          (a)
          Scope
          of Introductory Article. 

         

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

         

        (b)
          References to the “State.” 

         

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

         

        (c)
          Severability. 

         

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

         

        (d)
          Survival of terms. 

         

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

         

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

         

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

         

        (e)
          Headings. 

         

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

         

        (f)
          Global drafting conventions. 

         

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

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

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

         

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

         

        Section
          1.05 No
          implied authority. 

         

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

         

        (1)
          make
          public policy; 

         

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

         

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

         

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

         

        Section
          1.06 Legal
          Authority. 

         

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

         

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

         

          Article
          2. Definitions 

         

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

         

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

         

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

         

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

         

        Action
          (Medicaid only)
          means:

         

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

         

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

         

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

         

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

         

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

         

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

         

        An
          Adverse Determination is one type of Action. 

         

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

         

        Acute
          Care Hospital means
          a
          hospital that provides acute care services 

         

        Adjudicate
          means to
          deny or pay a clean claim. 

         

        Administrative
          Services
          see HMO
          Administrative Services. 

         

        Administrative
          Services Contractor see
          HHSC
          Administrative Services Contractor. 

         

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

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

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

         

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

         

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

         

        AAP
          means
          the American Academy of Pediatrics. 

         

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

         

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

         

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

         

        Auxiliary
          Aids and Services
          includes: 

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

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

         

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

         

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

         

        CHIP
          HMOs
          means
          HMOs participating in the CHIP HMO Program. 

         

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

         

        CHIP
          Perinatal Program
          means
          the State of Texas program in which HHSC contracts with HMOs to provide,
          arrange
          for, and coordinate Covered Services for enrolled CHIP Perinate and CHIP
          Perinate Newborn Members. Although the CHIP Perinatal Program is part of
          the
          CHIP Program, for Contract administration purposes it is identified
          independently in this Contract. An HMO must specifically contract with
          HHSC as a
          CHIP Perinatal HMO in order to participate in this part of the CHIP Program.
          

         

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

         

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

         

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

         

        Clean
          Claim
          means a
          claim submitted by a physician or provider for medical care or health care
          services rendered to an enrollee, with documentation reasonably necessary
          for
          the HMO to process the claim. The HMO may not require a physician or provider
          to
          submit documentation that conflicts with the requirements of Texas
          Administrative Code, Title 28, Part 1, Chapter 21, Subchapters C and T.
          

         

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

         

        COLA
          means
          the
          Cost of Living Adjustment. 

         

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

         

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

         

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

         

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

         

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

         

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

         

        Comprehensive
          Care Program:
          See
          definition for Texas Health Steps. 

         

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

         

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

         

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

         

        (3)
          All
          Privileged Work Product; 

         

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

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        as
          confidential under the Texas Public Information Act, Texas Government Code,
          Chapter 552; 

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

        Day
          means
          a
          calendar day unless specified otherwise. 

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

        Disability
          means a
          physical or mental impairment that substantially limits one or more of
          an
          individual’s major life activities, such as caring for oneself, performing
          manual tasks, walking, seeing, hearing, speaking, breathing, learning,
          and/or
          working.  

         

        Disability-related
          Access
          means
          that facilities are readily accessible to and usable by individuals with
          disabilities, and

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

         

        that
          auxiliary aids and services are provided to ensure effective communication,
          in
          compliance with Title III of the Americans with Disabilities Act. 

         

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

         

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

         

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

         

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

         

        EDI
          means
          electronic data interchange. 

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

        (2)
          serious impairment to bodily functions; 

         

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

         

        (4)
          serious disfigurement; or 

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

        Expedited
          Appeal
          means an
          appeal to the HMO in which the decision is required quickly based on the
          Member's health status, and the amount of time necessary to participate
          in a
          standard appeal could jeopardize the Member's life or health or ability
          to
          attain, maintain, or regain maximum function. 

         

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

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

         

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

         

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

         

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

         

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

         

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

         

        FPL
          means
          the Federal Poverty Level. 

         

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

         

        FSR
          means
          Financial Statistical Report. 

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

        Home
          and Community Support Services Agency or HCSS
          means an
          entity licensed to provide home health, hospice, or personal assistance
          services
          provided to individuals in their own home or independent living environment
          as

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        prescribed
          by a physician or individualized service plan. Each HCSS must provide clients
          with a plan of care that includes specific services the agency agrees to
          perform. The agencies are licensed and monitored by DADS or its successor.
          

         

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

         

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

         

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

         

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

         

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

         

        JCAHO
          means
          Joint Commission on Accreditation of Health Care Organizations. 

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

          (1)
          enroll with the HMO; or 

         

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

         

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

         

        MCO
          means
          managed care organization. 

         

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

         

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

         

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

         

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

         

        Medically
          Necessary means:
          

         

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

         

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

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

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

         

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

         

        (d)
          consistent with the diagnoses of the conditions; 

         

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

         

        (f)
          are
          not experimental or investigative; and 

         

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

         

        (2)
          Behavioral Health Services that are: 

         

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

         

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

         

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

         

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

         

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

         

        (f)
          are
          not experimental or investigative; and 

         

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

         

        Member
          means a
          person who: 

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

        MIS
          means
          Management Information System. 

         

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

         

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

         

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

         

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

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

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

         

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

         

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

         

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

         

        OB/GYN
          means
          obstetrician-gynecologist. 

         

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

         

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

         

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

         

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

         

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

         

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

         

        Parties
          means
          HHSC and HMO, collectively. 

         

        Party
          means
          either HHSC or HMO, individually.  

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

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

         

        Public
          Information
          means
          information that: 

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

        SDX
          means
          State Data Exchange. 

         

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

         

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

         

        Service
          Management is
          an
          administrative service in the STAR, CHIP and CHIP Perinatal Programs performed
          by the

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        HMO
          to
          facilitate development of a Service Plan and coordination of services among
          a
          Member’s PCP, specialty providers and non-medical providers to ensure Members
          with Special Health Care Needs and/or Members needing high-cost treatment
          have
          access to, and appropriately utilize, Medically Necessary Covered Services,
          Non-capitated Services, and other services and supports. 

         

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

         

        (1)
          the
          Member’s history; 

         

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

         

        (3)
          short
          and long term needs and goals; 

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

        SSA
          means
          the Social Security Administration. 

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

        T.A.C.
          means
          Texas Administrative Code. 

         

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

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        TDI
          means
          the Texas Department of Insurance. 

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

        Waste
          means
          practices that are not cost-efficient. 

         

        Article
          3. General Terms & Conditions 

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        Section
          3.01 Contract elements. 

         

          (a)
          Contract documentation. 

         

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

         

        (b)
          Order
          of documents. 

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

          Section
          3.02 Term
          of the Contract. 

         

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

         

        Section
          3.03 Funding.
          

         

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

         

        Section
          3.04 Delegation
          of authority. 

         

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

         

        Section
          3.05 No
          waiver of sovereign immunity. 

         

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

         

        Section
          3.06 Force
          majeure. 

         

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

         

        Section
          3.07 Publicity.
          

         

        (a)
          HMO
          may use the name of HHSC, the State of Texas, any HHS Agency, and the name
          of
          the HHSC HMO Program in any media release, public announcement, or public
          disclosure relating to the Contract or its subject matter only if, at least
          seven (7) calendar days prior to distributing the material, the HMO submits
          the
          information to HHSC for review and comment. If HHSC has not responded within
          seven (7) calendar days, the HMO may use the submitted information. HHSC
          reserves the right to object to and require changes to the publication
          if, at
          HHSC’s sole discretion, it determines that the publication does not accurately
          reflect the terms of the Contract or the HMO’s performance under the Contract. .

         

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

         

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

         

        (1)
          proposals or reports submitted to HHSC, an administrative agency of the
          State of
          Texas, or a governmental

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        agency
          or
          unit of another state or the federal government; 

         

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

         

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

         

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

         

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

         

        Section
          3.08 Assignment.
          

         

        (a)
          Assignment by HMO. 

         

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

         

        (b)
          Assignment by HHSC. 

         

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

         

        (c)
          Assumption. 

         

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

         

          Section
          3.09 Cooperation
          with other vendors and prospective vendors. 

         

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

         

        Section
          3.10 Renegotiation
          and reprocurement rights. 

         

        (a)
          Renegotiation of Contract terms. 

         

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

         

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

         

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

         

        (c)
          Termination rights upon reprocurement. 

         

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

         

        Section
          3.11 RFP
          errors and omissions. 

         

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

         

        Section
          3.12 Attorneys’
          fees. 

         

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

         

        Section
          3.13 Preferences
          under service contracts. 

         

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

         

        Section
          3.14 Time
          of the essence. 

         

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

         

        Section
          3.15 Notice
          

         

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

         

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

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        with
          return receipt requested; 

         

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

         

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

         

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

         

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

         

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

         

          Article
          4. Contract Administration & Management 

         

        Section
          4.01 Qualifications,
          retention and replacement of HMO employees. 

         

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

         

        Section
          4.02 HMO’s
          Key Personnel. 

         

          (a)
          Designation of Key Personnel. 

         

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

         

        (1)
          Member Services; 

         

        (2)
          Management Information Systems; 

         

        (3)
          Claims Processing, 

         

        (4)
          Provider Network Development and Management; 

         

        (5)
          Benefit Administration and Utilization and Care Management; 

         

        (6)
          Quality Improvement; 

         

        (7)
          Behavioral Health Services; 

         

        (8)
          Financial Functions; 

         

        (9)
          Reporting; 

         

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

         

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

         

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

         

        (b)
          Support and Replacement of Key Personnel. 

         

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

         

        (c)
          Notification of replacement of Key Personnel. 

         

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

         

          Section
          4.03 Executive
          Director. 

         

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

         

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

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

        Section
          4.04 Medical
          Director. 

         

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

         

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

         

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

         

          Section
          4.04.1
          STAR+PLUS Service Coordinator 

         

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

         

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

         

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

         

        (d)
          The
          STAR+PLUS HMO must empower its Service Coordinators to authorize the provision
          and delivery of Covered Services, including Community Long-term Care Covered
          Services. 

         

          Section
          4.05 Responsibility
          for HMO personnel and Subcontractors. 

         

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

         

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

         

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

         

        (d)
          HMO
          agrees that any claim on behalf of any person arising out of employment
          or
          alleged employment by the HMO (including, but not limited to, claims of
          discrimination against HMO, its officers, or its agents) is the sole
          responsibility of HMO and not the responsibility of HHSC. HMO will indemnify
          and
          hold harmless the State from any and all claims asserted against the State
          arising out of such employment or alleged employment by the HMO. HMO understands
          that any person

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        who
          alleges a claim arising out of employment or alleged employment by HMO
          will not
          be entitled to any compensation, rights, or benefits from HHSC (including,
          but
          not limited to, tenure rights, medical and hospital care, sick and
          annual/vacation leave, severance pay, or retirement benefits). 

         

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

         

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

         

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

         

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

         

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

         

        Section
          4.06 Cooperation
          with HHSC and state administrative agencies. 

         

          (a)
          Cooperation with Other MCOs. 

         

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

         

        (b)
          Cooperation with state and federal administrative agencies. 

         

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

         

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

         

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

         

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

         

        Section
          4.07 Conduct
          of HMO personnel. 

         

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

         

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

         

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

         

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

         

        (1)
          Removing the employee from the project; 

         

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

         

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

         

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

         

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

         

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

         

        Section
          4.08 Subcontractors.
          

         

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

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        (b)
          HMO
          must: 

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

        (6)
          a
          Readiness Review is requested by HHSC. 

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

        Section
          4.09 HHSC’s
          ability to contract with Subcontractors. 

         

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

         

        Section
          4.10 HMO
          Agreements with Third Parties 

         

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

         

         

        (b)
          All
          agreements whereby HMO receives rebates, recoupments, discounts, payments,
          or
          other consideration from a

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        third
          party (including without limitation Affiliates) pursuant to or related
          to the
          execution of this Contract, must be in writing and must provide HHSC the
          right
          to examine the agreement and all records relating to such consideration.
          .

         

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

         

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

         

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

         

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

         

        Article
          5. Member Eligibility & Enrollment 

         

        Section
          5.01 Eligibility
          Determination 

         

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

         

        Section
          5.02 Member
          Enrollment & Disenrollment. 

         

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

         

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

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

         

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

         

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

         

        Section
          5.03 STAR
          enrollment for pregnant women and infants. 

         

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

         

        (b)
          The
          HHSC Administrative Services Contractor will enroll newborns born to Medicaid
          eligible mothers who are enrolled in a STAR HMO in the same HMO for 90
          days
          following the date of birth, unless the mother requests a plan change

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        as
          a
          special exception. The Administrative Service Contractor will consider
          such
          requests on a case-by-case basis. The HHSC Administrative Services Contractor
          will retroactively, to date of birth, enroll newborns in the applicable
          STAR
          HMO. 

         

        Section
          5.04 CHIP
          eligibility and enrollment. 

         

          (a)
          Continuous coverage. 

         

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

         

        (b)
          Pregnant Members and Infants. 

         

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

         

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

         

        Section
          5.04.1 CHIP
          Perinatal eligibility, enrollment, and disenrollment 

         

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

         

        (b)
          CHIP
          Perinate Newborns are eligible for 12 months continuous enrollment, beginning
          with the month of enrollment as a CHIP Perinate (month of enrollment plus
          11
          months). A CHIP Perinate Newborn will maintain coverage in his or her CHIP
          Perinatal health plan. 

         

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

         

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

         

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

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

         

        Section
          5.05 Span
          of Coverage 

         

          (a)
          Medicaid HMOs. 

         

        (1)
          HHSC
          will conduct continuous open enrollment for Medicaid Eligibles and the
          HMO must
          accept all persons who choose to enroll as Members in the HMO or who are
          assigned as Members in the HMO by HHSC, without regard to the Member’s health
          status or any other factor. Persons in a hospital on the enrollment date
          will
          not be enrolled until they are discharged from the hospital. 

         

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

         

        (3)
          A
          Member cannot change from one Medicaid MCO to another Medicaid MCO during an
          inpatient hospital stay. The MCO responsible for the hospital charges at
          the
          start of an Inpatient Stay remains responsible for hospital charges until
          the
          time of discharge, or until such time that there is a loss of Medicaid
          eligibility. Medicaid MCOs are responsible for professional charges during
          every
          month for which the MCO receives a full capitation for a Member. 

         

        (b)
          CHIP
          HMOs. 

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

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

         

        (c)
          CHIP
          Perinatal HMOs. 

         

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

         

        Section
          5.06 Verification
          of Member Eligibility. 

         

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

         

        Section
          5.07 Special
          Temporary STAR Default Process 

         

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

         

        (b)
          For
          the Bexar, Dallas, El Paso, Harris, Tarrant, and Travis Service Areas,
          the
          special default process will begin with the Operational Start Date and
          conclude
          when the HMO has achieved an enrollment of 15,000 mandatory STAR members,
          or at
          the end of six months, whichever comes first. 

         

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

         

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

         

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

         

        Section
          5.08 Special
          Temporary STAR+PLUS Default Process 

         

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

         

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

         

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

         

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

         

          Article
          6. Service Levels & Performance Measurement 

         

        Section
          6.01 Performance
          measurement. 

         

        Satisfactory
          performance of this Contract will be measured by: 

         

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

         

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

         

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

         

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

         

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

         

          Article
          7. Governing Law & Regulations 

         

        Section
          7.01 Governing
          law and venue. 

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

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

        Section
          7.02 HMO
          responsibility for compliance with laws and regulations.

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

        (7)
          1
          T.A.C. Part 15, Chapters 361, 370, 391, and 392; and 

         

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

         

        (b)
          The
          Parties acknowledge that the federal and/or state laws, rules, regulations,
          policies, or guidelines, and court-ordered consent decrees, settlement
          agreements, or other court orders that affect the performance of the Scope
          of
          Work may change from time to time or be added, judicially interpreted,
          or
          amended by competent authority. HMO acknowledges that the HMO Programs
          will be
          subject to continuous change during the term of the Contract and, except
          as
          provided in Section 8.02, HMO has provided for or will provide for adequate
          resources, at no additional charge to HHSC, to reasonably accommodate such
          changes. The Parties further acknowledge that HMO was selected, in part,
          because
          of its expertise, experience, and knowledge concerning applicable Federal
          and/or
          state laws, regulations, policies, or guidelines that affect the performance
          of
          the Scope of Work. In keeping with HHSC’s reliance on this knowledge and
          expertise, HMO is responsible for identifying the impact of changes in
          applicable Federal or state legislative enactments and regulations that
          affect
          the performance of the Scope of Work or the State’s use of the Services and
          Deliverables. HMO must timely notify HHSC of such changes and must work
          with
          HHSC to identify the impact of such changes on how the State uses the Services
          and Deliverables. 

         

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

         

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

         

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

         

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

         

        Section
          7.03 TDI
          licensure/ANHC certification and solvency. 

         

          (a)
          Licensure 

         

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

         

        (b)
          Solvency 

         

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

         

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

         

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

         

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

         

        Provision
          against the risk of insolvency must be made by establishing adequate reserves,
          insurance or other guarantees in

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        full
          compliance with all financial requirements of TDI. 

         

        Section
          7.04 Immigration
          Reform and Control Act of 1986. 

         

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

         

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

         

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

         

        Section
          7.06 Environmental
          protection laws. 

         

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

         

          (a)
          Pro-Children Act of 1994. 

         

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

         

        (b)
          National Environmental Policy Act of 1969. 

         

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

         

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

         

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

         

        (d)
          State
          Clean Air Implementation Plan. 

         

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

         

        (e)
          Safe
          Drinking Water Act of 1974. 

         

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

         

          Section
          7.07 HIPAA.
          

         

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

         

          Article
          8. Amendments & Modifications 

         

          Section
          8.01 Mutual
          agreement. 

         

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

         

        Section
          8.02 Changes
          in law or contract. 

         

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

         

        Section
          8.03 Modifications
          as a remedy. 

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

         

        Section
          8.04 Modifications
          upon renewal or extension of Contract. 

         

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

         

        (b)
          HMO
          must respond to HHSC’s proposed modification within the timeframe specified by
          HHSC, generally within thirty (30) days of receipt. Upon receipt of HMO’s
          response to the proposed modifications, HHSC may enter into negotiations
          with
          HMO to arrive at mutually agreeable Contract amendments. In the event that
          HHSC
          determines that the Parties will be unable to reach agreement on mutually
          satisfactory contract modifications, then HHSC will provide written

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        notice
          to
          HMO of its intent not to extend the Contract beyond the Contract Term then
          in
          effect. 

         

        Section
          8.05 Modification
          of HHSC Uniform Managed Care Manual. 

         

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

         

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

         

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

         

        Section
          8.06 CMS
          approval of Medicaid amendments 

         

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

         

        Section
          8.07 Required
          compliance with amendment and modification procedures.

         

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

         

          Article
          9. Audit & Financial Compliance 

         

          Section
          9.01 Financial
          record retention and audit. 

         

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

         

        Section
          9.02 Access
          to records, books, and documents. 

         

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

         

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

         

        (1)
          Examination; 

         

        (2)
          Audit; 

         

        (3)
          Investigation; 

         

        (4)
          Contract administration; or 

         

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

         

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

         

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

         

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

         

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

         

        (4)
          The
          Office of Inspector General; 

         

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

         

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

         

        (7)
          A
          State or Federal law enforcement agency; 

         

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

         

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

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

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

         

        Section
          9.03 Audits
          of Services, Deliverables and inspections. 

         

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

         

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

         

        (2)
          HMO
          Software and Equipment. 

         

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

         

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

         

        (2)
          the
          Services and Deliverables provided; 

         

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

         

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

         

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

         

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

         

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

         

        Section
          9.04 SAO
          Audit 

         

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

         

          Section
          9.05 Response/compliance
          with audit or inspection findings. 

         

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

         

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

         

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

         

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

         

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

         

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

         

          Article
          10. Terms & Conditions of Payment 

         

        Section
          10.01 Calculation
          of monthly Capitation Payment. 

         

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

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

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

         

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

         

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

         

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

         

        (2)
          an
          amount for administering the program, 

         

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

              

         

          and
          

         

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

         

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

         

        (e)
          HMO
          understands and expressly assumes the risks associated with the performance
          of
          the duties and responsibilities under this Contract, including the failure,
          termination or suspension of funding to HHSC, delays or denials of required
          approvals, and cost overruns not reasonably attributable to HHSC. 

         

        Section
          10.02 Time
          and Manner of Payment. 

         

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

         

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

         

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

         

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

         

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

         

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

         

        Section
          10.03 Certification
          of Capitation Rates. 

         

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

         

        Section
          10.04 Modification
          of Capitation Rates. 

         

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

         

        Section
          10.05 STAR
          Capitation Structure. 

         

          (a)
          STAR
          Rate Cells. 

         

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

         

        (1)
          TANF
          adults; 

         

        (2)
          TANF
          children over 12 months of age; 

         

        (3)
          Expansion children over 12 months of age; 

         

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

         

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

         

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

         

        (7)
          Federal mandate children; and 

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        (8)
          Pregnant women. 

         

        (b)
          STAR
          Capitation Rate development: 

         

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

         

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

         

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

         

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

         

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

         

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

         

        (c)
          Acuity adjustment. 

         

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

         

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

         

        Section
          10.05.1STAR+PLUS
          Capitation Structure. 

         

        (a)
          STAR+PLUS Rate Cells. 

         

        STAR+PLUS
          Capitation Rates are defined on a per Member per month basis by Rate Cells.
          STAR+PLUS Rate Cells are based on client category as follows: 

         

        (1)
          Medicaid Only Standard Rate 

         

        (2)
          Medicaid Only 1915 (c) Nursing Facility Waiver Rate 

         

        (3)
          Dual
          Eligible Standard Rate 

         

        (4)
          Dual
          Eligible 1915(c) Nursing Facility Waiver Rate 

         

        (5)
          Nursing Facility - Medicaid only 

         

        (6)
          Nursing Facility - Dual Eligible 

         

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

         

        (b)
          STAR+PLUS Capitation Rates 

         

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

         

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

         

        Section
          10.06 CHIP
          Capitation Rates Structure. 

         

          (a)
          CHIP
          Rate Cells. 

         

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

         

        (1)
          under
          age one (1); 

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

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

         

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

         

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

         

        (b)
          CHIP
          Capitation Rate development: 

         

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

         

        (c)
          Acuity adjustment. 

         

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

         

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

         

        Section
          10.06.1
          CHIP Perinatal Program Capitation Structure. 

         

        (a)
          CHIP
          Perinatal Program Rate Cells. 

         

        CHIP
          Perinatal Capitation Rates are defined on a per Member per month basis
          by the
          Rate Cells applicable to a Service Area. CHIP Perinatal Rate Cells are
          based on
          the Member’s birth status and household income as follows: 

         

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

         

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

         

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

         

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

         

        (b)
          CHIP
          Perinatal Program Capitation Rate Development 

         

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

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

         

        Section
          10.07 HMO
          input during rate setting process. 

         

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

         

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

         

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

         

        Section
          10.08 Adjustments
          to Capitation Payments. 

         

          (a)
          Recoupment. 

         

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

         

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

         

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

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

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

         

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

         

        (b)
          Appeal of recoupment. 

         

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

         

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

         

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

         

        (b)
          CHIP
          and STAR HMOs will receive a Delivery Supplemental Payment (DSP) from HHSC
          for
          each live or stillbirth by a Member. CHIP Perinatal HMOs will receive a
          DSP from
          HHSC for each live or stillbirth by a mother of a CHIP Perinatal Program
          Member
          in the 186% to 200% FPL (measured at the time of enrollment in the CHIP
          Perinatal Program). CHIP Perinatal HMOs will not receive a DSP from HHSC
          for a
          live or stillbirth by the mother of a CHIP Perinatal Program Member in
          the
          100%-185% FPL. For STAR, CHIP and CHIP Perinatal Program HMOs, the one-time
          DSP
          payment is made in the amount identified in the HHSC
          Managed Care Contract
          document
          regardless of whether there is a single birth or there are multiple births
          at
          time of delivery. A delivery is the birth of a live born infant, regardless
          of
          the duration of the pregnancy, or a stillborn (fetal death) infant of twenty
          (20) weeks or more of gestation. A delivery does not include a spontaneous
          or
          induced abortion, regardless of the duration of the pregnancy. 

         

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

         

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

         

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

         

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

         

        Section
          10.10 Administrative
          Fee for SSI Members 

         

          (a)
          Administrative Fee. 

         

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

         

        (b)
          Administrative services and functions. 

         

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

         

        (i)
          prior
          authorization of services; 

         

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

         

        (iii)
          health education; 

         

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

         

        (v)
          quality assessment and performance improvement activities; 

         

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

         

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

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

         

        (c)
          Members who become eligible for SSI 

         

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

         

        Section
          10.11 STAR,
          CHIP, and CHIP Perinatal Experience Rebate 

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        (a)
          HMO’s
          duty to pay. 

         

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

         

        (b)
          Graduated Experience Rebate Sharing Method. 

         

        
           

          
            	
                     

                    Experience
                      Rebate as a % of Revenues 

                     

                  	
                     

                    HMO
                      Share 

                     

                  	
                     

                    HHSC
                      Share 

                     

                  
	
                    <
                      3% 

                  	
                    100%
                      

                  	
                    0%
                      

                  
	
                    >
                      3% and < 7% 

                  	
                    75%
                      

                  	
                    25%
                      

                  
	
                    >
                      7% and < 10% 

                  	
                    50%
                      

                  	
                    50%
                      

                  
	
                    >
                      10% and < 15% 

                  	
                    25%
                      

                  	
                    75%
                      

                  
	
                    >
                      15% 

                  	
                    0%
                      

                  	
                    100%
                      

                  

          

        

         

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

         

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

         

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

         

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

         

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

         

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

         

        (c)
          Net
          income before taxes. 

         

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

         

        (d)
          Carry
          forward of prior Rate Year losses. 

         

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

         

        (e)
          Settlements for payment. 

         

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

         

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

         

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

         

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

         

        (f)
          Interest on Experience Rebate. 

         

        Interest
          on any Experience Rebate owed to HHSC shall be charged beginning thirty
          (30)
          days after the date that the first and second settlements are due. In addition,
          if any adjusted amount is owed to HHSC at the final settlement date, then
          interest will be charged on the adjusted amount owed beginning thirty (30)
          days
          after the second settlement date to the date of the final settlement payment.
          HHSC will calculate interest at the Department of Treasury’s Median Rate
          (resulting from

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        the
          Treasury’s auction of 13-week bills) for the week in which the liability is
          assessed. 

         

        Section
          10.11.1
          STAR+PLUS Experience Rebate 

         

        (a)
          HMO’s
          duty to pay. 

         

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

         

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

        
           

          
            	
                    Experience
                      Rebate as a % of Revenues 

                  	
                    HMO
                      Share 

                  	
                    HHSC
                      Share 

                  
	
                    <
                      3% 

                  	
                    50%
                      

                  	
                    50%
                      

                  
	
                    >
                      3% 

                  	
                    75%
                      

                  	
                    25%
                      

                  

          

           

        

         

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

         

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

         

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

         

        (c)
          Net
          income before taxes. 

         

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

         

        (d)
          Carry
          forward of prior Rate Year losses. 

         

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

         

        (e)
          Settlements for payment. 

         

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

         

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

         

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

         

        (4)
          HHSC
          may offset any Experience Rebates owed to the State from future STAR+PLUS
          Capitation Payments, or collect such sums directly from the HMO. HHSC must
          receive the first and second settlements by the specified due dates for
          the
          first and second FSRs respectively or HMO will incur interest on the amounts
          due
          at the current prime interest rate as set forth below. 

         

        (f)
          Interest on Experience Rebate. 

         

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

         

          Section
          10.12 Payment
          by Members. 

         

          (a)
          Medicaid HMOs 

         

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

         

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

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

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

         

        (b)
          CHIP
          HMOs. 

         

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

         

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

         

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

         

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

         

        (c)
          CHIP
          Perinatal HMOs 

         

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

         

        Section
          10.13 Restriction
          on assignment of fees. 

         

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

         

        Section
          10.14 Liability
          for taxes. 

         

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

         

        Section
          10.15 Liability
          for employment-related charges and benefits. 

         

        HMO
          will
          perform work under this Contract as an independent contractor and not as
          agent
          or representative of HHSC. HMO is solely and exclusively liable for payment
          of
          all employment-related charges incurred in connection with the performance
          of
          this Contract, including but not limited to salaries, benefits, employment
          taxes, workers compensation benefits, unemployment insurance and benefits,
          and
          other insurance or fringe benefits for Staff. 

         

        Section
          10.16 No
          additional consideration. 

         

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

         

         

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

         

         

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

         

        Section
          10.17 Federal
          Disallowance 

         

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

         

          Article
          11. Disclosure & Confidentiality of Information 

         

        Section
          11.01 Confidentiality.
          

         

        (a)
          HMO
          and all Subcontractors, consultants, or agents under the Contract must
          treat all
          information that is obtained through performance of the Services under
          the
          Contract, including, but not limited to, information relating to applicants
          or

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        recipients
          of HHSC Programs as Confidential Information to the extent that confidential
          treatment is provided under law and regulations. 

         

        (b)
          HMO
          is responsible for understanding the degree to which information obtained
          through performance of this Contract is confidential under State and Federal
          law, regulations, or administrative rules. 

         

        (c)
          HMO
          and all Subcontractors, consultants, or agents under the Contract may not
          use
          any information obtained through performance of this Contract in any manner
          except as is necessary for the proper discharge of obligations and securing
          of
          rights under the Contract. 

         

        (d)
          HMO
          must have a system in effect to protect all records and all other documents
          deemed confidential under this Contract maintained in connection with the
          activities funded under the Contract. Any disclosure or transfer of Confidential
          Information by HMO, including information required by HHSC, will be in
          accordance with applicable law. If the HMO receives a request for information
          deemed confidential under this Contract, the HMO will immediately notify
          HHSC of
          such request, and will make reasonable efforts to protect the information
          from
          public disclosure. 

         

        (e)
          In
          addition to the requirements expressly stated in this Section, HMO must
          comply
          with any policy, rule, or reasonable requirement of HHSC that relates to
          the
          safeguarding or disclosure of information relating to Members, HMO’S operations,
          or HMO’s performance of the Contract. 

         

        (f)
          In
          the event of the expiration of the Contract or termination of the Contract
          for
          any reason, all Confidential Information disclosed to and all copies thereof
          made by the HMOI shall be returned to HHSC or, at HHSC’s option, erased or
          destroyed. HMO shall provide HHSC certificates evidencing such destruction.
          

         

        (g)
          The
          obligations in this Section shall not restrict any disclosure by the HMO
          pursuant to any applicable law, or by order of any court or government
          agency,
          provided that the HMO shall give prompt notice to HHSC of such order.

         

        (h)
          With
          the exception of confidential Member information, Confidential Information
          shall
          not be afforded the protection of the Contract if such data was: 

         

        (1)
          Already known to the receiving Party without restrictions at the time of
          its
          disclosure by the furnishing Party; 

         

        (2)
          Independently developed by the receiving Party without reference to the
          furnishing Party’s Confidential Information; 

         

        (3)
          Rightfully obtained by the other Party without restriction from a third
          party
          after its disclosure by the furnishing Party; 

         

        (4)
          Publicly available other than through the fault or negligence of the other
          Party; or 

         

        (5)
          Lawfully released without restriction to anyone. 

         

        Section
          11.02 Disclosure
          of HHSC’s Confidential Information. 

         

        (a)
          HMO
          will immediately report to HHSC any and all unauthorized disclosures or
          uses of
          HHSC’s Confidential Information of which it or its Subcontractor(s),
          consultant(s), or agent(s) is aware or has knowledge. HMO acknowledges
          that any
          publication or disclosure of HHSC’s Confidential Information to others may cause
          immediate and irreparable harm to HHSC and may constitute a violation of
          State
          or federal laws. If HMO, its Subcontractor(s), consultant(s), or agent(s)
          should
          publish or disclose such Confidential Information to others without
          authorization, HHSC will immediately be entitled to injunctive relief or
          any
          other remedies to which it is entitled under law or equity. HHSC will have
          the
          right to recover from HMO all damages and liabilities caused by or arising
          from
          HMO’s, its Subcontractors’, consultants’, or agents’ failure to protect HHSC’s
          Confidential Information. HMO will defend with counsel approved by HHSC,
          indemnify and hold harmless HHSC from all damages, costs, liabilities,
          and
          expenses (including without limitation reasonable attorneys’ fees and costs)
          caused by or arising from HMO’s or its Subcontractors’, consultants’ or agents’
failure to protect HHSC’s Confidential Information. HHSC will not unreasonably
          withhold approval of counsel selected by the HMO. 

         

        (b)
          HMO
          will require its Subcontractor(s), consultant(s), and agent(s) to comply
          with
          the terms of this provision. 

         

        Section
          11.03 Member
          Records 

         

        (a)
          HMO
          must comply with the requirements of state and federal laws, including
          the HIPAA
          requirements set forth in Section
          7.07,
          regarding the transfer of Member Records. 

         

        (b)
          If at
          any time during the Contract Term this Contract is terminated, HHSC may
          require
          the transfer of Member Records, upon written notice to HMO, to another
          entity,
          as consistent with federal and state laws and applicable releases. 

         

        (c)
          The
          term “Member Record” for this Section means only those administrative,
          enrollment, case management and other such records maintained by HMO and
          is not
          intended to include patient records maintained by participating Network
          Providers. 

         

        Section
          11.04 Requests
          for public information. 

         

        (a)
          HHSC
          agrees that it will promptly notify HMO of a request for disclosure of
          information filed in accordance with the Texas Public Information Act,
          Chapter
          552 of the Texas Government Code, that consists of the HMO’S confidential
          information, including without limitation, information or data to which
          HMO has
          a proprietary or commercial interest. HHSC will deliver a copy of the request
          for public information to HMO. 

         

        (b)
          With
          respect to any information that is the subject of a request for disclosure,
          HMO
          is required to demonstrate to the Texas Office of Attorney General the
          specific
          reasons why the requested information is confidential or otherwise excepted
          from
          required public disclosure under law. HMO will provide HHSC with copies
          of all
          such communications. 

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        (c)
          To
          the extent authorized under the Texas Public Information Act, HHSC agrees
          to
          safeguard from disclosure information received from HMO that the HMO believes
          to
          be confidential information. HMO must clearly mark such information as
          confidential information or provide written notice to HHSC that it considers
          the
          information confidential. 

         

        Section
          11.05 Privileged
          Work Product. 

         

        (a)
          HMO
          acknowledges that HHSC asserts that privileged work product may be prepared
          in
          anticipation of litigation and that HMO is performing the Services with
          respect
          to privileged work product as an agent of HHSC, and that all matters related
          thereto are protected from disclosure by the Texas Rules of Civil Procedure,
          Texas Rules of Evidence, Federal Rules of Civil Procedure, or Federal Rules
          of
          Evidence. 

         

        (b)
          HHSC
          will notify HMO of any privileged work product to which HMO has or may
          have
          access. After the HMO is notified or otherwise becomes aware that such
          documents, data, database, or communications are privileged work product,
          only
          HMO personnel, for whom such access is necessary for the purposes of providing
          the Services, may have access to privileged work product. 

         

        (c)
          If
          HMO receives notice of any judicial or other proceeding seeking to obtain
          access
          to HHSC’s privileged work product, HMO will: 

         

        (1)
          Immediately notify HHSC; and 

         

        (2)
          Use
          all reasonable efforts to resist providing such access. 

         

        (d)
          If
          HMO resists disclosure of HHSC’s privileged work product in accordance with this
          Section, HHSC will, to the extent authorized under Civil Practices and
          Remedies
          Code or other applicable State law, have the right and duty to: 

         

        (1)
          represent HMO in such resistance; 

         

        (2)
          to
          retain counsel to represent HMO; or 

         

        (3)
          to
          reimburse HMO for reasonable attorneys' fees and expenses incurred in resisting
          such access. 

         

        (e)
          If a
          court of competent jurisdiction orders HMO to produce documents, disclose
          data,
          or otherwise breach the confidentiality obligations imposed in the Contract,
          or
          otherwise with respect to maintaining the confidentiality, proprietary
          nature,
          and secrecy of privileged work product, HMO will not be liable for breach
          of
          such obligation. 

         

        Section
          11.06 Unauthorized
          acts. 

         

        Each
          Party agrees to: 

         

        (1)
          Notify the other Party promptly of any unauthorized possession, use, or
          knowledge, or attempt thereof, by any person or entity that may become
          known to
          it, of any HHSC Confidential Information or any information identified
          by the
          HMO as confidential or proprietary; 

         

        (2)
          Promptly furnish to the other Party full details of the unauthorized possession,
          use, or knowledge, or attempt thereof, and use reasonable efforts to assist
          the
          other Party in investigating or preventing the reoccurrence of any unauthorized
          possession, use, or knowledge, or attempt thereof, of Confidential Information;
          

         

        (3)
          Cooperate with the other Party in any litigation and investigation against
          third
          Parties deemed necessary by such Party to protect its proprietary rights;
          and

         

        (4)
          Promptly prevent a reoccurrence of any such unauthorized possession, use,
          or
          knowledge such information. 

         

        Section
          11.07 Legal
          action. 

         

        Neither
          party may commence any legal action or proceeding in respect to any unauthorized
          possession, use, or knowledge, or attempt thereof by any person or entity
          of
          HHSC’s Confidential Information or information identified by the HMO as
          confidential or proprietary, which action or proceeding identifies the
          other
          Party such information without such Party’s consent. 

         

          Article
          12. Remedies & Disputes 

         

        Section
          12.01 Understanding
          and expectations. 

         

        The
          remedies described in this Section are directed to HMO’s timely and responsive
          performance of the Services and production of Deliverables, and the creation
          of
          a flexible and responsive relationship between the Parties. The HMO is
          expected
          to meet or exceed all HHSC objectives and standards, as set forth in the
          Contract. All areas of responsibility and all Contract requirements will
          be
          subject to performance evaluation by HHSC. Performance reviews may be conducted
          at the discretion of HHSC at any time and may relate to any responsibility
          and/or requirement. Any and all responsibilities and/or requirements not
          fulfilled may be subject to remedies set forth in the Contract. 

         

        Section
          12.02 Tailored
          remedies. 

         

          (a)
          Understanding of the Parties. 

         

        HMO
          agrees and understands that HHSC may pursue tailored contractual remedies
          for
          noncompliance with the Contract. At any time and at its discretion, HHSC
          may
          impose or pursue one or more remedies for each item of noncompliance and
          will
          determine remedies on a case-by-case basis. HHSC’s pursuit or non-pursuit of a
          tailored remedy does not constitute a waiver of any other remedy that HHSC
          may
          have at law or equity. 

         

        (b)
          Notice and opportunity to cure for non-material breach. 

         

        (1)
          HHSC
          will notify HMO in writing of specific areas of HMO performance that fail
          to
          meet performance expectations,

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        standards,
          or schedules set forth in the Contract, but that, in the determination
          of HHSC,
          do not result in a material deficiency or delay in the implementation or
          operation of the Services. 

         

        (2)
          HMO
          will, within five (5) Business Days (or another date approved by HHSC)
          of
          receipt of written notice of a non-material deficiency, provide the HHSC
          Project
          Manager a written response that: 

         

        (A)
          Explains the reasons for the deficiency, HMO’s plan to address or cure the
          deficiency, and the date and time by which the deficiency will be cured;
          or

         

        (B)
          If
          HMO disagrees with HHSC’s findings, its reasons for disagreeing with HHSC’s
          findings. 

         

        (3)
          HMO’s
          proposed cure of a non-material deficiency is subject to the approval of
          HHSC.
          HMO’s repeated commission of non-material deficiencies or repeated failure
          to
          resolve any such deficiencies may be regarded by HHSC as a material deficiency
          and entitle HHSC to pursue any other remedy provided in the Contract or
          any
          other appropriate remedy HHSC may have at law or equity. 

         

        (c)
          Corrective action plan. 

         

        (1)
          At
          its option, HHSC may require HMO to submit to HHSC a written plan (the
          “Corrective Action Plan”) to correct or resolve a material breach of this
          Contract, as determined by HHSC. 

         

        (2)
          The
          Corrective Action Plan must provide: 

         

        (A)
          A
          detailed explanation of the reasons for the cited deficiency; 

         

        (B)
          HMO’s
          assessment or diagnosis of the cause; and 

         

        (C)
          A
          specific proposal to cure or resolve the deficiency. 

         

        (3)
          The
          Corrective Action Plan must be submitted by the deadline set forth in HHSC’s
          request for a Corrective Action Plan. The Corrective Action Plan is subject
          to
          approval by HHSC, which will not unreasonably be withheld. 

         

        (4)
          HHSC
          will notify HMO in writing of HHSC’s final disposition of HHSC’s concerns. If
          HHSC accepts HMO’s proposed Corrective Action Plan, HHSC may: 

         

        (A)
          Condition such approval on completion of tasks in the order or priority
          that
          HHSC may reasonably prescribe; 

         

        (B)
          Disapprove portions of HMO’s proposed Corrective Action Plan; or 

         

        (C)
          Require additional or different corrective action(s). 

         

        Notwithstanding
          the submission and acceptance of a Corrective Action Plan, HMO remains
          responsible for achieving all written performance criteria.  

         

        (5)
          HHSC’s acceptance of a Corrective Action Plan under this Section will not:

         

        (A)
          Excuse HMO’s prior substandard performance; 

         

        (B)
          Relieve HMO of its duty to comply with performance standards; or 

         

        (C)
          Prohibit HHSC from assessing additional tailored remedies or pursuing other
          appropriate remedies for continued substandard performance. 

         

        (d)
          Administrative remedies. 

         

        (1)
          At
          its discretion, HHSC may impose one or more of the following remedies for
          each
          item of material noncompliance and will determine the scope and severity
          of the
          remedy on a case-by-case basis: 

         

        (A)
          Assess liquidated damages in accordance with Attachment
          B-5
          to the
HHSC
          Managed Care Contract,
          “Liquidated Damages Matrix;” 

         

        (B)
          Conduct accelerated monitoring of the HMO. Accelerated monitoring includes
          more
          frequent or more extensive monitoring by HHSC or its agent; 

         

        (C)
          Require additional, more detailed, financial and/or programmatic reports
          to be
          submitted by HMO; 

         

        (D)
          Decline to renew or extend the Contract; 

         

        (E)
          Appoint temporary management; 

         

        (F)
          Initiate disenrollment of a Member or Members; 

         

        (G)
          Suspend enrollment of Members; 

         

        (H)
          Withhold or recoup payment to HMO; 

         

        (I)
          Require forfeiture of all or part of the HMO’s bond; or 

         

        (J)
          Terminate the Contract in accordance with Section
          12.03,
          (“Termination by HHSC”). 

         

        (2)
          For
          purposes of the Contract, an item of material noncompliance means a specific
          action of HMO that: 

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        (A)
          Violates a material provision of the Contract; 

         

        (B)
          Fails
          to meet an agreed measure of performance; or 

         

        (C)
          Represents a failure of HMO to be reasonably responsive to a reasonable
          request
          of HHSC relating to the Services for information, assistance, or support
          within
          the timeframe specified by HHSC. 

         

        (3)
          HHSC
          will provide notice to HMO of the imposition of an administrative remedy
          in
          accordance with this Section, with the exception of accelerated monitoring,
          which may be unannounced. HHSC may require HMO to file a written response
          in
          accordance with this Section. 

         

        (4)
          The
          Parties agree that a State or Federal statute, rule, regulation, or Federal
          guideline will prevail over the provisions of this Section unless the statute,
          rule, regulation, or guidelines can be read together with this Section
          to give
          effect to both. 

         

        (e)
          Damages. 

         

        (1)
          HHSC
          will be entitled to actual and consequential damages resulting from the
          HMO’S
          failure to comply with any of the terms of the Contract. In some cases,
          the
          actual damage to HHSC or State of Texas as a result of HMO’S failure to meet any
          aspect of the responsibilities of the Contract and/or to meet specific
          performance standards set forth in the Contract are difficult or impossible
          to
          determine with precise accuracy. Therefore, liquidated damages will be
          assessed
          in writing against and paid by the HMO in accordance with and for failure
          to
          meet any aspect of the responsibilities of the Contract and/or to meet
          the
          specific performance standards identified by the HHSC in Attachment
          B-5 to the HHSC Managed Care Contract, “Deliverables/Liquidated
          Damages Matrix.” Liquidated damages will be assessed if HHSC determines such
          failure is the fault of the HMO (including the HMO’S Subcontractors and/or
          consultants) and is not materially caused or contributed to by HHSC or
          its
          agents. If at any time, HHSC determines the HMO has not met any aspect
          of the
          responsibilities of the Contract and/or the specific performance standards
          due
          to mitigating circumstances, HHSC reserves the right to waive all or part
          of the
          liquidated damages. All such waivers must be in writing, contain the reasons
          for
          the waiver, and be signed by the appropriate executive of HHSC. 

         

        (2)
          The
          liquidated damages prescribed in this Section are not intended to be in
          the
          nature of a penalty, but are intended to be reasonable estimates of HHSC’s
          projected financial loss and damage resulting from the HMO’s nonperformance,
          including financial loss as a result of project delays. Accordingly, in
          the
          event HMO fails to perform in accordance with the Contract, HHSC may assess
          liquidated damages as provided in this Section. 

         

        (3)
          If
          HMO fails to perform any of the Services described in the Contract, HHSC
          may
          assess liquidated damages for each occurrence of a liquidated damages event,
          to
          the extent consistent with HHSC's tailored approach to remedies and Texas
          law.

         

        (4)
          HHSC
          may elect to collect liquidated damages: 

         

        (A)
          Through direct assessment and demand for payment delivered to HMO; or

         

        (B)
          By
          deduction of amounts assessed as liquidated damages as set-off against
          payments
          then due to HMO or that become due at any time after assessment of the
          liquidated damages. HHSC will make deductions until the full amount payable
          by
          the HMO is received by HHSC. 

         

        (f)
          Equitable Remedies 

         

        (1)
          HMO
          acknowledges that, if HMO breaches (or attempts or threatens to breach)
          its
          material obligation under this Contract, HHSC may be irreparably harmed.
          In such
          a circumstance, HHSC may proceed directly to court to pursue equitable
          remedies.

         

        (2)
          If a
          court of competent jurisdiction finds that HMO breached (or attempted or
          threatened to breach) any such obligations, HMO agrees that without any
          additional findings of irreparable injury or other conditions to injunctive
          relief, it will not oppose the entry of an appropriate order compelling
          performance by HMO and restraining it from any further breaches (or attempted
          or
          threatened breaches). 

         

        (g)
          Suspension of Contract 

         

        (1)
          HHSC
          may suspend performance of all or any part of the Contract if: 

         

        (A)
          HHSC
          determines that HMO has committed a material breach of the Contract;

         

        (B)
          HHSC
          has reason to believe that HMO has committed, assisted in the commission
          of
          Fraud, Abuse, Waste, malfeasance, misfeasance, or nonfeasance by any party
          concerning the Contract; 

         

        (C)
          HHSC
          determines that the HMO knew, or should have known of, Fraud, Abuse, Waste,
          malfeasance, or nonfeasance by any party concerning the Contract, and the
          HMO
          failed to take appropriate action; or 

         

        (D)
          HHSC
          determines that suspension of the Contract in whole or in part is in the
          best
          interests of the State of Texas or the HHSC Programs. 

         

        (2)
          HHSC
          will notify HMO in writing of its intention to suspend the Contract in
          whole or
          in part. Such notice will: 

         

        (A)
          Be
          delivered in writing to HMO; 

         

        (B)
          Include a concise description of the facts or matter leading to HHSC’s decision;
          and 

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        (C)
          Unless HHSC is suspending the contract for convenience, request a Corrective
          Action Plan from HMO or describe actions that HMO may take to avoid the
          contemplated suspension of the Contract. 

         

        Section
          12.03 Termination
          by HHSC. 

         

        This
          Contract will terminate upon the Expiration Date. In addition, prior to
          completion of the Contract Term, all or a part of this Contract may be
          terminated for any of the following reasons: 

         

          (a)
          Termination in the best interest of HHSC. 

         

        HHSC
          may
          terminate the Contract without cause at any time when, in its sole discretion,
          HHSC determines that termination is in the best interests of the State
          of Texas.
          HHSC will provide reasonable advance written notice of the termination,
          as it
          deems appropriate under the circumstances. The termination will be effective
          on
          the date specified in HHSC’s notice of termination. 

         

        (b)
          Termination for cause. 

         

        HHSC
          reserves the right to terminate this Contract, in whole or in part, upon
          the
          following conditions: 

         

        (1)
          Assignment
          for the benefit of creditors, appointment of receiver, or inability to
          pay
          debts.
          

         

        HHSC
          may
          terminate this Contract at any time if HMO: 

         

        (A)
          Makes
          an assignment for the benefit of its creditors; 

         

        (B)
          Admits in writing its inability to pay its debts generally as they become
          due;
          or 

         

        (C)
          Consents to the appointment of a receiver, trustee, or liquidator of HMO
          or of
          all or any part of its property. 

         

        (2)
          Failure to adhere to laws, rules, ordinances, or orders. 

         

        HHSC
          may
          terminate this Contract if a court of competent jurisdiction finds HMO
          failed to
          adhere to any laws, ordinances, rules, regulations or orders of any public
          authority having jurisdiction and such violation prevents or substantially
          impairs performance of HMO’s duties under this Contract. HHSC will provide at
          least thirty (30) days advance written notice of such termination. 

         

        (3)
          Breach
          of
          confidentiality.
          

         

        HHSC
          may
          terminate this Contract at any time if HMO breaches confidentiality laws
          with
          respect to the Services and Deliverables provided under this Contract.
          

         

        (4)
          Failure
          to maintain adequate personnel or resources. 

         

        HHSC
          may
          terminate this Contract if, after providing notice and an opportunity to
          correct, HHSC determines that HMO has failed to supply personnel or resources
          and such failure results in HMO’s inability to fulfill its duties under this
          Contract. HHSC will provide at least thirty (30) days advance written notice
          of
          such termination. 

         

        (5)
          Termination
          for gifts and gratuities.
          

         

        (A)
          HHSC
          may terminate this Contract at any time following the determination by
          a
          competent judicial or quasi-judicial authority and HMO’s exhaustion of all legal
          remedies that HMO, its employees, agents or representatives have either
          offered
          or given any thing of value to an officer or employee of HHSC or the State
          of
          Texas in violation of state law. 

         

        (B)
          HMO
          must include a similar provision in each of its Subcontracts and shall
          enforce
          this provision against a Subcontractor who has offered or given any thing
          of
          value to any of the persons or entities described in this Section, whether
          or
          not the offer or gift was in HMO’s behalf. 

         

        (C)
          Termination of a Subcontract by HMO pursuant to this provision will not
          be a
          cause for termination of the Contract unless: 

         

        (1)
          HMO
          fails to replace such terminated Subcontractor within a reasonable time;
          and

         

        (2)
          Such
          failure constitutes cause, as described in this Subsection 12.03(b).

         

        (D)
          For
          purposes of this Section, a “thing of value” means any item of tangible or
          intangible property that has a monetary value of more than $50.00 and includes,
          but is not limited to, cash, food, lodging, entertainment, and charitable
          contributions. The term does not include contributions to holders of public
          office or candidates for public office that are paid and reported in accordance
          with State and/or Federal law. 

         

        (6)
          Termination
          for non-appropriation of funds.
          

         

        Notwithstanding
          any other provision of this Contract, if funds for the continued fulfillment
          of
          this Contract by HHSC are at any time not forthcoming or are insufficient,
          through failure of any entity to appropriate funds or otherwise, then HHSC
          will
          have the right to terminate this Contract at no additional cost and with
          no
          penalty whatsoever by giving prior written notice documenting the lack
          of
          funding. HHSC will provide at least thirty (30) days advance written notice
          of
          such termination. HHSC will use reasonable efforts to ensure appropriated
          funds
          are available. 

         

        (7)
          Judgment
          and execution. 

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        (A)
          HHSC
          may terminate the Contract at any time if judgment for the payment of money
          in
          excess of $500,000.00 that is not covered by insurance, is rendered by
          any court
          or governmental body against HMO, and HMO does not: 

         

        (1)
          Discharge the judgment or provide for its discharge in accordance with
          the terms
          of the judgment; 

         

        (2)
          Procure a stay of execution of the judgment within thirty (30) days from
          the
          date of entry thereof; or 

         

        (3)
          Perfect an appeal of such judgment and cause the execution of such judgment
          to
          be stayed during the appeal, providing such financial reserves as may be
          required under generally accepted accounting principles. 

         

        (B)
          If a
          writ or warrant of attachment or any similar process is issued by any court
          against all or any material portion of the property of HMO, and such writ
          or
          warrant of attachment or any similar process is not released or bonded
          within
          thirty (30) days after its entry, HHSC may terminate the Contract in accordance
          with this Section. 

         

          (8)
          Termination
          for insolvency. 

         

        (A)
          HHSC
          may terminate the Contract at any time if HMO: 

         

        (1)
          Files
          for bankruptcy; 

         

        (2)
          Becomes or is declared insolvent, or is the subject of any proceedings
          related
          to its liquidation, insolvency, or the appointment of a receiver or similar
          officer for it; 

         

        (3)
          Makes
          an assignment for the benefit of all or substantially all of its creditors;
          or

         

        (4)
          Enters into an Contract for the composition, extension, or readjustment
          of
          substantially all of its obligations. 

         

        (B)
          HMO
          agrees to pay for all reasonable expenses of HHSC including the cost of
          counsel,
          incident to: 

         

        (1)
          The
          enforcement of payment of all obligations of the HMO by any action or
          participation in, or in connection with a case or proceeding under Chapters
          7,
          11, or 13 of the United States Bankruptcy Code, or any successor statute;
          

         

        (2)
          A
          case or proceeding involving a receiver or other similar officer duly appointed
          to handle the HMO's business; or 

         

        (3)
          A
          case or proceeding in a State court initiated by HHSC when previous collection
          attempts have been unsuccessful. 

         

        (9)
          Termination
          for HMO’S material breach of the Contract. 

         

          HHSC
          will
          have the right to terminate the Contract in whole or in part if HHSC determines,
          at its sole discretion, that HMO has materially breached the Contract.
          HHSC will
          provide at least thirty (30) days advance written notice of such termination.
          

         

          Section
          12.04 Termination
          by HMO. 

         

          (a)
          Failure to pay. 

         

        HMO
          may
          terminate this Contract if HHSC fails to pay the HMO undisputed charges
          when due
          as required under this Contract. Retaining premium, recoupment, sanctions,
          or
          penalties that are allowed under this Contract or that result from the
          HMO’s
          failure to perform or the HMO’s default under the terms of this Contract is not
          cause for termination. Termination for failure to pay does not release
          HHSC from
          the obligation to pay undisputed charges for services provided prior to
          the
          termination date. 

         

        If
          HHSC
          fails to pay undisputed charges when due, then the HMO may submit a notice
          of
          intent to terminate for failure to pay in accordance with the requirements
          of
Subsection
          12.04(d).
          If HHSC
          pays all undisputed amounts then due within thirty (30)-days after receiving
          the
          notice of intent to terminate, the HMO cannot proceed with termination
          of the
          Contract under this Article. 

         

        (b)
          Change to HHSC Uniform Managed Care Manual. 

         

        HMO
          may
          terminate this agreement if the Parties are unable to resolve a dispute
          concerning a material and substantive change to the HHSC Uniform Managed
          Care
          Manual (a change that materially and substantively alters the HMO’s ability to
          fulfill its obligations under the Contract). HMO must submit a notice of
          intent
          to terminate due to a material and substantive change in the HHSC Uniform
          Managed Care Manual no later than thirty (30) days after the effective
          date of
          the policy change. HHSC will not enforce the policy change during the period
          of
          time between the receipt of the notice of intent to terminate and the effective
          date of termination. 

         

        (c)
          Change to Capitation Rate. 

         

        If
          HHSC
          proposes a modification to the Capitation Rate that is unacceptable to
          the HMO,
          the HMO may terminate the Contract. HMO must submit a written notice of
          intent
          to terminate due to a change in the Capitation Rate no later than thirty
          (30)
          days after HHSC’s notice of the proposed change. HHSC will not enforce the rate
          change during the period of time between the receipt of the notice of intent
          to
          terminate and the effective date of termination. 

         

        (d)
          Notice of intent to terminate. 

         

        In
          order
          to terminate the Contract pursuant to this Section, HMO must give HHSC
          at least
          ninety (90) days written notice of intent to terminate. The termination
          date
          will be calculated as the last day of the month following ninety (90) days
          from
          the date the notice of intent to terminate is received by HHSC. 

         

        Section
          12.05 Termination
          by mutual agreement. 

         

        This
          Contract may be terminated by mutual written agreement of the Parties.
          

         

        Section
          12.06 Effective
          date of termination. 

         

        Except
          as
          otherwise provided in this Contract, termination will be effective as of
          the
          date specified in the notice of termination. 

         

        Section
          12.07 Extension
          of termination effective date. 

         

        The
          Parties may extend the effective date of termination one or more times
          by mutual
          written agreement. 

         

        Section
          12.08 Payment
          and other provisions at Contract termination. 

         

        (a)
          In
          the event of termination pursuant to this Article, HHSC will pay the Capitation
          Payment for Services and Deliverables rendered through the effective date
          of
          termination. All pertinent provisions of the Contract will form the basis
          of
          settlement. 

         

        (b)
          HMO
          must provide HHSC all reasonable access to records, facilities, and
          documentation as is required to efficiently and expeditiously close out
          the
          Services and Deliverables provided under this Contract. 

         

        (c)
          HMO
          must prepare a Turnover Plan, which is acceptable to and approved by HHSC.
          The
          Turnover Plan will be implemented during the time period between receipt
          of
          notice and the termination date. 

         

        Section
          12.09 Modification
          of Contract in the event of remedies. 

         

        HHSC
          may
          propose a modification of this Contract in response to the imposition of
          a
          remedy under this Article. Any modifications under this Section must be
          reasonable, limited to the matters causing the exercise of a remedy, in
          writing,
          and executed in accordance with Article
          8.
          HMO
          must negotiate such proposed modifications in good faith. 

         

        Section
          12.10 Turnover
          assistance. 

         

        Upon
          receipt of notice of termination of the Contract by HHSC, HMO will provide
          any
          turnover assistance reasonably necessary to enable HHSC or its designee
          to
          effectively close out the Contract and move the work to another vendor
          or to
          perform the work itself. 

         

        Section
          12.11 Rights
          upon termination or expiration of Contract. 

         

        In
          the
          event that the Contract is terminated for any reason, or upon its expiration,
          HHSC will, at HHSC's discretion, retain ownership of any and all associated
          work
          products, Deliverables and/or documentation in whatever form that they
          exist.

         

        Section
          12.12 HMO
          responsibility for associated costs. 

         

        If
          HHSC
          terminates the Contract for Cause, the HMO will be responsible to HHSC
          for all
          reasonable costs incurred by HHSC, the State of Texas, or any of its
          administrative agencies to replace the HMO. These costs include, but are
          not
          limited to, the costs of procuring a substitute vendor and the cost of
          any claim
          or litigation that is reasonably attributable to HMO’s failure to perform any
          Service in accordance with the terms of the Contract 

         

        Section
          12.13 Dispute
          resolution. 

         

          (a)
          General agreement of the Parties. 

         

        The
          Parties mutually agree that the interests of fairness, efficiency, and
          good
          business practices are best served when the Parties employ all reasonable
          and
          informal means to resolve any dispute under this Contract. The Parties
          express
          their mutual commitment to using all reasonable and informal means of resolving
          disputes prior to invoking a remedy provided elsewhere in this Section.
          

         

        (b)
          Duty
          to negotiate in good faith. 

         

        Any
          dispute that in the judgment of any Party to this Contract may materially
          or
          substantially affect the performance of any Party will be reduced to writing
          and
          delivered to the other Party. The Parties must then negotiate in good faith
          and
          use every reasonable effort to resolve such dispute and the Parties shall
          not
          resort to any formal proceedings unless they have reasonably determined
          that a
          negotiated resolution is not possible. The resolution of any dispute disposed
          of
          by Contract between the Parties shall be reduced to writing and delivered
          to all
          Parties within ten (10) Business Days. 

         

        (c)
          Claims for breach of Contract. 

         

        (1)
          General
          requirement.
          HMO’s
          claim for breach of this Contract will be resolved in accordance with the
          dispute resolution process established by HHSC in accordance with Chapter
          2260,
          Texas Government Code. 

         

        (2)
          Negotiation
          of claims.
          The
          Parties expressly agree that the HMO’s claim for breach of this Contract that
          the Parties cannot resolve in the ordinary course of business or through
          the use
          of all reasonable and informal means will be submitted to the negotiation
          process provided in Chapter 2260, Subchapter B, Texas Government Code.
          

         

        (A)
          To
          initiate the process, HMO must submit written notice to HHSC that specifically
          states that HMO invokes the provisions of Chapter 2260, Subchapter B, Texas
          Government Code. The notice must comply with the requirements of Title
          1,
          Chapter 392, Subchapter B of the Texas Administrative Code. 

         

        (B)
          The
          Parties expressly agree that the HMO’s compliance with Chapter 2260, Subchapter
          B, Texas Government Code, will be a condition precedent to the filing of
          a
          contested case proceeding under Chapter 2260, Subchapter C, of the Texas
          Government Code. 

         

        (3)
          Contested
          case proceedings.
          The
          contested case process provided in Chapter 2260, Subchapter C, Texas Government
          Code, will be HMO’s sole and exclusive process for seeking a remedy for any and
          all alleged breaches of contract by HHSC if the Parties are unable to resolve
          their disputes under Subsection (c)(2) of this Section. 

         

        The
          Parties expressly agree that compliance with the contested case process
          provided
          in Chapter 2260, Subchapter C, Texas Government Code, will be a condition
          precedent to seeking consent to sue from the Texas Legislature under Chapter
          107, Civil Practices & Remedies Code. Neither the execution of this Contract
          by HHSC nor any other conduct of any representative of HHSC relating to
          this
          Contract shall be considered a waiver of HHSC’s sovereign immunity to suit.

         

        (4)
          HHSC
          rules.
          The
          submission, processing and resolution of HMO’s claim is governed by the rules
          adopted by HHSC pursuant to Chapter 2260, Texas Government Code, found
          at Title
          1, Chapter 392, Subchapter B of the Texas Administrative Code. 

         

        (5)
          HMO’s
          duty to perform.
          Neither
          the occurrence of an event constituting an alleged breach of contract nor
          the
          pending status of any claim for breach of contract is grounds for the suspension
          of performance, in whole or in part, by HMO of any duty or obligation with
          respect to the performance of this Contract. Any changes to the Contract
          as a
          result of a dispute resolution will be implemented in accordance with
Article
          8
          (“Amendments and Modifications”). 

         

        Section
          12.14 Liability
          of HMO. 

         

        (a)
          HMO
          bears all risk of loss or damage to HHSC or the State due to: 

         

        (1)
          Defects in Services or Deliverables; 

         

        (2)
          Unfitness or obsolescence of Services or Deliverables; or 

         

        (3)
          The
          negligence or intentional misconduct of HMO or its employees, agents,
          Subcontractors, or representatives. 

         

        (b)
          HMO
          must, at the HMO’s own expense, defend with counsel approved by HHSC, indemnify,
          and hold harmless HHSC and State employees, officers, directors, contractors
          and
          agents from and against any losses, liabilities, damages, penalties, costs,
          fees, including without limitation reasonable attorneys' fees, and expenses
          from
          any claim or action for property damage, bodily injury or death, to the
          extent
          caused by or arising from the negligence or intentional misconduct of the
          HMO
          and its employees, officers, agents, or Subcontractors. HHSC will not
          unreasonably withhold approval of counsel selected by HMO. 

         

        (c)
          HMO
          will not be liable to HHSC for any loss, damages or liabilities attributable
          to
          or arising from the failure of HHSC or any state agency to perform a service
          or
          activity in connection with this Contract. 

         

          Article
          13. Assurances & Certifications 

         

        Section
          13.01 Proposal
          certifications. 

         

        HMO
          acknowledges its continuing obligation to comply with the requirements
          of the
          following certifications contained in its Proposal, and will immediately
          notify
          HHSC of any changes in circumstances affecting these certifications:

         

        (1)
          Federal lobbying; 

         

        (2)
          Debarment and suspension; 

         

        (3)
          Child
          support; and 

         

        (4)
          Nondisclosure statement.  

         

        Section
          13.02 Conflicts
          of interest. 

         

          (a)
          Representation. 

         

        HMO
          agrees to comply with applicable state and federal laws, rules, and regulations
          regarding conflicts of interest in the performance of its duties under
          this
          Contract. HMO warrants that it has no interest and will not acquire any
          direct
          or indirect interest that would conflict in any manner or degree with its
          performance under this Contract. 

         

        (b)
          General duty regarding conflicts of interest. 

         

        HMO
          will
          establish safeguards to prohibit employees from using their positions for
          a
          purpose that constitutes or presents the appearance of personal or
          organizational conflict of interest, or personal gain. HMO will operate
          with
          complete independence and objectivity without actual, potential or apparent
          conflict of interest with respect to the activities conducted under this
          Contract with the State of Texas. 

         

          Section
          13.03 Organizational
          conflicts of interest. 

         

          (a)
          Definition. 

         

        An
          organizational conflict of interest is a set of facts or circumstances,
          a
          relationship, or other situation under which a HMO, or a Subcontractor
          has past,
          present, or currently planned personal or financial activities or interests
          that
          either directly or indirectly: 

         

        (1)
          Impairs or diminishes the HMO’s, or Subcontractor’s ability to render impartial
          or objective assistance or advice to HHSC; or 

         

        (2)
          Provides the HMO or Subcontractor an unfair competitive advantage in future
          HHSC
          procurements (excluding the award of this Contract). 

         

        (b)
          Warranty. 

         

        Except
          as
          otherwise disclosed and approved by HHSC prior to the Effective Date of
          the
          Contract, HMO warrants that, as of the Effective Date and to the best of
          its
          knowledge and belief, there are no relevant facts or circumstances that
          could
          give rise to an organizational conflict of interest affecting this Contract.
          HMO
          affirms that it has neither given, nor intends to give, at any time hereafter,
          any economic opportunity, future employment, gift, loan, gratuity, special
          discount, trip, favor, or service to a public servant or any employee or
          representative of same, at any time during the procurement process or in
          connection with the procurement process except as allowed under relevant
          state
          and federal law. 

         

        (c)
          Continuing duty to disclose. 

         

        (1)
          HMO
          agrees that, if after the Effective Date, HMO discovers or is made aware
          of an
          organizational conflict of interest, HMO will immediately and fully disclose
          such interest in writing to the HHSC project manager. In addition, HMO
          must
          promptly disclose any relationship that might be perceived or represented
          as a
          conflict after its discovery by HMO or by HHSC as a potential conflict.
          HHSC
          reserves the right to make a final determination regarding the existence
          of
          conflicts of interest, and HMO agrees to abide by HHSC’s decision. 

         

        (2)
          The
          disclosure will include a description of the action(s) that HMO has taken
          or
          proposes to take to avoid or mitigate such conflicts. 

         

        (d)
          Remedy. 

         

        If
          HHSC
          determines that an organizational conflict of interest exists, HHSC may,
          at its
          discretion, terminate the Contract pursuant to Subsection
          12.03(b)(9). If
          HHSC
          determines that HMO was aware of an organizational conflict of interest
          before
          the award of this Contract and did not disclose the conflict to the contracting
          officer, such nondisclosure will be considered a material breach of the
          Contract. Furthermore, such breach may be submitted to the Office of the
          Attorney General, Texas Ethics Commission, or appropriate State or Federal
          law
          enforcement officials for further action. 

         

        (e)
          Flow
          down obligation. 

         

        HMO
          must
          include the provisions of this Section in all Subcontracts for work to
          be
          performed similar to the service provided by HMO, and the terms "Contract,"
          "HMO," and "project manager" modified appropriately to preserve the State's
          rights. 

         

        Section
          13.04 HHSC
          personnel recruitment prohibition. 

         

        HMO
          has
          not retained or promised to retain any person or company, or utilized or
          promised to utilize a consultant that participated in HHSC’s development of
          specific criteria of the RFP or who participated in the selection of the
          HMO for
          this Contract. 

         

        Unless
          authorized in writing by HHSC, HMO will not recruit or employ any HHSC
          professional or technical personnel who have worked on projects relating
          to the
          subject matter of this Contract, or who have had any influence on decisions
          affecting the subject matter of this Contract, for two (2) years following
          the
          completion of this Contract. 

         

        Section
          13.05 Anti-kickback
          provision. 

         

        HMO
          certifies that it will comply with the Anti-Kickback Act of 1986, 41 U.S.C.
          §51-58 and Federal Acquisition Regulation 52.203-7, to the extent applicable.
          

         

        Section
          13.06 Debt
          or back taxes owed to State of Texas. 

         

        In
          accordance with Section 403.055 of the Texas Government Code, HMO agrees
          that
          any payments due to HMO under the Contract will be first applied toward
          any debt
          and/or back taxes HMO owes State of Texas. HMO further agrees that payments
          will
          be so applied until such debts and back taxes are paid in full. 

         

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

         

        Article
          IX, Section 163 of the General Appropriations Act for the 1998/1999 state
          fiscal
          biennium prohibits an agency that receives an appropriation under either
          Article
          II or V of the General Appropriations Act from awarding a contract with
          the
          owner, operator, or administrator of a facility that has had a license,
          certificate, or permit revoked by another Article II or V agency. HMO certifies
          it is not ineligible for an award under this provision. 

         

        Section
          13.08 Outstanding
          debts and judgments. 

         

        HMO
          certifies that it is not presently indebted to the State of Texas, and
          that HMO
          is not subject to an outstanding judgment in a suit by State of Texas against
          HMO for collection of the balance. For purposes of this Section, an indebtedness
          is any amount sum of money that is due and owing to the State of Texas
          and is
          not currently under dispute. A false statement regarding HMO’s status will be
          treated as a material breach of this Contract and may be grounds for termination
          at the option of HHSC. 

         

          Article
          14. Representations & Warranties 

         

        Section
          14.01 Authorization.
          

         

        (a)
          The
          execution, delivery and performance of this Contract has been duly authorized
          by
          HMO and no additional approval, authorization or consent of any governmental
          or
          regulatory agency is required to be obtained in order for HMO to enter
          into this
          Contract and perform its obligations under this Contract. 

         

        (b)
          HMO
          has obtained all licenses, certifications, permits, and authorizations
          necessary
          to perform the Services under this Contract and currently is in good standing
          with all regulatory agencies that regulate any or all aspects of HMO’s
          performance of this Contract. HMO will maintain all required certifications,
          licenses, permits, and authorizations during the term of this Contract.
          

         

        Section
          14.02 Ability
          to perform. 

         

        HMO
          warrants that it has the financial resources to fund the capital expenditures
          required under the Contract without advances by HHSC or assignment of any
          payments by HHSC to a financing source. 

         

        Section
          14.03 Minimum
          Net Worth. 

         

        The
          HMO
          has, and will maintain throughout the life of this Contract, minimum net
          worth
          to the greater of (a) $1,500,000; (b) an amount equal to the sum of twenty-five
          dollars ($25) times the number of all enrollees including Members; or (c)
          an
          amount that complies with standards adopted by TDI. Minimum net worth means
          the
          excess total admitted assets over total liabilities, excluding liability
          for
          subordinated debt issued in compliance with Chapter 843 of the Texas Insurance
          Code. 

         

        Section
          14.04 Insurer
          solvency. 

         

        (a)
          The
          HMO must be and remain in full compliance with all applicable state and
          federal
          solvency requirements for basic-service health maintenance organizations,
          including but not limited to, all reserve requirements, net worth standards,
          debt-to-equity ratios, or other debt limitations. In the event the HMO
          fails to
          maintain such compliance, HHSC, without limiting any other rights it may
          have by
          law or under the Contract, may terminate the Contract. 

         

        (b)
          If
          the HMO becomes aware of any impending changes to its financial or business
          structure that could adversely impact its compliance with the requirements
          of
          the Contract or its ability to pay its debts as they come due, the HMO
          must
          notify HHSC immediately in writing. 

         

        (c)
          The
          HMO must have a plan and take appropriate measures to ensure adequate provision
          against the risk of insolvency as required by TDI. Such provision must
          be
          adequate to provide for the following in the event of insolvency: 

         

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

         

        (2)
          payments to unaffiliated health care providers and affiliated healthcare
          providers whose Contracts do not contain Member “hold harmless” clauses
          acceptable to the TDI; 

         

        (3)
          continuation of Covered Services for the duration of the Contract Period
          for
          which a capitation has been paid for a Member; 

         

        (4)
          provision against the risk of insolvency must be made by establishing adequate
          reserves, insurance or other guarantees in full compliance with all financial
          requirements of TDI and the Contract. 

         

        Should
          TDI determine that there is an immediate risk of insolvency or the HMO
          is unable
          to provide Covered Services to its Members, HHSC, without limiting any
          other
          rights it may have by law, or under the Contract, may terminate the Contract.
          

         

        Section
          14.05 Workmanship
          and performance. 

         

        (a)
          All
          Services and Deliverables provided under this Contract will be provided
          in a
          manner consistent with the standards of quality and integrity as outlined
          in the
          Contract. 

         

        (b)
          All
          Services and Deliverables must meet or exceed the required levels of performance
          specified in or pursuant to this Contract. 

         

        (c)
          HMO
          will perform the Services and provide the Deliverables in a workmanlike
          manner,
          in accordance with best practices and high professional standards used
          in
          well-managed operations performing services similar to the services described
          in
          this Contract. 

         

        Section
          14.06 Warranty
          of deliverables. 

         

        HMO
          warrants that Deliverables developed and delivered under this Contract
          will meet
          in all material respects the specifications as described in the Contract
          during
          the period following its acceptance by HHSC, through the term of the Contract,
          including any subsequently negotiated by HMO and HHSC. HMO will promptly
          repair
          or replace any such Deliverables not in compliance with this warranty at
          no
          charge to HHSC. 

         

        Section
          14.07 Compliance
          with Contract. 

         

        HMO
          will
          not take any action substantially or materially inconsistent with any of
          the
          terms and conditions set forth in this Contract without the express written
          approval of HHSC. 

         

        Section
          14.08 Technology
          Access 

         

        (a)
          HMO
          expressly acknowledges that State funds may not be expended in connection
          with
          the purchase of an automated information system unless that system meets
          certain
          statutory requirements relating to accessibility by persons with visual
          impairments. Accordingly, HMO represents and warrants to HHSC that this
          technology is capable, either by virtue of features included within the
          technology or because it is readily adaptable by use with other technology,
          of:

         

        (1)
          Providing equivalent access for effective use by both visual and non-visual
          means; 

         

        (2)
          Presenting information, including prompts used for interactive communications,
          in formats intended for non-visual use; and 

         

        (3)
          Being
          integrated into networks for obtaining, retrieving, and disseminating
          information used by individuals who are not blind or visually impaired.
          

         

        (b)
          For
          purposes of this Section, the phrase "equivalent access" means a substantially
          similar ability to communicate with or make use of the technology, either
          directly by features incorporated within the technology or by other reasonable
          means such as assistive devices or services that would constitute reasonable
          accommodations under the Americans with Disabilities Act or similar State
          or
          Federal laws. Examples of methods by which equivalent access may be provided
          include, but are not limited to, keyboard alternatives to mouse commands
          and
          other means of navigating graphical displays, and customizable display
          appearance. 

         

        (c)
          In
          addition, all technological solutions offered by the HMO must comply with
          the
          requirements of Texas Government Code §531.0162. This includes, but is not
          limited to providing technological solutions that meet federal accessibility
          standards for persons with disabilities, as applicable. 

         

          Article
          15. Intellectual Property 

         

        Section
          15.01 Infringement
          and misappropriation. 

         

        (a)
          HMO
          warrants that all Deliverables provided by HMO will not infringe or
          misappropriate any right of, and will be free of any claim of, any third
          person
          or entity based on copyright, patent, trade secret, or other intellectual
          property rights. 

         

        (b)
          HMO
          will, at its expense, defend with counsel approved by HHSC, indemnify,
          and hold
          harmless HHSC, its employees, officers, directors, contractors, and agents
          from
          and against any losses, liabilities, damages, penalties, costs, fees, including
          without limitation reasonable attorneys’ fees and expenses, from any claim or
          action against HHSC that is based on a claim of breach of the warranty
          set forth
          in the preceding paragraph. HHSC will promptly notify HMO in writing of
          the
          claim, provide HMO a copy of all information received by HHSC with respect
          to
          the claim, and cooperate with HMO in defending or settling the claim. HHSC
          will
          not unreasonably withhold, delay or condition approval of counsel selected
          by
          the HMO. 

         

        (c)
          In
          case the Deliverables, or any one or part thereof, is in such action held
          to
          constitute an infringement or misappropriation, or the use thereof is enjoined
          or restricted or if a proceeding appears to HMO to be likely to be brought,
          HMO
          will, at its own expense, either: 

         

        (1)
          Procure for HHSC the right to continue using the Deliverables; or 

         

        (2)
          Modify or replace the Deliverables to comply with the Specifications and
          to not
          violate any intellectual property rights. 

         

        If
          neither of the alternatives set forth in (1) or (2) above are available
          to the
          HMO on commercially reasonable terms, HMO may require that HHSC return
          the
          allegedly infringing Deliverable(s) in which case HMO will refund all amounts
          paid for all such Deliverables. 

         

        Section
          15.02 Exceptions.
          

         

        HMO
          is
          not responsible for any claimed breaches of the warranties set forth in
          Section
          15.01 to the extent caused by: 

         

        (a)
          Modifications made to the item in question by anyone other than HMO or
          its
          Subcontractors, or modifications made by HHSC or its contractors working
          at
          HMO’s direction or in accordance with the specifications; or 

         

        (b)
          The
          combination, operation, or use of the item with other items if HMO did
          not
          supply or approve for use with the item; or 

         

        (c)
          HHSC’s failure to use any new or corrected versions of the item made available
          by HMO. 

         

        Section
          15.03 Ownership
          and Licenses 

         

          (a)
          Definitions. 

         

        For
          purposes of this Section 15.03, the following terms have the meanings set
          forth
          below: 

         

        (1)
          “Custom
          Software”
means
          any software developed by the HMO: for HHSC; in connection with the Contract;
          and with funds received from HHSC. The term does not include HMO Proprietary
          Software or Third Party Software. 

         

        (2)
          “HMO
          Proprietary Software”
means
          software: (i) developed by the HMO prior to the Effective Date of the Contract,
          or (ii) software developed by the HMO after the Effective Date of the Contract
          that is not developed: for HHSC; in connection with the Contract; and with
          funds
          received from HHSC. 

         

        (3)
          “Third
          Party Software”
means
          software that is: developed for general commercial use; available to the
          public;
          or not developed for HHSC. Third Party Software includes without limitation:
          commercial off-the-shelf software; operating system software; and application
          software, tools, and utilities. 

         

        (b)
          Deliverables. 

         

        The
          Parties agree that any Deliverable, including without limitation the Custom
          Software, will be the exclusive property of HHSC. 

         

        (c)
          Ownership rights. 

         

        (1)
          HHSC
          will own all right, title, and interest in and to its Confidential Information
          and the Deliverables provided by the HMO, including without limitation
          the
          Custom Software and associated documentation. For purposes of this Section
          15.03, the Deliverables will not include HMO Proprietary Software or Third
          Party
          Software. HMO will take all actions necessary and transfer ownership of
          the
          Deliverables to HHSC, including, without limitation, the Custom Software
          and
          associated documentation prior to Contract termination. 

         

        (2)
          HMO
          will furnish such Deliverables, upon request of HHSC, in accordance with
          applicable State law. All Deliverables, in whole and in part, will be deemed
          works made for hire of HHSC for all purposes of copyright law, and copyright
          will belong solely to HHSC. To the extent that any such Deliverable does
          not
          qualify as a work for hire under applicable law, and to the extent that
          the
          Deliverable includes materials subject to copyright, patent, trade secret,
          or
          other proprietary right protection, HMO agrees to assign, and hereby assigns,
          all right, title, and interest in and to Deliverables, including without
          limitation all copyrights, inventions, patents, trade secrets, and other
          proprietary rights therein (including renewals thereof) to HHSC. 

         

        (3)
          HMO
          will, at the expense of HHSC, assist HHSC or its nominees to obtain copyrights,
          trademarks, or patents for all such Deliverables in the United States and
          any
          other countries. HMO agrees to execute all papers and to give all facts
          known to
          it necessary to secure United States or foreign country copyrights and
          patents,
          and to transfer or cause to transfer to HHSC all the right, title, and
          interest
          in and to such Deliverables. HMO also agrees not to assert any moral rights
          under applicable copyright law with regard to such Deliverables. 

         

        (d)
          License Rights 

         

        HHSC
          will
          have a royalty-free and non-exclusive license to access the HMO Proprietary
          Software and associated documentation during the term of the Contract.
          HHSC will
          also have ownership and unlimited rights to use, disclose, duplicate, or
          publish
          all information and data developed, derived, documented, or furnished by
          HMO
          under or resulting from the Contract. Such data will include all results,
          technical information, and materials developed for and/or obtained by HHSC
          from
          HMO in the performance of the Services hereunder, including but not limited
          to
          all reports, surveys, plans, charts, recordings (video and/or sound), pictures,
          drawings, analyses, graphic representations, computer printouts, notes
          and
          memoranda, and documents whether finished or unfinished, which result from
          or
          are prepared in connection with the Services performed as a result of the
          Contract. 

         

        (e)
          Proprietary Notices 

         

        HMO
          will
          reproduce and include HHSC’s copyright and other proprietary notices and product
          identifications provided by HMO on such copies, in whole or in part, or
          on any
          form of the Deliverables. 

         

        (f)
          State
          and Federal Governments 

         

        In
          accordance with 45 C.F.R. §95.617, all appropriate State and Federal agencies
          will have a royalty-free, nonexclusive, and irrevocable license to reproduce,
          publish, translate, or otherwise use, and to authorize others to use for
          Federal
          Government purposes all materials, the Custom Software and modifications
          thereof, and associated documentation designed, developed, or installed
          with
          federal financial participation under the Contract, including but not limited
          to
          those materials covered by copyright, all software source and object code,
          instructions, files, and documentation. 

         

        Article
          16. Liability 

         

        Section
          16.01 Property
          damage. 

         

        (a)
          HMO
          will protect HHSC’s real and personal property from damage arising from HMO’s,
          its agent’s, employees’ and Subcontractors’ performance of the Contract, and HMO
          will be responsible for any loss, destruction, or damage to HHSC’s property that
          results from or is caused by HMO’s, its agents’, employees’ or Subcontractors’
negligent or wrongful acts or omissions. Upon the loss of, destruction
          of, or
          damage to any property of HHSC, HMO will notify the HHSC Project Manager
          thereof
          and, subject to direction from the Project Manager or her or his designee,
          will
          take all reasonable steps to protect that property from further damage.
          

         

        (b)
          HMO
          agrees to observe and encourage its employees and agents to observe safety
          measures and proper operating procedures at HHSC sites at all times.

         

        (c)
          HMO
          will distribute a policy statement to all of its employees and agents that
          directs the employee or agent to promptly report to HHSC or to HMO any
          special
          defect or unsafe condition encountered while on HHSC premises. HMO will
          promptly
          report to HHSC any special defect or an unsafe condition it encounters
          or
          otherwise learns about. 

         

        Section
          16.02 Risk
          of Loss. 

         

        During
          the period Deliverables are in transit and in possession of HMO, its carriers
          or
          HHSC prior to being accepted by HHSC, HMO will bear the risk of loss or
          damage
          thereto, unless such loss or damage is caused by the negligence or intentional
          misconduct of HHSC. After HHSC accepts a Deliverable, the risk of loss
          or damage
          to the Deliverable will be borne by HHSC, except loss or damage attributable
          to
          the negligence or intentional misconduct of HMO’s agents, employees or
          Subcontractors. 

         

        Section
          16.03 Limitation
          of HHSC’s Liability. 

         

        HHSC
          WILL
          NOT BE LIABLE FOR ANY INCIDENTAL, INDIRECT, SPECIAL, OR CONSEQUENTIAL DAMAGES
          UNDER CONTRACT, TORT (INCLUDING NEGLIGENCE), OR OTHER LEGAL THEORY. THIS
          WILL
          APPLY REGARDLESS OF THE CAUSE OF ACTION AND EVEN IF HHSC HAS BEEN ADVISED
          OF THE
          POSSIBILITY OF SUCH DAMAGES. 

         

        HHSC’S
          LIABILITY TO HMO UNDER THE CONTRACT WILL NOT EXCEED THE TOTAL CHARGES TO
          BE PAID
          BY HHSC TO HMO UNDER THE CONTRACT, INCLUDING CHANGE ORDER PRICES AGREED
          TO BY
          THE PARTIES OR OTHERWISE ADJUDICATED. 

         

        HMO’s
          remedies are governed by the provisions in Article 12. 

         

          Article
          17. Insurance & Bonding 

         

        Section
          17.01 Insurance
          Coverage. 

          (a)
          Statutory and General Coverage 

         

        HMO
          will
          maintain the following insurance coverage. 

         

        (1)
          Standard Worker's Compensation Insurance coverage; 

         

        (2)
          Automobile Liability; 

         

        (3)
          Comprehensive Liability Insurance including Bodily Injury coverage of
          $100,000.00 per each occurrence and Property Damage Coverage of $25,000.00
          per
          each occurrence; and 

         

        (4)
          General Liability Insurance of at least $1,000,000.00 per occurrence and
          $5,000,000.00 in the aggregate. 

         

        If
          HMO’s
          current Comprehensive General Liability insurance coverage does not meet
          the
          above stated requirements, HMO will obtain excess liability insurance to
          compensate for the difference in the coverage amounts. 

         

        (b)
          Professional Liability Coverage. 

         

        (1)
          HMO
          must maintain, or cause its Network Providers to maintain, Professional
          Liability Insurance for each Network Provider of $100,000.00 per occurrence
          and
          $300,000.00 in the aggregate, or the limits required by the hospital at
          which
          the Network Provider has admitting privileges. 

         

        (2)
          HMO
          must maintain an Umbrella Professional Liability Insurance Policy for the
          greater of $3,000,000.00 or an amount (rounded to the nearest $100,000.00)
          that
          represents the number of Members enrolled in the HMO in the first month
          of the
          applicable State Fiscal Year multiplied by $150.00, not to exceed
          $10,000,000.00. 

         

        (c)
          General Requirements for All Insurance Coverage 

         

        (1)
          Except as provided herein, all exceptions to the Contract’s insurance
          requirements must be approved in writing by HHSC. HHSC’s written approval is not
          required in the following situations: 

          (A)
          An
          HMO or a Network Provider is not required to obtain the insurance coverage
          described in Section 17.01 if the HMO or Network Provider qualifies as
          a state
          governmental unit or municipality under the Texas Tort Claims Act, and
          is
          required to comply with, and subject to the provisions of, the Texas Tort
          Claims
          Act. 

          (B)
          An
          HMO may waive the Professional Liability Insurance requirement described
          in
          Section 17.01(b)(1) for a Network Provider of Community-based Long Term
          Care
          Services. An HMO may not waive this requirement if the Network Provider
          provides
          other Covered Services in addition to Community-based Long Term Care Services,
          or if a Texas licensing entity requires the Network Provider to carry such
          Professional Liability coverage. An HMO that waives the Professional Liability
          Insurance requirement for a Network Provider pursuant to this provision
          is not
          required to obtain such coverage on behalf of the Network Provider.

         

        (2)
          HMO
          or the Network Provider is responsible for any and all deductibles stated
          in the
          insurance policies.  

         

        (3)Insurance
          coverage must be issued by insurance companies authorized to conduct business
          in
          the State of Texas. 

         

        (4)
          Insurance coverage must name HHSC as an additional insured with the following
          exceptions: Standard Workers’ Compensation Insurance maintained by the HMO, and
          Professional Liability Insurance maintained by Network Providers.

         

        (5)
          Insurance coverage kept by the HMO must be maintained throughout the Term
          of the
          Contract, and until HHSC’s final acceptance of all Services and Deliverables.
          Failure to maintain such insurance coverage will constitute a material
          breach of
          this Contract. 

         

        (6)
          With
          the exception of Professional Liability Insurance maintained by Network
          Providers, the insurance policies described in this Section must have extended
          reporting periods of two years. When policies are renewed or replaced,
          the
          policy retroactive date must coincide with, or precede, the Contract Effective
          Date. 

         

        (7)
          With
          the exception of Professional Liability Insurance maintained by Network
          Providers, the insurance policies described in this Section must provide
          that
          prior written notice to be given to HHSC at least thirty (30) calendar
          days
          before coverage is substantially changed, canceled, or non-renewed. HMO
          must
          submit a new coverage binder to HHSC to ensure no break in coverage.

         

        (8)
          The
          Parties expressly understand and agree that any insurance coverages and
          limits
          furnished by HMO will in no way expand or limit HMO’s liabilities and
          responsibilities specified within the Contract documents or by applicable
          law.

         

        (9)
          HMO
          expressly understands and agrees that any insurance maintained by HHSC
          will
          apply in excess of and not contribute to insurance provided by HMO under
          the
          Contract. 

         

        (10)
          If
          HMO, or its Network Providers, desire additional coverage, higher limits
          of
          liability, or other modifications for its own protection, HMO or its Network
          Providers will be responsible for the acquisition and cost of such additional
          protection. Such additional protection will not be an Allowable Expense
          under
          this Contract. 

         

        (d)
          Proof
          of Insurance Coverage 

         

        (1)
          Except as provided in Section 17.01(d)(2), the HMO must furnish the HHSC
          Project
          Manager original Certificates of Insurance evidencing the required insurance
          coverage on or before the Effective Date of the Contract. If insurance
          coverage
          is renewed during the Term of the Contract, the HMO must furnish the HHSC
          Project Manager renewal certificates of insurance, or such similar evidence,
          within five (5) Business Days of renewal. The failure of HHSC to obtain
          such
          evidence from HMO will not be deemed to be a waiver by HHSC and HMO will
          remain
          under continuing obligation to maintain and provide proof of insurance
          coverage.

         

        (2)
          The
          HMO is not required to furnish the HHSC Project Manager proof of Professional
          Liability Insurance maintained by Network Providers on or before the Effective
          Date of the Contract, but must provide such information upon HHSC’s request
          during the Term of the Contract. 

         

        Section
          17.02 Performance
          Bond. 

         

        (a)
          Beginning on the Operational Start Date of the Contract, and each year
          thereafter, the HMO must obtain a performance bond with a one (1) year
          term. The
          performance bond must continue to be in effect for one (1) year following
          the
          expiration of the one (1) year term. HMO must obtain and maintain the annual
          performance bonds in the form prescribed by HHSC and approved by TDI, naming
          HHSC as Obligee, securing HMO’s faithful performance of the terms and conditions
          of this Contract. The annual performance bonds must comply with Chapter
          843 of
          the Texas Insurance Code and 28 T.A.C. §11.1805. The annual performance bond(s)
          must be issued in the amount of $100,000.00 for each applicable HMO Program
          within each Service Area that the HMO covers under this Contract. All
          performance bonds must be issued by a surety licensed by TDI, and specify
          cash
          payment as the sole remedy. HMO must deliver the initial performance bond
          to
          HHSC prior to the Operational Start Date of the Contract, and each renewal
          performance bond prior to the first day of the State Fiscal Year. 

         

        (b)
          Since
          the CHIP Perinatal Program is a sub-program of the CHIP Program, neither
          a
          separate performance bond for the CHIP Perinatal Program nor a combined
          performance bond for the CHIP and CHIP Perinatal Programs is required.
          The same
          bond that the HMO obtains for its CHIP Program within a particular Service
          Area
          also will cover the HMO’s CHIP Perinatal Program, if applicable, in that same
          Service Area. 

         

        Section
          17.03 TDI
          Fidelity Bond 

         

        The
          HMO
          will secure and maintain throughout the life of the Contract a fidelity
          bond in
          compliance with Chapter 843 of the Texas Insurance Code and 28 T.A.C. §11.1805.
          The HMO must promptly provide HHSC with copies of the bond and any amendments
          or
          renewals thereto. 

         

         

        
 

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        

          Contractual
            Document (CD) Responsible Office: HHSC Office of General Counsel (OGC)
            

          Subject:
            Attachment B-1 - HHSC Joint Medicaid/CHIP HMO RFP, Section 6

          Version
            1.6

        

        
          

          
            	 
	
                    DOCUMENT
                      HISTORY LOG

                  
	
                    STATUS1

                  	
                    DOCUMENT
                      

                    REVISION2

                  	
                    EFFECTIVE
                      

                    DATE
                      

                  	
                    DESCRIPTION3

                  
	
                     

                    Baseline
                      

                     

                  	
                     

                    n/a
                      

                     

                  	
                     

                     

                     

                  	
                     

                    Initial
                      version Attachment B-1, Section 6 

                  
	
                     

                    Revision
                      

                  	
                     

                    1.1
                      

                  	
                     

                    June
                      30, 2006 

                  	
                     

                    Revised
                      version of the Attachment B-1, Section 6, that includes provisions
                      applicable to MCOs participating in the STAR+PLUS Program.

                     

                    Section
                      6.3.2.1, Experience Rebate Reward, is modified to delete references
                      to the
                      selected performance indicators and the Quality Challenge Pool.
                      

                     

                    Section
                      6.3.2.2, Performance-Based Capitation Rate, is modified to
                      include
                      STAR+PLUS and to add Additional STAR+PLUS Performance Indicators.
                      Section
                      6.3.2.3, Quality Challenge Award, is modified to include STAR+PLUS.
                      Section 6.3.2.5, STAR+PLUS Hospital Inpatient Performance Based
                      Capitation
                      Rate: Hospital Inpatient Stay Cost Incentives and Disincentives,
                      is added.
                      

                     

                    Section
                      6.3.2.5.1, STAR+PLUS Hospital Inpatient Disincentive - Administrative
                      Fee
                      at Risk, is added. 

                     

                    Section
                      6.3.2.5.2, STAR+PLUS Hospital Inpatient Incentive - Shared
                      Savings Award,
                      is added. 

                  
	
                     

                    Revision
                      

                  	
                     

                    1.2
                      

                  	
                     

                    September
                      1, 2006 

                  	
                     

                    Revised
                      version of the Attachment B-1, Section 6, that includes provisions
                      applicable to MCOs participating in the STAR and CHIP Programs.
                      

                     

                    Section
                      6.3.2.2, Performance-Based Capitation Rate, modifies the standard
                      performance indicator for the Behavioral Health Hotline to
                      change the
                      maximum abandonment rate from 5% to 7% (except in the Dallas
                      Core Service
                      Area). 

                     

                    Section
                      6.3.2.3, Quality Challenge Award, is modified to reflect the
                      new start
                      date for the Quality Challenge Award, which will not be implemented
                      until
                      State Fiscal Year 2008. 

                     

                  
	
                     

                    Revision
                      

                     

                  	
                     

                    1.3
                      

                     

                  	
                     

                    September
                      1, 2006 

                     

                     

                     

                     

                  	
                     

                    Revised
                      version of the Attachment B-1, Section 6, that includes provisions
                      applicable to MCOs participating in the CHIP Perinatal Program.
                      

                     

                    Section
                      6.3.2.1 modified to clarify that the Experience Rebate Reward
                      incentive
                      may apply to the CHIP Perinatal Program at a later date. 

                     

                    Section
                      6.3.2.2 modified to clarify that the Performance-based Capitation
                      Rate
                      will not apply for the CHIP Perinatal Program in SFY 2007.

                     

                  
	
                     

                    Revision
                      

                     

                  	
                     

                    1.4
                      

                     

                  	
                     

                    September
                      1, 2006 

                     

                  	
                     

                    Contract
                      amendment did not revise Attachment B-1 Section 6 - Premium
                      Payment,
                      Incentives, and Disincentives 

                     

                  
	
                     

                    Revision
                      

                     

                  	
                     

                    1.5
                      

                     

                  	
                     

                    January
                      1, 2007 

                     

                  	
                     

                    Contract
                      amendment did not revise Attachment B-1 Section 6 - Premium
                      Payment,
                      Incentives, and Disincentives 

                     

                  
	
                     

                    Revision
                      

                     

                  	
                     

                    1.6
                      

                     

                  	
                     

                    February
                      1, 2007 

                     

                  	
                     

                    Revised
                      version of the Attachment B-1, Section 6, that includes provisions
                      applicable to MCOs participating in the STAR+PLUS Program.

                     

                    Section
                      6.3.2.5 is modified to clarify the months included in Rate
                      Period 1.
                      

                     

                  
	
                     

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

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

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

                  

          

          

           

          6.
            Premium Payment, Incentives, and Disincentives 

           

          This
            section documents how the Capitation Rates are developed and describes
            performance incentives and disincentives related to HHSC’s value-based
            purchasing approach. For further information, HMOs should refer to the
            HHSC
Uniform
            Managed Care Contract Terms and Conditions. 

           

          Under
            the
            HMO Contracts, health care coverage for Members will be provided on a
            fully
            insured basis. The HMO must provide the Services and Deliverables, including
            Covered Services to enrolled Members in order for monthly Capitation
            Payments to
            be paid by HHSC. Attachment B-1, Section
            8 includes
            the HMO’s financial responsibilities regarding out-of-network Emergency Services
            and Medically Necessary Covered Services not available through Network
            Providers. 

           

          6.1
            Capitation Rate Development 

           

          Refer
            to
Attachment
            A,
            HHSC
            Uniform Managed Care Contract Terms & Conditions, Article 10, “Terms &
Conditions of Payment,”
            for
            information concerning Capitation Rate development. 

           

          6.2
            Financial Payment Structure and Provisions 

           

          HHSC
            will
            pay the HMO monthly Capitation Payments based on the number of eligible
            and
            enrolled Members. HHSC will calculate the monthly Capitation Payments
            by
            multiplying the number of Member Months times the applicable monthly
            Capitation
            Rate by Member Rate Cell. The HMO must provide the Services and Deliverables,
            including Covered Services to Members, described in the Contract for
            monthly
            Capitation Payments to be paid by HHSC. 

           

          The
            HMO
            must understand and expressly assume the risks associated with the performance
            of the duties and responsibilities under the Contract, including the
            failure,
            termination, or suspension of funding to HHSC, delays or denials of required
            approvals, cost of claims incorrectly paid by the HMO, and cost overruns
            not
            reasonably attributable to HHSC. The HMO must further agree that no other
            charges for tasks, functions, or activities that are incidental or ancillary
            to
            the delivery of the Services and Deliverables will be sought from HHSC
            or any
            other state agency, nor will the failure of HHSC or any other party to
            pay for
            such incidental or ancillary services entitle the HMO to withhold Services
            or
            Deliverables due under the Contract. 

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          6.2.1
            Capitation Payments 

          The
            HMO
            must refer to the HHSC
            Uniform Managed Care Contract Terms & Conditions
            for
            information and Contract requirements on the: 

           

          
            	 	 	
                    1)
                      Time and Manner of Payment, 

                  

          

           

          
            	 	 	
                    2)
                      Adjustments to Capitation Payments,

                  

          

           

          
            	 	 	
                    3)
                      Delivery Supplemental Payment, and 

                  

          

           

          
            	 	 	
                    4)
                      Experience Rebate. 

                  

          

          

          6.3
            Performance Incentives and Disincentives 

           

          HHSC
            introduces several financial and non-financial performance incentives
            and
            disincentives through this Contract. These incentives and disincentives
            are
            subject to change by HHSC over the course of the Contract Period. The
            methodologies required to implement these strategies will be refined
            by HHSC
            after collaboration with contracting HMOs through a new incentives workgroup
            to
            be established by HHSC. 

           

          6.3.1
            Non-financial Incentives 

           

          6.3.1.1
            Performance Profiling 

           

          HHSC
            intends to distribute information on key performance indicators to HMOs
            on a
            regular basis, identifying an HMO’s performance, and comparing that performance
            to other HMOs, and HHSC standards and/or external Benchmarks. HHSC will
            recognize HMOs that attain superior performance and/or improvement by
            publicizing their achievements. For example, HHSC may post information
            concerning exceptional performance on its website, where it will be available
            to
            both stakeholders and members of the public. 

           

          6.3.1.2
            Auto-assignment Methodology for Medicaid HMOs 

           

          HHSC
            may
            also revise its auto-assignment methodology during the Contract Period
            for new
            Medicaid Members who do not select an HMO (Default Members). The new
            assignment
            methodology would reward those HMOs that demonstrate superior performance
            and/or
            improvement on one or more key dimensions of performance. In establishing
            the
            assignment methodology, HHSC will employ a subset of the performance
            indicators
            contained within the Performance
            Indicator Dashboard.
            At
            present, HHSC intends to recognize those HMOs that exceed the minimum
            geographic
            access standards defined within Attachment
            B-1, Section 8 and the Performance Indicator Dashboard. HHSC
            may
            also use its assessment of HMO performance on annual quality improvement
            goals
            (described in Attachment
            B-1, Section 8)
            in
            developing the assignment methodology. The methodology would disproportionately
            assign Default Members to the HMO(s) in a given Service Area that performed
            comparably favorably on the selected performance indicators. 

           

          HHSC
            anticipates that it will not implement a performance-based auto-assignment
            algorithm before September 1, 2007. HHSC will invite HMO comments on
            potential
            approaches prior to implementation of the new performance-based auto-assignment
            algorithm. 

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          6.3.2
            Financial Incentives and Disincentives 

           

          6.3.2.1
            Experience Rebate Reward 

           

          HHSC
            historically has required HMOs to provide HHSC with an Experience Rebate
            (see
            the Uniform
            Managed Care Contract Terms and Conditions, Article 10.11) when
            there has been an aggregate excess of Revenues over Allowable Expenses.
            During
            the Contract Period, should the HMO experience an aggregate excess of
            Revenues
            over Allowable Expenses across STAR and CHIP HMO Programs and Service
            Areas,
            HHSC will allow the HMO to retain that portion of the aggregate excess
            of
            Revenues over Allowable Expenses that is equal to or less than 3.5% of
            the total
            Revenue for the period should the HMO demonstrate superior performance
            on
            selected performance indicators. The retention of 3.5% of revenue exceeds
            the
            retention of 3.0% of revenue that would otherwise be afforded to a HMO
            without
            demonstrated superior performance on these performance indicators relative
            to
            other HMOs. HHSC will develop the methodology for determining the level
            of
            performance necessary for an HMO to retain the additional 0.5% of revenue
            after
            consultation with HMOs. The finalized methodology will be added to the
            Uniform
            Managed Care Manual.
            

           

          HHSC
            will
            calculate the Experience Rebate Reward after it has calculated the HMO’s at-risk
            Capitation Rate payment, as described below in Section
            6.3.2.2.
            HHSC
            will calculate whether a HMO is eligible for the Experience Rebate Reward
            prior
            to the 90-day Financial Statistical Report (FSR) filing. 

           

          HHSC
            anticipates that it will not implement the incentive for Rate Period
            1 of the
            Contract. HHSC will invite HMO comments on potential approaches prior
            to
            implementation of the new performance-based Experience Rebate Reward.
            HHSC may
            also implement this incentive option for the STAR+PLUS and CHIP Perinatal
            programs in the future. 

           

          6.3.2.2
            Performance-Based Capitation Rate 

           

          Beginning
            in State Fiscal Year 2007 of the Contract, HHSC will place each STAR
            and CHIP
            HMO at risk for 1% of the Capitation Rate(s). Beginning in State Fiscal
            Year
            2008 of the Contract, HHSC will also place each STAR+PLUS HMO at risk
            for 1% of
            the Capitation Rate(s). HHSC retains the right to vary the percentage
            of the
            Capitation Rate placed at risk in a given Rate Period. HHSC will not
            place CHIP
            Perinatal HMOs at risk for 1% of the Capitation Rate(s) in State Fiscal
            Year
            2007, but reserves this right in subsequent State Fiscal Years. 

           

          As
            noted
            in Section 6.2, HHSC will pay the HMO monthly Capitation Payments based
            on the
            number of eligible and enrolled Members. HHSC will calculate the monthly
            Capitation Payments by multiplying the number of Member months times
            the
            applicable monthly Capitation Rate by Member rate cell. At the end of
            each Rate
            Period, HHSC will evaluate if the HMO has demonstrated that it has fully
            met the
            performance expectations for which the HMO is at risk. Should the HMO
            fall short
            on some or all of the performance expectations, HHSC will adjust a future
            monthly Capitation Payment by an appropriate portion of the 1% at-risk
            amount.
            HMOs will be able to earn variable percentages up to 100% of the 1% at-risk
            Capitation Rate. HHSC’s objective is that all HMOs achieve performance levels
            that enable them to receive the full at-risk amount. 

           

          HHSC
            will
            determine the extent to which the HMO has met the performance expectations
            by
            assessing the HMO’s performance for each applicable HMO Program relative to
            performance targets for the rate period. HHSC will conduct separate accounting
            for each HMO Program’s at-risk Capitation Rate amount. 

           

          HHSC
            will
            identify no more than 10 performance indicators for each HMO Program.
            Some of
            the performance indicators will be standard across the HMO Programs while
            others
            may apply to only one of the HMO Programs. 

           

          HHSC’s
            performance indicators may include some or all of the following measures.
            The
            specific

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          performance
            indicators, periods of data collection, and associated points are detailed
            in
            the HHSC
            Uniform Managed Care Manual. The
            minimum percentage targets identified in this section were developed
            based, in
            part, on the HHSC HMO Program objective of ensuring access to care and
            quality
            of care, past performance of the HHSC HMOs, and performance of Medicaid
            and CHIP
            HMOs nationally on HEDIS and CAHPS measures of plan performance. The
            Performance Indicator Dashboard
            includes
            a more detailed explanation. 

           

          Standard
            Performance Indicators: 

           

          
            	 	 	
                    1.
                      98% of Clean Claims are properly Adjudicated within 30 calendar
                      days.
                      

                  

          

           

          
            	 	 	
                    2.
                      The Member Services Hotline abandonment rate does not exceed
                      7%.
                      

                  

          

           

          
            	 	 	
                    3.
                      The Behavioral Health Hotline abandonment rate does not exceed
                      7%.1 

                  

          

           

          
            	 	 	
                    4.
                      The Provider Services Hotline abandonment rate does not exceed
                      7%.
                      

                  

          

           

          Additional
            STAR Performance Indicators 

           

          1.
            90% of
            child Members have access to at least one child-appropriate PCP with
            an Open
            Panel within 30 miles travel distance. 

           

          2.
            90% of
            adult Members have access to at least one adult-appropriate PCP with
            an Open
            Panel within 30 miles travel distance. 

           

          3.
            36% of
            age-qualified child Members receive six or more well-child visits (in
            the first
            15 months of life. 

           

          4.
            56% of
            age-qualified child Members receive at least one well-child visit in
            the 3rd,
            4th, 5th, or 6th year of life. 

           

          5.
            72% of
            pregnant women Members receive a prenatal care visit in the first trimester
            or
            within 42 days of enrollment. 

           

          Additional
            CHIP Performance Indicators 

           

          1.
            90% of
            child Members have access to at least one child-appropriate PCP with
            an Open
            Panel within 30 miles travel distance. 

           

          2.
            90% of
            child Members have access to at least one otolaryngologist (ENT) within
            75 miles
            travel distance. 

           

          3.
            56% of
            age-qualified child Members receive at least one well-child visit in
            the 3rd,
            4th, 5th, or 6th year of life 

           

          
            	 	 	
                    4.
                      38% of adolescents receive an annual well visit.
                      

                  

          

          

          1
            Will not
            apply in the Dallas Core Service Area. Points will be allocated proportionately
            over the remaining standard performance indicators. 

           

          Additional
            STAR+PLUS Performance Indicators 

           

          
            	 	 	
                    1.
                      57% of adult Members report no problem with delays in getting
                      approval
                      from the HMO 

                  

          

           

          2.
            90% of
            adult Members have access to at least one adult-appropriate PCP with
            an Open
            Panel within 30 miles travel distance 

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          3.
            62% of
            adult Members report no problem in getting a referral to a Specialty
            Physician

           

          4.
            47% of
            adult Members report no problem getting needed Special Therapy (physical
            therapy, occupational therapy, and speech therapy) from the HMO 

           

          5.
            57% of
            adult Members report no problem getting needed Behavioral Health Services
            from
            the HMO 

           

          Failure
            to timely provide HHSC with necessary data related to the calculation
            of the
            performance indicators will result in HHSC’s assignment of a zero percent
            performance rate for each related performance indicator. 

           

          Should
            Member survey-based indicators yield response rates deemed by HHSC to
            be too low
            to yield credible data, HHSC will reapportion points across the remaining
            measures. 

           

          Actual
            plan rates will be rounded to the nearest whole number. HHSC will calculate
            performance assessment for the at-risk portion of the capitation payments
            by
            summing all earned points and converting them to a percentage. For example,
            an
            HMO that earns 92 points will earn 92% of the at-risk Capitation Rate.
            HHSC will
            apply the premium assessment of 8% of the at-risk Capitation Rate as
            a reduction
            to the monthly Capitation Payment ninety days after the end of the contract
            period. 

           

          HMOs
            will
            report actual Capitation Payments received on the Financial Statistical
            Report
            (FSR). Actual Capitation Payments received include all of the at-risk
            Capitation
            Payment paid to the HMO. Any performance assessment based on performance
            for a
            contract period will appear on the second final (334-day) FSR for that
            contract
            period. 

           

          HHSC
            will
            evaluate the performance-based Capitation Rate methodology annually in
            consultation with HMOs. HHSC may then modify the methodology it deems
            necessary
            and appropriate to motivate, recognize, and reward HMOs for performance.
            The
            methodologies for Rate Periods 1 and 2 will be included in the HHSC
            Uniform Managed Care Manual.
            

           

          6.3.2.3
            Quality Challenge Award 

           

          Data
            collection for the Quality Challenge Award will begin on September 1,
            2006;
            however, the Quality Challenge Award will not be implemented until State
            Fiscal
            Year 2008. Should one or more HMOs be unable to earn the full amount
            of the
            performance-based at-risk portion of the Capitation Rate, HHSC will reallocate
            the funds through the HMO Program’s Quality Challenge Award. HHSC will use these
            funds to reward HMOs that demonstrate superior clinical quality. HHSC
            will
            determine the number of HMOs that will receive Quality Challenge Award
            funds
            annually based on the amount of the funds to be reallocated. Separate
            Quality
            Challenge Award payments will be made for each of the HMO programs. As
            with the
            performance-based Capitation Rate, each HMO will be evaluated separately
            for
            each HMO Program. HHSC intends to evaluate HMO performance annually on
            some
            combination of the following performance indicators in order to determine
            which
            HMOs demonstrate superior clinical quality. In no event will a distribution
            from
            the Quality Challenge Award, plus any other incentive payments made in
            accordance with the HMO Contract, when combined with the Capitation Rate
            payments, exceed 105% of the Capitation Rate payments to an HMO. 

           

          Information
            about the data collection period to be used for each indicator is found
            in the
HHSC
            Uniform Managed Care Manual.
            

           

          6.3.2.4
            Remedies and Liquidated Damages 

           

          All
            areas
            of responsibility and all requirements in the Contract will be subject
            to
            performance evaluation by HHSC. Any and all responsibilities or requirements
            not
            fulfilled may have remedies and HHSC will assess either actual or liquidated
            damages. Refer to Attachment
            A, HHSC Uniform Managed Care

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          Contract
            Terms and Conditions
            and
Attachment
            B-5
            for
            performance standards that carry liquidated damage values. 

           

          6.3.2.5
            STAR+PLUS Hospital Inpatient Performance-Based Capitation Rate: Hospital
            Inpatient Stay Cost Incentives & Disincentives 

           

          Effective
            as of the STAR+PLUS Operational Start Date, HHSC will place at-risk a
            portion of
            the HMO’s Medicaid-Only Capitation Rate. Settlements for Inpatient Stay costs
            will be calculated by the State after the end of each State Fiscal Year
            (SFY)
            using three (3) months of completed Hospital paid data for the preliminary
            settlement and 11 months of completed data for the final settlement.
            The SFY
            2006 Fee-for-Service (FFS) Inpatient Hospital per-member-per-month (PMPM)
            rate
            will be projected for Rate Period 1 (February 1, 2007 through August
            31, 2007)
            for the first settlement. Adjustments for the projection will include
            trending
            and risk adjustment. The base and final inpatient hospital PMPM rate
            will be
            calculated separately for each HMO, Service Area, and Rate Cell. Harris
            County
            is excluded from the Harris Service Area calculations. 

           

          6.3.2.5.1
            STAR+PLUS Hospital Inpatient Disincentive - Administrative Fee at Risk
            

           

          HHSC
            has
            assumed that STAR+PLUS HMOs will achieve a 22% reduction in projected
            FFS
            Hospital Inpatient Stay costs, for the Medicaid-Only population, through
            the
            implementation of the STAR+PLUS model. HMOs achieving savings beyond
            22% will be
            eligible for the STAR+PLUS Shared Savings Award described in Section
            6.3.2.5.2.
            The HMO
            will be at-risk for savings less than 22%. 

           

          The
            maximum risk to the HMO will be equal to 50% of the difference between
            15%
            Hospital inpatient savings and 22% Hospital inpatient savings. The disincentive
            for savings above 15%, but still less than 22% will be equal to 50% of
            the
            difference between the level of achieved savings and 22%. HHSC retains
            the right
            to vary the disincentive percentage in a given Rate Period by Contract
            amendment. 

           

          6.3.2.5.2
            STAR+PLUS Hospital Inpatient Incentive - Shared Savings Award

           

          HMOs
            that
            exceed the 22% reduction in Inpatient Stay costs incurred by STAR+PLUS
            Members
            specified in Section
            6.3.2.5.1
            will be
            eligible to obtain a 20% share of the savings achieved beyond the 22%
            target.
            HHSC will determine the extent to which the HMO has met and exceeded
            the
            performance expectation in the manner described within Section
            6.3.2.5.
            Should
            HHSC determine that the HMO exceeded the 22% target, HHSC will adjust
            a future
            monthly Capitation Payment upward by 20% of the calculated savings. This
            shared
            savings award is limited to 5% of the HMO’s capitation in accordance with
            Federal Balance Budget Act requirements and is calculated off of total
            of
            STAR+PLUS Capitation Payment. An HMO will be subject to contractual remedies
            and
            determined ineligible for the award, if a HHSC audit reveals that the
            HMO has
            inappropriately averted Medically Necessary Inpatient Stay admissions
            and
            potentially endangered Member safety. 

           

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
Contractual
            Document (CD) Responsible Office: HHSC Office of General Counsel (OGC)
            

          
            Subject:
              Attachment B-1 - HHSC Joint Medicaid/CHIP HMO RFP, Section 7

            Version
              1.6

             

            
              	
                      DOCUMENT
                        HISTORY LOG

                    
	
                      STATUS1

                    	
                      DOCUMENT
                        

                      REVISION2

                    	
                      EFFECTIVE
                        

                      DATE
                        

                    	
                      DESCRIPTION3

                    
	
                       

                      Baseline
                        

                       

                    	
                       

                      n/a
                        

                       

                    	
                       

                       

                       

                    	
                       

                      Initial
                        version Attachment B-1, Section 7 

                       

                    
	
                       

                      Revision
                        

                    	
                       

                      1.1
                        

                    	
                       

                      June
                        30, 2006 

                    	
                       

                      Revised
                        version of the Attachment B-1, Section 7, that includes provisions
                        applicable to MCOs participating in the STAR+PLUS Program.

                       

                      Sections
                        7.1 to 7.3 modified to include STAR+PLUS. 

                       

                    
	
                       

                      Revision
                        

                    	
                       

                      1.2
                        

                    	
                       

                      September
                        1, 2006 

                    	
                       

                      Revised
                        version of the Attachment B-1, Section 7, that includes provisions
                        applicable to MCOs participating in the STAR and CHIP Programs.
                        

                       

                      Section
                        7.3.1.7, Operations Readiness, changes reference from “Operational Date”
                        to “Effective Date.” 

                       

                    
	
                       

                      Revision
                        

                       

                    	
                       

                      1.3
                        

                       

                    	
                       

                      September
                        1, 2006 

                       

                    	
                       

                      Revised
                        version of the Attachment B-1, Section 7, that includes provisions
                        applicable to MCOs participating in the CHIP Perinatal Program.
                        

                       

                       

                      Sections
                        7.2, 7.3, and 7.3.1.2 through 7.3.1.7 modified to include
                        the CHIP
                        Perinatal Program. 

                       

                    
	
                       

                      Revision
                        

                       

                    	
                       

                      1.4
                        

                       

                    	
                       

                      September
                        1, 2006 

                       

                    	
                       

                      Contract
                        amendment did not revise Attachment B-1 Section 7 - Transition
                        Phase
                        Requirements 

                       

                    
	
                       

                      Revision
                        

                       

                    	
                       

                      1.5
                        

                       

                    	
                       

                      January
                        1, 2007 

                       

                    	
                       

                      Contract
                        amendment did not revise Attachment B-1 Section 7 - Transition
                        Phase
                        Requirements 

                       

                    
	
                       

                      Revision
                        

                       

                    	
                       

                      1.6
                        

                       

                    	
                       

                      February
                        1, 2007 

                       

                    	
                       

                      Contract
                        amendment did not revise Attachment B-1 Section 7 - Transition
                        Phase
                        Requirements 

                       

                    
	
                       

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

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

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

                    

            

            

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

            7.
                Transition
              Phase Requirements 

            7.1
                Introduction
              

             

            This
              Section presents the scope of work for the Transition Phase of the
              Contract,
              which includes those activities that must take place between the time
              of
              Contract award and the Operational Start Date. 

             

            The
              Transition Phase will include a Readiness Review of each HMO, which
              must be
              completed successfully prior to a HMO’s Operational Start Date for each
              applicable HMO Program. HHSC may, at its discretion, postpone the Operational
              Start Date of the Contract for any such HMO that fails to satisfy all
              Transition
              Phase requirements. 

             

            If
              for
              any reason, a HMO does not fully meet the Readiness Review prior to
              the
              Operational Start Date, and HHSC has not approved a delay in the Operational
              Start Date or approved a delay in the HMO’s compliance with the applicable
              Readiness Review requirement, then HHSC shall impose remedies and either
              actual
              or liquidated damages. If the HMO is a current HMO Contractor, HHSC
              may also
              freeze enrollment into the HMO’s plan for any of its HMO Programs. Refer to
              the
              HHSC Uniform Managed Care Contract Terms and Conditions (Attachment
              A)
              and
              the
              Liquidated Damages Matrix (Attachment B-5)
              for
              additional information. 

             

            Section
              7.1 modified by Version 1.1 

             

            7.2
                Transition
              Phase Scope for HMOs 

            

            STAR,
              STAR+PLUS and CHIP HMOs must meet the Readiness Review requirements
              established
              by HHSC no later than 90 days prior to the Operational Start Date for
              each
              applicable HMO Program. CHIP Perinatal HMOS must meet the Readiness
              Review
              requirements established by HHSC not later than 60 days prior to the
              Operational
              Start Date for the CHIP Perinatal Program. HMO agrees to provide all
              materials
              required to complete the readiness review by the dates established
              by HHSC and
              its Contracted Readiness Review Vendor. 

             

            Section
              7.2 modified by Versions 1.1 and 1.3 

             

            7.3
                Transition
              Phase Schedule and Tasks 

            

            The
              Transition Phase will begin after both Parties sign the Contract. The
              start date
              for the STAR and CHIP Transition Phase is November 15, 2005. The start
              date for
              the STAR+PLUS Transition Phase is June 30, 2006. The start date for
              the CHIP
              Perinate Transition Phase is September 1, 2006. 

             

            The
              Transition Phase must be completed no later than the agreed upon Operational
              Start Date(s) for each HMO Program and Service Area. The HMO may be
              subject to
              liquidated damages for failure to meet the agreed upon Operational
              Start Date
              (see Attachment
              B-5).
              

             

            Section
              7.3 modified by Versions 1.1 and 1.3 

             

            7.3.1
                Transition
              Phase Tasks 

            

            The
              HMO
              has overall responsibility for the timely and successful completion
              of each of
              the Transition Phase tasks. The HMO is responsible for clearly specifying
              and
              requesting information needed from HHSC, other HHSC contractors, and
              Providers
              in a manner that does not delay the schedule or work to be
              performed.

             

            7.3.1.1
               Contract
              Start-Up and Planning 

            

            HHSC
              and
              the HMO will work together during the initial Contract start-up phase
              to:

             

            •
define
              project management and reporting standards;

             

            •
              establish communication protocols between HHSC and the HMO; 

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

             

            •
              establish contacts with other HHSC contractors; 

             

            •
              establish a schedule for key activities and milestones; and 

             

            •
clarify
              expectations for the content and format of Contract Deliverables. 

            

            The
              HMO
              will be responsible for developing a written work plan, referred to
              as the
              Transition/Implementation Plan, which will be used to monitor progress
              throughout the Transition Phase. An updated and detailed Transition
              /Implementation Plan will be due to HHSC. 

             

            7.3.1.2
               Administration
              and Key HMO Personnel 

             

            No
              later
              than the Effective Date of the Contract, the HMO must designate and
              identify Key
              HMO Personnel that meet the requirements in HHSC
              Uniform Managed Care Contract Terms & Conditions, Article
              4.
              The HMO
              will supply HHSC with resumes of each Key HMO Personnel as well as
              organizational information that has changed relative to the HMO’s Proposal, such
              as updated job descriptions and updated organizational charts, (including
              updated Management Information System (MIS) job descriptions and an
              updated MIS
              staff organizational chart), if applicable. If the HMO is using a Material
              Subcontractor(s), the HMO must also provide the organizational chart
              for such
              Material Subcontractor(s). 

             

            Section
              7.3.1.2 modified by Versions 1.1 and 1.3 

             

            No
              later
              than the Contract execution date, STAR+PLUS HMOs must update the information
              above and provide any additional information as it relates to the STAR+PLUS
              Program. 

             

            No
              later
              than the Contract execution date, CHIP Perinatal HMOs must update the
              information above and provide any additional information as it relates
              to the
              CHIP Perinatal Program. 

             

            7.3.1.3
               Financial
              Readiness Review 

             

            In
              order
              to complete a Financial Readiness Review, HHSC will require that HMOs
              update
              information submitted in their proposals. Note: STAR+PLUS and/or CHIP
              Perinatal
              HMOs who have already submitted proposal updates for HHSC’s review for STAR
              and/or CHIP, must either verify that the information has not changed
              and that it
              applies to STAR+PLUS and/or the CHIP Perinatal Program or provide updated
              information for STAR+PLUS by July 10, 2006 and for the CHIP Perinatal
              Program by
              September 1, 2006. This information will include the following: 

             

            Section
              7.3.1.3 modified by Versions 1.1 and 1.3 

             

            Contractor
              Identification and Information 

             

            1.
              The
              Contractor’s legal name, trade name, or any other name under which the
              Contractor does business, if any. 

             

            2.
              The
              address and telephone number of the Contractor’s headquarters office.

             

            3.
              A copy
              of its current Texas Department of Insurance Certificate of Authority
              to provide
              HMO or ANHC services in the applicable Service Area(s). The Certificate
              of
              Authority must include all counties in the Service Area(s) for which
              the
              Contractor is proposing to serve HMO Members. 

             

            4.
              Indicate with a “Yes-HMO”, “Yes-ANHC” or “No” in the applicable cell(s) of the
              Column B of the following chart whether the Contractor is currently
              certified by
              TDI as an HMO or ANHC in all
              counties
              in each of the CSAs in which the Contractor proposes to participate
              in one or
              more of the HHSC HMO Programs. If the Contractor is not proposing to
              serve a CSA
              for a particular HMO Program, the Contractor should leave the applicable
              cells
              in the table empty. 

             

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

            Table
              2:
              TDI Certificate of Authority in Proposed HMO Program CSAs 

            

            
              	
                      Column
                        A 

                    	
                      Column
                        B

                    	
                      Column
                        C 

                    
	
                      Core
                        Service Area (CSA) 

                       

                    	
                      TDI
                        Certificate of Authority 

                    	
                      Counties/Partial
                        Counties without a TDI Certificate of Authority
                        

                    
	
                      Bexar
                        

                    	
                       

                    	
                       

                    
	
                      Dallas
                        

                    	
                       

                    	
                       

                    
	
                      El
                        Paso 

                    	
                       

                    	
                       

                    
	
                      Harris
                        

                    	
                       

                    	
                       

                    
	
                      Lubbock
                        

                    	
                       

                    	
                       

                    
	
                      Nueces
                        

                    	
                       

                    	
                       

                    
	
                      Tarrant
                        

                    	
                       

                    	
                       

                    
	
                      Travis

                    	
                       

                    	
                       

                    
	
                      Webb
                        

                    	
                       

                    	
                       

                    

            

            

             

            If
              the
              Contractor is not
              currently certified by TDI as an HMO or ANHC in any one or more counties
              in a
              proposed CSA, the Contractor must identify such entire counties in
              Column C for
              each CSA. For each county listed in Column C, the Contractor must document
              that
              it applied to TDI for such certification of authority prior to the
              submission of
              a Proposal for this RFP. The Contractor shall indicate the date that
              it applied
              for such certification and the status of its application to get TDI
              certification in the relevant counties in this section of its submission
              to
              HHSC. 

             

            5.
              For
              Contractors serving any CHIP and CHIP Perinatal OSAs, indicate with
              a “Yes-HMO”,
“Yes-ANHC” or “No” in the applicable cell(s) of the Column C of the following
              chart whether the Contractor is currently certified by TDI as an HMO
              or ANHC in
              the entire county in the OSA. If the Contractor is not proposing to
              serve an
              OSA, the Contractor should leave the applicable cells in the table
              empty.

             

             

            Table
              3: TDI Certificate of Authority in Proposed HMO Program 

            

            
              	
                      CHIP
                        Program 

                    
	
                      Column
                        A 

                    	
                      Column
                        B 

                    	
                      Column
                        C 

                    
	
                      Core
                        Service Area (CSA) 

                       

                    	
                      Affiliated
                        CHIP OSA 

                    	
                       

                      TDI
                        Certificate of Authority 

                    
	
                      Bexar
                        

                    	
                       

                    	
                       

                    
	
                      El
                        Paso 

                    	
                       

                    	
                       

                    
	
                      Harris
                        

                    	
                       

                    	
                       

                    
	
                      Lubbock
                        

                    	
                       

                    	
                       

                    
	
                      Nueces

                    	
                       

                    	
                       

                    
	
                      Travis

                    	
                       

                    	
                       

                    

            

            

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

             

            
              	
                      CHIP
                        Perinatal Program 

                    
	
                      Column
                        A 

                    	
                      Column
                        B 

                    	
                      Column
                        C 

                    
	
                      Core
                        Service Area (CSA) 

                    	
                      Affiliated
                        CHIP OSA 

                    	
                      TDI
                        Certificate of Authority 

                    
	
                      Bexar
                        

                    	
                       

                    	
                       

                    
	
                      El
                        Paso 

                    	
                       

                    	
                       

                    
	
                      Harris
                        

                    	
                       

                    	
                       

                    
	
                      Lubbock
                        

                    	
                       

                    	
                       

                    
	
                      Nueces
                        

                    	
                       

                    	
                       

                    
	
                      Travis
                        

                    	
                       

                    	
                       

                    

            

            

             

            For
              each
              county listed in Column C, the Contractor must document that it applied
              to TDI
              for such certification of authority prior to the submission of a Proposal
              for
              this RFP. The Contractor shall indicate the date that it applied for
              such
              certification and the status of its application to get TDI certification
              in the
              relevant counties in this section of its submission to HHSC. 

             

            6.
              If the
              Contractor proposes to participate in STAR or STAR+PLUS and seeks to
              be
              considered as an organization meeting the requirements of Section §533.004(a) or
              (e) of the Texas Government Code, describe how the Contractor meets
              the
              requirements of §§533.004(a)(1), (a)(2), (a)(3), or (e) for each proposed
              Service Areas. 

             

            7.
              The
              type of ownership (proprietary, partnership, corporation). 

             

            8.
              The
              type of incorporation (for profit, not-for-profit, or non-profit) and
              whether
              the Contractor is publicly or privately owned. 

             

            9.
              If the
              Contractor is an Affiliate or Subsidiary, identify the parent organization.
              

             

            10.
              If
              any change of ownership of the Contractor’s company is anticipated during the 12
              months following the Proposal due date, the Contractor must describe
              the
              circumstances of such change and indicate when the change is likely
              to occur.

             

            11.
              The
              name and address of any sponsoring corporation or others who provide
              financial
              support to the Contractor and type of support, e.g., guarantees, letters
              of
              credit, etc. Indicate if there are maximum limits of the additional
              financial
              support. 

             

            12.
              The
              name and address of any health professional that has at least a five
              percent
              financial interest in the Contractor and the type of financial interest.
              

             

            13.
              The
              names of officers and directors. 

             

            14.
              The
              state in which the Contractor is incorporated and the state(s) in which
              the
              Contractor is licensed to do business as an HMO. The Contractor must
              also
              indicate the state where it is commercially domiciled, if applicable.
              

             

            15.
              The
              Contractor’s federal taxpayer identification number. 

             

            16.
              The
              Contractor’s Texas Provider Identifier (TPI) number if the Contractor is
              Medicaid-enrolled in Texas. 

             

            17.
              Whether the Contractor had a contract terminated or not renewed for
              non-performance or poor

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

             

            performance
              within the past five years. In such instance, the Contractor must describe
              the
              issues and the parties involved, and provide the address and telephone
              number of
              the principal terminating party. The Contractor must also describe
              any
              corrective action taken to prevent any future occurrence of the problem
              leading
              to the termination. 

             

            18.
              A
              current Certificate of Good Standing issued by the Texas Comptroller
              of Public
              Accounts, or an explanation for why this form is not applicable to
              the
              Contractor. 

             

            19.
              Whether the Contractor has ever sought, or is currently seeking, National
              Committee for Quality Assurance (NCQA) or American Accreditation HealthCare
              Commission (URAC) accreditation status, and if it has or is, indicate:
              

            
              	 	 	
                      •
                        its current NCQA or URAC accreditation status;

                    

            

             

            
              	 	 	
                      •
                        if NCQA or URAC accredited, its accreditation term effective
                        dates; and
                        

                    

            

             

            •
if
              not
              accredited, a statement describing whether and when NCQA or URAC accreditation
              status was ever denied the Contractor. 

             

            Material
              Subcontractor Information

             

            A
              Material Subcontractor means any entity retained by the HMO to provide
              all or
              part of the HMO Administrative Services where the value of the subcontracted
              HMO
              Administrative Service(s) exceeds $100,000 per fiscal year. HMO Administrative
              Services are those services or functions other than the direct delivery
              of
              Covered Services necessary to manage the delivery of and payment for
              Covered
              Services. HMO Administrative Services include but are not limited to
              Network,
              utilization, clinical and/or quality management, service authorization,
              claims
              processing, Management Information System (MIS) operation and reporting.
              The
              term Material Subcontractor does not include Providers in the HMO’s Provider
              Network. 

             

            Contractors
              must submit the following for each proposed Material Subcontractor,
              if any:

             

            1.
              A
              signed letter of commitment from each Material Subcontractor that states
              the
              Material Subcontractor’s willingness to enter into a Subcontractor agreement
              with the Contractor and a statement of work for activities to be subcontracted.
              Letters of Commitment must be provided on the Material Subcontractor’s official
              company letterhead and signed by an official with the authority to
              bind the
              company for the subcontracted work. The Letter of Commitment must state,
              if
              applicable, the company’s certified HUB status. 

             

            2.
              The
              Material Subcontractor’s legal name, trade name, or any other name under which
              the Material Subcontractor does business, if any. 

             

            3.
              The
              address and telephone number of the Material Subcontractor’s headquarters
              office. 

             

            4.
              The
              type of ownership (e.g., proprietary, partnership, corporation). 

             

            5.
              The
              type of incorporation (i.e., for profit, not-for-profit, or non-profit)
              and
              whether the Material Subcontractor is publicly or privately owned.

             

            6.
              If a
              Subsidiary or Affiliate, the identification of the parent organization.
              

             

            7.
              The
              name and address of any sponsoring corporation or others who provide
              financial
              support to the Material Subcontractor and type of support, e.g., guarantees,
              letters of credit, etc. Indicate if there are maximum limits of the
              additional
              financial support. 

             

            8.
              The
              name and address of any health professional that has at least a five
              percent
              (5%) financial interest in the Material Subcontractor and the type
              of financial
              interest. 

             

            9.
              The
              state in which the Material Subcontractor is incorporated, commercially
              domiciled, and the state(s) in which the organization is licensed to
              do
              business. 

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

             

            10.
              The
              Material Subcontractor’s Texas Provider Identifier if Medicaid-enrolled in
              Texas. 

             

            11.
              The
              Material Subcontractor’s federal taxpayer identification number. 

             

            12.
              Whether the Material Subcontractor had a contract terminated or not
              renewed for
              non-performance or poor performance within the past five years. In
              such
              instance, the Contractor must describe the issues and the parties involved,
              and
              provide the address and telephone number of the principal terminating
              party. The
              Contractor must also describe any corrective action taken to prevent
              any future
              occurrence of the problem leading to the termination. 

             

            13.
              Whether the Material Subcontractor has ever sought, or is currently
              seeking,
              National Committee for Quality Assurance (NCQA) or American Accreditation
              HealthCare Commission (URAC) accreditation or certification status,
              and if it
              has or is, indicate: 

             

            
              	 	 	
                      •
                        its current NCQA or URAC accreditation or certification status;
                        

                    

            

            •
if
              NCQA
              or URAC accredited or certified, its accreditation or certification
              term
              effective dates; and 

            •
if
              not
              accredited, a statement describing whether and when NCQA or URAC accreditation
              status was ever denied the Material Subcontractor. 

             

            Organizational
              Overview

             

            1.
              Submit
              an organizational chart (labeled Chart A), showing the corporate structure
              and
              lines of responsibility and authority in the administration of the
              Bidder’s
              business as a health plan. 

             

            2.
              Submit
              an organizational chart (labeled Chart B) showing the Texas organizational
              structure and how it relates to the proposed Service Area(s), including
              staffing
              and functions performed at the local level. If Chart A represents the
              entire
              organizational structure, label the submission as Charts A and B. 

             

            3.
              Submit
              an organizational chart (labeled Chart C) showing the Management Information
              System (MIS) staff organizational structure and how it relates to the
              proposed
              Service Area(s) including staffing and functions performed at the local
              level.

             

            4.
              If the
              Bidder is proposing to use a Material Subcontractor(s), the Bidder
              shall include
              an organizational chart demonstrating how the Material Subcontractor(s)
              will be
              managed within the Bidder’s Texas organizational structure, including the
              primary individuals at the Bidder’s organization and at each Material
              Subcontractor organization responsible for overseeing such Material
              Subcontract.
              This information may be included in Chart B, or in a separate organizational
              chart(s). 

             

            5.
              Submit
              a brief narrative explaining the organizational charts submitted, and
              highlighting the key functional responsibilities and reporting requirements
              of
              each organizational unit relating to the Bidder’s proposed management of the HMO
              Program(s), including its management of any proposed Material Subcontractors.
              

             

            Other
              Information

             

            1.
              Briefly describe any regulatory action, sanctions, and/or fines imposed
              by any
              federal or Texas regulatory entity or a regulatory entity in another
              state
              within the last 3 years, including a description of any letters of
              deficiencies,
              corrective actions, findings of non-compliance, and/or sanctions. Please
              indicate which of these actions or fines, if any, were related to Medicaid
              or
              CHIP programs. HHSC may, at its option, contact these clients or regulatory
              agencies and any other individual or organization whether or not identified
              by
              the Contractor. 

             

            2.
              No
              later than ten (10) days after the Contract Effective Date, submit
              documentation
              that demonstrates that the HMO has secured the required insurance and
              bonds in
              accordance with

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

             

            TDI
              requirements and Attachment B-1, Section 8. 

             

            3.
              Submit
              annual audited financial statement for fiscal years 2004 and 2005 (2005
              to be
              submitted no later than six months after the close of the fiscal year).
              

             

            4.
              Submit
              an Affiliate Report containing a list of all Affiliates and for HHSC’s prior
              review and approval, a schedule of all transactions with Affiliates
              that, under
              the provisions of the Contract, will be allowable as expenses in the
              FSR Report
              for services provided to the HMO by the Affiliate. Those should include
              financial terms, a detailed description of the services to be provided,
              and an
              estimated amount that will be incurred by the HMO for such services
              during the
              Contract Period. 

             

            7.3.1.4
              System Testing and Transfer of Data 

             

            The
              HMO
              must have hardware, software, network and communications systems with
              the
              capability and capacity to handle and operate all MIS systems and subsystems
              identified in Attachment
              B-1, Section
              8.1.18.
              For
              example, the HMO’s MIS system must comply with the Health Insurance Portability
              and Accountability Act of 1996 (HIPAA) as indicated in Section
              8.1.18.4.
              

             

            During
              this Readiness Review task, the HMO will accept into its system any
              and all
              necessary data files and information available from HHSC or its contractors.
              The
              HMO will install and test all hardware, software, and telecommunications
              required to support the Contract. The HMO will define and test modifications
              to
              the HMO’s system(s) required to support the business functions of the Contract.
              

             

            The
              HMO
              will produce data extracts and receive all electronic data transfers
              and
              transmissions. STAR and CHIP HMOs must be able to demonstrate the ability
              to
              produce an EQRO (currently, Institute for Child Health Policy (ICHP))
              encounter
              file by April 1, 2006, and the 837-encounter file by August 1, 2006.
              STAR+PLUS
              HMOs must be able to demonstrate the ability to produce the STAR+PLUS
              encounter
              file by the STAR+PLUS Operational Start Date and the 837- encounter
              file by
              September 1, 2007. CHIP Perinatal HMOs who have already demonstrated
              the ability
              to produce an EQRO encounter file and 837-encounter file for the CHIP
              Program
              are not required to produce separate files for the CHIP Perinatal Program.
              

             

            If
              any
              errors or deficiencies are evident, the HMO will develop resolution
              procedures
              to address problems identified. The HMO will provide HHSC, or a designated
              vendor, with test data files for systems and interface testing for
              all external
              interfaces. This includes testing of the required telephone lines for
              Providers
              and Members and any necessary connections to the HHSC Administrative
              Services
              Contractor and the External Quality Review Organization. The HHSC Administrative
              Services Contractor will provide enrollment test files to new HMOs
              that do not
              have previous HHSC enrollment files. The HMO will demonstrate its system
              capabilities and adherence to Contract specifications during readiness
              review.

             

            Section
              7.3.1.4 modified by Versions 1.1 and 1.3 

             

            7.3.1.5
              System Readiness Review 

             

            The
              HMO
              must assure that systems services are not disrupted or interrupted
              during the
              Operations Phase of the Contract. The HMO must coordinate with HHSC
              and other
              contractors to ensure the business and systems continuity for the processing
              of
              all health care claims and data as required under this contract. 

             

            The
              HMO
              must submit to HHSC, descriptions of interface and data and process
              flow for
              each key business processes described in Section
              8.1.18.3,
              System-wide Functions. 

             

            The
              HMO
              must clearly define and document the policies and procedures that will
              be
              followed to support day-to-day systems activities. The HMO must develop,
              and
              submit for State review and approval, the following information by
              December 14,
              2005 for STAR and CHIP, by July 31, 2006 for STAR+PLUS: 

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

             

            1.
              Joint
              Interface Plan. 

             

            
              	 	 	
                      2.
                        Disaster Recovery Plan 

                    

            

             

            
              	 	 	
                      3.
                        Business Continuity Plan 

                    

            

             

            
              	 	 	
                      4.
                        Risk Management Plan, and 

                    

            

             

            
              	 	 	
                      5.
                        Systems Quality Assurance Plan. 

                    

            

             

            Separate
              plans are not required for CHIP Perinatal HMOs.

             

            Section
              7.3.1.5 modified by Versions 1.1 and 1.3 

             

            7.3.1.6
              Demonstration and Assessment of System Readiness 

             

            The
              HMO
              must provide documentation on systems and facility security and provide
              evidence
              or demonstrate that it is compliant with HIPAA. The HMO shall also
              provide HHSC
              with a summary of all recent external audit reports, including findings
              and
              corrective actions, relating to the HMO’s proposed systems, including any SAS70
              audits that have been conducted in the past three years. The HMO shall
              promptly
              make additional information on the detail of such system audits available
              to
              HHSC upon request. 

             

            In
              addition, HHSC will provide to the HMO a test plan that will outline
              the
              activities that need to be performed by the HMO prior to the Operational
              Start
              Date of the Contract. The HMO must be prepared to assure and demonstrate
              system
              readiness. The HMO must execute system readiness test cycles to include
              all
              external data interfaces, including those with Material Subcontractors.
              

             

            HHSC,
              or
              its agents, may independently test whether the HMO’s MIS has the capacity to
              administer the STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO business,
              as
              applicable to the HMO. This Readiness Review of a HMO’s MIS may include a desk
              review and/or an onsite review. HHSC may request from the HMO additional
              documentation to support the provision of STAR, STAR+PLUS, CHIP, and/or
              CHIP
              Perinatal HMO Services, as applicable to the HMO. Based in part on
              the HMO’s
              assurances of systems readiness, information contained in the Proposal,
              additional documentation submitted by the HMO, and any review conducted
              by HHSC
              or its agents, HHSC will assess the HMO’s understanding of its responsibilities
              and the HMO’s capability to assume the MIS functions required under the
              Contract. 

             

            The
              HMO
              is required to provide a Corrective Action Plan in response to any
              Readiness
              Review deficiency no later than ten (10) calendar days after notification
              of any
              such deficiency by HHSC. If the HMO documents to HHSC’s satisfaction that the
              deficiency has been corrected within ten (10) calendar days of such
              deficiency
              notification by HHSC, no Corrective Action Plan is required. 

             

            Section
              7.3.1.6 modified by Versions 1.1 and 1.3

             

            7.3.1.7
              Operations Readiness 

             

            The
              HMO
              must clearly define and document the policies and procedures that will
              be
              followed to support day-to-day business activities related to the provision
              of
              STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO Services, including
              coordination with contractors. The HMO will be responsible for developing
              and
              documenting its approach to quality assurance. 

             

            Readiness
              Review. Includes
              all plans to be implemented in one or more Service Areas on the anticipated
              Operational Start Date. At a minimum, the HMO shall, for each HMO Program:
              

             

            1.
              Develop new, or revise existing, operations procedures and associated
              documentation to support the HMO’s proposed approach to conducting operations
              activities in compliance with the contracted scope of work. 

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

             

            2.
              Submit
              to HHSC, a listing of all contracted and credentialed Providers, in
              a HHSC
              approved format including
              a
              description of additional contracting and credentialing activities
              scheduled to
              be completed before the Operational Start Date. 

             

            3.
              Prepare and implement a Member Services staff training curriculum and
              a Provider
              training curriculum. 

             

            4.
              Prepare a Coordination Plan documenting how the HMO will coordinate
              its business
              activities with those activities performed by HHSC contractors and
              the HMO’s
              Material Subcontractors, if any. The Coordination Plan will include
              identification of coordinated activities and protocols for the Transition
              Phase.

             

            5.
              Develop and submit to HHSC the draft Member Handbook, draft Provider
              Manual,
              draft Provider Directory, and draft Member Identification Card for
              HHSC’s review
              and approval. The materials must at a minimum meet the requirements
              specified in
Section
              8.1.5 and include
              the Critical Elements to be defined in the HHSC
              Uniform Managed Care Manual.
              

             

            6.
              Develop and submit to HHSC the HMO’s proposed Member complaint and appeals
              processes for Medicaid, CHIP, and CHIP Perinatal as applicable to the
              HMO’s
              Program participation. 

             

            7.
              Provide sufficient copies of the final Provider Directory to the HHSC
              Administrative Services Contractor in sufficient time to meet the enrollment
              schedule. 

             

            8.
              Demonstrate toll-free telephone systems and reporting capabilities
              for the
              Member Services Hotline, the Behavioral Health Hotline, and the Provider
              Services Hotline. 

             

            9.
              Submit
              a written Fraud and Abuse Compliance Plan to HHSC for approval no later
              than 30
              days after the Contract Effective Date. See Section
              8.1.19,
              Fraud
              and Abuse, for
              the
              requirements of the plan, including new requirements for special investigation
              units. As part of the Fraud and Abuse Compliance Plan, the HMO shall:
              

             

            •
              designate executive and essential personnel to attend mandatory training
              in
              fraud and abuse detection, prevention and reporting. Executive and
              essential
              fraud and abuse personnel means HMO staff persons who supervise staff
              in the
              following areas: data collection, provider enrollment or disenrollment,
              encounter data, claims processing, utilization review, appeals or grievances,
              quality assurance and marketing, and who are directly involved in the
              decision-making and administration of the fraud and abuse detection
              program
              within the HMO. The training will be conducted by the Office of Inspector
              General, Health and Human Services Commission, and will be provided
              free of
              charge. The HMO must schedule and complete training no later than 90
              days after
              the Effective Date. 

             

            •
              designate an officer or director within the organization responsible
              for
              carrying out the provisions of the Fraud and Abuse Compliance Plan.
              

             

            •
The
              HMO
              is held to the same requirements and must ensure that, if this function
              is
              subcontracted to another entity, the subcontractor also meets all the
              requirements in this section and the Fraud and Abuse section as stated
              in
Attachment
              B-1, Section 8.
              

             

            •
Note:
              STAR+PLUS HMOs who have already submitted and received HHSC’s approval for their
              Fraud and Abuse Compliance Plans must submit acknowledgement that the
              HMO’s
              approved Fraud and Abuse Compliance Plan also applies to the STAR+PLUS
              program,
              or submit a revised Fraud and Abuse Compliance Plan for HHSC’s approval, with an
              explanation of changes to be made to incorporate the STAR+PLUS program
              into the
              plan, by July 10, 2006. 

             

            •
CHIP
              Perinatal HMOs who have already submitted and received HHSC’s approval for their
              Fraud and Abuse Compliance Plans must submit acknowledgement that the
              HMO’s
              approved Fraud and Abuse Compliance Plan also applies to the CHIP Perinatal
              Program, or submit a revised Fraud and Abuse Compliance Plan for HHSC’s
              approval, with an explanation of changes to be made to incorporate
              the CHIP
              Perinatal program into the plan, by September 15, 2006. 

             

            •
              Complete hiring and training of STAR+PLUS Service Coordination staff,
              no later
              than 45 days prior to the STAR+PLUS Operational Start Date. 

             

            During
              the Readiness Review, HHSC may request from the HMO certain operating
              procedures
              and updates to documentation to support the provision of STAR, STAR+PLUS,
              CHIP,
              and/or CHIP Perinatal HMO Services. HHSC will assess the HMO’s understanding of
              its responsibilities and the HMO’s capability to assume the functions required
              under the Contract, based in part on the HMO’s assurances of operational
              readiness, information contained in the Proposal, and in Transition
              Phase
              documentation submitted by the HMO. 

             

            Section
              7.3.1.7 modified by Versions 1.1, 1.2, and 1.3

             

            The
              HMO
              is required to promptly provide a Corrective Action Plan and/or Risk
              Mitigation
              Plan as requested by HHSC in response to Operational Readiness Review
              deficiencies identified by the HMO or by HHSC or its agent. The HMO
              must
              promptly alert HHSC of deficiencies, and must correct a deficiency
              or provide a
              Corrective Action Plan and/or Risk Mitigation Plan no later than ten
              (10)
              calendar days after HHSC’s notification of deficiencies. If the Contractor
              documents to HHSC’s satisfaction that the deficiency has been corrected within
              ten (10) calendar days of such deficiency notification by HHSC, no
              Corrective
              Action Plan is required. 

             

            7.3.1.8
              Assurance of System and Operational Readiness 

             

            In
              addition to successfully providing the Deliverables described in Section
              7.3.1,
              the HMO
              must assure HHSC that all processes, MIS systems, and staffed functions
              are
              ready and able to successfully assume responsibilities for operations
              prior to
              the Operational Start Date. In particular, the HMO must assure that
              Key HMO
              Personnel, Member Services staff, Provider Services staff, and MIS
              staff are
              hired and trained, MIS systems and interfaces are in place and functioning
              properly, communications procedures are in place, Provider Manuals
              have been
              distributed, and that Provider training sessions have occurred according
              to the
              schedule approved by HHSC. 

             

            7.3.1.9
              Post-Transition 

             

            The
              HMO
              will work with HHSC, Providers, and Members to promptly identify and
              resolve
              problems identified after the Operational Start Date and to communicate
              to HHSC,
              Providers, and Members, as applicable, the steps the HMO is taking
              to resolve
              the problems. 

             

            If
              a HMO
              makes assurances to HHSC of its readiness to meet Contract requirements,
              including MIS and operational requirements, but fails to satisfy requirements
              set forth in this Section, or as otherwise required pursuant to the
              Contract,
              HHSC may, at its discretion do any of the following in accordance with
              the
              severity of the non-compliance and the potential impact on Members
              and
              Providers: 

             

            1.
              freeze
              enrollment into the HMO’s plan for the affected HMO Program(s) and Service
              Area(s); 

             

            2.
              freeze
              enrollment into the HMO’s plan for all HMO Programs or for all Service Areas of
              an affected HMO Program; 

             

            3.
              impose
              contractual remedies, including liquidated damages; or 

             

            4.
              pursue
              other equitable, injunctive, or regulatory relief. 

             

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

        

        

          Contractual
            Document (CD) Responsible Office: HHSC Office of General Counsel (OGC)
            

          Subject:
            Attachment B-1 - HHSC Joint Medicaid/CHIP HMO RFP, Section 8

          Version
            1.6

           

          

             

            
              	
                      STATUS1

                    	
                      DOCUMENT
                        

                      REVISION2

                    	
                      EFFECTIVE
                        

                      DATE
                        

                    	
                      DESCRIPTION3

                    
	
                       

                      Baseline
                        

                       

                    	
                       

                      n/a
                        

                       

                    	
                       

                       

                       

                    	
                       

                      Initial
                        version Attachment B-1, Section 8 

                       

                    
	
                       

                      Revision
                        

                    	
                       

                      1.1
                        

                    	
                       

                      June
                        30, 2006 

                    	
                       

                      Revised
                        version of the Attachment B-1, Section 8, that includes provisions
                        applicable to MCOs participating in the STAR+PLUS Program.

                       

                      Section
                        8.1.1.1, Performance Evaluation, is modified to include STAR+PLUS
                        Performance Improvement Goals. 

                       

                      Section
                        8.1.2, Covered Services, is modified to include Functionally
                        Necessary
                        Community Long-term Care Services for STAR+PLUS. 

                       

                      Section
                        8.1.2.1 Value-Added Services, is modified to add language
                        allowing for the
                        HMO to distinguish between the Dual Eligible and non-Dual
                        Eligible
                        populations. 

                       

                      Section
                        8.1.2.2 Case-by-Case Added Services, is modified to clarify
                        for STAR+Plus
                        members it is based on functionality. 

                       

                      Section
                        8.1.3, Access to Care, is modified to include STAR+PLUS Functional
                        Necessity and 1915(c) Nursing Facility Waiver clarifications.
                        

                       

                      Section
                        8.1.4, Provider Network, is modified to include STAR+PLUS.

                       

                      Section
                        8.1.4.2, Primary Care Providers, is modified to include STAR+PLUS
                        

                       

                      Section
                        8.1.4.8, Provider Reimbursement, is modified to include Functionally
                        Necessary Long-term care services for STAR+PLUS. 

                       

                      Section
                        8.1.7.7, Provider Profiling, is modified to include STAR+PLUS.
                        

                       

                      Sections
                        8.1.12 and 8.1.12.2, Services for People with Special Health
                        Care Needs,
                        are modified to include STAR+PLUS. 

                       

                      Section
                        8.1.13, Service Management for Certain Populations, is modified
                        to include
                        STAR+PLUS. 

                       

                      Section
                        8.1.14, Disease Management, is modified to include STAR+PLUS.
                        

                       

                      Section
                        8.2, Additional Medicaid HMO Scope of Work, is modified to
                        include
                        STAR+PLUS. 

                       

                      Section
                        8.3, Additional STAR+PLUS Scope of Work, is added. 

                       

                    
	
                       

                      Revision
                        

                    	
                       

                      1.2
                        

                    	
                       

                      September
                        1, 2006 

                    	
                       

                      Revised
                        version of Attachment B-1, Section 8, that includes provisions
                        applicable
                        to MCOs participating in the STAR and CHIP Programs. 

                       

                      Section
                        8.1.1.1, Performance Evaluation, is modified to clarify that
                        the HMOs
                        goals are Service Area and Program specific; when the percentages
                        for
                        Goals 1 and 2 are to be negotiated; and when Goal 3 is to
                        be negotiated.
                        

                       

                      Section
                        8.1.2.1, Value-Added Services, is modified to add language
                        allowing for
                        the addition of two Value-added Services during the Transition
                        Phase of
                        the Contract and to clarify the effective dates for Value
                        Added Services
                        for the Transition Phase and the Operation Phase of the Contract.
                        

                       

                      Section
                        8.1.3.2, Access to Network Providers, is modified to delete
                        references to
                        Open Panels. 

                       

                      Section
                        8.1.4, Provider Network, is modified to clarify that “Out-of-Network
                        reimbursement arrangements” with certain providers must be in writing.
                        

                       

                      Section
                        8.1.5.1, Member Materials, is modified to clarify the date
                        that the member
                        ID card and the member handbook are to be sent to members.

                       

                      Section
                        8.1.5.6, Member Hotline, is modified to clarify the hotline
                        performance
                        requirements. 

                       

                      Section
                        8.1.17.2, Financial Reporting Requirements, is modified to
                        clarify that
                        the Bonus Incentive Plan refers to the Employee Bonus Incentive
                        Plan. It
                        has also been modified to clarify the reports and deliverable
                        due dates
                        and to change the name of the Claims Summary Lag Report and
                        clarify that
                        the report format has been moved to the Uniform Managed Care
                        Manual.
                        

                       

                      Section
                        8.1.18.5, Claims Processing Requirements, is modified to
                        revise the claims
                        processing requirements and move many of the specifics to
                        the Uniform
                        Managed Care Manual. 

                       

                      Section
                        8.1.20, Reporting Requirements, is modified to clarify the
                        reports and
                        deliverable due dates. 

                       

                      Section
                        8.1.20.2, Reports, is modified to delete the Claims Data
                        Specifications
                        Report, amend the All Claims Summary Report, and add two
                        new
                        provider-related reports to the contract. 

                       

                      Section
                        8.2.2.10, Cooperation with Immunization Registry, is added
                        to comply with
                        legislation, SB 1188 sec. 6(e)(1), 79th
                        Legislature, Regular Session, 2005. 

                       

                      Section
                        8.2.2.11, Case Management for Children and Pregnant Women,
                        is added.
                        

                       

                      Section
                        8.2.5.1, Provider Complaints, is modified to include the
                        30-day resolution
                        requirement. 

                       

                      Section
                        8.2.10.2, Non-Reimbursed Arrangements with Local Public Health
                        Entities,
                        is modified to update the requirements and delete the requirement
                        for an
                        MOU. 

                       

                      Section
                        8.2.11, Coordination with Other State Health and Human Services
                        (HHS)
                        Programs, is modified to update the requirements and delete
                        the
                        requirement for an MOU. 

                       

                      Section
                        8.4.2, CHIP Provider Complaint and Appeals, is modified to
                        include the
                        30-day resolution requirement. 

                       

                    
	
                       

                      Revision
                        

                    	
                       

                      1.3
                        

                    	
                       

                      September
                        1, 2006 

                    	
                       

                      Revised
                        version of Attachment B-1, Section 8, that includes provisions
                        applicable
                        to MCOs participating in the CHIP Perinatal Program. 

                       

                      Section
                        8.1.1.1, Performance Evaluation, is modified to clarify that
                        HHSC will
                        negotiate and implement Performance Improvement Goals for
                        the first full
                        State Fiscal Year following the CHIP Perinatal Operational
                        Start Date
                        

                       

                      Section
                        8.1.2, Covered Services is amended to: (a) clarify that Fee
                        For Service
                        will pay the Hospital costs for CHIP Perinate Newborns; (b)
                        add a
                        reference to new Attachment B-2.2 concerning covered services;
                        (c) add
                        CHIP Perinate references where appropriate. 

                       

                      Section
                        8.1.2.2 Case-by-Case Added Services, is modified to clarify
                        that this does
                        not apply to the CHIP Perinatal Program. 

                       

                      Section
                        8.1.3, Access to Care, is amended to include emergency services
                        limitations. 

                       

                      Section
                        8.1.3.2, Access to Network Providers, is amended to include
                        the Provider
                        access standards for the CHIP Perinatal Program. 

                       

                      Section
                        8.1.4.2 Primary Care Providers, is modified to clarify the
                        development of
                        the PCP networks between the CHIP Perinates and the CHIP
                        Perinate
                        Newborns. 

                       

                      Section
                        8.1.4.6 Provider Manual, Materials and Training, modified
                        to include the
                        CHIP Perinatal Program 

                       

                      Section
                        8.1.4.9 Termination of Provider Contracts modified to include
                        the CHIP
                        Perinatal Program. 

                       

                      Section
                        8.1.5.2 Member Identification (ID) Card, modified to include
                        the CHIP
                        Perinatal Program. 

                       

                      Section
                        8.1.5.3 Member Handbook, modified to include the CHIP Perinatal
                        Program.
                        

                       

                      Section
                        8.1.5.4 Provider Directory, modified to include the CHIP
                        Perinatal
                        Program. 

                       

                      Section
                        8.1.5.6 Member Hotline, modified to include the CHIP Perinatal
                        Program.
                        

                       

                      Section
                        8.1.5.7 Member Education, modified to include the CHIP Perinatal
                        Program.
                        

                       

                      Section
                        8.1.5.9 Member Complaint and Appeal Process, modified to
                        include the CHIP
                        Perinatal Program. 

                       

                      Section
                        8.1.7.7, Provider Profiling, is modified to include the CHIP
                        Perinatal
                        Program. 

                       

                      Section
                        8.1.12, Services for People with Special Health Care Needs,
                        modified to
                        clarify between CHIP Perinatal Program and CHIP Perinatal
                        Newborn.
                        

                       

                      Section
                        8.1.13, Service Management for Certain Populations, modified
                        to clarify
                        the CHIP Perinatal Program. 

                       

                      Section
                        8.1.15, Behavioral Health (BH) Network and Services, modified
                        to clarify
                        between CHIP Perinatal and Perinate members. 

                       

                      Section
                        8.1.17.2, Financial Reporting Requirements, modified to include
                        the CHIP
                        Perinatal Program. 

                       

                      Section
                        8.1.18.3, System-wide Functions, modified to include the
                        CHIP Perinatal
                        Program. 

                       

                      Section
                        8.1.18.5, Claims Processing Requirements, modified to include
                        the CHIP
                        Perinatal Program. 

                       

                      Section
                        8.1.19, Fraud and Abuse, modified to include the CHIP Perinatal
                        Program
                        

                       

                      Section
                        8.1.20.2, Provider Termination Report and Provider Network
                        Capacity
                        Report, is modified to include the CHIP Perinatal Program.

                       

                      Section
                        8.5, Additional Scope of Work for CHIP Perinatal Program
                        HMOs, is added to
                        Attachment B-1. 

                       

                       

                    
	
                       

                      Revision
                        

                    	
                       

                      1.4
                        

                    	
                       

                      September
                        1, 2006 

                    	
                       

                      Contract
                        amendment did not revise Attachment B-1, Section 8-Operations
                        Phase
                        Requirements. 

                       

                       

                    
	
                       

                      Revision
                        

                    	
                       

                      1.5
                        

                    	
                       

                      January
                        1, 2007 

                    	
                       

                      Revised
                        version of the Attachment B-1, Section 8, that includes provisions
                        applicable to MCOs participating in the STAR and STAR+PLUS
                        Program.
                        

                       

                      Section
                        8.1.2 is modified to include a reference to STAR and STAR+PLUS
                        covered
                        services. 

                       

                      Section
                        8.1.20.2 is modified to update the references to the Uniform
                        Managed Care
                        Manual for the “Summary Report of Member Complaints and Appeals” and the
                        “Summary Report of Provider Complaints.” 

                       

                      Section
                        8.2.2.5 is modified to require the Provider to coordinate
                        with the
                        Regional Health Authority. 

                       

                      Section
                        8.2.4 is amended to clarify cost settlements and encounter
                        rates for
                        Federally Qualified Health Centers (FQHCs) and Rural Health
                        Clinics (RHCs)
                        for STAR and STAR+PLUS service areas. 

                       

                      Section
                        8.3.2.4 is amended to clarify the timeframe for initial STAR+PLUS
                        assessments. 

                       

                      Section
                        8.3.3 is amended to: (1) clarify the use of the DHS Form
                        2060; (2) require
                        the HMO to complete the Individual Service Plan (ISP), Form
                        3671 for each
                        Member receiving 1915(c) Nursing Facility Waiver Services;
                        (3) require
                        HMOs to complete Form 3652 and Form 3671annually at reassessment;
                        (4)
                        allow the HMOs to administer the Minimum Data Set for Home
                        Care (MDS-HC)
                        instrument for non-waiver STAR+PLUS Members over the course
                        of the first
                        year of operation; (5) allow HMOs to submit other supplemental
                        assessment
                        instruments. 

                       

                      Section
                        8.3.4 is modified to include the criteria for participation
                        in 1915(c)
                        nursing facility waiver services. 

                       

                      Section
                        8.3.4.3 is amended to remove the six-month timeframe for
                        Nursing Facility
                        Cost Ceiling. Deletes provision stating DADS Commissioner
                        may grant
                        exceptions in individual cases. 

                       

                      Section
                        8.3.5 is amended to delete the requirement that HMOs use
                        the Consumer
                        Directed Services option for the delivery of Personal Attendant
                        Services.
                        The new language provides HMOs with three options for delivering
                        these
                        services. The options are described in the following new
                        subsections:
                        8.3.5.1, Personal Attendant Services Delivery Option - Self-Directed
                        Model; 8.3.5.2, Personal Attendant Services Delivery Option
                        - Agency
                        Model, Self-Directed; and 8.3.5.3, Personal Attendant Services
                        Delivery
                        Option - Agency Model. 

                       

                      Section
                        8.3.7.3 is modified to reflect the changes made by the HMO
                        workgroup
                        regarding enhanced payments for attendant care. The section
                        also includes
                        a reference to new Attachment B-7, which contains the HMO’s methodology
                        for implementing and paying the enhanced payments. 

                    
	
                       

                      Revision
                        

                    	
                       

                      1.6
                        

                    	
                       

                      February
                        1, 2007 

                    	
                       

                      Revised
                        version of the Attachment B-1, Section 8, that includes provisions
                        applicable to MCOs participating in the STAR+PLUS and CHIP
                        Perinatal
                        Programs. 

                       

                      Section
                        8.1 is modified to clarify the Operational Start Date of
                        the STAR+PLUS
                        Program. 

                       

                      Section
                        8.1.3.2 is modified to allow exceptions to hospital access
                        standards on a
                        case-by-case basis only for HMOs participating in the CHIP
                        Perinatal
                        Program. 

                       

                      Section
                        8.3.3 is modified to clarify when the 12-month period begins
                        for the
                        STAR+PLUS HMOs to complete the MDS-HC instruments for non-1915(c)
                        Nursing
                        Facility Waiver Members who are receiving Community-based
                        Long-term Care
                        Services.  

                       

                       

                    
	
                       

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

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

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

                    

            

          

          
8.
            OPERATIONS PHASE REQUIREMENTS 

           

          This
            Section is designed to provide HMOs with sufficient information to understand
            the HMOs' responsibilities. This Section describes scope of work requirements
            for the Operations Phase of the Contract. 

           

          Section
            8.1
            includes
            the general scope of work that applies to the STAR, STAR+PLUS, CHIP,
            and CHIP
            Perinatal HMO Programs. 

           

          Section
            8.2
            includes
            the additional Medicaid scope of work that applies only to the STAR and
            STAR+PLUS HMOs. 

           

          Section
            8.3
            includes
            the additional scope of work that applies only to STAR+PLUS HMOs. 

           

          Section
            8.4 includes
            the additional scope of work that applies only to CHIP HMOs. 

           

          Section
            8.5 includes
            the additional scope of work that applies only to CHIP Perinatal HMOs.
            

           

          The
            Section does not include detailed information on the STAR, STAR+PLUS,
            CHIP, and
            CHIP Perinatal HMO Program requirements, such as the time frame and format
            for
            all reporting requirements. HHSC has included this information in the
            Uniform
            Managed Care Contract Terms and Conditions (Attachment
            A)
            and the
Uniform
            Managed Care Manual.
            HHSC
            reserves the right to modify these documents as it deems necessary using
            the
            procedures set forth in the Uniform
            Managed Care Contract Terms and Conditions.
            

           

          8.1
            General Scope of Work 

           

          In
            each
            HMO Program Service Area, HHSC will select HMOs for each HMO Program
            to provide
            health care services to Members. The HMO must be licensed by the Texas
            Department of Insurance (TDI) as an HMO or an ANHC in all zip codes in
            the
            respective Service Area(s). 

           

          Coverage
            for benefits will be available to enrolled Members effective on the Operational
            Start Date. The Operational Start Date is September 1, 2006 for STAR
            and CHIP
            HMOs, January 1, 2007 for CHIP Perinatal HMOs, and February 1, 2007 for
            the
            STAR+PLUS HMOs. 

           

          8.1.1
            Administration and Contract Management 

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          The
            HMO
            must comply, to the satisfaction of HHSC, with (1) all provisions set
            forth in
            this Contract, and (2) all applicable provisions of state and federal
            laws,
            rules, regulations, and waivers. 

           

          Section
            8
            modified by Versions 1.1 and 1.3 

           

          Section
            8.1 modified by Versions 1.1, 1.3, and 1.6 

           

          8.1.1.1
            Performance Evaluation 

           

          The
            HMO
            must identify and propose to HHSC, in writing, no later than May 1st
            of each
            State Fiscal Year (SFY) after the Operational Start Date, annual HMO
            Performance
            Improvement Goals for the next fiscal year, as well as measures and time
            frames
            for demonstrating that such goals are being met. Performance Improvement
            Goals
            must be based on HHSC priorities and identified opportunities for improvement
            (see Attachment
            B-4, Performance Improvement Goals).
            The
            Parties will negotiate such Performance Improvement Goals, the measures
            that
            will be used to assess goal achievement, and the time frames for completion,
            which will be incorporated into the Contract. If HHSC and the HMO cannot
            agree
            on the Performance Improvement Goals, measures, or time frames, HHSC
            will set
            the goals, measures, or time frames. 

           

          For
            State
            Fiscal Year 2007, HHSC has established three overarching goals for each
            Program.
            These overarching goals are as follows: 

           

          Goal
            1 (STAR and CHIP) Improve Access to Primary Care Services for Members
             

           

          Goal
            2 (STAR and CHIP) Improve Access to Behavioral Health Services for
            Members,
            

           

          Goal
            3 (STAR Only) Improve Access to Clinically Appropriate Alternatives to
            

          Emergency
            Room Services Outside of Regular Office Hours 

          (CHIP
            Only) Improve Current Member Understanding About the CHIP Benefit Renewal
            Processes 

           

          Note:
            The HMO
            is required to propose customized sub-goals specific to the HMO’s Service Areas
            and Programs for all overarching goals. The sub-goals must be approved
            by HHSC
            as part of the negotiation process. 

           

          The
            specific percentages of expected achievement for each sub-goal will be
            negotiated by HHSC and the HMO before the Operational Start Date. 

           

          For
            STAR+PLUS HMOs, HHSC will negotiate and implement Performance Improvement
            Goals
            for the first full fiscal year following the STAR+PLUS Operational Start
            Date.
            One standard STAR+PLUS goal will relate to Consumer-Directed Services.
            STAR+PLUS
            improvement goals for SFY2008 will be included in Attachment
            B-4.1.
            

           

          For
            CHIP
            Perinatal HMOs, HHSC will negotiate and implement Performance Improvement
            Goals
            for the first full State Fiscal Year following the CHIP Perinatal Operational
            Start Date. 

           

          The
            HMO
            must participate in semi-annual Contract Status Meetings (CSMs) with
            HHSC for
            the primary purpose of reviewing progress toward the achievement of annual
            Performance Improvement Goals and Contract requirements. HHSC may request
            additional CSMs, as it deems necessary to address areas of noncompliance.
            HHSC
            will provide the HMO with reasonable advance notice of additional CSMs,
            generally at least five (5) business days. 

           

          Section
            8.1.1.1 modified by Versions 1.1, 1.2, and 1.3 

           

          The
            HMO
            must provide to HHSC, no later than 14 business days prior to each semi-annual
            CSM, one electronic copy of a written update, detailing and documenting
            the
            HMO’s progress toward meeting the annual Performance Improvement Goals or
            other
            areas of noncompliance. 

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          HHSC
            will
            track HMO performance on Performance Improvement Goals. It will also
            track other
            key facets of HMO performance through the use of a Performance
            Indicator Dashboard (see HHSC’s Uniform Managed Care
            Manual).
            HHSC
            will compile the Performance Indicator Dashboard based on HMO submissions,
            data
            from the External Quality Review Organization (EQRO), and other data
            available
            to HHSC. HHSC will share the Performance Indicator Dashboard with the
            HMO on a
            quarterly basis. 

           

          8.1.2
            Covered Services 

           

          The
            HMO
            is responsible for authorizing, arranging, coordinating, and providing
            Covered
            Services in accordance with the requirements of the Contract. The HMO
            must
            provide Medically Necessary Covered Services to all Members beginning
            on the
            Member’s date of enrollment regardless of pre-existing conditions, prior
            diagnosis and/or receipt of any prior health care services. STAR+PLUS
            HMOs must
            also provide Functionally Necessary Community Long-term Care Services
            to all
            Members beginning on the Member’s date of enrollment regardless of pre-existing
            conditions, prior diagnosis and/or receipt of any prior health care services.
            The HMO must not impose any pre-existing condition limitations or exclusions
            or
            require Evidence of Insurability to provide coverage to any Member.

           

          The
            HMO
            must provide full coverage for Medically Necessary Covered Services to
            all
            Members and, for STAR+PLUS Members, Functionally Necessary Community
            Long-term
            Care Services, without regard to the Member’s: 

           

          
            	 	 	
                    1.
                      previous coverage, if any, or the reason for termination of
                      such coverage;
                      

                  

          

           

          
            	 	 	
                    2.
                      health status; 

                  

          

           

          
            	 	 	
                    3.
                      confinement in a health care facility; or

                  

          

           

          
            	 	 	
                    4.
                      for any other reason. 

                  

          

           

          Please
            Note: 

          (STAR
            HMOs): A Member cannot change from one STAR HMO to another STAR HMO during
            an
            inpatient hospital stay. The STAR HMO responsible for the hospital charges
            for
            STAR Members at the start of an Inpatient Stay remains responsible for
            hospital
            charges until the time of discharge or until such time that there is
            a loss of
            Medicaid eligibility. STAR HMOs are responsible for professional charges
            during
            every month for which the HMO receives a full capitation for a Member.
            

           

          (STAR+PLUS
            HMOs): A Member cannot change from one STAR+PLUS HMO to another STAR+PLUS
            HMO
            during an inpatient hospital stay. The STAR+PLUS HMO is responsible for
            authorization and management of the inpatient hospital stay until the
            time of
            discharge, or until such time that there is a loss of Medicaid eligibility.
            STAR+PLUS HMOs are responsible for professional charges during every
            month for
            which the HMO receives a full capitation for a Member. 

           

          Section
            8.1.2 modified by Versions 1.1 and13

           

          A
            Member
            cannot change from one STAR+PLUS HMO to another STAR+PLUS HMO during
            a nursing
            facility stay. 

           

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

           

          (CHIP
            Perinatal HMOs): If a CHIP Perinate’s Effective Date of Coverage occurs while
            the CHIP Perinate is confined in a Hospital, HMO is responsible for the
            CHIP
            Perinate’s costs of Covered Services beginning on the Effective Date of
            Coverage. If a CHIP Perinate is disenrolled while the CHIP Perinate is
            confined
            in a Hospital,

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          HMO’s
            responsibility for the CHIP Perinate’s costs of Covered Services terminates on
            the Date of Disenrollment. 

           

          The
            HMO
            must not practice discriminatory selection, or encourage segregation
            among the
            total group of eligible Members by excluding, seeking to exclude, or
            otherwise
            discriminating against any group or class of individuals. 

           

          Covered
            Services for all Medicaid HMO Members are listed in Attachments
            B-2 and B-2.1 of the Contract (STAR and STAR+PLUS Covered
            Services).
            As
            noted in Attachments
            B-2 and B-2.1,
            all
            Medicaid HMOs must provide Covered Services described in the most recent
            Texas
            Medicaid Provider Procedures Manual
            (Provider Procedures Manual), the THSteps
            Manual
            (a
            supplement to the Provider Procedures Manual), and in all Texas
            Medicaid Bulletins,
            which
            update the Provider Procedures Manual except for those services identified
            in
Section
            8.2.2.8
            as
            non-capitated services. A description of CHIP Covered Services and exclusions
            is
            provided in Attachment
            B-2 of the Contract.
            A
            description of CHIP Perinatal Program Covered Services and exclusions
            is
            provided in Attachment
            B-2.2 of the Contract.
            Covered
            Services are subject to change due to changes in federal and state law,
            changes
            in Medicaid, CHIP or CHIP Perinatal Program policy, and changes in medical
            practice, clinical protocols, or technology. 

           

          8.1.2.1
            Value-added Services 

           

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

           

          If
            offered, Value-added Services must be offered to all mandatory STAR,
            and CHIP
            and CHIP Perinatal HMO Members within the applicable HMO Program and
            Service
            Area. For STAR+PLUS Acute Care services, the HMO may distinguish between
            the
            Dual Eligible and non-Dual Eligible populations. Value-added Services
            do not
            need to be consistent across more than one HMO Program or across more
            than one
            Service Area. Value-added Services that are approved by HHSC during the
            contracting process will be included in the Contract’s scope of services.

           

          Section
            8.1.2.1 modified by Versions 1.1, 1.2, and 1.3 

           

          Section
            8.1.2 Modified by Version 1.5 

           

          The
            HMO
            must provide Value-added Services at no additional cost to HHSC. The
            HMO must
            not pass on the cost of the Value-added Services to Providers. The HMO
            must
            specify the conditions and parameters regarding the delivery of the Value-added
            Services in the HMO’s Marketing Materials and Member Handbook, and must clearly
            describe any limitations or conditions specific to the Value-added Services.
            

           

          Transition
            Phase.
            During
            the Transition Phase, HHSC will offer a one-time opportunity for the
            HMO to
            propose two additional Value-added Services to its list of current, approved
            Value-added Services. (See Attachment
            B-3, Value-Added Services).
            HHSC
            will establish the requirements and the timeframes for submitting the
            two
            additional proposed Value-added Services. 

           

          During
            this HHSC-designated opportunity, the HMO may propose either to add new
            Value-added Services or to enhance its current, approved Value-added
            Services.
            The HMO may propose two additional Value-added Services per HMO Program,
            and the
            services do not have to be the same for each HMO Program. HHSC will review
            the
            proposed additional services and, if appropriate, will approve the additional
            Value-added Services, which will be effective on the Operational Start
            Date. The
            HMO’s Contract will be amended to reflect the additional, approved Value-added
            Services. 

           

          The
            HMO
            does not have to add Value-added Services during the HHSC-designated
            opportunity, but this will be the only time during the Transition Phase
            for the
            HMO to add Value-added Services. At no time during the

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          Transition
            Phase will the HMO be allowed to delete, limit or restrict any of its
            current,
            approved Value-added Services. 

           

          Operations
            Phase.
            During
            the Operations Phase, Value-added Services can be added or removed only
            by
            written amendment of the Contract one time per fiscal year to be effective
            September 1 of the fiscal year, except when services are amended by HHSC
            during
            the fiscal year. This will allow HHSC to coordinate with annual revisions
            to
            HHSC’s HMO Comparison Charts for Members. A HMO’s request to add or delete a
            Value-added Service must be submitted to HHSC by May 1 of each year to
            be
            effective September 1 for the following contract period. (For STAR and
            CHIP, see
Attachment
            B-3, Value-Added Services.
            For
            STAR+PLUS, see Attachment
            B-3.1, STAR+PLUS Value-Added Services.
            For
            CHIP Perinatal, see
            Attachment
            B-3.2, CHIP Perinatal Value-Added Services.)
            

           

          A
            HMO’s
            request to add a Value-added Service must: 

           

          
            	 	 	
                    a.
                      Define and describe the proposed Value-added Service;
                      

                  

          

           

          
            	 	 	
                    b.
                      Specify the Service Areas and HMO Programs for the proposed
                      Value-added
                      Service; 

                  

          

           

          
            	 	 	
                    c.
                      Identify the category or group of mandatory Members eligible
                      to receive
                      the Value-added Service if it is a type of service that is
                      not appropriate
                      for all mandatory Members; 

                  

          

           

          
            	 	 	
                    d.
                      Note any limits or restrictions that apply to the Value-added
                      Service;
                      

                  

          

           

          
            	 	 	
                    e.
                      Identify the Providers responsible for providing the Value-added
                      Service;
                      

                  

          

           

          
            	 	 	
                    f.
                      Describe how the HMO will identify the Value-added Service
                      in
                      administrative (Encounter) data; 

                  

          

           

          
            	 	 	
                    g.
                      Propose how and when the HMO will notify Providers and mandatory
                      Members
                      about the availability of such Value-added Service;
                      

                  

          

           

          
            	 	 	
                    h.
                      Describe how a Member may obtain or access the Value-added
                      Service; and
                      

                  

          

           

          
            	 	 	
                    i.
                      Include a statement that the HMO will provide such Value-added
                      Service for
                      at least 12 months from the September 1 effective date.   

                  

          

           

          A
            HMO
            cannot include a Value-added Service in any material distributed to mandatory
            Members or prospective mandatory Members until the Parties have amended
            the
            Contract to include that Value-added Service. If a Value-added Service
            is
            deleted by amendment, the HMO must notify each mandatory Member that
            the service
            is no longer available through the HMO. The HMO must also revise all
            materials
            distributed to prospective mandatory Members to reflect the change in
            Value-added Services. 

           

          8.1.2.2
            Case-by-Case Added Services 

           

          Except
            as
            provided below, the HMO may offer additional benefits that are outside
            the scope
            of services to individual Members on a case-by-case basis, based on Medical
            Necessity, cost-effectiveness, the wishes of the Member/Member’s family, the
            potential for improved health status of the Member, and for STAR+PLUS
            Members
            based on functional necessity. 

           

          Section
            8.1.2.2, Case-by-Case Added Services, does not apply to the CHIP Perinatal
            Program. 

           

          8.1.3
            Access to Care 

           

          All
            Covered Services must be available to Members on a timely basis in accordance
            with medically appropriate guidelines, and consistent with generally
            accepted
            practice parameters, requirements in this Contract. The HMO must comply
            with the
            access requirements as established by the Texas Department of Insurance
            (TDI)
            for all HMOs doing business in Texas, except as otherwise required by
            this
            Contract. Medicaid HMOs must be responsive to the possibility of increased
            Members due to the phase-out of the PCCM model in Service Areas

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          where
            adequate HMO coverage exists. 

           

          The
            HMO
            must provide coverage for Emergency Services to Members 24 hours a day
            and 7
            days a week, without regard to prior authorization or the Emergency Service
            provider’s contractual relationship with the HMO. The HMO’s policy and
            procedures, Covered Services, claims adjudication methodology, and reimbursement
            performance for Emergency Services must comply with all applicable state
            and
            federal laws and regulations, whether the provider is in-network or
            Out-of-Network. A HMO is not responsible for payment for unauthorized
            non-emergency services provided to a Member by Out-of-Network providers.
            

           

          The
            HMO
            must also have an emergency and crisis Behavioral Health Services Hotline
            available 24 hours a day, 7 days a week, toll-free throughout the Service
            Area.
            The Behavioral Health Services Hotline must meet the requirements described
            in
Section
            8.1.15.
            For
            Medicaid Members, a HMO must provide coverage for Emergency Services
            in
            compliance with 42 C.F.R. §438.114, and as described in more detail in
Section
            8.2.2.1.
            The HMO
            may arrange Emergency Services and crisis Behavioral Health Services
            through
            mobile crisis teams. 

           

          For
            CHIP
            Members, Emergency Services, including emergency Behavioral Health Services,
            must be provided in accordance with the Texas Insurance Code and TDI
            regulations. 

           

          Section
            8.1.2.2 modified by Versions 1.1 and 1.3 

           

          Section
            8.1.3 modified by Versions 1.1 and 1.3 

           

          For
            the
            CHIP Perinatal Program, refer to Attachment B-2.2 for description of
            emergency
            services for CHIP Perinates and CHIP Perinate Newborns. 

           

          For
            the
            STAR, STAR+PLUS, and CHIP Programs, and for CHIP Perinate Newborns, HMO
            must
            require, and make best efforts to ensure, that PCPs are accessible to
            Members 24
            hours a day, 7 days a week and that its Network Primary Care Providers
            (PCPs)
            have after-hours telephone availability that is consistent with, Section
            8.1.4.
            CHIP
            Perinatal HMOs are not required to establish PCP Networks for CHIP Perinates.
            

           

          The
            HMO
            must provide that if Medically Necessary Covered Services are not available
            through Network physicians or other Providers, the HMO must, upon the
            request of
            a Network physician or other Provider, within the time appropriate to
            the
            circumstances relating to the delivery of the services and the condition
            of the
            patient, but in no event to exceed five business days after receipt of
            reasonably requested documentation, allow a referral to a non-network
            physician
            or provider. The HMO must fully reimburse the non-network provider in
            accordance
            with the Out-of-Network methodology for Medicaid as defined by HHSC,
            and for
            CHIP, at the usual and customary rate defined by TDI in 28 T.A.C. Section
            11.506. 

           

          The
            Member will not be responsible for any payment for Medically Necessary
            Covered
            Services, including Functionally Necessary Covered Services, other than:
            

           

              (1)
            HHSC-specified co-payments for CHIP Members, where applicable; and 

              

              (2)
            STAR+PLUS
            Members who qualify for 1915(c) Nursing Facility Waiver services and
            enter a
            24-hour setting will be required to pay the provider of care room and
            board
            costs and any income in excess of the personal needs allowance, as established
            by HHSC. If the HMO provides Members who do not qualify for the 1915(c)
            Nursing
            Facility Waiver services in a 24-hour setting as an alternative to nursing
            facility or hospitalization, the Member will be required to pay the provider
            of
            care room and board costs and any income in excess of the personal needs
            allowance, as established by HHSC. 

           

          8.1.3.1
            Waiting Times for Appointments 

           

          Through
            its Provider Network composition and management, the HMO must ensure
            that
            appointments for the following types of Covered Services are provided
            within the
            time frames specified below. In all cases below, “day” is defined as a calendar
            day. 

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          1.
            Emergency Services must be provided upon Member presentation at the service
            delivery site, including at non-network and out-of-area facilities;

           

          
            	 	 	
                    2.
                      Urgent care, including urgent specialty care, must be provided
                      within 24
                      hours of request. 

                  

          

           

          
            	 	 	
                    3.
                      Routine primary care must be provided within 14 days of request;
                      

                  

          

           

          
            	 	 	
                    4.
                      Initial outpatient behavioral health visits must be provided
                      within 14
                      days of request; 

                  

          

           

          
            	 	 	
                    5.
                      Routine specialty care referrals must be provided within 30
                      days of
                      request; 

                  

          

           

          
            	 	 	
                    6.
                      Pre-natal care must be provided within 14 days of request,
                      except for
                      high-risk pregnancies or new Members in the third trimester,
                      for whom an
                      appointment must be offered within five days, or immediately,
                      if an
                      emergency exists; 

                  

          

           

          
            	 	 	
                    7.
                      Preventive health services for adults must be offered to a
                      Member within
                      90 days of request; and 

                  

          

           

          
            	 	 	
                    8.
                      Preventive health services for children, including well-child
                      check-ups
                      should be offered to Members in accordance with the American
                      Academy of
                      Pediatrics (AAP) periodicity schedule. Please note that for
                      Medicaid
                      Members, HMOs should use the THSteps Program modifications
                      to the AAP
                      periodicity schedule. For newly enrolled Members under age
                      21, overdue or
                      upcoming well-child checkups, including THSteps medical checkups,
                      should
                      be offered as soon as practicable, but in no case later than
                      14 days of
                      enrollment for newborns, and no later than 60 days of enrollment
                      for all
                      other eligible child Members. 

                  

          

           

          8.1.3.2
            Access to Network Providers 

           

          The
            HMO’s
            Network shall have within its Network, PCPs in sufficient numbers, and
            with
            sufficient capacity, to provide timely access to regular and preventive
            pediatric care and THSteps services to all child Members in accordance
            with the
            waiting times for appointments in Section
            8.1.3.1. 

           

          PCP
            Access:
            At a
            minimum, the HMO must ensure that all Members have access to an age-appropriate
            PCP in the Provider Network with an Open Panel within 30 miles of the
            Member’s
            residence. For the purposes of assessing compliance with this requirement,
            an
            internist who provides primary care to adults only is not considered
            an
            age-appropriate PCP choice for a Member under age 21, and a pediatrician
            is not
            considered an age-appropriate choice for a Member age 21 and over. Note:
            This
            provision does not apply to CHIP Perinates, but it does apply to CHIP
            Perinate
            Newborns. 

           

          OB/GYN
            Access and CHIP Perinatal Program Provider Access:
            STAR,
            STAR+PLUS and CHIP Program Network: at a minimum, STAR, STAR+PLUS and
            CHIP HMOs
            must ensure that all female Members have access to an OB/GYN in the Provider
            Network within 75 miles of the Member’s residence. (If the OB/GYN is acting as
            the Member’s PCP, the HMO must follow the access requirements for the PCP.) The
            HMO must allow female Members to select an OB/GYN within its Provider
            Network. A
            female Member who selects an OB/GYN must be allowed direct access to
            the
            OB/GYN’s health care services without a referral from the Member’s PCP or a
            prior authorization. A pregnant Member with 12 weeks or less remaining
            before
            the expected delivery date must be allowed to remain under the Member’s current
            OB/GYN care though the Member’s post-partum checkup, even if the OB/GYN provider
            is, or becomes, Out-of-Network. 

           

          CHIP
            Perinatal Program Network: At a minimum, CHIP Perinatal HMOs must ensure
            that
            CHIP Perinates have access to a Provider of perinate services within
            75 miles of
            the Member’s residence if the Member resides in an urban area and within 125
            miles of the Member’s residence if the Member resides in a rural area.

           

          Outpatient
            Behavioral Health Service Provider Access:
            At a
            minimum, the HMO must ensure that all Members except CHIP Perinates have
            access
            to an outpatient Behavioral Health Service Provider in the Network within
            75
            miles of the Member’s residence. Outpatient Behavioral Health Service Providers
            must include Masters and Doctorate-level trained practitioners practicing
            independently or at community mental health centers, other clinics or
            at
            outpatient hospital departments. A Qualified Mental Health Provider
            (QMHP),

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          as
            defined and credentialed by the Texas Department of State Health Services
            standards (T.A.C. Title 25, Part I, Chapter 412), is an acceptable outpatient
            behavioral health provider as long as the QMHP is working under the authority
            of
            an MHMR entity and is supervised by a licensed mental health professional
            or
            physician. 

           

          Section
            8.1.3.2 modified by Versions 1.2 and 1.3 

           

          Other
            Specialist Physician Access:
            At a
            minimum, the HMO must ensure that all Members except CHIP Perinates have
            access
            to a Network specialist physician within 75 miles of the Member’s residence for
            common medical specialties. For adult Members, common medical specialties
            shall
            include general surgery, cardiology, orthopedics, urology, and ophthalmology.
            For child Members, common medical specialties shall include orthopedics
            and
            otolaryngology. 

           

          Hospital
            Access:
            The HMO
            must ensure that all Members have access to an Acute Care hospital in
            the
            Provider Network within 30 miles of the Member’s residence. For HMOs
            participating in the CHIP Perinatal Program, exceptions to this access
            standard
            may be requested on a case-by-case basis and must have HHSC approval.
            

           

          All
            other Covered Services, except for services provided in the Member’s
            residence:
            At a
            minimum, the HMO must ensure that all Members have access to at least
            one
            Network Provider for each of the remaining Covered Services described
            in
Attachment
            B-2,
            within
            75 miles of the Member’s residence. This access requirement includes, but is not
            limited to, specialists, specialty hospitals, psychiatric hospitals,
            diagnostic
            and therapeutic services, and single or limited service health care physicians
            or Providers, as applicable to the HMO Program. 

           

          The
            HMO
            is not precluded from making arrangements with physicians or providers
            outside
            the HMO’s Service Area for Members to receive a higher level of skill or
            specialty than the level available within the Service Area, including
            but not
            limited to, treatment of cancer, burns, and cardiac diseases. HHSC may
            consider
            exceptions to the above access-related requirements when an HMO has established,
            through utilization data provided to HHSC, that a normal pattern for
            securing
            health care services within an area does not meet these standards, or
            when an
            HMO is providing care of a higher skill level or specialty than the level
            which
            is available within the Service Area such as, but not limited to, treatment
            of
            cancer, burns, and cardiac diseases. 

           

          8.1.3.3
            Monitoring Access 

           

          The
            HMO
            is required to systematically and regularly verify that Covered Services
            furnished by Network Providers are available and accessible to Members
            in
            compliance with the standards described in Sections
            8.1.3.1 and 8.1.3.2,
            and for
            Covered Services furnished by PCPs, the standards described in Section
            8.1.4.2.
            

           

          The
            HMO
            must enforce access and other Network standards required by the Contract
            and
            take appropriate action with Providers whose performance is determined
            by the
            HMO to be out of compliance. 

           

          8.1.4
            Provider Network 

           

          The
            HMO
            must enter into written contracts with properly credentialed Providers
            as
            described in this Section. The Provider contracts must comply with the
            Uniform
            Managed Care Manual’s requirements.
            

           

          Section
            8.1.4 Modified by Version 1.1 and 1.2 

           

          Section
            8.1.3.2 Modified by Version 1.6 

           

          The
            HMO
            must maintain a Provider Network sufficient to provide all Members with
            access
            to the full range of Covered Services required under the Contract. The
            HMO must
            ensure its Providers and subcontractors meet all current and future state
            and
            federal eligibility criteria, reporting requirements, and any other applicable
            rules and/or regulations related to the Contract. 

           

          The
            Provider Network must be responsive to the linguistic, cultural, and
            other
            unique needs of any minority, elderly, or disabled individuals, or other
            special
            population in the Service Areas and HMO Programs served by

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          the
            HMO,
            including the capacity to communicate with Members in languages other
            than
            English, when necessary, as well as with those who are deaf or hearing
            impaired.

           

          The
            HMO
            must seek to obtain the participation in its Provider Network of qualified
            providers currently serving the Medicaid and CHIP Members in the HMO’s proposed
            Service Area(s). 

           

          NOTE:
            The
            following Provider descriptions do not require STAR+PLUS HMOs to contract
            with
            Hospital providers for Inpatient Stay services. STAR+PLUS HMOs are required,
            however, to contract with Hospitals for Outpatient Hospital
            Services. 

           

          All
            Providers: All
            Providers must be licensed in the State of Texas to provide the Covered
            Services
            for which the HMO is contracting with the Provider, and not be under
            sanction or
            exclusion from the Medicaid program. All Acute Care Providers serving
            Medicaid
            Members must be enrolled as Medicaid providers and have a Texas Provider
            Identification Number (TPIN). Long-term Care Providers are not required
            to have
            a TPIN but must have a LTC Provider number. Providers must also have
            a National
            Provider Identifier (NPI) in accordance with the timelines established
            in 45
            C.F.R. Part 162, Subpart D (for most Providers, the NPI must be in place
            by May
            23, 2007.) 

           

          Inpatient
            hospital and medical services:
            The HMO
            must ensure that Acute Care hospitals and specialty hospitals are available
            and
            accessible 24 hours per day, seven days per week, within the HMO’s Network to
            provide Covered Services to Members throughout the Service Area. 

           

          Children’s
            Hospitals/hospitals with specialized pediatric services: The
            HMO
            must ensure Members access to hospitals designated as Children’s Hospitals by
            Medicare and hospitals with specialized pediatric services, such as teaching
            hospitals and hospitals with designated children’s wings, so that these services
            are available and accessible 24 hours per day, seven days per week, to
            provide
            Covered Services to Members throughout the Service Area. The HMO must
            make
            Out-of-Network reimbursement arrangements with a designated Children’s Hospital
            and/or hospital with specialized pediatric services in proximity to the
            Member’s
            residence, and such arrangements must be in writing, if the HMO does
            not include
            such hospitals in its Provider Network. Provider Directories, Member
            materials,
            and Marketing materials must clearly distinguish between hospitals designated
            as
            Children’s Hospitals and hospitals that have designated children’s units.

           

          Trauma:
            The HMO
            must ensure Members access to Texas Department of State Health Services
            (TDSHS)
            designated Level I and Level II trauma centers within the State or hospitals
            meeting the equivalent level of trauma care in the HMO’s Service Area, or in
            close proximity to such Service Area. The HMO must make Out-of-Network
            reimbursement arrangements with the DSHS-designated Level I and Level
            II trauma
            centers or hospitals meeting equivalent levels of trauma care, and such
            arrangements must be in writing, if the HMO does not include such a trauma
            center in its Provider Network. 

           

          Transplant
            centers: The
            HMO
            must ensure Member access to HHSC-designated transplant centers or centers
            meeting equivalent levels of care. A list of HHSC-designated transplant
            centers
            can be found in the Procurement Library in Attachment H. The HMO must
            make
            Out-of-Network reimbursement arrangements with a designated transplant
            center or
            center meeting equivalent levels of care in proximity to the Member’s residence,
            and such arrangements must be in writing, if the HMO does not include
            such a
            center in its Provider Network. 

           

          Hemophilia
            centers:
            The HMO
            must ensure Member access to hemophilia centers supported by the Centers
            for
            Disease Control (CDC). A list of these hemophilia centers can be found
            at
            http://www.cdc.gov/ncbddd/hbd/htc_list.htm. The HMO must make Out-of-Network
            reimbursement arrangements with a CDC-supported hemophilia center, and
            such
            arrangements must be in writing, if the HMO does not include such a center
            in
            its Provider Network. 

           

          Physician
            services:
            The HMO
            must ensure that Primary Care Providers are available and accessible
            24 hours
            per day, seven days per week, within the Provider Network. The HMO must
            contract
            with a sufficient number of participating physicians and specialists
            within each
            Service Area to comply with the access requirements throughout Section
            8.1.3
            and meet
            the needs of Members for all Covered Services. 

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          The
            HMO
            must ensure that an adequate number of participating physicians have
            admitting
            privileges at one or more participating Acute Care hospitals in the Provider
            Network to ensure that necessary admissions are made. In no case may
            there be
            less than one in-network PCP with admitting privileges available and
            accessible
            24 hours per day, seven days per week for each Acute Care hospital in
            the
            Provider Network. 

           

          The
            HMO
            must ensure that an adequate number of participating specialty physicians
            have
            admitting privileges at one or more participating hospitals in the HMO’s
            Provider Network to ensure necessary admissions are made. The HMO shall
            require
            that all physicians who admit to hospitals maintain hospital access for
            their
            patients through appropriate call coverage. 

           

          Laboratory
            services:
            The HMO
            must ensure that in-network reference laboratory services must be of
            sufficient
            size and scope to meet the non-emergency and emergency needs of the enrolled
            population and the access requirements in
            Section 8.1.3.
            Reference laboratory specimen procurement services must facilitate the
            provision
            of clinical diagnostic services for physicians, Providers and Members
            through
            the use of convenient reference satellite labs in each Service Area,
            strategically located specimen collection areas in each Service Area,
            and the
            use of a courier system under the management of the reference lab. For
            Medicaid
            Members, THSteps requires that laboratory specimens obtained as part
            of a
            THSteps medical checkup visit must be sent to the TDSHS Laboratory.

           

          Diagnostic
            imaging:
            The HMO
            must ensure that diagnostic imaging services are available and accessible
            to all
            Members in each Service Area in accordance with the access standards
            in
Section
            8.1.3.
            The HMO
            must ensure that diagnostic imaging procedures that require the injection
            or
            ingestion of radiopaque chemicals are performed only under the direction
            of
            physicians qualified to perform those procedures. 

           

          Home
            health services:
            The HMO
            must have a contract(s) with a home health Provider so that all Members
            living
            within the HMO’s Service Area will have access to at least one such Provider for
            home health Covered Services. (These services are provided as part of
            the Acute
            Care Covered Services, not the Community Long-term Care Services.) 

           

          Community
            Long-term Care services:
            STAR+PLUS HMOs must have contracts with Community Long-term Care service
            Providers, so that all Members living within the Contractor’s Service Area will
            have access to Medically Necessary and Functionally Necessary Covered
            Services.

           

          8.1.4.1
            Provider Contract Requirements 

           

          The
            HMO
            is prohibited from requiring a provider or provider group to enter into
            an
            exclusive contracting arrangement with the HMO as a condition for participation
            in its Provider Network. 

           

          The
            HMO’s
            contract with health care Providers must be in writing, must be in compliance
            with applicable federal and state laws and regulations, and must include
            minimum
            requirements specified in the Uniform
            Managed Care Contract Terms and Conditions (Attachment A) and
            HHSC’s Uniform
            Managed Care Manual.
            

           

          The
            HMO
            must submit model Provider contracts to HHSC for review during Readiness
            Review.
            HHSC retains the right to reject or require changes to any model Provider
            contract that does not comply with HMO Program requirements or the HHSC-HMO
            Contract. 

           

          8.1.4.2
            Primary Care Providers 

           

          The
            HMO’s
            PCP Network may include Providers from any of the following practice
            areas:
            General Practice; Family Practice; Internal Medicine; Pediatrics;
            Obstetrics/Gynecology (OB/GYN); Certified Nurse Midwives (CNM) and Physician
            Assistants (PAs) practicing under the supervision of a physician; Federally
            Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and similar
            community clinics; and specialist physicians who are willing to provide
            a
            Medical Home to selected Members with special needs and conditions. Section
            533.005(a)(13), Government Code, requires the HMO to use Pediatric and
            Family
            Advanced Practice Nurses practicing under the supervision of a physician
            as PCPs
            in its Provider Network for STAR and STAR+PLUS. 

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          CHIP
            Perinatal HMOs are not required to develop PCP Networks for CHIP Perinates.
            CHIP
            Perinatal HMOs may use the same PCP Network for CHIP Members and CHIP
            Perinatal
            Newborns. 

           

          An
            internist or other Provider who provides primary care to adults only
            is not
            considered an age-appropriate PCP choice for a Member under age 21. An
            internist
            or other Provider who provides primary care to adults and children may
            be a PCP
            for children if: 

           

          
            	 	 	
                    1.
                      the Provider assumes all HMO PCP responsibilities for such
                      Members in a
                      specific age group under age 21, 

                  

          

           

          
            	 	 	
                    2.
                      the Provider has a history of practicing as a PCP for the specified
                      age
                      group as evidenced by the Provider’s primary care practice including an
                      established patient population under age 20 and within the
                      specified age
                      range, and 

                  

          

           

          
            	 	 	
                    3.
                      the Provider has admitting privileges to a local hospital that
                      includes
                      admissions to pediatric units. 

                  

          

           

          Section
            8.1.4.2 modified by Versions 1.1 and 1.3 

           

          A
            pediatrician is not considered an age-appropriate choice for a Member
            age 21 and
            over. 

           

          The
            PCP
            for a Member with disabilities, Special Health Care Needs, or Chronic
            or Complex
            Conditions may be a specialist physician who agrees to provide PCP services
            to
            the Member. The specialty physician must agree to perform all PCP duties
            required in the Contract and PCP duties must be within the scope of the
            specialist’s license. Any interested person may initiate the request through the
            HMO for a specialist to serve as a PCP for a Member with disabilities,
            Special
            Health Care Needs, or Chronic or Complex Conditions. The HMO shall handle
            such
            requests in accordance with 28 T.A.C. Part 1, Chapter 11, Subchapter
            J.

           

          PCPs
            who
            provide Covered Services for STAR, CHIP, and CHIP Perinatal Newborns
            must either
            have admitting privileges at a Hospital that is part of the HMO’s Provider
            Network or make referral arrangements with a Provider who has admitting
            privileges to a Network Hospital. STAR+PLUS PCPs must either have admitting
            privileges at a Medicaid Hospital or make referral arrangements with
            a Provider
            who has admitting privileges to a Medicaid Hospital. 

           

          The
            HMO
            must require, through contract provisions, that PCPs are accessible to
            Members
            24 hours a day, 7 days a week. The HMO is encouraged to include in its
            Network
            sites that offer primary care services during evening and weekend hours.
            The
            following are acceptable and unacceptable telephone arrangements for
            contacting
            PCPs after their normal business hours. 

           

          Acceptable
            after-hours coverage: 

           

          
            	 	 	
                    1.
                      The office telephone is answered after-hours by an answering
                      service,
                      which meets language requirements of the Major Population Groups
                      and which
                      can contact the PCP or another designated medical practitioner.
                      All calls
                      answered by an answering service must be returned within 30
                      minutes;
                      

                  

          

           

          
            	 	 	
                    2.
                      The office telephone is answered after normal business hours
                      by a
                      recording in the language of each of the Major Population Groups
                      served,
                      directing the patient to call another number to reach the PCP
                      or another
                      provider designated by the PCP. Someone must be available to
                      answer the
                      designated provider’s telephone. Another recording is not acceptable; and
                      

                  

          

           

          
            	 	 	
                    3.
                      The office telephone is transferred after office hours to another
                      location
                      where someone will answer the telephone and be able to contact
                      the PCP or
                      another designated medical practitioner, who can return the
                      call within 30
                      minutes. 

                  

          

           

          Unacceptable
            after-hours coverage: 

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          1.
            The
            office telephone is only answered during office hours; 

           

          
            	 	 	
                    2.
                      The office telephone is answered after-hours by a recording
                      that tells
                      patients to leave a message; 

                  

          

           

          
            	 	 	
                    3.
                      The office telephone is answered after-hours by a recording
                      that directs
                      patients to go to an Emergency Room for any services needed;
                      and
                      

                  

          

           

          
            	 	 	
                    4.
                      Returning after-hours calls outside of 30 minutes.
                      

                  

          

           

          The
            HMO
            must require PCPs, through contract provisions or Provider Manual, to
            provide
            children under the age of 21 with preventive services in accordance with
            the AAP
            recommendations for CHIP Members and CHIP Perinate Newborns, and the
            THSteps
            periodicity schedule published in the THSteps Manual for Medicaid Members.
            The
            HMO must require PCPs, through contract provisions or Provider Manual,
            to
            provide adults with preventive services in accordance with the U.S. Preventive
            Services Task Force requirements. The HMO must make best efforts to ensure
            that
            PCPs follow these periodicity requirements for children and adult Members.
            Best
            efforts must include, but not be limited to, Provider education, Provider
            profiling, monitoring, and feedback activities. 

           

          The
            HMO
            must require PCPs, through contract provisions or Provider Manual, to
            assess the
            medical needs of Members for referral to specialty care providers and
            provide
            referrals as needed. PCPs must coordinate Members’ care with specialty care
            providers after referral. The HMO must make best efforts to ensure that
            PCPs
            assess Member needs for referrals and make such referrals. Best efforts
            must
            include, but not be limited to, Provider education activities and review
            of
            Provider referral patterns. 

           

          8.1.4.3
            PCP Notification 

           

          The
            HMO
            must furnish each PCP with a current list of enrolled Members enrolled
            or
            assigned to that Provider no later than five (5) working days after the
            HMO
            receives the Enrollment File from the HHSC Administrative Services Contractor
            each month. The HMO may offer and provide such enrollment information
            in
            alternative formats, such as through access to a secure Internet site,
            when such
            format is acceptable to the PCP. 

           

          8.1.4.4
            Provider Credentialing and Re-credentialing 

           

          The
            HMO
            must review, approve and periodically recertify the credentials of all
            participating physician Providers and all other licensed Providers who
            participate in the HMO’s Provider Network. The HMO may subcontract with another
            entity to which it delegates such credentialing activities if such delegated
            credentialing is maintained in accordance with the National Committee
            for
            Quality Assurance (NCQA) delegated credentialing requirements and any
            comparable
            requirements defined by HHSC. 

           

          At
            a
            minimum, the scope and structure of a HMO’s credentialing and re-credentialing
            processes must be consistent with recognized HMO industry standards such
            as
            those provided by NCQA and relevant state and federal regulations including
            28
            T.A.C. §11.1902, relating to credentialing of providers in HMOs, and as an
            additional requirement for Medicaid HMOs, 42 C.F.R. §438.214(b). The initial
            credentialing process, including application, verification of information,
            and a
            site visit (if applicable), must be completed before the effective date
            of the
            initial contract with the physician or Provider. The re-credentialing
            process
            must occur at least every three years. 

           

          The
            re-credentialing process must take into consideration Provider performance
            data
            including, but not be limited to, Member Complaints and Appeals, quality
            of
            care, and utilization management. 

           

          8.1.4.5
            Board Certification Status 

           

          The
            HMO
            must maintain a policy with respect to Board Certification for PCPs and
            specialty physicians that encourage participation of board certified
            PCPs and
            specialty physicians in the Provider Network. The HMO must make information
            on
            the percentage of Board-certified PCPs in the Provider Network and the
            percentage of Board-certified specialty physicians, by specialty, available
            to
            HHSC upon request. 

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

           

          8.1.4.6
            Provider Manual, Materials and Training 

           

          The
            HMO
            must prepare and issue a Provider Manual(s), including any necessary
            specialty
            manuals (e.g., behavioral health) to all existing Network Providers.
            For newly
            contracted Providers, the HMO must issue copies of the Provider Manual(s)
            within
            five (5) working days from inclusion of the Provider into the Network.
            The
            Provider Manual must contain sections relating to special requirements
            of the
            HMO Program(s) and the enrolled populations in compliance with the requirements
            of this Contract. 

           

          HHSC
            or
            its designee must approve the Provider Manual, and any substantive revisions
            to
            the Provider Manual, prior to publication and distribution to Providers.
            The
            Provider Manual must contain the critical elements defined in the Uniform
            Managed Care Manual.
            HHSC’s
            initial review of the Provider Manual is part of the Operational Readiness
            Review described in Attachment
            B-1, Section
            7.
            

           

          The
            HMO
            must provide training to all Providers and their staff regarding the
            requirements of the Contract and special needs of Members. The HMO’s Medicaid,
            CHIP and/or CHIP Perinatal Program training must be completed within
            30 days of
            placing a newly contracted Provider on active status. The HMO must provide
            on-going training to new and existing Providers as required by the HMO
            or HHSC
            to comply with the Contract. The HMO must maintain and make available
            upon
            request enrollment or attendance rosters dated and signed by each attendee
            or
            other written evidence of training of each Provider and their staff.
            

           

          The
            HMO
            must establish ongoing Provider training that includes, but is not limited
            to,
            the following issues: 

           

          
            	 	 	
                    1.
                      Covered Services and the Provider’s responsibilities for providing and/or
                      coordinating such services. Special emphasis must be placed
                      on areas that
                      vary from commercial coverage rules (e.g., Early Intervention
                      services,
                      therapies and DME/Medical Supplies); and for Medicaid, making
                      referrals
                      and coordination with Non-capitated Services;

                  

          

           

          
            	 	 	
                    2.
                      Relevant requirements of the Contract;

                  

          

           

          
            	 	 	
                    3.
                      The HMO’s quality assurance and performance improvement program and
                      the
                      Provider’s role in such a program; and

                  

          

           

          
            	 	 	
                    4.
                      The HMO’s policies and procedures, especially regarding in-network
                      and
                      Out-of-Network referrals. 

                  

          

           

          Section
            8.1.4.6 modified by Version 1.3 

           

          Provider
            Materials produced by the HMO, relating to Medicaid Managed Care, the
            CHIP
            Program, and/or the CHIP Perinatal Program must be in compliance with
            State and
            Federal laws and requirements of the HHSC
            Uniform Managed Care Contract Terms and Conditions.
            HMO
            must make available any provider materials to HHSC upon request. 

           

          8.1.4.7
            Provider Hotline 

           

          The
            HMO
            must operate a toll-free telephone line for Provider inquiries from 8
            a.m. to 5
            p.m. local time for the Service Area, Monday through Friday, except for
            State-approved holidays. The Provider Hotline must be staffed with personnel
            who
            are knowledgeable about Covered Services and each applicable HMO Program,
            and
            for Medicaid, about Non-capitated Services. 

           

          The
            HMO
            must ensure that after regular business hours the line is answered by
            an
            automated system with the capability to provide callers with operating
            hours
            information and instructions on how to verify enrollment for a Member
            with an
            Urgent Condition or an Emergency Medical Condition. The HMO must have
            a process
            in place to handle after-hours inquiries from Providers seeking to verify
            enrollment for a Member with an Urgent Condition or an Emergency Medical
            Condition, provided, however, that the HMO and its Providers must not
            require
            such verification prior to providing Emergency Services. 

           

          The
            HMO
            must ensure that the Provider Hotline meets the following minimum performance
            requirements for

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          all
            HMO
            Programs and Service Areas: 

           

          
            	 	 	
                    1.
                      99% of calls are answered by the fourth ring or an automated
                      call pick-up
                      system is used; 

                  

          

           

          
            	 	 	
                    2.
                      no more than one percent of incoming calls receive a busy signal;
                      

                  

          

           

          
            	 	 	
                    3.
                      the average hold time is 2 minutes or less; and

                  

          

           

          
            	 	 	
                    4.
                      the call abandonment rate is 7% or less.

                  

          

           

          The
            HMO
            must conduct ongoing call quality assurance to ensure these standards
            are met.
            The Provider Hotline may serve multiple HMO Programs if Hotline staff
            is
            knowledgeable about all of the HMO’s Programs. The Provider Hotline may serve
            multiple Service Areas if the Hotline staff is knowledgeable about all
            such
            Service Areas, including the Provider Network in such Service Areas.
            

           

          The
            HMO
            must monitor its performance regarding Provider Hotline standards and
            submit
            performance reports summarizing call center performance for the Hotline
            as
            indicated in Section
            8.1.20.
            If the
            HMO subcontracts with a Behavioral Health Organization (BHO) that is
            responsible
            for Provider Hotline functions related to Behavioral Health Services,
            the BHO’s
            Provider Hotline must meet the requirements in Section
            8.1.4.7.
            

           

          8.1.4.8
            Provider Reimbursement 

           

          The
            HMO
            must make payment for all Medically Necessary Covered Services provided
            to all
            Members for whom the HMO is paid a capitation. A STAR+PLUS HMO must also
            make
            payment for all Functionally Necessary Covered Services provided to all
            Members
            for whom the HMO is paid a capitation. The HMO must ensure that claims
            payment
            is timely and accurate as described in Section 8.1.18.5.
            The
            HMO
            must require tax identification numbers from all participating Providers.
            The
            HMO is required to do back-up withholding from all payments to Providers
            who
            fail to give tax identification numbers or who give incorrect numbers.
            

           

          Section
            8.1.4.8 modified by Version 1.1 

           

          8.1.4.9
            Termination of Provider Contracts 

           

          Unless
            prohibited or limited by applicable law, at least 15 days prior to the
            effective
            date of the HMO’s termination of contract of any participating Provider the HMO
            must notify the HHSC Administrative Services Contractor and notify affected
            current Members in writing. Affected Members include all Members in a
            PCP’s
            panel and all Members who have been receiving ongoing care from the terminated
            Provider, where ongoing care is defined as two or more visits for home-based
            or
            office-based care in the past 12 months. 

           

          For
            the
            CHIP and CHIP Perinatal Programs, the HMO’s process for terminating Provider
            contracts must comply with the Texas Insurance Code and TDI regulations.
            

           

          8.1.5
            Member Services 

           

          The
            HMO
            must maintain a Member Services Department to assist Members and Members’ family
            members or guardians in obtaining Covered Services for Members. The HMO
            must
            maintain employment standards and requirements (e.g., education, training,
            and
            experience) for Member Services Department staff and provide a sufficient
            number
            of staff for the Member Services Department to meet the requirements
            of this
            Section, including Member Hotline response times, and Linguistic Access
            capabilities, see 8.1.5.6 Member Hotline Requirements. 

           

          8.1.5.1
            Member Materials 

           

          The
            HMO
            must design, print and distribute Member identification (ID) cards and
            a Member
            Handbook to Members. Within five business days following the receipt
            of an
            Enrollment File from the HHSC Administrative Services Contractor, the
            HMO must
            mail a Member’s ID card and Member Handbook to the Case Head or Account Name for
            each new Member. When the Case Head or Account Name is on behalf of
            two

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          or
            more
            new Members, the HMO is only required to send one Member Handbook. The
            HMO is
            responsible for mailing materials only to those Members for whom valid
            address
            data are contained in the Enrollment File. 

           

          The
            HMO
            must design, print and distribute a Provider Directory to the HHSC
            Administrative Services Contractor as described in Section
            8.1.5.4. 

           

          Member
            materials must be at or below a 6th grade reading level as measured by
            the
            appropriate score on the Flesch reading ease test. Member materials must
            be
            available in English, Spanish, and the languages of other Major Population
            Groups making up 10% or more of the managed care eligible population
            in the
            HMO’s Service Area, as specified by HHSC. HHSC will provide the HMO with
            reasonable notice when the enrolled population reaches 10% within the
            HMO’s
            Service Area. All Member materials must be available in a format accessible
            to
            the visually impaired, which may include large print, Braille, and audiotapes.
            

           

          The
            HMO
            must submit member materials to HHSC for approval prior to use or mailing.
            HHSC
            will identify any required changes to the Member materials within 15
            business
            days. If HHSC has not responded to the Contractor by the fifteenth day,
            the
            Contractor may proceed to use the submitted materials. HHSC reserves
            the right
            to require discontinuation of any Member materials that violate the terms
            of the
Uniform
            Managed Care Terms and Conditions,
            including but not limited to “Marketing Policies and Procedures” as described in
            the Uniform
            Managed Care Manual.
            

           

          Section
            8.1.5.1 modified by Version 1.2 

           

          Section
            8.1.4.9 modified by Version 1.3 

           

          8.1.5.2
            Member Identification (ID) Card 

           

          All
            Member ID cards must, at a minimum, include the following information:
            

           

          
            	 	 	
                    1.
                      the Member’s name; 

                  

          

             

               
            2. the Member’s Medicaid, CHIP or CHIP Perinatal Program number; 

           

          
            	 	 	
                    3.
                      the effective date of the PCP assignment (excluding CHIP Perinates);
                      

                  

          

           

          
            	 	 	
                    4.
                      the PCP’s name, address (optional for all products), and telephone
                      number
                      (excluding CHIP Perinates); 

                  

          

           

          
            	 	 	
                    5.
                      the name of the HMO; 

                  

          

           

          
            	 	 	
                    6.
                      the 24-hour, seven (7) day a week toll-free Member services
                      telephone
                      number and BH Hotline number operated by the HMO; and
                      

                  

          

           

          
            	 	 	
                    7.
                      any other critical elements identified in the Uniform
                      Managed Care Manual.
                      

                  

          

           

          The
            HMO
            must reissue the Member ID card if a Member reports a lost card, there
            is a
            Member name change, if the Member requests a new PCP, or for any other
            reason
            that results in a change to the information disclosed on the ID card.
            CHIP
            Perinatal HMOs must issue Member ID cards to both CHIP Perinates and
            CHIP
            Perinate Newborns. 

           

          8.1.5.3
            Member Handbook 

           

          HHSC
            must
            approve the Member Handbook, and any substantive revisions, prior to
            publication
            and distribution. As described in Attachment
            B-1, Section
            7,
            the HMO
            must develop and submit to HHSC the draft Member Handbook for approval
            during
            the Readiness Review and must submit a final Member Handbook incorporating
            changes required by HHSC prior to the Operational Start Date. 

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

           

          The
            Member Handbook for each applicable HMO Program must, at a minimum, meet
            the
            Member materials requirements specified by Section
            8.1.5.1
            above
            and must include critical elements in the Uniform
            Managed Care Manual.
            CHIP
            Perinatal HMOs must issue Member Handbooks to both CHIP Perinates and
            CHIP
            Perinate Newborns. The Member Handbook for CHIP Perinate Newborns may
            be the
            same as that used for CHIP. 

           

          The
            HMO
            must produce a revised Member Handbook, or an insert informing Members
            of
            changes to Covered Services upon HHSC notification and at least 30 days
            prior to
            the effective date of such change in Covered Services. In addition to
            modifying
            the Member materials for new Members, the HMO must notify all existing
            Members
            of the Covered Services change during the time frame specified in this
            subsection. 

           

          Section
            8.1.5.2 modified by Version 1.3 

           

          Section
            8.1.5.3 modified by Version 1.3 

           

          8.1.5.4
            Provider Directory 

           

          The
            Provider Directory for each applicable HMO Program, and any substantive
            revisions, must be approved by HHSC prior to publication and distribution.
            The
            HMO is responsible for submitting draft Provider directory updates to
            HHSC for
            prior review and approval if changes other than PCP information or clerical
            corrections are incorporated into the Provider Directory. 

           

           

          As
            described in Attachment
            B-1, Section 7,
            during
            the Readiness Review, the HMO must develop and submit to HHSC the draft
            Provider
            Directory template for approval and must submit a final Provider Directory
            incorporating changes required by HHSC prior to the Operational Start
            Date. Such
            draft and final Provider Directories must be submitted according to the
            deadlines established in Attachment
            B-1, Section 7.
            

           

           

          The
            Provider Directory for each applicable HMO Program must, at a minimum,
            meet the
            Member Materials requirements specified by Section
            8.1.5.1
            above
            and must include critical elements in the Uniform
            Managed Care Manual.
            The
            Provider Directory must include only Network Providers credentialed by
            the HMO
            in accordance with Section
            8.1.4.4.
            If the
            HMO contracts with limited Provider Networks, the Provider Directory
            must comply
            with the requirements of 28 T.A.C. §11.1600(b)(11), relating to the disclosure
            and notice of limited Provider Networks. 

           

           

          CHIP
            Perinatal HMOs must develop Provider Directories for both CHIP Perinates
            and
            CHIP Perinate Newborns. The Provider Directory for CHIP Perinate Newborns
            may be
            the same as that used for the CHIP Program. 

           

           

          The
            HMO
            must update the Provider Directory on a quarterly basis. The HMO must
            make such
            update available to existing Members on request, and must provide such
            update to
            the HHSC Administrative Services Contractor at the beginning of each
            state
            fiscal quarter. HHSC will consult with the HMOs and the HHSC Administrative
            Services Contractors to discuss methods for reducing the HMO’s administrative
            costs of producing new Provider Directories, including considering submission
            of
            new Provider Directories on a semi-annual rather than a quarterly basis
            if a HMO
            has not made major changes in its Provider Network, as determined by
            HHSC. HHSC
            will establish weight limits for the Provider Directories. Weight limits
            may
            vary by Service Area. HHSC will require HMOs that exceed the weight limits
            to
            compensate HHSC for postage fees in excess of the weight limits. 

           

           

          The
            HMO
            must send the most recent Provider Directory, including any updates,
            to Members
            upon request. The HMO must, at least annually, include written and verbal
            offers
            of such Provider Directory in its Member outreach and education materials.
            

           

           

          8.1.5.5
            Internet Website 

           

           

          The
            HMO
            must develop and maintain, consistent with HHSC standards and Section
            843.2015
            of the Texas Insurance Code and other applicable state laws, a website
            to
            provide general information about the HMO’s

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          Program(s),
            its Provider Network, its customer services, and its Complaints and Appeals
            process. The HMO may develop a page within its existing website to meet
            the
            requirements of this section. The HMO must maintain a Provider Directory
            for its
            HMO Program(s) on the HMO’s website with designation of open versus closed
            panels. The HMO’s website must comply with the Marketing Policies and Procedures
            for each applicable HHSC HMO Program. 

           

          Section
            8.1.5.4 modified by Version 1.3 

           

          The
            website’s HMO Program content must be: 

           

          1.
            Written in Major Population Group languages (which under this contract
            include
            only English and Spanish); 

           

          2.
            Culturally appropriate; 

           

          3.
            Written for understanding at the 6th grade reading level; and 

           

          4.
            Be
            geared to the health needs of the enrolled HMO Program population. 

           

          To
            minimize download and “wait times,” the website must avoid tools or techniques
            that require significant memory or disk resources or require special
            intervention on the customer side to install plug-ins or additional software.
            Use of proprietary items that would require a specific browser are not
            allowed.
            HHSC strongly encourages the use of tools that take advantage of efficient
            data
            access methods and reduce the load on the server or bandwidth. 

           

          8.1.5.6
            Member Hotline 

           

          The
            HMO
            must operate a toll-free hotline that Members can call 24 hours a day,
            seven (7)
            days a week. The Member Hotline must be staffed with personnel who are
            knowledgeable about its HMO Program(s) and Covered Services, between
            the hours
            of 8:00 a.m. to 5:00 p.m. local time for the Service Area, Monday through
            Friday, excluding state-approved holidays. 

           

          The
            HMO
            must ensure that after hours, on weekends, and on holidays the Member
            Services
            Hotline is answered by an automated system with the capability to provide
            callers with operating hours and instructions on what to do in cases
            of
            emergency. All recordings must be in English and in Spanish. A voice
            mailbox
            must be available after hours for callers to leave messages. The HMO’s Member
            Services representatives must return member calls received by the automated
            system on the next working day. 

           

          If
            the
            Member Hotline does not have a voice-activated menu system, the HMO must
            have a
            menu system that will accommodate Members who cannot access the system
            through
            other physical means, such as pushing a button. 

           

          The
            HMO
            must ensure that its Member Service representatives treat all callers
            with
            dignity and respect the callers’ need for privacy. At a minimum, the HMO’s
            Member Service representatives must be: 

           

          
            	 	 	
                    1.
                      Knowledgeable about Covered Services;

                  

          

           

          
            	 	 	
                    2.
                      Able to answer non-technical questions pertaining to the role
                      of the PCP,
                      as applicable; 

                  

          

           

          
            	 	 	
                    3.
                      Able to answer non-clinical questions pertaining to referrals
                      or the
                      process for receiving authorization for procedures or services;
                      

                  

          

           

          
            	 	 	
                    4.
                      Able to give information about Providers in a particular area;
                      

                  

          

           

          
            	 	 	
                    5.
                      Knowledgeable about Fraud, Abuse, and Waste and the requirements
                      to report
                      any conduct that, if substantiated, may constitute Fraud, Abuse,
                      or Waste
                      in the HMO Program; 

                  

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          
            	 	 	
                    6.
                      Trained regarding Cultural Competency;

                  

          

           

           

          Section
            8.1.5.6 modified by Versions 1.2 and 1.3  

           

          7.
            Trained regarding the process used to confirm the status of persons with
            Special
            Health Care Needs; 

           

          
            	 	 	
                    8.
                      For Medicaid members, able to answer non-clinical questions
                      pertaining to
                      accessing Non-capitated Services; and

                  

          

           

          
            	 	 	
                    9.
                      For CHIP Members, able to give correct cost-sharing information
                      relating
                      to premiums, co-pays or deductibles, as applicable. (Cost-sharing
                      does not
                      apply to CHIP Perinates or CHIP Perinate Newborns.)
                      

                  

          

           

          Hotline
            services must meet Cultural Competency requirements and must appropriately
            handle calls from non-English speaking (and particularly, Spanish-speaking)
            callers, as well as calls from individuals who are deaf or hard-of-hearing.
            To
            meet these requirements, the HMO must employ bilingual Spanish-speaking
            Member
            Services representatives and must secure the services of other contractors
            as
            necessary to meet these requirements. 

           

          The
            HMO
            must process all incoming Member correspondence and telephone inquiries
            in a
            timely and responsive manner. The HMO cannot impose maximum call duration
            limits
            but must allow calls to be of sufficient length to ensure adequate information
            is provided to the Member. The HMO must ensure that the toll-free Member
            Hotline
            meets the following minimum performance requirements for all HMO Programs
            and
            Service Areas: 

           

          
            	 	 	
                    1.
                      99% of calls are answered by the fourth ring or an automated
                      call pick-up
                      system; 

                  

          

           

          
            	 	 	
                    2.
                      no more than one percent (1%) of incoming calls receive a busy
                      signal;
                      

                  

          

           

          
            	 	 	
                    3.
                      at least 80% of calls must be answered by toll-free line staff
                      within 30
                      seconds measured from the time the call is placed in queue
                      after selecting
                      an option; and 

                  

          

           

          
            	 	 	
                    4.
                      the call abandonment rate is 7% or less.

                  

          

           

          The
            HMO
            must conduct ongoing quality assurance to ensure these standards are
            met.

           

          The
            Member Services Hotline may serve multiple HMO Programs if Hotline staff
            is
            knowledgeable about all of the HMO’s Medicaid and/or CHIP Programs. The Member
            Services Hotline may serve multiple Service Areas if the Hotline staff
            is
            knowledgeable about all such Service Areas, including the Provider Network
            in
            each Service Area. 

           

          The
            HMO
            must monitor its performance regarding HHSC Member Hotline standards
            and submit
            performance reports summarizing call center performance for the Member
            Hotline
            as indicated in Section
            8.1.20
            and the
Uniform
            Managed Care Manual.
            

           

          8.1.5.7
            Member Education 

           

          The
            HMO
            must, at a minimum, develop and implement health education initiatives
            that
            educate Members about: 

           

          
            	 	 	
                    1.
                      How the HMO system operates, including the role of the PCP;
                      

                  

          

           

          
            	 	 	
                    2.
                      Covered Services, limitations and any Value-added Services
                      offered by the
                      HMO; 

                  

          

           

          
            	 	 	
                    3.
                      The value of screening and preventive care, and

                  

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          
            	 	 	
                    4.
                      How to obtain Covered Services, including:

                  

          

           

          a.
            Emergency Services; 

           

          b.
            Accessing OB/GYN and specialty care; 

           

          c.
            Behavioral Health Services; 

           

          d.
            Disease Management programs; 

           

          e.
            Service Coordination, treatment for pregnant women, Members with Special
            Health
            Care Needs, including Children with Special Health Care Needs; and other
            special
            populations; 

           

          f.
            Early
            Childhood Intervention (ECI) Services; 

           

          g.
            Screening and preventive services, including well-child care (THSteps
            medical
            checkups for Medicaid Members); 

           

          h.
            For
            CHIP Members, Member co-payments 

           

          i.
            Suicide prevention; and 

           

          j.
            Identification and health education related to Obesity. 

          

           

          Section
            8.1.5.7 modified by Version 1.3 

           

          Section
            8.1.5.6 modified by Version 1.3 

           

          The
            HMO
            must provide a range of health promotion and wellness information and
            activities
            for Members in formats that meet the needs of all Members. The HMO must
            propose,
            implement, and assess innovative Member education strategies for wellness
            care
            and immunization, as well as general health promotion and prevention.
            The HMO
            must conduct wellness promotion programs to improve the health status
            of its
            Members. The HMO may cooperatively conduct health education classes for
            all
            enrolled Members with one or more HMOs also contracting with HHSC in
            the Service
            Area. The HMO must work with its Providers to integrate health education,
            wellness and prevention training into the care of each Member. 

           

          The
            HMO
            also must provide condition and disease-specific information and educational
            materials to Members, including information on its Service Management
            and
            Disease Management programs described in Section
            8.1.13 and Section 8.1.
            Condition- and disease-specific information must be oriented to various
            groups
            within the managed care eligible population, such as children, the elderly,
            persons with disabilities and non-English speaking Members, as appropriate
            to
            the HMO’s Medicaid, CHIP and/or CHIP Perinatal Program(s). 

           

          8.1.5.8
            Cultural Competency Plan 

           

          The
            HMO
            must have a comprehensive written Cultural Competency Plan describing
            how the
            HMO will ensure culturally competent services, and provide Linguistic
            Access and
            Disability-related Access. The Cultural Competency Plan must describe
            how the
            individuals and systems within the HMO will effectively provide services
            to
            people of all cultures, races, ethnic backgrounds, and religions as well
            as
            those with disabilities in a manner that recognizes, values, affirms,
            and
            respects the worth of the individuals and protects and preserves the
            dignity of
            each. The HMO must submit the Cultural Competency Plan to HHSC for Readiness
            Review. Modifications and amendments to the plan must be submitted to
            HHSC no
            later than 30 days prior to implementation. The Plan must also be made
            available
            to the HMO’s Network of Providers. 

           

          8.1.5.9
            Member Complaint and Appeal Process 

           

          The
            HMO
            must develop, implement and maintain a system for tracking, resolving,
            and
            reporting Member Complaints regarding its services, processes, procedures,
            and
            staff. The HMO must ensure that Member

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          Complaints
            are resolved within 30 calendar days after receipt. The HMO is subject
            to
            remedies, including liquidated damages, if at least 98 percent of Member
            Complaints are not resolved within 30 days of receipt of the Complaint
            by the
            HMO. Please see the Uniform
            Managed Care Contract Terms & Conditions and
            Attachment B-5, Deliverables/Liquidated Damages Matrix. 

           

          The
            HMO
            must develop, implement and maintain a system for tracking, resolving,
            and
            reporting Member Appeals regarding the denial or limited authorization
            of a
            requested service, including the type or level of service and the denial,
            in
            whole or in part, of payment for service. Within this process, the HMO
            must
            respond fully and completely to each Appeal and establish a tracking
            mechanism
            to document the status and final disposition of each Appeal. 

           

          The
            HMO
            must ensure that Member Appeals are resolved within 30 calendar days,
            unless the
            HMO can document that the Member requested an extension or the HMO shows
            there
            is a need for additional information and the delay is in the Member's
            interest.
            The HMO is subject to liquidated damages if at least 98 percent of Member
            Appeals are not resolved within 30 days of receipt of the Appeal by the
            HMO.
            Please see the Uniform
            Managed Care Contract Terms & Conditions and
            Attachment B-5, Deliverables/Liquidated Damages Matrix. 

           

          Medicaid
            HMOs must follow the Member Complaint and Appeal Process described in
            Section
            8.2.6.
            CHIP
            and CHIP Perinatal HMOs must comply with the CHIP Complaint and Appeal
            Process
            described in Sections
            8.4.2 and
            8.5.2, respectively.
            

           

          8.1.6
            Marketing and Prohibited Practices 

           

          The
            HMO
            and its Subcontractors must adhere to the Marketing Policies and Procedures
            as
            set forth by HHSC in the Contract, and the HHSC
            Uniform Managed Care Manual.
            

           

          8.1.7
            Quality Assessment and Performance Improvement 

           

          The
            HMO
            must provide for the delivery of quality care with the primary goal of
            improving
            the health status of Members and, where the Member’s condition is not amenable
            to improvement, maintain the Member’s current health status by implementing
            measures to prevent any further decline in condition or deterioration
            of health
            status. The HMO must work in collaboration with Providers to actively
            improve
            the quality of care provided to Members, consistent with the Quality
            Improvement
            Goals and all other requirements of the Contract. The HMO must provide
            mechanisms for Members and Providers to offer input into the HMO’s quality
            improvement activities. 

           

          8.1.7.1
            QAPI Program Overview 

           

          The
            HMO
            must develop, maintain, and operate a quality assessment and performance
            improvement (QAPI) Program consistent with the Contract, and TDI requirements,
            including 28 T.A.C. §11.1901(a)(5) and §11.1902. Medicaid HMOs must also meet
            the requirements of 42 C.F.R. §438.240. 

           

          The
            HMO
            must have on file with HHSC an approved plan describing its QAPI Program,
            including how the HMO will accomplish the activities required by this
            section.
            The HMO must submit a QAPI Program Annual Summary in a format and timeframe
            specified by HHSC or its designee. The HMO must keep participating physicians
            and other Network Providers informed about the QAPI Program and related
            activities. The HMO must include in Provider contracts a requirement
            securing
            cooperation with the QAPI. 

           

          Section
            8.1.5.8 modified by Version 1.3 

           

          The
            HMO
            must approach all clinical and non-clinical aspects of quality assessment
            and
            performance improvement based on principles of Continuous Quality Improvement
            (CQI)/Total Quality Management (TQM) and must: 

           

          
            	 	 	
                    1.
                      Evaluate performance using objective quality indicators;
                      

                  

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

           

          
            	 	 	
                    2.
                      Foster data-driven decision-making;

                  

          

           

          
            	 	 	
                    3.
                      Recognize that opportunities for improvement are unlimited;
                      

                  

          

           

          
            	 	 	
                    4.
                      Solicit Member and Provider input on performance and QAPI activities;
                      

                  

          

           

          
            	 	 	
                    5.
                      Support continuous ongoing measurement of clinical and non-clinical
                      effectiveness and Member satisfaction;

                  

          

           

          
            	 	 	
                    6.
                      Support programmatic improvements of clinical and non-clinical
                      processes
                      based on findings from on-going measurements; and
                      

                  

          

           

          
            	 	 	
                    7.
                      Support re-measurement of effectiveness and Member satisfaction,
                      and
                      continued development and implementation of improvement interventions
                      as
                      appropriate. 

                  

          

           

          8.1.7.2
            QAPI Program Structure 

           

          The
            HMO
            must maintain a well-defined QAPI structure that includes a planned systematic
            approach to improving clinical and non-clinical processes and outcomes.
            The HMO
            must designate a senior executive responsible for the QAPI Program and
            the
            Medical Director must have substantial involvement in QAPI Program activities.
            At a minimum, the HMO must ensure that the QAPI Program structure: 

           

          
            	 	 	
                    1.
                      Is organization-wide, with clear lines of accountability within
                      the
                      organization; 

                  

          

           

          
            	 	 	
                    2.
                      Includes a set of functions, roles, and responsibilities for
                      the oversight
                      of QAPI activities that are clearly defined and assigned to
                      appropriate
                      individuals, including physicians, other clinicians, and non-clinicians;
                      

                  

          

           

          
            	 	 	
                    3.
                      Includes annual objectives and/or goals for planned projects
                      or activities
                      including clinical and non-clinical programs or initiatives
                      and
                      measurement activities; and 

                  

          

           

          
            	 	 	
                    4.
                      Evaluates the effectiveness of clinical and non-clinical initiatives.
                      

                  

          

           

          8.1.7.3
            Clinical Indicators 

           

          The
            HMO
            must engage in the collection of clinical indicator data. The HMO must
            use such
            clinical indicator data in the development, assessment, and modification
            of its
            QAPI Program. 

           

          8.1.7.4
            QAPI Program Subcontracting 

           

          If
            the
            HMO subcontracts any of the essential functions or reporting requirements
            contained within the QAPI Program to another entity, the HMO must maintain
            a
            file of the subcontractors. The file must be available for review by
            HHSC or its
            designee upon request. 

           

          8.1.7.5
            Behavioral Health Integration into QAPI Program 

           

          If
            the
            HMO provides Behavioral Health Services within the Covered Services as
            defined
            in Attachments
            B-2, B-2.1, and B-2.2,
            it must
            integrate behavioral health into its QAPI Program and include a systematic
            and
            on-going process for monitoring, evaluating, and improving the quality
            and
            appropriateness of Behavioral Health Services provided to Members. The
            HMO must
            collect data, and monitor and evaluate for improvements to physical health
            outcomes resulting from behavioral health integration into the Member’s overall
            care. 

           

          8.1.7.6
            Clinical Practice Guidelines 

           

          The
            HMO
            must adopt not less than two evidence-based clinical practice guidelines
            for
            each applicable HMO Program. Such practice guidelines must be based on
            valid and
            reliable clinical evidence, consider the needs of the HMO’s Members, be adopted
            in consultation with contracting health care professionals, and be
            reviewed

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          and
            updated periodically, as appropriate. The HMO must develop practice guidelines
            based on the health needs and opportunities for improvement identified
            as part
            of the QAPI Program. 

           

          The
            HMO
            may coordinate the development of clinical practice guidelines with other
            HHSC
            HMOs to avoid providers in a Service Area receiving conflicting practice
            guidelines from different HMOs. 

           

          The
            HMO
            must disseminate the practice guidelines to all affected Providers and,
            upon
            request, to Members and potential Members. 

           

          The
            HMO
            must take steps to encourage adoption of the guidelines, and to measure
            compliance with the guidelines, until such point that 90% or more of
            the
            Providers are consistently in compliance, based on HMO measurement findings.
            The
            HMO must employ substantive Provider motivational incentive strategies,
            such as
            financial and non-financial incentives, to improve Provider compliance
            with
            clinical practice guidelines. The HMO’s decisions regarding utilization
            management, Member education, coverage of services, and other areas included
            in
            the practice guidelines must be consistent with the HMO’s clinical practice
            guidelines. 

           

          8.1.7.7
            Provider Profiling 

           

          The
            HMO
            must conduct PCP and other Provider profiling activities at least annually.
            As
            part of its QAPI Program, the HMO must describe the methodology it uses
            to
            identify which and how many Providers to profile and to identify measures
            to use
            for profiling such Providers. 

           

          Provider
            profiling activities must include, but not be limited to: 

           

          
            	 	 	
                    1.
                      Developing PCP and Provider-specific reports that include a
                      multi-dimensional assessment of a PCP or Provider’s performance using
                      clinical, administrative, and Member satisfaction indicators
                      of care that
                      are accurate, measurable, and relevant to the enrolled population;
                      

                  

          

           

          
            	 	 	
                    2.
                      Establishing PCP, Provider, group, Service Area or regional
                      Benchmarks for
                      areas profiled, where applicable, including STAR, STAR+PLUS,
                      CHIP and CHIP
                      Perinatal Program-specific Benchmarks, where appropriate; and
                      

                  

          

           

          
            	 	 	
                    3.
                      Providing feedback to individual PCPs and Providers regarding
                      the results
                      of their performance and the overall performance of the Provider
                      Network.
                      

                  

          

           

          Section
            8.1.7.7 modified by Versions 1.1 and 1.3 

           

          Section
            8.1.7.5 modified by Version 1.3 

           

          8.1.7.8
            Network Management 

           

          The
            HMO
            must: 

           

          
            	 	 	
                    1.
                      Use the results of its Provider profiling activities to identify
                      areas of
                      improvement for individual PCPs and Providers, and/or groups
                      of Providers;
                      

                  

          

           

          
            	 	 	
                    2.
                      Establish Provider-specific quality improvement goals for priority
                      areas
                      in which a Provider or Providers do not meet established HMO
                      standards or
                      improvement goals; 

                  

          

           

          
            	 	 	
                    3.
                      Develop and implement incentives, which may include financial
                      and
                      non-financial incentives, to motivate Providers to improve
                      performance on
                      profiled measures; and 

                  

          

           

          
            	 	 	
                    4.
                      At least annually, measure and report to HHSC on the Provider
                      Network and
                      individual Providers’ progress, or lack of progress, towards such
                      improvement goals. 

                  

          

           

          8.1.7.9
            Collaboration with the EQRO 

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          The
            HMO
            will collaborate with HHSC’s external quality review organization (EQRO) to
            develop studies, surveys, or other analytical approaches that will be
            carried
            out by the EQRO. The purpose of the studies, surveys, or other analytical
            approaches is to assess the quality of care and service provided to Members
            and
            to identify opportunities for HMO improvement. To facilitate this process,
            the
            HMO will supply claims data to the EQRO in a format identified by HHSC
            in
            consultation with HMOs, and will supply medical records for focused clinical
            reviews conducted by the EQRO. The HMO must also work collaboratively
            with HHSC
            and the EQRO to annually measure selected HEDIS measures that require
            chart
            reviews. During the first year of operations, HHSC anticipates that the
            selected
            measures will include, at a minimum, well-child visits and immunizations,
            appropriate use of asthma medications, measures related to Members with
            diabetes, and control of high blood pressure. 

           

          8.1.8
            Utilization Management 

           

          The
            HMO
            must have a written utilization management (UM) program description,
            which
            includes, at a minimum: 

           

          
            	 	 	
                    1.
                      Procedures to evaluate the need for Medically Necessary Covered
                      Services;
                      

                  

          

           

          
            	 	 	
                    2.
                      The clinical review criteria used, the information sources,
                      the process
                      used to review and approve the provision of Covered Services;
                      

                  

          

           

          
            	 	 	
                    3.
                      The method for periodically reviewing and amending the UM clinical
                      review
                      criteria; and 

                  

          

           

          
            	 	 	
                    4.
                      The staff position functionally responsible for the day-to-day
                      management
                      of the UM function. 

                  

          

           

          The
            HMO
            must make best efforts to obtain all necessary information, including
            pertinent
            clinical information, and consult with the treating physician as appropriate
            in
            making UM determinations. 

           

          The
            HMO
            must issue coverage determinations, including adverse determinations,
            according
            to the following timelines: 

           

          •
Within
            three (3) business days after receipt of the request for authorization
            of
            services; 

           

          •
Within
            one (1) business day for concurrent hospitalization decisions; and 

           

          •
Within
            one (1) hour for post-stabilization or life-threatening conditions, except
            that
            for Emergency Medical Conditions and Emergency Behavioral Health Conditions,
            the
            HMO must not require prior authorization. 

           

          The
            HMO’s
            UM Program must include written policies and procedures to ensure: 

           

          
            	 	 	
                    1.
                      Consistent application of review criteria that are compatible
                      with
                      Members’ needs and situations; 

                  

          

           

          
            	 	 	
                    2.
                      Determinations to deny or limit services are made by physicians
                      under the
                      direction of the Medical Director; 

                  

          

           

          
            	 	 	
                    3.
                      Appropriate personnel are available to respond to utilization
                      review
                      inquiries 8:00 a.m. to 5:00 p.m., Monday through Friday, with
                      a telephone
                      system capable of accepting utilization review inquiries after
                      normal
                      business hours. The HMO must respond to calls within one business
                      day;
                      

                  

          

           

          
            	 	 	
                    4.
                      Confidentiality of clinical information; and

                  

          

           

          
            	 	 	
                    5.
                      Quality is not adversely impacted by financial and reimbursement-related
                      processes and decisions. 

                  

          

           

          For
            HMOs
            with preauthorization or concurrent review programs, qualified medical
            professionals must supervise

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          preauthorization
            and concurrent review decisions. 

           

          The
            HMO
            UM Program must include polices and procedures to: 

           

          
            	 	 	
                    1.
                      Routinely assess the effectiveness and the efficiency of the
                      UM Program;
                      

                  

          

           

          
            	 	 	
                    2.
                      Evaluate the appropriate use of medical technologies, including
                      medical
                      procedures, drugs and devices; 

                  

          

           

          
            	 	 	
                    3.
                      target areas of suspected inappropriate service utilization;
                      

                  

          

           

          
            	 	 	
                    4.
                      Detect over- and under-utilization;

                  

          

           

          
            	 	 	
                    5.
                      Routinely generate Provider profiles regarding utilization
                      patterns and
                      compliance with utilization review criteria and policies;
                      

                  

          

           

          
            	 	 	
                    6.
                      Compare Member and Provider utilization with norms for comparable
                      individuals; 

                  

          

           

          
            	 	 	
                    7.
                      Routinely monitor inpatient admissions, emergency room use,
                      ancillary, and
                      out-of-area services; 

                  

          

           

          
            	 	 	
                    8.
                      Ensure that when Members are receiving Behavioral Health Services
                      from the
                      local mental health authority that the HMO is using the same
                      UM guidelines
                      as those prescribed for use by Local Mental Health Authorities
                      by MHMR
                      which are published at: http://www.mhmr.state.tx.us/centraloffice/behavioralhealthservices/RDMClinGuide.html
                      ;
                      and 

                  

          

           

          
            	 	 	
                    9.
                      Refer suspected cases of provider or Member Fraud, Abuse, or
                      Waste to the
                      Office of Inspector General (OIG) as required by Section
                      8.1.19.
                      

                  

          

           

          8.1.9
            Early Childhood Intervention (ECI) 

           

          The
            HMO
            must ensure that Network Providers are educated regarding their responsibility
            under federal laws (e.g., 20 U.S.C. §1435 (a)(5); 34 C.F.R. §303.321(d)) to
            identify and refer any Member age three (3) or under suspected of having
            a
            developmental disability or delay, or who is at risk of delay, to the
            designated
            ECI program for screening and assessment within two (2) working days
            from the
            day the Provider identifies the Member. The HMO must use written educational
            materials developed or approved by the Department of Assistive and
            Rehabilitative Services - Division for Early Childhood Intervention Services
            for
            these “child find” activities. Eligibility for ECI services will be determined
            by the local ECI program using the criteria contained in 40 T.A.C. §108.25.

           

          The
            HMO
            must contract with qualified ECI Providers to provide ECI services to
            Members
            under age three who have been determined eligible for ECI services. The
            HMO must
            permit Members to self refer to local ECI Service Providers without requiring
            a
            referral from the Member’s PCP. The HMO’s policies and procedures, including its
            Provider Manual, must include written policies and procedures for allowing
            such
            self-referral to ECI providers. 

           

          The
            HMO
            must coordinate and cooperate with local ECI programs in the development
            and
            implementation of the Individual Family Service Plan (IFSP), including
            on-going
            case management and other non-capitated services required by the Member’s IFSP.
            The IFSP is an agreement developed by the interdisciplinary team that
            consists
            of the ECI Case Manager/Service Coordinator, the Member/family, and other
            professionals who participated in the Member’s evaluation or are providing
            direct services to the Member, and may include the Member’s Primary Care
            Physician (PCP) with parental consent. The IFSP identifies the Member’s present
            level of development based on assessment, describes the services to be
            provided
            to the child to meet the needs of the child and the family, and identifies
            the
            person or persons responsible for each service required by the plan.
            The IFSP
            shall be transmitted by the ECI Provider to the HMO and the PCP with
            parental
            consent to enhance coordination of the plan of care. The IFSP may be
            included in
            the Member’s medical record. 

           

          Cooperation
            with the ECI program includes covering medical diagnostic procedures
            and
            providing medical

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          records
            required to perform developmental assessments and developing the IFSP
            within the
            45-day timeline established in federal rule (34 C.F.R. §303.342(a)). The HMO
            must require compliance with these requirements through Provider contract
            provisions. The HMO must not withhold authorization for the provision
            of such
            medical diagnostic procedures. The HMO must promptly provide to the ECI
            program,
            relevant medical records available to the HMO. 

           

          The
            interdisciplinary team will determine Medical Necessity for health and
            Behavioral Health Services as approved by the Member’s PCP. The HMO must
            require, through contract provisions, that all Medically Necessary health
            and
            Behavioral Health Services contained in the Member’s IFSP are provided to the
            Member in the amount, duration, scope and service setting established
            by the
            IFSP. The HMO must allow services to be provided by a non-network provider
            if a
            Network Provider is not available to provide the services in the amount,
            duration, scope and service setting as required by the IFSP. The HMO
            cannot
            modify the plan of care or alter the amount, duration, scope, or service
            setting
            required by the Member’s IFSP. The HMO cannot create unnecessary barriers for
            the Member to obtain IFSP services, including requiring prior authorization
            for
            the ECI assessment or establishing insufficient authorization periods
            for prior
            authorized services. 

           

          8.1.10
            Special Supplemental Nutrition Program for Women, Infants, and Children
            (WIC) -
            Specific Requirements 

           

          The
            HMO
            must, by contract, require its Providers to coordinate with the Special
            Supplemental Nutrition Program for Women, Infants, and Children (WIC)
            to provide
            medical information necessary for WIC eligibility determinations, such
            as
            height, weight, hematocrit or hemoglobin. The HMO must make referrals
            to WIC for
            Members potentially eligible for WIC. The HMO may use the nutrition education
            provided by WIC to satisfy certain health education requirements of the
            Contract. 

           

          8.1.11
            Coordination with Texas Department of Family and Protective Services
            

           

          The
            HMO
            must cooperate and coordinate with the Texas Department of Family and
            Protective
            Services (TDFPS) (formerly the Department of Protective and Regulatory
            Services)
            for the care of a child who is receiving services from or has been placed
            in the
            conservatorship of TDFPS. 

           

          The
            HMO
            must comply with all provisions related to Covered Services, including
            Behavioral Health Services, in the following documents: 

           

          
            	 	 	
                    •
A
                      court order (Order) entered by a Court of Continuing Jurisdiction
                      placing
                      a child under the protective custody of TDFPS.

                  

          

           

          
            	 	 	
                    •
A
                      TDFPS Service Plan entered by a Court of Continuing Jurisdiction
                      placing a
                      child under the protective custody of TDFPS.

                  

          

           

          
            	 	 	
                    •
A
                      TDFPS Service Plan voluntarily entered into by the parents
                      or person
                      having legal custody of a Member and TDFPS.

                  

          

           

          The
            HMO
            cannot deny, reduce, or controvert the Medical Necessity of any health
            or
            Behavioral Health Services included in an Order. The HMO may participate
            in the
            preparation of the medical and behavioral care plan prior to TDFPS submitting
            the health care plan to the Court. Any modification or termination of
            court-ordered services must be presented and approved by the court having
            jurisdiction over the matter. 

           

          A
            Member
            or the parent or guardian whose rights are subject to an Order or Service
            Plan
            cannot use the HMO’s Complaint or Appeal processes, or the HHSC Fair Hearing
            process to Appeal the necessity of the Covered Services. 

           

          The
            HMO
            must include information in its Provider Manuals and training materials
            regarding: 

           

          
            	 	 	
                    1.
                      Providing medical records to TDFPS;

                  

          

           

          
            	 	 	
                    2.
                      Scheduling medical and Behavioral Health Services appointments
                      within 14
                      days unless requested

                  

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          earlier
            by TDFPS; and 

           

          
            	 	 	
                    3.
                      Recognition of abuse and neglect, and appropriate referral
                      to TDFPS.
                      

                  

          

           

          The
            HMO
            must continue to provide all Covered Services to a Member receiving services
            from, or in the protective custody of, TDFPS until the Member has been
            disenrolled from the HMO due to loss of Medicaid managed care eligibility
            or
            placed into foster care. 

           

          8.1.12
            Services for People with Special Health Care Needs 

           

          This
            section applies to STAR, STAR+PLUS, CHIP HMOs. It applies to CHIP Perinatal
            HMOs
            with respect to their Perinate Newborn Members only. 

           

          8.1.12.1
            Identification 

           

          The
            HMO
            must develop and maintain a system and procedures for identifying Members
            with
            Special Health Care Needs (MSHCN), including people with disabilities
            or chronic
            or complex medical and behavioral health conditions and Children with
            Special
            Health Care Needs (CSHCN)1.
            

           

          The
            HMO
            must contact Members pre-screened by the HHSC Administrative Services
            Contractor
            as MSHCN to determine whether they meet the HMO’s MSHCN assessment criteria, and
            to determine whether the Member requires special services described in
            this
            section. The HMO must provide information to the HHSC Administrative
            Services
            Contractor that identifies Members who the HMO has assessed to be MSHCN,
            including any Members pre-screened by the HHSC Administrative Services
            Contractor and confirmed by the HMO as a MSHCN. The information must
            be
            provided, in a format and on a timeline to be specified by HHSC in the
            Uniform
            Managed Care Manual,
            and
            updated with newly identified MSHCN by the 10th day of each month. In
            the event
            that a MSHCN changes HMOs, the HMO must provide the receiving contractor
            information concerning the results of the HMO’s identification and assessment of
            that Member’s needs, to prevent duplication of those activities. 

           

          8.1.12.2
            Access to Care and Service Management 

           

          Once
            identified, the HMO must have effective systems to ensure the provision
            of
            Covered Services to meet the special preventive, primary Acute Care,
            and
            specialty health care needs appropriate for treatment of the individual
            Member’s
            condition(s). All STAR+PLUS Members are considered to be MSHCN. 

           

          Section
            8.1.12 modified by Versions 1.1 and 1.3 

           

          Section
            8.1.12.2 modified by Version 1.1 

           

          1
            CSHCN is
            a term often used to refer to a services program for children with special
            health care needs administered by DSHS, and described in 25 TAC, Part
            1, Section
            38.1. Although children served through this program may also be served
            by
            Medicaid or CHIP, the reference to “CSHCN” in this Contract does not refer to
            children served through this program. 

           

          The
            HMO
            must provide access to identified PCPs and specialty care Providers with
            experience serving MSHCN. Such Providers must be board-qualified or
            board-eligible in their specialty. The HMO may request exceptions from
            HHSC for
            approval of traditional providers who are not board-qualified or board-eligible
            but who otherwise meet the HMO’s credentialing requirements. 

           

          For
            services to CSHCN, the HMO must have Network PCPs and specialty care
            Providers
            that have demonstrated experience with CSHCN in pediatric specialty centers
            such
            as children’s hospitals, teaching hospitals, and tertiary care centers.

           

          The
            HMO
            is responsible for working with MSHCN, their families and legal guardians
            if
            applicable, and their health care providers to develop a seamless package
            of
            care in which primary, Acute Care, and specialty service needs are met
            through a
            Service Plan that is understandable to the Member, or, when applicable,
            the
            Member’s legal guardian. 

           

          The
            HMO
            is responsible for providing Service Management to develop a Service
            Plan and
            ensure MSHCN, including CSHCN, have access to treatment by a multidisciplinary
            team when the Member’s PCP determines the treatment is Medically Necessary, or
            to avoid separate and fragmented evaluations and service plans. The team
            must
            include both physician and non-physician providers determined to be necessary
            by
            the Member’s PCP for the comprehensive treatment of the Member. The team must:

           

          
            	 	 	
                    1.
                      Participate in hospital discharge planning;

                  

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          
            	 	 	
                    2.
                      Participate in pre-admission hospital planning for non-emergency
                      hospitalizations; 

                  

          

           

          
            	 	 	
                    3.
                      Develop specialty care and support service recommendations
                      to be
                      incorporated into the Service Plan; and

                  

          

           

          
            	 	 	
                    4.
                      Provide information to the Member, or when applicable, the
                      Member’s legal
                      guardian concerning the specialty care recommendations.
                      

                  

          

           

          MSHCN,
            their families, or their health providers may request Service Management
            from
            the HMO. The HMO must make an assessment of whether Service Management
            is needed
            and furnish Service Management when appropriate. The HMO may also recommend
            to a
            MSHCN, or to a CSHCN’s family, that Service Management be furnished if the HMO
            determines that Service Management would benefit the Member. 

           

          The
            HMO
            must provide information and education in its Member Handbook and Provider
            Manual about the care and treatment available in the HMO’s plan for Members with
            Special Health Care Needs, including the availability of Service Management.
            

           

          The
            HMO
            must have a mechanism in place to allow Members with Special Health Care
            Needs
            to have direct access to a specialist as appropriate for the Member’s condition
            and identified needs, such as a standing referral to a specialty physician.
            The
            HMO must also provide MSHCN with access to non-primary care physician
            specialists as PCPs, as required by 28 T.A.C. §11.900 and Section
            8.1.
            

           

          The
            HMO
            must implement a systematic process to coordinate Non-capitated Services,
            and
            enlist the involvement of community organizations that may not be providing
            Covered Services but are otherwise important to the health and wellbeing
            of
            Members. The HMO also must make a best effort to establish relationships
            with
            State and local programs and community organizations, such as those listed
            below, in order to make referrals for MSHCN and other Members who need
            community
            services: 

           

          •
            Community Resource Coordination Groups (CRCGs); 

           

          •
Early
            Childhood Intervention (ECI) Program; 

           

          •
Local
            school districts (Special Education); 

           

          •
Texas
            Department of Transportation’s Medical Transportation Program (MTP);

           

          •
Texas
            Department of Assistive and Rehabilitative Services (DARS) Blind Children’s
            Vocational Discovery and Development Program; 

           

          •
Texas
            Department of State Health (DSHS) services, including community mental
            health
            programs, the Title V Maternal and Child Health and Children with Special
            Health
            Care Needs (CSHCN) Programs, and the Program for Amplification of Children
            of
            Texas (PACT); 

           

          •
Other
            state and local agencies and programs such as food stamps, and the Women,
            Infants, and Children’s (WIC) Program; 

           

          •
Civic
            and religious organizations and consumer and advocacy groups, such as
            United
            Cerebral Palsy, which also work on behalf of the MSHCN population.

           

          8.1.13
            Service Management for Certain Populations 

           

          The
            HMO
            must have service management programs and procedures for the following
            populations, as applicable to the HMO’s Medicaid and/or CHIP Program(s) (See
            CHIP Perinatal Program Covered Services, Attachment
            B-2.2,
            for the
            applicability of these services to the CHIP Perinatal Program): 

           

          1.
            High-cost catastrophic cases; 

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          2.
            Women
            with high-risk pregnancies (STAR and STAR+PLUS Programs only); and 

           

          3.
            Individuals with mental illness and co-occurring substance abuse. 

           

          8.1.14
            Disease Management (DM) 

           

          The
            HMO
            must provide, or arrange to have provided to Members, comprehensive disease
            management services consistent with state statutes and regulations. Such
            DM
            services must be part of person-based approach to DM and holistically
            address
            the needs of persons with multiple chronic conditions. The HMO must develop
            and
            implement DM services that relate to chronic conditions that are prevalent
            in
            HMO Program Members. In the first year of operations, STAR, STAR+PLUS
            and CHIP
            HMOs must have DM Programs that address Members with chronic conditions
            to be
            identified by HHSC and included within the Uniform
            Managed Care Manual.
            HHSC
            will not identify the Members with chronic conditions. The HMO must implement
            policies and procedures to ensure that Members that require DM services
            are
            identified and enrolled in a program to provide such DM services. The
            HMO must
            develop and maintain screening and evaluation procedures for the early
            detection, prevention, treatment, or referral of participants at risk
            for or
            diagnosed with chronic conditions identified by HHSC and included within
            the
Uniform
            Managed Care Manual.
            The HMO
            must ensure that all Members identified for DM are enrolled into a DM
            Program
            with the opportunity to opt out of these services within 30 days while
            still
            maintaining access to all other Covered Services. 

           

          Section
            8.1.13modified by Versions 1.1 and 1.3 

           

          Section
            8.1.14modified by Version 1.1 

           

          The
            DM
            Program(s) must include: 

           

          1.
            Patient self-management education; 

           

          2.
            Provider education; 

           

          3.
            Evidence-based models and minimum standards of care; 

           

          4.
            Standardized protocols and participation criteria; 

           

          5.
            Physician-directed or physician-supervised care; 

           

          6.
            Implementation of interventions that address the continuum of care;

           

          7.
            Mechanisms to modify or change interventions that are not proven effective;
            and

           

          8.
            Mechanisms to monitor the impact of the DM Program over time, including
            both the
            clinical and the financial impact. 

           

          The
            HMO
            must maintain a system to track and monitor all DM participants for clinical,
            utilization, and cost measures. 

           

          The
            HMO
            must provide designated staff to implement and maintain DM Programs and
            to
            assist participating Members in accessing DM services. The HMO must educate
            Members and Providers about the HMO’s DM Programs and activities. Additional
            requirements related to the HMO’s Disease Management Programs and activities are
            found in the HHSC
            Uniform Managed Care Manual.
            

           

          8.1.14.1
            DM Services and Participating Providers 

           

          At
            a
            minimum, the HMO must: 

           

          1.
            Implement a system for Providers to request specific DM interventions;
            

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          2.
            Give
            Providers information, including differences between recommended prevention
            and
            treatment and actual care received by Members enrolled in a DM Program,
            and
            information concerning such Members’ adherence to a service plan; and

           

          3.
            For
            Members enrolled in a DM Program, provide reports on changes in a Member’s
            health status to their PCP. 

           

          8.1.14.2
            HMO DM Evaluation 

           

          HHSC
            or
            its EQRO will evaluate the HMO’s DM Program. 

           

          8.1.15
            Behavioral Health (BH) Network and Services 

           

          The
            requirements in this sub-section pertain to all HMOs except: (1) the
            STAR HMOs
            in the Dallas CSA, whose Members receive Behavioral Health Services through
            the
            NorthSTAR Program, and (2) the CHIP Perinatal Program HMOs with respect
            to their
            Perinate Members. 

           

          The
            HMO
            must provide, or arrange to have provided, to Members all Medically Necessary
            Behavioral Health (BH) Services as described in Attachments
            B-2, B-2.1, and B-2.2.
            All BH
            Services must be provided in conformance with the access standards included
            in
Section
            8.1.3.
            For
            Medicaid HMOs, BH Services are described in more detail in the Texas
            Medicaid Provider Procedures Manual and
            the
Texas
            Medicaid Bulletins.
            When
            assessing Members for BH Services, the HMO and its Network Behavioral
            Health
            Service Providers must use the DSM-IV multi-axial classification. HHSC
            may
            require use of other assessment instrument/outcome measures in addition
            to the
            DSM-IV. Providers must document DSM-IV and assessment/outcome information
            in the
            Member’s medical record. 

           

          Section
            8.1.15 modified by Version 1.3 

           

          8.1.15.1
            BH Provider Network 

           

          The
            HMO
            must maintain a Behavioral Health Services Provider Network that includes
            psychiatrists, psychologists, and other Behavioral Health Service Providers.
            The
            Provider Network must include Behavioral Health Service Providers with
            experience serving special populations among the HMO Program(s)’ enrolled
            population, including, as applicable, children and adolescents, persons
            with
            disabilities, the elderly, and cultural or linguistic minorities, to
            ensure
            accessibility and availability of qualified Providers to all Members
            in the
            Service Area. 

           

          8.1.15.2
            Member Education and Self-referral for Behavioral Health Services

           

          The
            HMO
            must maintain a Member education process to help Members know where and
            how to
            obtain Behavioral Health Services. 

           

          The
            HMO
            must permit Members to self refer to any in-network Behavioral Health
            Services
            Provider without a referral from the Member’s PCP. The HMOs’ policies and
            procedures, including its Provider Manual, must include written policies
            and
            procedures for allowing such self- referral to BH services. 

           

          The
            HMO
            must permit Members to participate in the selection of the appropriate
            behavioral health individual practitioner(s) who will serve them and
            must
            provide the Member with information on accessible in-network Providers
            with
            relevant experience. 

           

          8.1.15.3
            Behavioral Health Services Hotline 

           

          This
            Section includes Hotline functions pertaining to Members. Requirements
            for
            Provider Hotlines are found in Section
            8.1.4.7.
            The HMO
            must have an emergency and crisis Behavioral Health Services Hotline
            staffed by
            trained personnel 24 hours a day, 7 days a week, toll-free throughout
            the
            Service Area. Crisis hotline staff must include or have access to qualified
            Behavioral Health Services professionals to assess behavioral
            health

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          emergencies.
            Emergency and crisis Behavioral Health Services may be arranged through
            mobile
            crisis teams. It is not acceptable for an emergency intake line to be
            answered
            by an answering machine. 

           

          The
            HMO
            must operate a toll-free hotline as described in Section
            8.1.5.6 to
            handle
            Behavioral Health-related calls. The HMO may operate one hotline to handle
            emergency and crisis calls and routine Member calls. The HMO cannot impose
            maximum call duration limits and must allow calls to be of sufficient
            length to
            ensure adequate information is provided to the Member. Hotline services
            must
            meet Cultural Competency requirements and provide linguistic access to
            all
            Members, including the interpretive services required for effective
            communication. 

           

          The
            Behavioral Health Services Hotline may serve multiple HMO Programs Hotline
            staff
            is knowledgeable about all of the HMO Programs. The Behavioral Health
            Services
            Hotline may serve multiple Service Areas if the Hotline staff is knowledgeable
            about all such Service Areas, including the Behavioral Health Provider
            Network
            in each Service Area. The HMO must ensure that the toll-free Behavioral
            Health
            Services Hotline meets the following minimum performance requirements
            for all
            HMO Programs and Service Areas: 

           

          1.
            99% of
            calls are answered by the fourth ring or an automated call pick-up system;
            

           

          
            	 	 	
                    2.
                      No incoming calls receive a busy signal;

                  

          

           

          
            	 	 	
                    3.
                      At least 80% of calls must be answered by toll-free line staff
                      within 30
                      seconds measured from the time the call is placed in queue
                      after selecting
                      an option; and 

                  

          

           

          
            	 	 	
                    4.
                      The call abandonment rate is 7% or less.

                  

          

           

          The
            HMO
            must conduct on-going quality assurance to ensure these standards are
            met.

           

          The
            HMO
            must monitor the HMO’s performance against the Behavioral Health Services
            Hotline standards and submit performance reports summarizing call center
            performance as indicated in Section
            8.1.20
            and the
Uniform
            Managed Care Manual. 

           

          8.1.15.4
            Coordination between the BH Provider and the PCP 

           

          The
            HMO
            must require, through contract provisions, that PCPs have screening and
            evaluation procedures for the detection and treatment of, or referral
            for, any
            known or suspected behavioral health problems and disorders. PCPs may
            provide
            any clinically appropriate Behavioral Health Services within the scope
            of their
            practice. 

           

          The
            HMO
            must provide training to network PCPs on how to screen for and identify
            behavioral health disorders, the HMO’s referral process for Behavioral Health
            Services and clinical coordination requirements for such services. The
            HMO must
            include training on coordination and quality of care such as behavioral
            health
            screening techniques for PCPs and new models of behavioral health interventions.
            

           

          The
            HMO
            shall develop and disseminate policies regarding clinical coordination
            between
            Behavioral Health Service Providers and PCPs. The HMO must require that
            Behavioral Health Service Providers refer Members with known or suspected
            and
            untreated physical health problems or disorders to their PCP for examination
            and
            treatment, with the Member’s or the Member’s legal guardian’s consent.
            Behavioral Health Providers may only provide physical health care services
            if
            they are licensed to do so. This requirement must be specified in all
            Provider
            Manuals. 

           

          The
            HMO
            must require that behavioral health Providers send initial and quarterly
            (or
            more frequently if clinically indicated) summary reports of a Members’
behavioral health status to the PCP, with the Member’s or the Member’s legal
            guardian’s consent. This requirement must be specified in all Provider Manuals.
            

           

          8.1.15.5
            Follow-up after Hospitalization for Behavioral Health Services

           

          The
            HMO
            must require, through Provider contract provisions, that all Members
            receiving
            inpatient psychiatric services are scheduled for outpatient follow-up
            and/or
            continuing treatment prior to discharge. The outpatient

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          treatment
            must occur within seven (7) days from the date of discharge. The HMO
            must ensure
            that Behavioral Health Service Providers contact Members who have missed
            appointments within 24 hours to reschedule appointments. 

           

          Section
            8.1.15.3 modified by Version 1.2 

           

          8.1.15.6
            Chemical Dependency 

           

          The
            HMO
            must comply with 28 T.A.C. §3.8001 et
            seq.,
            regarding utilization review for Chemical Dependency Treatment. Chemical
            Dependency Treatment must conform to the standards set forth in 28 T.A.C.
            Part
            1, Chapter 3, Subchapter HH. 

           

          8.1.15.7
            Court-Ordered Services 

           

          “Court-Ordered
            Commitment” means
            a
            commitment of a Member to a psychiatric facility for treatment that is
            ordered
            by a court of law pursuant to the Texas Health and Safety Code, Title
            VII,
            Subtitle C. 

           

          The
            HMO
            must provide inpatient psychiatric services to Members under the age
            of 21, up
            to the annual limit, who have been ordered to receive the services by
            a court of
            competent jurisdiction under the provisions of Chapters 573 and 574 of
            the Texas
            Health and Safety Code, relating to Court-Ordered Commitments to psychiatric
            facilities. The HMO is not obligated to cover placements as a condition
            of
            probation, authorized by the Texas Family Code. 

           

          The
            HMO
            cannot deny, reduce or controvert the Medical Necessity of inpatient
            psychiatric
            services provided pursuant to a Court-ordered Commitment for Members
            under age
            21. Any modification or termination of services must be presented to
            the court
            with jurisdiction over the matter for determination. 

           

          A
            Member
            who has been ordered to receive treatment under the provisions of Chapter
            573 or
            574 of the Texas Health and Safety Code can only Appeal the commitment
            through
            the court system. 

           

          8.1.15.8
            Local Mental Health Authority (LMHA) 

           

          The
            HMO
            must coordinate with the Local Mental Health Authority (LMHA) and state
            psychiatric facility regarding admission and discharge planning, treatment
            objectives and projected length of stay for Members committed by a court
            of law
            to the state psychiatric facility. 

           

          Medicaid
            HMOs are required to comply with additional Behavioral Health Services
            requirements relating to coordination with the LMHA and care for special
            populations. These Medicaid HMO requirements are described in Section
            8.2.8.
            

           

          8.1.16
            Financial Requirements for Covered Services 

           

          The
            HMO
            must pay for or reimburse Providers for all Medically Necessary Covered
            Services
            provided to all Members. The HMO is not liable for cost incurred in connection
            with health care rendered prior to the date of the Member’s Effective Date of
            Coverage in that HMO. A Member may receive collateral health benefits
            under a
            different type of insurance such as workers compensation or personal
            injury
            protection under an automobile policy. If a Member is entitled to coverage
            for
            specific services payable under another insurance plan and the HMO paid
            for such
            Covered Services, the HMO may obtain reimbursement from the responsible
            insurance entity not to exceed 100% of the value of Covered Services
            paid.

           

          8.1.17
            Accounting and Financial Reporting Requirements 

           

          The
            HMO’s
            accounting records and supporting information related to all aspects
            of the
            Contract must be accumulated in accordance with Generally Accepted Accounting
            Principles (GAAP) and the cost principles contained in the Cost Principles
            Document in the
            Uniform
            Managed Care Manual.
            The
            State will not recognize or pay services that cannot be properly substantiated
            by the HMO and verified by HHSC. 

           

          The
            HMO
            must: 

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

           

          1.
            Maintain accounting records for each applicable HMO Program separate
            and apart
            from other corporate accounting records; 

           

          
            	 	 	
                    2.
                      Maintain records for all claims payments, refunds and adjustment
                      payments
                      to providers, capitation payments, interest income and payments
                      for
                      administrative services or functions and must maintain separate
                      records
                      for medical and administrative fees, charges, and payments;
                      

                  

          

           

          
            	 	 	
                    3.
                      Maintain an accounting system that provides an audit trail
                      containing
                      sufficient financial documentation to allow for the reconciliation
                      of
                      billings, reports, and financial statements with all general
                      ledger
                      accounts; and 

                  

          

           

          
            	 	 	
                    4.
                      Within 60 days after Contract execution, submit an accounting
                      policy
                      manual that includes all proposed policies and procedures the
                      HMO will
                      follow during the duration of the Contract. Substantive modifications
                      to
                      the accounting policy manual must be approved by HHSC.
                      

                  

          

           

          The
            HMO
            agrees to pay for all reasonable costs incurred by HHSC to perform an
            examination, review or audit of the HMO’s books pertaining to the Contract.

           

          8.1.17.1
            General Access to Accounting Records 

           

          The
            HMO
            must provide authorized representatives of the Texas and federal government
            full
            access to all financial and accounting records related to the performance
            of the
            Contract. 

           

          The
            HMO
            must: 

           

          
            	 	 	
                    1.
                      Cooperate with the State and federal governments in their evaluation,
                      inspection, audit, and/or review of accounting records and
                      any necessary
                      supporting information; 

                  

          

           

          
            	 	 	
                    2.
                      Permit authorized representatives of the State and federal
                      governments
                      full access, during normal business hours, to the accounting
                      records that
                      the State and the Federal government determine are relevant
                      to the
                      Contract. Such access is guaranteed at all times during the
                      performance
                      and retention period of the Contract, and will include both
                      announced and
                      unannounced inspections, on-site audits, and the review, analysis,
                      and
                      reproduction of reports produced by the HMO;

                  

          

           

          
            	 	 	
                    3.
                      Make copies of any accounting records or supporting documentation
                      relevant
                      to the Contract available to HHSC or its agents within ten
                      (10) business
                      days of receiving a written request from HHSC for specified
                      records or
                      information. If such documentation is not made available as
                      requested, the
                      HMO agrees to reimburse HHSC for all costs, including, but
                      not limited to,
                      transportation, lodging, and subsistence for all State and
                      federal
                      representatives, or their agents, to carry out their inspection,
                      audit,
                      review, analysis, and reproduction functions at the location(s)
                      of such
                      accounting records; and 

                  

          

           

          
            	 	 	
                    4.
                      Pay any and all additional costs incurred by the State and
                      federal
                      government that are the result of the HMO’s failure to provide the
                      requested accounting records or financial information within
                      ten (10)
                      business days of receiving a written request from the State
                      or federal
                      government. 

                  

          

           

          8.1.17.2
            Financial Reporting Requirements 

           

          HHSC
            will
            require the HMO to provide financial reports by HMO Program and by Service
            Area
            to support Contract monitoring as well as State and Federal reporting
            requirements. HHSC will consult with HMOs regarding the format and frequency
            of
            such reporting. All financial information and reports that are not
            Member-specific are property of HHSC and will be public record. Any deliverable
            or report in Section 8.1.17.2 without a specified due date is due quarterly
            on
            the last day of the month. Where
            the
            due date states 30 days, the HMO is to provide the deliverable by the
            last day
            of the month following the end of the reporting period. Where the due
            date
            states 45 days, the HMO is to provide the deliverable by the 15th day
            of the
            second month following the end of the reporting period. 

           

          CHIP
            Perinatal Program data must be reported, and the data will be integrated
            into
            existing CHIP Program

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          financial
            reports. Except for the Financial Statistical Report, no separate CHIP
            Perinatal
            Program reports are required. For all other CHIP financial reports, where
            appropriate, HHSC will designate specific attributes within the CHIP
            Program
            financial reports that the CHIP Perinatal HMOs must complete to allow
            HHSC to
            extract financial data particular to the CHIP Perinatal Program. 

           

          HHSC’s
            Uniform
            Managed Care Manual
            will
            govern the timing, format and content for the following reports. 

           

          Audited
            Financial Statement -The
            HMO
            must provide the annual audited financial statement, for each year covered
            under
            the Contract, no later than June 30. The HMO must provide the most recent
            annual
            financial statements, as required by the Texas Department of Insurance
            for each
            year covered under the Contract, no later than March 1. 

           

          Affiliate
            Report - The
            HMO
            must submit an Affiliate Report to HHSC if this information has changed
            since
            the last report submission. The report must contain the
            following:  

           

          
            	 	 	
                    1.
                      A list of all Affiliates, and 

                  

          

           

          
            	 	 	
                    2.
                      For HHSC’s prior review and approval, a schedule of all transactions
                      with
                      Affiliates that, under the provisions of the Contract, will
                      be allowable
                      as expenses in the FSR Report for services provided to the
                      HMO by the
                      Affiliate. Those should include financial terms, a detailed
                      description of
                      the services to be provided, and an estimated amount that will
                      be incurred
                      by the HMO for such services during the Contract Period.
                      

                  

          

           

          Section
            8.1.17.2 modified by Versions 1.2 and 1.3

           

          Employee
            Bonus and/or Incentive Payment Plan -
            If a HMO
            intends to include Employee Bonus or Incentive Payments as allowable
            administrative expenses, the HMO must furnish a written Employee Bonus
            and/or
            Incentive Payments Plan to HHSC so it may determine whether such payments
            are
            allowable administrative expenses in accordance with Cost Principles
            Document in
            the Uniform
            Managed Care Manual.
            The
            written plan must include a description of the HMO’s criteria for establishing
            bonus and/or incentive payments, the methodology to calculate bonus and/or
            incentive payments, and the timing of bonus and/or incentive payments.
            The Bonus
            and/or Incentive Payment Plan and description must be submitted to HHSC
            for
            approval no later than 30 days after the Effective Date of the Contract
            and any
            Contract renewal. If the HMO substantively revises the Employee Bonus
            and/or
            Incentive Payment Plan, the HMO must submit the revised plan to HHSC
            for prior
            review and approval. 

           

          Claims
            Lag Report - The
            HMO
            must submit Claims Lag Report as a Contract year-to-date report. The
            report must
            be submitted quarterly by the last day of the month following the reporting
            period. The report must be submitted to HHSC in a format specified by
            HHSC. The
            report format is contained in the Uniform
            Managed Care Manual Chapter
            5, Section 5.6.2. The report must disclose the amount of incurred claims
            each
            month and the amount paid each month by categories of service, such as
            inpatient
            facility, out-patient facility, professional and other services, if applicable.
            The report must include total claims incurred and paid by month. 

           

          DSP
            Report - The
            HMO
            must submit a monthly Delivery Supplemental Payment (DSP) Report that
            includes
            the data elements specified by HHSC in the format specified by HHSC.
            HHSC will
            consult with contracted HMOs prior to revising the DSP Report data elements
            and
            requirements. The DSP Report must include only unduplicated deliveries
            and only
            deliveries for which the HMO has made a payment, to either a hospital
            or other
            provider.  

           

          Form
            CMS-1513 - The
            HMO
            must file an original Form CMS-1513 prior to beginning operations regarding
            the
            HMO’s control, ownership, or affiliations. An updated Form CMS-1513 must
            also be
            filed no later than 30 days after any change in control, ownership, or
            affiliations.  

           

          FSR
            Reports - The
            HMO
            must file quarterly and annual Financial-Statistical Reports (FSR) in
            the format
            and timeframe specified by HHSC. HHSC will include FSR format and directions
            in
            the Uniform
            Managed Care Manual.
            The HMO
            must incorporate financial and statistical data of delegated networks
            (e.g.,
            IPAs, ANHCs,

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

           

          Limited
            Provider Networks), if any, in its FSR Reports. Administrative expenses
            reported
            in the FSRs must be reported in accordance with the Cost Principles Document
            in
            the Uniform
            Managed Care Manual.
            Quarterly FSR reports are due no later than 30 days after the end of
            the quarter
            and must provide information for the current quarter and year-to-date
            information through the current quarter. The first annual FSR report
            must
            reflect expenses incurred through the 90th day after the end of the fiscal
            year.
            The first annual report must be filed on or before the 120th day after
            the end
            of each fiscal year and accompanied by an actuarial opinion by a qualified
            actuary who is in good standing with the American Academy of Actuaries.
            Subsequent annual reports must reflect data completed through the 334th
            day
            after the end of each fiscal year and must be filed on or before the
            365th day
            following the end of each fiscal year. 

           

          CHIP
            Perinatal HMOs are required to submit separate FSRs for the CHIP Perinatal
            Program following the instructions outlined above and in the Uniform
            Managed Care Manual. 

           

          Out-of-Network
            Utilization Reports -
            The HMO
            must file quarterly Out-of
            Network Utilization Reports in the format and timeframe specified by
            HHSC. HHSC
            will include the report format and directions in the Uniform
            Managed Care Manual.
            Quarterly reports are due 30 days after the end of each quarter. 

           

          HUB
            Reports - Upon
            contract award, the HMO must attend a post award meeting in Austin, Texas,
            at a
            time specified by HHSC, to discuss the development and submission of
            a Client
            Services HUB Subcontracting Plan for inclusion and the HMO’s good faith efforts
            to notify HUBs of subcontracting opportunities. The HMO must maintain
            its HUB
            Subcontracting Plan and submit monthly reports documenting the HMO’s
            Historically Underutilized Business (HUB) program efforts and accomplishments
            to
            the HHSC HUB Office. The report must include a narrative description
            of the
            HMO’s program efforts and a financial report reflecting payments made to
            HUBs.
            HMOs must use the formats included in HHSC’s Uniform
            Managed Care Manual for
            the
            HUB monthly reports. The
            HMO
            must comply with HHSC’s standard Client Services HUB Subcontracting Plan
            requirements for all subcontractors. 

           

          IBNR
            Plan - The
            HMO
            must furnish a written IBNR Plan to manage incurred-but-not-reported
            (IBNR)
            expenses, and a description of the method of insuring against insolvency,
            including information on all existing or proposed insurance policies.
            The Plan
            must include the methodology for estimating IBNR. The plan and description
            must
            be submitted to HHSC no later than 60 days after the Effective Date of
            the
            Contract. Substantive changes to a HMO’s IBNR plan and description must be
            submitted to HHSC no later than 30 days before the HMO implements changes
            to the
            IBNR plan. 

           

          Medicaid
            Disproportionate Share Hospital (DSH) Reports -
            Medicaid HMOs must file preliminary and final Medicaid DSH reports, required
            by
            HHSC to identify and reimburse hospitals that qualify for Medicaid DSH
            funds.
            The preliminary and final DSH reports must include the data elements
            and be
            submitted in the form and format specified by HHSC in the Uniform
            Managed Care Manual.
            The
            preliminary DSH reports are due on or before June 1 of the year following
            the
            state fiscal reporting year. The final DSH reports are due no later than
            July 15
            of the year following the state fiscal reporting year. This reporting
            requirement does not apply to CHIP or CHIP Perinatal Program HMOs. For
            STAR+PLUS, HMOs will include only outpatient services in the DSH report.
            

           

          TDI
            Examination Report - The
            HMO
            must furnish a copy of any TDI Examination Report, including the financial,
            market conduct, target exam, quality of care components, and corrective
            action
            plans and responses, no later than 10 days after receipt of the final
            report
            from TDI.  

           

          TDI
            Filings - The
            HMO
            must submit annual figures for controlled risk-based capital, as well
            as its
            quarterly financial statements, both as required by TDI. 

           

          Registration
            Statement (also known as the “Form B”) - If
            the
            HMO is a part of an insurance holding company system, the HMO must submit
            to
            HHSC a complete registration statement, also known as Form B, and all
            amendments
            to this form, and any other information filed by such insurer with the
            insurance
            regulatory authority of its domiciliary jurisdiction. 

           

          Section
            1318 Financial Disclosure Report - The
            HMO
            must file an original CMS Public Health Service (PHS) Section 1318 Financial
            Disclosure Report prior to the start of Operations and an updated CMS
            PHS
            Section

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          1318
            Financial Disclosure Report no later than 30 days after the end of each
            Contract
            Year and no later than 30 days after entering into, renewing, or terminating
            a
            relationship with an affiliated party. 

           

          Third
            Party Recovery (TPR) Reports - The
            HMO
            must file TPR Reports in accordance with the format developed by HHSC
            in the
Uniform
            Managed Care Manual.
            HHSC
            will require the HMO to submit TPR reports no more often than quarterly.
            TPR
            reports must include total dollars recovered from third party payers
            for each
            HMO Program for services to the HMO’s Members, and the total dollars recovered
            through coordination of benefits, subrogation, and worker’s compensation. For
            CHIP HMOs, the TPR Reports only apply if the HMO chooses to engage in
            TPR
            activities. 

           

          8.1.18
            Management Information System Requirements 

           

          The
            HMO
            must maintain a Management Information System (MIS) that supports all
            functions
            of the HMO’s processes and procedures for the flow and use of HMO data. The HMO
            must have hardware, software, and a network and communications system
            with the
            capability and capacity to handle and operate all MIS subsystems for
            the
            following operational and administrative areas: 

           

          
            	 	 	
                    1.
                      Enrollment/Eligibility Subsystem; 

                  

          

           

          
            	 	 	
                    2.
                      Provider Subsystem; 

                  

          

           

          
            	 	 	
                    3.
                      Encounter/Claims Processing Subsystem;

                  

          

           

          
            	 	 	
                    4.
                      Financial Subsystem; 

                  

          

           

          
            	 	 	
                    5.
                      Utilization/Quality Improvement Subsystem;

                  

          

           

          
            	 	 	
                    6.
                      Reporting Subsystem; 

                  

          

           

          
            	 	 	
                    7.
                      Interface Subsystem; and 

                  

          

           

          
            	 	 	
                    8.
                      TPR Subsystem, as applicable to each HMO Program.
                      

                  

          

           

          The
            MIS
            must enable the HMO to meet the Contract requirements, including all
            applicable
            state and federal laws, rules, and regulations. The MIS must have the
            capacity
            and capability to capture and utilize various data elements required
            for HMO
            administration. 

           

          HHSC
            will
            provide the HMO with pharmacy data on the HMO’s Members on a weekly basis
            through the HHSC Vendor Drug Program, or should these services be outsourced,
            through the Pharmacy Benefit Manager. HHSC will provide a sample format
            of
            pharmacy data to contract awardees. 

           

          The
            HMO
            must have a system that can be adapted to changes in Business Practices/Policies
            within the timeframes negotiated by the Parties. The HMO is expected
            to cover
            the cost of such systems modifications over the life of the Contract.
            

           

          The
            HMO
            is required to participate in the HHSC Systems Work Group. 

           

          The
            HMO
            must provide HHSC prior written notice of major systems changes, generally
            within 90 days, and implementations, including any changes relating to
            Material
            Subcontractors, in accordance with the requirements of this Contract
            and the
Uniform
            Managed Care Terms and Conditions. 

           

          The
            HMO
            must provide HHSC any updates to the HMO’s organizational chart relating to MIS
            and the description of MIS responsibilities at least 30 days prior to
            the
            effective date of the change. The HMO must provide HHSC official points
            of
            contact for MIS issues on an on-going basis. 

           

          HHSC,
            or
            its agent, may conduct a Systems Readiness Review to validate the HMO’s ability
            to meet the MIS requirements as described in Attachment
            B-1, Section
            7.
            The
            System Readiness Review may include a desk review and/or an onsite review
            and
            must be conducted for the following events: 

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          1.
            A new
            plan is brought into the HMO Program; 

           

          
            	 	 	
                    2.
                      An existing plan begins business in a new Service Area;
                      

                  

          

           

          
            	 	 	
                    3.
                      An existing plan changes location; 

                  

          

           

          
            	 	 	
                    4.
                      An existing plan changes its processing system, including changes
                      in
                      Material Subcontractors performing MIS or claims processing
                      functions; and
                      

                  

          

           

          
            	 	 	
                    5.
                      An existing plan in one or two HHSC HMO Programs is initiating
                      a Contract
                      to participate in any additional HMO Programs.

                  

          

           

          If
            for
            any reason, a HMO does not fully meet the MIS requirements, then the
            HMO must,
            upon request by HHSC, either correct such deficiency or submit to HHSC
            a
            Corrective Action Plan and Risk Mitigation Plan to address such deficiency
            as
            requested by HHSC. Immediately upon identifying a deficiency, HHSC may
            impose
            remedies and either actual or liquidated damages according to the severity
            of
            the deficiency. HHSC may also freeze enrollment into the HMO’s plan for any of
            its HMO Programs until such deficiency is corrected. Refer to the Uniform
            Managed Care Terms and Conditions and
            Attachment
            B-5
            for
            additional information. 

           

          8.1.18.1
            Encounter Data 

           

          The
            HMO
            must provide complete Encounter Data for all Covered Services, including
            Value-added Services. Encounter Data must follow the format, and data
            elements
            as described in the HIPAA-compliant 837 format. HHSC will specify the
            method of
            transmission, and the submission schedule, in the Uniform
            Managed Care Manual.
            The HMO
            must submit monthly Encounter Data transmissions, and include all Encounter
            Data
            and Encounter Data adjustments processed by the HMO. Encounter Data quality
            validation must incorporate assessment standards developed jointly by
            the HMO
            and HHSC. The HMO must make original records available for inspection
            by HHSC
            for validation purposes. Encounter Data that do not meet quality standards
            must
            be corrected and returned within a time period specified by HHSC. 

           

          In
            addition to providing Encounter Data in the 837 format described above,
            HMOs
            must submit an Encounter Data file to HHSC's EQRO, in the format provided
            in the
Uniform
            Managed Care Manual.
            This
            additional submission requirement is time-limited and may not be required
            for
            the entire term of the Contract. 

           

          For
            reporting Encounters and fee-for-service claims to HHSC, the HMO must
            use the
            procedure codes, diagnosis codes, and other codes as directed by HHSC.
            Any
            exceptions will be considered on a code-by-code basis after HHSC receives
            written notice from the HMO requesting an exception. The HMO must also
            use the
            provider numbers as directed by HHSC for both Encounter and fee-for-service
            claims submissions, as applicable. 

           

          8.1.18.2
            HMO Deliverables related to MIS Requirements 

           

          At
            the
            beginning of each state fiscal year, the HMO must submit for HHSC’s review and
            approval any modifications to the following documents: 

           

          
            	 	 	
                    1.
                      Joint Interface Plan; 

                  

          

           

          
            	 	 	
                    2.
                      Disaster Recovery Plan; 

                  

          

           

          
            	 	 	
                    3.
                      Business Continuity Plan; 

                  

          

           

          
            	 	 	
                    4.
                      Risk Management Plan; and 

                  

          

           

          
            	 	 	
                    5.
                      Systems Quality Assurance Plan. 

                  

          

           

          The
            HMO
            must submit such modifications to HHSC according to the format and schedule
            identified the HHSC Uniform
            Managed Care Manual.
            

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          8.1.18.3
            System-wide Functions 

           

          The
            HMO’s
            MIS system must include key business processing functions and/or features,
            which
            must apply across all subsystems as follows: 

           

          
            	 	 	
                    1.
                      Process electronic data transmission or media to add, delete
                      or modify
                      membership records with accurate begin and end dates;
                      

                  

          

           

          
            	 	 	
                    2.
                      Track Covered Services received by Members through the system,
                      and
                      accurately and fully maintain those Covered Services as HIPAA-compliant
                      Encounter transactions; 

                  

          

           

          
            	 	 	
                    3.
                      Transmit or transfer Encounter Data transactions on electronic
                      media in
                      the HIPAA format to the contractor designated by HHSC to receive
                      the
                      Encounter Data; 

                  

          

           

          
            	 	 	
                    4.
                      Maintain a history of changes and adjustments and audit trails
                      for current
                      and retroactive data; 

                  

          

           

          
            	 	 	
                    5.
                      Maintain procedures and processes for accumulating, archiving,
                      and
                      restoring data in the event of a system or subsystem failure;
                      

                  

          

           

          
            	 	 	
                    6.
                      Employ industry standard medical billing taxonomies (procedure
                      codes,
                      diagnosis codes) to describe services delivered and Encounter
                      transactions
                      produced; 

                  

          

           

          
            	 	 	
                    7.
                      Accommodate the coordination of benefits;

                  

          

           

          
            	 	 	
                    8.
                      Produce standard Explanation of Benefits (EOBs);
                      

                  

          

           

          
            	 	 	
                    9.
                      Pay financial transactions to Providers in compliance with
                      federal and
                      state laws, rules and regulations; 

                  

          

           

          
            	 	 	
                    10.
                      Ensure that all financial transactions are auditable according
                      to GAAP
                      guidelines. 

                  

          

           

          
            	 	 	
                    11.
                      Relate and extract data elements to produce report formats
                      (provided
                      within the Uniform
                      Managed Care Manual) or
                      otherwise required by HHSC; 

                  

          

           

          
            	 	 	
                    12.
                      Ensure that written process and procedures manuals document
                      and describe
                      all manual and automated system procedures and processes for
                      the MIS;
                      

                  

          

           

          
            	 	 	
                    13.
                      Maintain and cross-reference all Member-related information
                      with the most
                      current Medicaid, CHIP or CHIP Perinatal Program Provider number;
                      and
                      

                  

          

           

          
            	 	 	
                    14.
                      Ensure that the MIS is able to integrate pharmacy data from
                      HHSC’s Drug
                      Vendor file (available through the Virtual Private Network
                      (VPN)) into the
                      HMO’s Member data. 

                  

          

           

          Section
            8.1.18.3 modified by Version 1.3 

           

          8.1.18.4
            Health Insurance Portability and Accountability Act (HIPAA) Compliance
            

           

          The
            HMO’s
            MIS system must comply with applicable certificate of coverage and data
            specification and reporting requirements promulgated pursuant to the
            Health
            Insurance Portability and Accountability Act (HIPAA) of 1996, P.L. 104-191
            (August 21, 1996), as amended or modified. The HMO must comply with HIPAA
            EDI
            requirements. HMO’s enrollment files must be in the 834 HIPAA-compliant format.
            Eligibility inquiries must be in the 270/271 format and all claims and
            remittance transactions in the 837/835 format. 

           

          The
            HMO
            must provide its Members with a privacy notice as required by HIPAA.
            The HMO
            must provide HHSC with a copy of its privacy notice for filing. 

           

          8.1.18.5
            Claims Processing Requirements 

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          The
            HMO
            must process and adjudicate
            all provider claims for Medically Necessary Covered Services that are
            filed
            within the time frames specified in the Uniform
            Managed Care Manual.
            The HMO
            is subject to remedies, including liquidated damages and interest, if
            the HMO
            does not process and adjudicate claims within the timeframes listed in
            the
Uniform
            Managed Care Manual. 

           

          The
            HMO
            must administer an effective, accurate, and efficient claims payment
            process in
            compliance with federal laws and regulations, applicable state laws and
            rules,
            the Contract, and the Uniform
            Managed Care Manual.
            In
            addition, a Medicaid HMO must be able to accept and process provider
            claims in
            compliance with the Medicaid Provider Procedures Manual and The Texas
            Medicaid
            Bulletin. 

           

          The
            HMO
            must maintain an automated claims processing system that registers the
            date a
            claim is received by the MCO, the detail of each claim transaction (or
            action)
            at the time the transaction occurs, and has the capability to report
            each claim
            transaction by date and type to include interest payments. The claims
            system
            must maintain information at the claim and line detail level. The claims
            system
            must maintain adequate audit trails and report accurate claims performance
            measures to HHSC. 

           

          The
            HMO’s
            claims system must maintain online and archived files. The HMO must keep
            online
            automated claims payment history for the most current 18 months. The
            HMO must
            retain other financial information and records, including all original
            claims
            forms, for the time period established in Attachment
            A, Section 9.01.
             All
            claims data must be easily sorted and produced in formats as requested
            by HHSC.

           

          The
            HMO
            must offer its Providers/Subcontractors the option of submitting and
            receiving
            claims information through electronic data interchange (EDI) that allows
            for
            automated processing and adjudication of claims. EDI processing must
            be offered
            as an alternative to the filing of paper claims. Electronic claims must
            use
            HIPAA-compliant electronic formats. 

           

          The
            HMO
            may deny a claim submitted by a provider for failure to file in a timely
            manner
            as provided for in the Uniform
            Managed Care Manual.
            The HMO
            must not pay any claim submitted by a provider excluded or suspended
            from the
            Medicare, Medicaid, CHIP or CHIP Perinatal programs for Fraud, Abuse,
            or Waste.
            The HMO must not pay any claim submitted by a Provider that is on payment
            hold
            under the authority of HHSC or its authorized agent(s), or who has pending
            accounts receivable with HHSC. 

           

          Section
            8.1.18.5 modified by Versions 1.2 and 1.3 

           

          The
            HMO
            is subject to the requirements related to coordination of benefits for
            secondary
            payors in the Texas Insurance Code Section 843.349 (e) and (f). 

           

          The
            HMO
            must notify HHSC of major claim system changes in writing no later than
            90 days
            prior to implementation. The HMO must provide an implementation plan
            and
            schedule of proposed changes. HHSC reserves the right to require a desk
            or
            on-site readiness review of the changes. 

           

          The
            HMO
            must inform all Network Providers about the information required to submit
            a
            claim at least 30 days prior to the Operational Start Date and as a provision
            within the HMO/Provider contract. The HMO must make available to Providers
            claims coding and processing guidelines for the applicable provider type.
            Providers must receive 90 days notice prior to the HMO’s implementation of
            changes to claims guidelines.  

           

          8.1.19
            Fraud and Abuse 

           

          A
            HMO is
            subject to all state and federal laws and regulations relating to Fraud,
            Abuse,
            and Waste in health care and the Medicaid and CHIP programs. The HMO
            must
            cooperate and assist HHSC and any state or federal agency charged with
            the duty
            of identifying, investigating, sanctioning or prosecuting suspected Fraud,
            Abuse
            or Waste. The HMO must provide originals and/or copies of all records
            and
            information requested and allow access to premises and provide records
            to the
            Inspector General for the Texas Health and Human Services System, HHSC
            or its
            authorized agent(s), the Centers for Medicare and Medicaid Services (CMS),
            the
            U.S. Department of Health and Human Services (DHHS), Federal Bureau of
            Investigation, TDI, or other units of

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          state
            government. The HMO must provide all copies of records free of charge.
            

           

          The
            HMO
            must submit a written Fraud and Abuse compliance plan to the Office of
            Inspector
            General at HHSC for approval (See Attachment
            B-1, Section
            7
            for
            requirements regarding timeframes for submitting the original plan.)
            The plan
            must ensure that all officers, directors, managers and employees know
            and
            understand the provisions of the HMO’s Fraud and Abuse compliance plan. The plan
            must include the name, address, telephone number, electronic mail address,
            and
            fax number of the individual(s) responsible for carrying out the plan.
            

           

          The
            written Fraud and Abuse compliance plan must: 

           

          
            	 	 	
                    1.
                      Contain procedures designed to prevent and detect potential
                      or suspected
                      Abuse, Fraud and Waste in the administration and delivery of
                      services
                      under the Contract; 

                  

          

           

          
            	 	 	
                    2.
                      Contain a description of the HMO’s procedures for educating and training
                      personnel to prevent Fraud, Abuse, or Waste;

                  

          

           

          
            	 	 	
                    3.
                      Include provisions for the confidential reporting of plan violations
                      to
                      the designated person within the HMO’s organization and ensure that the
                      identity of an individual reporting violations is protected
                      from
                      retaliation; 

                  

          

           

          
            	 	 	
                    4.
                      Include provisions for maintaining the confidentiality of any
                      patient
                      information relevant to an investigation of Fraud, Abuse, or
                      Waste;
                      

                  

          

           

          
            	 	 	
                    5.
                      Provide for the investigation and follow-up of any allegations
                      of Fraud,
                      Abuse, or Waste and contain specific and detailed internal
                      procedures for
                      officers, directors, managers and employees for detecting,
                      reporting, and
                      investigating Fraud and Abuse compliance plan violations;
                      

                  

          

           

          
            	 	 	
                    6.
                      Require that confirmed violations be reported to the Office
                      of Inspector
                      General (OIG); and 

                  

          

           

          
            	 	 	
                    7.
                      Require any confirmed violations or confirmed or suspected
                      Fraud, Abuse,
                      or Waste under state or federal law be reported to OIG.
                      

                  

          

           

          Section
            8.1.19 modified by Version 1.3 

           

          If
            the
            HMO contracts for the investigation of allegations of Fraud, Abuse, or
            Waste and
            other types of program abuse by Members or Providers, the plan must include
            a
            copy of the subcontract; the names, addresses, telephone numbers, electronic
            mail addresses, and fax numbers of the principals of the subcontracted
            entity;
            and a description of the qualifications of the subcontracted entity.
            Such
            subcontractors must be held to the requirements stated in this Section.
            

           

          The
            HMO
            must designate executive and essential personnel to attend mandatory
            training in
            Fraud and Abuse detection, prevention and reporting. Designated executive
            and
            essential personnel means the HMO staff persons who supervise staff in
            the
            following areas: data collection, provider enrollment or disenrollment,
            encounter data, claims processing, utilization review, appeals or grievances,
            quality assurance and marketing, and who are directly involved in the
            decision-making and administration of the Fraud and Abuse detection program
            within the HMO. The training will be conducted by the OIG free of charge.
            The
            HMO must schedule and complete training no later than 90 days after the
            Effective Date of the Contract. If the HMO updates or modifies its written
            Fraud
            and Abuse compliance plan, the HMO must train its executive and essential
            personnel on these updates or modifications no later than 90 days after
            the
            effective date of the updates or modifications. 

           

          The
            HMO
            must designate an officer or director in its organization with responsibility
            and authority to carry out the provisions of the Fraud and Abuse compliance
            plan. A HMO’s failure to report potential or suspected Fraud or Abuse may result
            in sanctions, cancellation of the Contract, and/or exclusion from participation
            in the Medicaid, CHIP or CHIP Perinatal HMO Programs. The HMO must allow
            the
            OIG, HHSC, its agents, or other governmental units to conduct private
            interviews
            of the HMO’s personnel, subcontractors and their personnel,

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          witnesses,
            and Members with regard to a confirmed violation. The HMO’s personnel and it
            subcontractors must reasonably cooperate, to the satisfaction of HHSC,
            by being
            available in person for interviews, consultation, grand jury proceedings,
            pre-trial conferences, hearings, trials and in any other process, including
            investigations, at the HMO’s and subcontractors’ own expense. 

           

          8.1.20
            Reporting Requirements 

           

          The
            HMO
            must provide and must require its subcontractors to provide: 

           

          
            	 	 	
                    1.
                      All information required under the Contract, including but
                      not limited to,
                      the reporting requirements or other information related to
                      the performance
                      of its responsibilities hereunder as reasonably requested by
                      the HHSC; and
                      

                  

          

           

          
            	 	 	
                    2.
                      Any information in its possession sufficient to permit HHSC
                      to comply with
                      the Federal Balanced Budget Act of 1997 or other Federal or
                      state laws,
                      rules, and regulations. All information must be provided in
                      accordance
                      with the timelines, definitions, formats and instructions as
                      specified by
                      HHSC. Where practicable, HHSC may consult with HMOs to establish
                      time
                      frames and formats reasonably acceptable to both parties.
                      

                  

          

           

          Section
            8.1.20 modified by Version 1.2 

           

          Any
            deliverable or report in Section 8.1.20 without a specified due date
            is due
            quarterly on the last day of the month following the end of the reporting
            period. Where
            the
            due date states 30 days, the HMO is to provide the deliverable by the
            last day
            of the month following the end of the reporting period. Where the due
            date
            states 45 days, the HMO is to provide the deliverable by the 15th day
            of the
            second month following the end of the reporting period.  

           

          The
            HMO’s
            Chief Executive and Chief Financial Officers, or persons in equivalent
            positions, must certify that financial data, Encounter Data and other
            measurement data has been reviewed by the HMO and is true and accurate
            to the
            best of their knowledge after reasonable inquiry. 

           

          8.1.20.1
            HEDIS and Other Statistical Performance Measures 

           

          The
            HMO
            must provide to HHSC or its designee all information necessary to analyze
            the
            HMO’s provision of quality care to Members using measures to be determined
            by
            HHSC in consultation with the HMO. Such measures must be consistent with
            HEDIS
            or other externally based measures or measurement sets, and involve collection
            of information beyond that present in Encounter Data. The Performance
            Indicator Dashboard,
            found
            in the Uniform
            Managed Care Manual
            provides
            additional information on the role of the HMO and the EQRO in the collection
            and
            calculation of HEDIS, CAHPS, and other performance measures. 

           

          8.1.20.2
            Reports 

           

          The
            HMO
            must provide the following reports, in addition to the Financial Reports
            described in Section
            8.1.17
            and
            those reporting requirements listed elsewhere in the Contract. The HHSC
            Uniform Managed Care Manual
            will
            include a list of all required reports, and a description of the format,
            content, file layout and submission deadlines for each report. 

           

          For
            the
            following reports, CHIP Perinatal Program data will be integrated into
            existing
            CHIP Program reports. Generally, no separate CHIP Perinatal Program reports
            are
            required. Where appropriate, HHSC will designate specific attributes
            within the
            CHIP Program reports that the CHIP Perinatal HMOs must complete to allow
            HHSC to
            extract data particular to the CHIP Perinatal Program. 

           

          Claims
            Summary Report
            - The
            HMO must submit quarterly Claims Summary Reports to HHSC by HMO Program,
            Service
            Area and claims processing subcontractor by the 30th
            day
            following the end of the reporting period unless otherwise specified.
            The format
            for the Claims Summary Report is contained in Chapter 5, Section 5.6.1
            of the
Uniform
            Managed Care Manual.
            

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          QAPI
            Program Annual Summary Report
            - The
            HMO must submit a QAPI Program Annual Summary in a format and timeframe
            as
            specified in the Uniform Managed Care Manual. 

           

          Section
            8.1.20.2 modified by Versions 1.2 and 1.3 

           

          Fraudulent
            Practices Report
            -
            Utilizing the HHSC-Office of Inspector General (OIG) fraud referral form,
            the
            HMO’s assigned officer or director must report and refer all possible acts
            of
            waste, abuse or fraud to the HHSC-OIG within 30 working days of receiving
            the
            reports of possible acts of waste, abuse or fraud from the HMO’s Special
            Investigative Unit (SIU). The report and referral must include: an investigative
            report identifying the allegation, statutes/regulations violated or considered,
            and the results of the investigation; copies of program rules and regulations
            violated for the time period in question; the estimated overpayment identified;
            a summary of the interviews conducted; the encounter data submitted by
            the
            provider for the time period in question; and all supporting documentation
            obtained as the result of the investigation. This requirement applies
            to all
            reports of possible acts of waste, abuse and fraud. 

           

          Additional
            reports required by the Office of the Inspector General relating to waste,
            abuse
            or fraud are listed in the HHSC Uniform
            Managed Care Manual.
            

           

          Provider
            Termination Report: (CHIP (including integrated CHIP Perinatal Program
            data)
& STAR)

           

          MCO
            must
            submit a quarterly report that identifies any providers who cease to
            participate
            in MCO's provider network, either voluntarily or involuntarily. The report
            must
            be submitted to HHSC in the format specified by HHSC, no later than 30
            days
            after the end of the reporting period. 

           

          PCP
            Network & Capacity Report: (CHIP only (including integrated CHIP Perinatal
            Program data))

           

          For
            the
            CHIP Program, MCO must submit a quarterly report listing all unduplicated
            PCPs
            in the MCO's Provider Network. For the CHIP Perinatal Program, the Perinatal
            Newborns are assigned PCPs that are part of the CHIP PCP Network. The
            report
            must be submitted to HHSC in the format specified by HHSC, no later than
            30 days
            after the end of the reporting quarter. 

           

          Summary
            Report of Member Complaints and Appeals
            - The
            HMO must submit quarterly Member Complaints and Appeals reports. The
            HMO must
            include in its reports Complaints and Appeals submitted to its subcontracted
            risk groups (e.g., IPAs) and any other subcontractor that provides Member
            services. The HMO must submit the Complaint and Appeals reports electronically
            on or before 45 days following the end of the state fiscal quarter, using
            the
            format specified by HHSC in the HHSC
            Uniform Managed Care Manual,
            Chapter
            5.4.2. 

           

          HHSC
            may
            direct the CHIP Perinatal HMOs to provide segregated Member Complaints
            and
            Appeals reports on an as-needed basis. 

           

          Summary
            Report of Provider Complaints -
            The HMO
            must submit Provider complaints reports on a quarterly basis. The HMO
            must
            include in its reports complaints submitted by providers to its subcontracted
            risk groups (e.g., IPAs) and any other subcontractor that provides Provider
            services. The complaint reports must be submitted electronically on or
            before 45
            days following the end of the state fiscal quarter, using the format
            specified
            by HHSC in the HHSC Uniform
            Managed Care Manual,
            Chapter
            5.4.2. 

           

          HHSC
            may
            direct the CHIP Perinatal HMOs to provide segregated Provider Complaints
            and
            Appeals reports on an as-needed basis. 

           

          Section
            8.1.20.2 modified by Version 1.5 

           

          Section
            8.1.20.2 modified by Version 1.5 

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

           

          Hotline
            Reports - The
            HMO
            must submit, on a quarterly basis, a status report for the Member Hotline,
            the
            Behavioral Health Services Hotline, and the Provider Hotline in comparison
            with
            the performance standards set out in Sections
            8.1.5.6, 8.1.14.3, and 8.1.4.7.
            The HMO
            shall submit such reports using a format to be prescribed by HHSC in
            consultation with the HMOs. 

           

          If
            the
            HMO is not meeting a hotline performance standard, HHSC may require the
            HMO to
            submit monthly hotline performance reports and implement corrective actions
            until the hotline performance standards are met. If a HMO has a single
            hotline
            serving multiple Service Areas, multiple HMO Programs, or multiple hotline
            functions, (i.e. Member, Provider, Behavioral Health Services hotlines),
            HHSC
            may request on an annual basis that the HMO submit certain hotline response
            information by HMO Program, by Service Area, and by hotline function,
            as
            applicable to the HMO. HHSC may also request this type of hotline information
            if
            a HMO is not meeting a hotline performance standard. 

           

          The
            HMO
            must follow all applicable Joint Interface Plans (JIPs) and all required
            file
            submissions for HHSC’s Administrative Services Contractor, External Quality
            Review Organization (EQRO) and HHSC Medicaid Claims Administrator. The
            JIPs can
            be accessed through the Uniform Managed Care Manual. 

           

          8.2
            Additional Medicaid HMO Scope of Work 

           

          The
            following provisions apply to any HMO participating in the STAR or STAR+PLUS
            HMO
            Program. 

           

          8.2.1
            Continuity of Care and Out-of-Network Providers 

           

          The
            HMO
            must ensure that the care of newly enrolled Members is not disrupted
            or
            interrupted. The HMO must take special care to provide continuity in
            the care of
            newly enrolled Members whose health or behavioral health condition has
            been
            treated by specialty care providers or whose health could be placed in
            jeopardy
            if Medically Necessary Covered Services are disrupted or interrupted.
            

           

          The
            HMO
            must allow pregnant Members with 12 weeks or less remaining before the
            expected
            delivery date to remain under the care of the Member’s current OB/GYN through
            the Member’s postpartum checkup, even if the provider is Out-of-Network. If a
            Member wants to change her OB/GYN to one who is in the Network, she must
            be
            allowed to do so if the Provider to whom she wishes to transfer agrees
            to accept
            her in the last trimester of pregnancy. 

           

          The
            HMO
            must pay a Member’s existing Out-of-Network providers for Medically Necessary
            Covered Services until the Member’s records, clinical information and care can
            be transferred to a Network Provider, or until such time as the Member
            is no
            longer enrolled in that HMO, whichever is shorter. Payment to Out-of-Network
            providers must be made within the time period required for Network Providers.
            The HMO must comply with out-of-network provider reimbursement rules
            as adopted
            by HHSC. 

           

          Section
            8.2 modified by Version 1.1 

           

          This
            Article does not extend the obligation of the HMO to reimburse the Member’s
            existing Out-of-Network providers for on-going care for: 

           

          
            	 	 	
                    1.
                      More than 90 days after a Member enrolls in the HMO’s Program, or
                      

                  

          

           

          
            	 	 	
                    2.
                      For more than nine (9) months in the case of a Member who,
                      at the time of
                      enrollment in the HMO, has been diagnosed with and receiving
                      treatment for
                      a terminal illness and remains enrolled in the HMO.
                      

                  

          

           

          The
            HMO’s
            obligation to reimburse the Member’s existing Out-of-Network provider for
            services provided to a pregnant Member with 12 weeks or less remaining
            before
            the expected delivery date extends through delivery of the child, immediate
            postpartum care, and the follow-up checkup within the first six weeks
            of
            delivery. 

           

          The
            HMO
            must provide or pay Out-of-Network providers who provide Medically Necessary
            Covered Services

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          to
            Members who move out of the Service Area through the end of the period
            for which
            capitation has been paid for the Member. 

           

          The
            HMO
            must provide Members with timely and adequate access to Out-of-Network
            services
            for as long as those services are necessary and covered benefits not
            available
            within the network, in accordance with 42 C.F.R. §438.206(b)(4). The HMO will
            not be obligated to provide a Member with access to Out-of-Network services
            if
            such services become available from a Network Provider. 

           

          The
            HMO
            must ensure that each Member has access to a second opinion regarding
            the use of
            any Medically Necessary Covered Service. A Member must be allowed access
            to a
            second opinion from a Network Provider or Out-of-Network provider if
            a Network
            Provider is not available, at no cost to the Member, in accordance with
            42
            C.F.R. §438.206(b)(3). 

           

          8.2.2
            Provisions Related to Covered Services for Medicaid Members

           

          8.2.2.1
            Emergency Services 

           

          HMO
            policy and procedures, Covered Services, claims adjudication methodology,
            and
            reimbursement performance for Emergency Services must comply with all
            applicable
            state and federal laws, rules, and regulations including 42 C.F.R. §438.114,
            whether the provider is in-network or Out-of-Network. HMO policies and
            procedures must be consistent with the prudent layperson definition of
            an
            Emergency Medical Condition and the claims adjudication processes required
            under
            the Contract and 42 C.F.R. §438.114. 

           

          The
            HMO
            must pay for the professional, facility, and ancillary services that
            are
            Medically Necessary to perform the medical screening examination and
            stabilization of a Member presenting with an
            Emergency Medical Condition or an Emergency Behavioral Health Condition
            to the
            hospital emergency department, 24 hours a day, 7 days a week, rendered
            by either
            the HMO's Network or Out-of-Network providers. 

           

          The
            HMO
            cannot require prior authorization as a condition for payment for an
            Emergency
            Medical Condition, an Emergency Behavioral Health Condition, or labor
            and
            delivery. The HMO cannot limit what constitutes an Emergency Medical
            Condition
            on the basis of lists of diagnoses or symptoms. The HMO cannot refuse
            to cover
            Emergency Services based on the emergency room provider, hospital, or
            fiscal
            agent not notifying the Member’s PCP or the HMO of the Member’s screening and
            treatment within 10 calendar days of presentation for Emergency Services.
            The
            HMO may not hold the Member who has an Emergency Medical Condition liable
            for
            payment of subsequent screening and treatment needed to diagnose the
            specific
            condition or stabilize the patient. The HMO must accept the emergency
            physician
            or provider’s determination of when the Member is sufficiently stabilized for
            transfer or discharge. 

           

          A
            medical
            screening examination needed to diagnose an Emergency Medical Condition
            must be
            provided in a hospital based emergency department that meets the requirements
            of
            the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 C.F.R.
            §§489.20, 489.24 and 438.114(b)&(c)). The HMO must pay for the emergency
            medical screening examination, as required by 42 U.S.C. §1395dd. The HMO must
            reimburse for both the physician's services and the hospital's Emergency
            Services, including the emergency room and its ancillary services. 

           

           

          When
            the
            medical screening examination determines that an Emergency Medical Condition
            exists, the HMO must pay for Emergency Services performed to stabilize
            the
            Member. The emergency physician must document these services in the Member's
            medical record. The HMO must reimburse for both the physician's and hospital's
            emergency stabilization services including the emergency room and its
            ancillary
            services. 

           

          The
            HMO
            must cover and pay for Post-Stabilization Care Services in the amount,
            duration,
            and scope necessary to comply with 42 C.F.R. §438.114(b)&(e) and 42 C.F.R.
§422.113(c)(iii). The HMO is financially responsible for post-stabilization
            care
            services obtained within or outside the Network that are not pre-approved
            by a
            Provider or other HMO representative, but administered to maintain, improve,
            or
            resolve the Member’s stabilized condition if: 

           

          
            	 	 	
                    1.
                      The HMO does not respond to a request for pre-approval within
                      1 hour;
                      

                  

          

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          
            	 	 	
                    2.
                      The HMO cannot be contacted; or 

                  

          

           

          
            	 	 	
                    3.
                      The HMO representative and the treating physician cannot reach
                      an
                      agreement concerning the Member’s care and a Network physician is not
                      available for consultation. In this situation, the HMO must
                      give the
                      treating physician the opportunity to consult with a Network
                      physician and
                      the treating physician may continue with care of the patient
                      until an HMO
                      physician is reached. The HMO’s financial responsibility ends as follows:
                      the HMO physician with privileges at the treating hospital
                      assumes
                      responsibility for the Member’s care; the HMO physician assumes
                      responsibility for the Member’s care through transfer; the HMO
                      representative and the treating physician reach an agreement
                      concerning
                      the Member’s care; or the Member is discharged.

                  

          

           

          8.2.2.2
            Family Planning - Specific Requirements 

           

          The
            HMO
            must require, through Provider contract provisions, that Members requesting
            contraceptive services or family planning services are also provided
            counseling
            and education about the family planning and family planning services
            available
            to Members. The HMO must develop outreach programs to increase community
            support
            for family planning and encourage Members to use available family planning
            services. 

           

          The
            HMO
            must ensure that Members have the right to choose any Medicaid participating
            family planning provider, whether the provider chosen by the Member is
            in or
            outside the Provider Network. The HMO must provide Members access to
            information
            about available providers of family planning services and the Member’s right to
            choose any Medicaid family planning provider. The HMO must provide access
            to
            confidential family planning services. 

           

          The
            HMO
            must provide, at minimum, the full scope of services available under
            the Texas
            Medicaid program for family planning services. The HMO will reimburse
            family
            planning agencies the Medicaid fee-for service amounts for family planning
            services, including Medically Necessary medications, contraceptives,
            and
            supplies not covered by the Vendor Drug Program and will reimburse
            Out-of-Network family planning providers in accordance with HHSC’s
            administrative rules. 

           

          The
            HMO
            must provide medically approved methods of contraception to Members,
            provided
            that the methods of contraception are Covered Services. Contraceptive
            methods
            must be accompanied by verbal and written instructions on their correct
            use. The
            HMO must establish mechanisms to ensure all medically approved methods
            of
            contraception are made available to the Member, either directly or by
            referral
            to a subcontractor. 

           

          The
            HMO
            must develop, implement, monitor, and maintain standards, policies and
            procedures for providing information regarding family planning to Providers
            and
            Members, specifically regarding State and federal laws governing Member
            confidentiality (including minors). Providers and family planning agencies
            cannot require parental consent for minors to receive family planning
            services.
            The HMO must require, through contractual provisions, that subcontractors
            have
            mechanisms in place to ensure Member’s (including minor’s) confidentiality for
            family planning services. 

           

          8.2.2.3
            Texas Health Steps (EPSDT) 

           

          The
            HMO
            must develop effective methods to ensure that children under the age
            of 21
            receive THSteps services when due and according to the recommendations
            established by the AAP and the THSteps periodicity schedule for children.
            The
            HMO must arrange for THSteps services for all eligible Members except
            when a
            Member knowingly and voluntarily declines or refuses services after receiving
            sufficient information to make an informed decision. 

           

          HMO
            must
            have mechanisms in place to ensure that all newly enrolled newborns receive
            an
            appointment for a THSteps checkup within 14 days of enrollment and all
            other
            eligible child Members receive a THSteps checkup within 60 days of enrollment,
            if one is due according to the AAP periodicity schedule. 

           

          The
            HMO
            must ensure that Members are provided information and educational materials
            about the services available through the THSteps Program, and how and
            when they
            may obtain the services. The information should tell the Member how they
            can
            obtain dental benefits, transportation services through the Texas

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          Department
            of Transportation’s Medical Transportation Program, and advocacy assistance from
            the HMO. 

           

          The
            HMO
            must provide appropriate training to all Network Providers and Provider
            staff in
            the Providers’ area of practice regarding the scope of benefits available and
            the THSteps Program. Training must include: 

           

          
            	 	 	
                    1.
                      THSteps benefits, 

                  

          

           

          
            	 	 	
                    2.
                      The periodicity schedule for THSteps medical checkups and immunizations,
                      

                  

          

           

          
            	 	 	
                    3.
                      The required elements of THSteps medical checkups,
                      

                  

          

           

          
            	 	 	
                    4.
                      Providing or arranging for all required lab screening tests
                      (including
                      lead screening), and Comprehensive Care Program (CCP) services
                      available
                      under the THSteps program to Members under age 21 years.
                      

                  

          

           

          HMO
            must
            also educate and train Providers regarding the requirements imposed on
            HHSC and
            contracting HMOs under the Consent Decree entered in Frew
            v. Hawkins, et. al.,
            Civil
            Action No. 3:93CV65, in the United States District Court for the Eastern
            District of Texas, Paris Division. Providers should be educated and trained
            to
            treat each THSteps visit as an opportunity for a comprehensive assessment
            of the
            Member. 

           

          The
            HMO
            must provide outreach to Members to ensure they receive prompt services
            and are
            effectively informed about available THSteps services. Each month, the
            HMO must
            retrieve from the HHSC Administrative Services Contractor Bulletin Board
            System
            a list of Members who are due and overdue THSteps services. Using these
            lists
            and its own internally generated list, the HMO will contact such Members
            to
            obtain the service as soon as possible. The HMO outreach staff must coordinate
            with DSHS THSteps outreach staff to ensure that Members have access to
            the
            Medical Transportation Program, and that any coordination with other
            agencies is
            maintained. 

           

          The
            HMO
            must cooperate and coordinate with the State, outreach programs and THSteps
            regional program staff and agents to ensure prompt delivery of services
            to
            children of migrant farm workers and other migrant populations who may
            transition into and out of the HMO’s Program more rapidly and/or unpredictably
            than the general population. 

           

          The
            HMO
            must have mechanisms in place to ensure that all newborn Members have
            an initial
            newborn checkup before discharge from the hospital and again within two
            weeks
            from the time of birth. The HMO must require Providers to send all THSteps
            newborn screens to the DSHS Bureau of Laboratories or a DSHS certified
            laboratory. Providers must include detailed identifying information for
            all
            screened newborn Members and the Member’s mother to allow DSHS to link the
            screens performed at the hospital with screens performed at the two-week
            follow-up. 

           

          All
            laboratory specimens collected as a required component of a THSteps checkup
            (see
            Medicaid Provider Procedures Manual for age-specific requirements) must
            be
            submitted to the DSHS Laboratory for analysis. The HMO must educate Providers
            about THSteps Program requirements for submitting laboratory tests to
            the DSHS
            Bureau of Laboratories. 

           

          The
            HMO
            must make an effort to coordinate and cooperate with existing community
            and
            school-based health and education programs that offer services to school-aged
            children in a location that is both familiar and convenient to the Members.
            The
            HMO must make a good faith effort to comply with Head Start’s requirement that
            Members participating in Head Start receive their THSteps checkup no
            later than
            45 days after enrolling into either program. 

           

          The
            HMO
            must educate Providers on the Immunization Standard Requirements set
            forth in
            Chapter 161, Health and Safety Code; the standards in the ACIP Immunization
            Schedule; the AAP Periodicity Schedule for CHIP Members; and the DSHS
            Periodicity Schedule for Medicaid Members. The HMO shall educate Providers
            that
            Medicaid Members under age 21 must be immunized during the THSteps checkup
            according to the DSHS routine immunization schedule. The HMO shall also
            educate
            Providers that the screening provider is responsible for administration
            of the
            immunization and should not refer children to Local Health Departments
            to

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          receive
            immunizations. 

           

          The
            HMO
            must educate Providers about, and require Providers to comply with, the
            requirements of Chapter 161, Health and Safety Code, relating to the
            Texas
            Immunization Registry (ImmTrac), to include parental consent on the Vaccine
            Information Statement. 

           

          The
            HMO
            must require all THSteps Providers to submit claims for services paid
            (either on
            a capitated or fee-for service basis) on the HCFA 1500 claim form and
            use the
            HIPAA compliant code set required by HHSC. 

           

          Encounter
            Data will be validated by chart review of a random sample of THSteps
            eligible
            enrollees against monthly Encounter Data reported by the HMO. HHSC or
            its
            designee will conduct chart reviews to validate that all screens are
            performed
            when due and as reported, and that reported data is accurate and timely.
            Substantial deviation between reported and charted Encounter Data could
            result
            in the HMO and/or Network Providers being investigated for potential
            Fraud,
            Abuse, or Waste without notice to the HMO or the Provider. 

           

          8.2.2.4
            Perinatal Services 

           

          The
            HMO’s
            perinatal health care services must ensure appropriate care is provided
            to women
            and infant Members of the HMO from the preconception period through the
            infant’s
            first year of life. The HMO’s perinatal health care system must comply with the
            requirements of the Texas Health and Safety Code, Chapter 32 (the Maternal
            and
            Infant Health Improvement Act) and administrative rules codified at 25
            T.A.C.
            Chapter 37, Subchapter M. 

           

          The
            HMO
            must have a perinatal health care system in place that, at a minimum,
            provides
            the following services: 

           

          
            	 	 	
                    1.
                      Pregnancy planning and perinatal health promotion and education
                      for
                      reproductive- age women; 

                  

          

           

          
            	 	 	
                    2.
                      Perinatal risk assessment of non-pregnant women, pregnant and
                      postpartum
                      women, and infants up to one year of age;

                  

          

           

          
            	 	 	
                    3.
                      Access to appropriate levels of care based on risk assessment,
                      including
                      emergency care; 

                  

          

           

          
            	 	 	
                    4.
                      Transfer and care of pregnant women, newborns, and infants
                      to tertiary
                      care facilities when necessary; 

                  

          

           

          
            	 	 	
                    5.
                      Availability and accessibility of OB/GYNs, anesthesiologists,
                      and
                      neonatologists capable of dealing with complicated perinatal
                      problems; and
                      

                  

          

           

          
            	 	 	
                    6.
                      Availability and accessibility of appropriate outpatient and
                      inpatient
                      facilities capable of dealing with complicated perinatal problems.
                      

                  

          

           

          The
            HMO
            must have a process to expedite scheduling a prenatal appointment for
            an
            obstetrical exam for a TP40 Member no later than two weeks after receiving
            the
            daily Enrollment File verifying the Member’s enrollment into the HMO.

           

          The
            HMO
            must have procedures in place to contact and assist a pregnant/delivering
            Member
            in selecting a PCP for her baby either before the birth or as soon as
            the baby
            is born. 

           

          The
            HMO
            must provide inpatient care and professional services relating to labor
            and
            delivery for its pregnant/delivering Members, and neonatal care for its
            newborn
            Members at the time of delivery and for up to 48 hours following an
            uncomplicated vaginal delivery and 96 hours following an uncomplicated
            Caesarian
            delivery. 

           

          The
            HMO
            must Adjudicate provider claims for services provided to a newborn Member
            in
            accordance with HHSC’s claims processing requirements using the proxy ID number
            or State-issued Medicaid ID number. The HMO cannot deny claims based
            on a
            provider’s non-use of State-issued Medicaid ID number for a newborn

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

Member.
            The HMO must accept provider claims for newborn services based on mother’s name
            and/or Medicaid ID number with accommodations for multiple births, as
            specified
            by the HMO. 

           

          The
            HMO
            must notify providers involved in the care of pregnant/delivering women
            and
            newborns (including Out-of-Network providers and hospitals) of the HMO’s prior
            authorization requirements. The HMO cannot require a prior authorization
            for
            services provided to a pregnant/delivering Member or newborn Member for
            a
            medical condition that requires Emergency Services, regardless of when
            the
            emergency condition arises. 

           

          8.2.2.5
            Sexually Transmitted Diseases (STDs) and Human Immunodeficiency Virus
            (HIV)

           

          The
            HMO
            must provide STD services that include STD/HIV prevention, screening,
            counseling, diagnosis, and treatment. The HMO is responsible for implementing
            procedures to ensure that Members have prompt access to appropriate services
            for
            STDs, including HIV. The HMO must allow Members access to STD services
            and HIV
            diagnosis services without prior authorization or referral by a PCP.
            

           

          The
            HMO
            must comply with Texas Family Code Section 32.003, relating to consent
            to
            treatment by a child. The HMO must provide all Covered Services required
            to form
            the basis for a diagnosis by the Provider as well as the STD/HIV treatment
            plan.

           

          The
            HMO
            must make education available to Providers and Members on the prevention,
            detection and effective treatment of STDs, including HIV. 

           

          The
            HMO
            must require Providers to report all confirmed cases of STDs, including
            HIV, to
            the local or regional health authority according to 25 T.A.C. §§97.131 - 97.134,
            using the required forms and procedures for reporting STDs. The HMO must
            require
            the Providers to coordinate with the HHSC regional health authority to
            ensure
            that Members with confirmed cases of syphilis, chancroid, gonorrhea,
            chlamydia
            and HIV receive risk reduction and partner elicitation/notification counseling.
            

           

          Section
            8.2.2.5 modified by Version 1.5 

           

          The
            HMO
            must have established procedures to make Member records available to
            public
            health agencies with authority to conduct disease investigation, receive
            confidential Member information, and provide follow up activities. 

           

          The
            HMO
            must require that Providers have procedures in place to protect the
            confidentiality of Members provided STD/HIV services. These procedures
            must
            include, but are not limited to, the manner in which medical records
            are to be
            safeguarded, how employees are to protect medical information, and under
            what
            conditions information can be shared. The HMO must inform and require
            its
            Providers who provide STD/HIV services to comply with all state laws
            relating to
            communicable disease reporting requirements. The HMO must implement policies
            and
            procedures to monitor Provider compliance with confidentiality requirements.
            

           

          The
            HMO
            must have policies and procedures in place regarding obtaining informed
            consent
            and counseling Members provided STD/HIV services. 

           

          8.2.2.6
            Tuberculosis (TB) 

           

          The
            HMO
            must provide Members and Providers with education on the prevention,
            detection
            and effective treatment of tuberculosis (TB). The HMO must establish
            mechanisms
            to ensure all procedures required to screen at-risk Members and to form
            the
            basis for a diagnosis and proper prophylaxis and management of TB are
            available
            to all Members, except services referenced in Section
            8.2.2.8
            as
            Non-Capitated Services. The HMO must develop policies and procedures
            to ensure
            that Members who may be or are at risk for exposure to TB are screened
            for TB.
            An at-risk Member means a person who is susceptible to TB because of
            the
            association with certain risk factors, behaviors, drug resistance, or
            environmental conditions. The HMO must consult with the local TB control
            program
            to ensure that all services and treatments are in compliance with the
            guidelines
            recommended by the American Thoracic Society (ATS), the Centers for Disease
            Control and Prevention (CDC), and DSHS policies and standards. 

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          The
            HMO
            must implement policies and procedures requiring Providers to report
            all
            confirmed or suspected cases of TB to the local TB control program within
            one
            working day of identification, using the most recent DSHS forms and procedures
            for reporting TB. The HMO must provide access to Member medical records
            to DSHS
            and the local TB control program for all confirmed and suspected TB cases
            upon
            request. 

           

          The
            HMO
            must coordinate with the local TB control program to ensure that all
            Members
            with confirmed or suspected TB have a contact investigation and receive
            Directly
            Observed Therapy (DOT). The HMO must require, through contract provisions,
            that
            Providers report to DSHS or the local TB control program any Member who
            is
            non-compliant, drug resistant, or who is or may be posing a public health
            threat. The HMO must cooperate with the local TB control program in enforcing
            the control measures and quarantine procedures contained in Chapter 81
            of the
            Texas Health and Safety Code. 

           

          The
            HMO
            must have a mechanism for coordinating a post-discharge plan for follow-up
            DOT
            with the local TB program. The HMO must coordinate with the DSHS South
            Texas
            Hospital and Texas Center for Infectious Disease for voluntary and court-ordered
            admission, discharge plans, treatment objectives and projected length
            of stay
            for Members with multi-drug resistant TB. 

           

          8.2.2.7
            Objection to Provide Certain Services 

           

          In
            accordance with 42 C.F.R. §438.102, the HMO may file an objection to providing,
            reimbursing for, or providing coverage of, a counseling or referral service
            for
            a Covered Service based on moral or religious grounds. The HMO must work
            with
            HHSC to develop a work plan to complete the necessary tasks and determine
            an
            appropriate date for implementation of the requested changes to the requirements
            related to Covered Services. The work plan will include timeframes for
            completing the necessary Contract and waiver amendments, adjustments
            to
            Capitation Rates, identification of the HMO and enrollment materials
            needing
            revision, and notifications to Members. 

           

          In
            order
            to meet the requirements of this section, the HMO must notify HHSC of
            grounds
            for and provide detail concerning its moral or religious objections and
            the
            specific services covered under the objection, no less than 120 days
            prior to
            the proposed effective date of the policy change.  

           

          8.2.2.8
            Medicaid Non-capitated Services 

           

          The
            following Texas Medicaid programs and services have been excluded from
            HMO
            Covered Services. Medicaid Members are eligible to receive these Non-capitated
            Services on a Fee-for-Service basis from Texas Medicaid providers. HMOs
            should
            refer to relevant chapters in the Provider
            Procedures Manual
            and the
Texas
            Medicaid Bulletins
            for more
            information. 

           

          
            	 	 	
                    1.
                      THSteps dental (including orthodontia);

                  

          

           

          
            	 	 	
                    2.
                      Early Childhood Intervention (ECI) case management/service
                      coordination;
                      

                  

          

           

          
            	 	 	
                    3.
                      DSHS targeted case management; 

                  

          

           

          
            	 	 	
                    4.
                      DSHS mental health rehabilitation; 

                  

          

           

          
            	 	 	
                    5.
                      DSHS case management for Children and Pregnant Women;
                      

                  

          

           

          
            	 	 	
                    6.
                      Texas School Health and Related Services (SHARS);
                      

                  

          

           

          
            	 	 	
                    7.
                      Department of Assistive and Rehabilitative Services Blind Children’s
                      Vocational Discovery and Development Program;

                  

          

           

          
            	 	 	
                    8.
                      Tuberculosis services provided by DSHS-approved providers (directly
                      observed therapy and contact investigation);

                  

          

           

          
            	 	 	
                    9.
                      Vendor Drug Program (out-of-office drugs);

                  

          

           

          
            	 	 	
                    10.
                      Texas Department of Transportation Medical Transportation;
                      

                  

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          
            	 	 	
                    11.
                      DADS hospice services (all Members are disenrolled from their
                      health plan
                      upon enrollment into hospice except STAR+PLUS members receiving
                      1915(c)
                      Nursing Facility Waiver services that are not covered by the
                      Hospice
                      Program); 

                  

          

           

          
            	 	 	
                    12.
                      Audiology services and hearing aids for children (under age
                      21) (hearing
                      screening services are provided through the THSteps Program
                      and are
                      capitated) through PACT (Program for Amplification for Children
                      of Texas).
                      

                  

          

           

          
            	 	 	
                    13.
                      For STAR+PLUS, Inpatient Stays are Non-capitated Services.
                      

                  

          

           

          8.2.2.9
            Referrals for Non-capitated Services 

           

          Although
            Medicaid HMOs are not responsible for paying or reimbursing for Non-capitated
            Services, HMOs are responsible for educating Members about the availability
            of
            Non-capitated Services, and for providing appropriate referrals for Members
            to
            obtain or access these services. The HMO is responsible for informing
            Providers
            that bills for all Non-capitated Services must be submitted to HHSC’s Claims
            Administrator for reimbursement. 

           

          Section
            8.2.2.8 modified by Version 1.1 

           

          Section
            8.2.2.9 modified by Version 1.1 

           

          8.2.2.10
            Cooperation with Immunization Registry 

           

          The
            HMO
            must work with HHSC and health care providers to improve the immunization
            rate
            of Medicaid clients and the reporting of immunization information for
            inclusion
            in the Texas Immunization Registry, called “ImmTrac.” 

           

          8.2.2.11
            Case Management for Children and Pregnant Women 

           

          The
            HMO
            must educate Members and Providers on the services available through
            Case
            Management for Children and Pregnant Women (CPW) as described on the
            program’s
            website at http://www.dshs.state.tx.us/caseman/default.shtm
            . An HMO
            may provide information about CPW’s website and basic information about CPW
            services in order to meet this requirement. CPW information and materials
            must
            be included in the HMO’s Provider Manual, Member Handbook and Provider
            orientations. The information and materials must also inform Providers
            that the
            disclosure of medical records or information between Providers, HMO’s and CPW
            case managers does not require a medical release form from the Member.
            

           

          The
            HMO
            must coordinate services with CPW regarding a Member’s health care needs that
            are identified by CPW and referred to the HMO. Upon receipt of a referral
            or
            assessment from a CPW case manager, the HMO’s designated staff are required to
            review the assessment and determine, based on the HMO’s policies, the
            appropriate level of health care and services. The HMO’s staff must also
            coordinate with the Member’s family, Member’s Primary Care Provider (PCP), in
            and Out-of-Network Providers, agencies, and the HMO’s utilization management
            staff to ensure that the health care and services identified are properly
            referred, authorized, scheduled and provided within a timely manner.
            

           

          The
            HMO
            must ensure that access to medically necessary health care needed by
            the Member
            is available within the standards established by HHSC for respective
            care. HMOs
            are not required to arrange or provide for any covered or non-covered
            services
            identified in the CPW assessment. The decision whether to authorize these
            services is made by the HMO. Within five (5) business days of identifying
            any
            non-covered health care services or other services that the Member may
            need, the
            HMO’s staff must report to the CPW case manager which items/services will
            not be
            performed by the HMO. Additionally, within ten (10) business days after
            all of
            the authorized services have been provided, the HMO’s staff must follow-up with
            CPW case manager to report the provision of services. The HMO’s staff must
            ensure that all services provided to a Member by an HMO Provider are
            reported to
            the Member’s PCP. 

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          The
            CPW
            program requires its contracted case managers to coordinate with the
            HMO and the
            HMO’s PCPs. The HMO should report problems regarding CPW referrals, assessments
            or coordination activities to HHSC for follow-up with CPW program staff.
            

           

          Section
            8.2.2.10 added by Version1.2

           

          Section
            8.2.2.11 added by Version1.2

           

          8.2.3
            Medicaid Significant Traditional Providers 

           

          In
            the
            first three (3) years of a Medicaid HMO Program operating in a Service
            Area, the
            HMO must seek participation in its Network from all Medicaid Significant
            Traditional Providers (STPs) defined by HHSC in the applicable Service
            Area for
            the applicable HMO Program. For STAR HMOs, the Medicaid STP requirements
            only
            apply in the Nueces Service Area. For STAR+PLUS HMOs, the Medicaid STP
            requirements apply to all Service Areas, except Harris County within
            the Harris
            Service Area. 

           

          Medicaid
            STPs are defined as PCPs and, for STAR+PLUS, Community-based Long Term
            Care
            providers in a county,
            that,
            when listed by provider type by county in descending order by unduplicated
            number of clients, served the top 80% of unduplicated clients. Hospitals
            receiving Disproportionate Share Hospital (DSH) funds are also considered
            STPs
            in the Service Area in which they are located. Note that STAR+PLUS HMOs
            are not
            required to contract with Hospitals for Inpatient Stays, but are required
            to
            contract with Hospitals for Outpatient Hospital Services. The HHSC website
            includes a list of Medicaid STPs by Service Area. 

           

          Because
            the STP lists were produced in FY2005, HHSC has developed an updated
            list for
            Long Term Care Providers. The list will be provided to HMOs and posted
            on HHSC’s
            website. 

           

          The
            STP
            requirement will be in place for three years after the program has been
            implemented. During that time, providers who believe they meet the STP
            requirements may contact HHSC request HHSC’s consideration for STP status.
            STAR+PLUS HMOs will be notified when Providers are added to the list
            of STPs for
            a Service Area. 

           

          The
            HMO
            must give STPs the opportunity to participate in its Network for at least
            three
            (3) years commencing on the implementation date of Medicaid managed care
            in the
            Service Area. However, the STP provider must: 

           

          
            	 	 	
                    1.
                      Agree to accept the HMO’s Provider reimbursement rate for the provider
                      type; and 

                  

          

           

          
            	 	 	
                    2.
                      Meet the standard credentialing requirements of the HMO, provided
                      that
                      lack of board certification or accreditation by the Joint Commission
                      on
                      Accreditation of Health Care Organizations (JCAHO) is not the
                      sole grounds
                      for exclusion from the Provider Network.

                  

          

           

          8.2.4
            Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)
            

           

          The
            HMO
            must make reasonable efforts to include FQHCs and RHCs (freestanding
            and
            hospital-based) in its Provider Network. The HMO must reimburse FQHCs
            and RHCs
            for health care services provided outside of regular business hours,
            as defined
            by HHSC in rules, including weekend days or holidays, at a rate that
            is equal to
            the allowable rate for those services as determined under Section 32.028,
            Human
            Resources Code, if the Member does not have a referral from their PCP.
            FQHCs or
            RHCs will receive a cost settlement from HHSC and must agree to accept
            initial
            payments from the HMO in an amount that is equal to or greater than the
            HMO’s
            payment terms for other Providers providing the same or similar services.
            Cost
            settlements will not be applicable to the Nueces Service Area and the
            STAR+PLUS
            Service Areas. The HMOs serving those Areas will pay the full encounter
            rates to
            the FQHCs and RHCs when claims payments are made. 

           

          Section
            8.2.3 modified by Version 1.1 

           

          Section
            8.2.4 Modified by Version 1.5 

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          The
            HMO
            must submit monthly FQHC and RHC encounter and payment reports to all
            contracted
            FQHCs and RHCs, and FQHCs and RHCs with which there have been encounters,
            not
            later than 21 days from the end of the month for which the report is
            submitted.
            The format will be developed by HHSC and provided in the Uniform
            Managed Care Manual.
            The
            FQHC and RHC must validate the encounter and payment information contained
            in
            the report(s). The HMO and the FQHC/RHC must both sign the report(s)
            after each
            party agrees that it accurately reflects encounters and payments for
            the month
            reported. The HMO must submit the signed FQHC and RHC encounter and payment
            reports to HHSC not later than 45 days from the end of the reported month.
            Encounter and payment reports will not be necessary for the Nueces Service
            Area
            and the STAR+PLUS Service Areas since the HMOs in those Areas will be
            paying the
            full encounter rates to the FQHCs and RHCs. 

           

          8.2.5
            Provider Complaints and Appeals 

           

          8.2.5.1
            Provider Complaints 

           

          Medicaid
            HMOs must develop, implement, and maintain a system for tracking and
            resolving
            all Medicaid Provider complaints. Within this process, the HMO must respond
            fully and completely to each complaint and establish a tracking mechanism
            to
            document the status and final disposition of each Provider complaint.
            The HMO
            must resolve Provider
            Complaints within 30 days from the date the Complaint is received.

           

          8.2.5.2
            Appeal of Provider Claims 

           

          Medicaid
            HMOs must develop, implement, and maintain a system for tracking and
            resolving
            all Medicaid Provider appeals related to claims payment. Within this
            process,
            the Provider must respond fully and completely to each Medicaid Provider’s
            claims payment appeal and establish a tracking mechanism to document
            the status
            and final disposition of each Medicaid Provider’s claims payment appeal.

           

          Medicaid
            HMOs must contract with physicians who are not Network Providers to resolve
            claims disputes related to denial on the basis of medical necessity that
            remain
            unresolved subsequent to a Provider appeal. The determination of the
            physician
            resolving the dispute must be binding on the HMO and the Provider. The
            physician
            resolving the dispute must hold the same specialty or a related specialty
            as the
            appealing Provider. HHSC reserves the right to amend this process to
            include an
            independent review process established by HHSC for final determination
            on these
            disputes. 

           

          8.2.6
            Member Rights and Responsibilities 

           

          In
            accordance with 42 C.F.R. §438.100, all Medicaid HMOs must maintain written
            policies and procedures for informing Members of their rights and
            responsibilities, and must notify their Members of their right to request
            a copy
            of these rights and responsibilities. The Member Handbook must include
            notification of Member rights and responsibilities. 

           

          Section
            8.2.5.1 modified by Version 1.2 

           

          8.2.7
            Medicaid Member Complaint and Appeal System 

           

          The
            HMO
            must develop, implement, and maintain a Member Complaint and Appeal system
            that
            complies with the requirements in applicable federal and state laws and
            regulations, including 42 C.F.R. §431.200, 42 C.F.R. Part 438, Subpart F,
“Grievance System,” and the provisions of 1 T.A.C. Chapter 357 relating to
            Medicaid managed care organizations. 

           

          The
            Complaint and Appeal system must include a Complaint process, an Appeal
            process,
            and access to HHSC’s Fair Hearing System. The procedures must be the same for
            all Members and must be reviewed and approved in writing by HHSC or its
            designee. Modifications and amendments to the Member Complaint and Appeal
            system
            must be submitted for HHSC’s approval at least 30 days prior to the
            implementation. 

           

          8.2.7.1
            Member Complaint Process 

           

          The
            HMO
            must have written policies and procedures for receiving, tracking, responding
            to, reviewing,

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          reporting
            and resolving Complaints by Members or their authorized representatives.
            For
            purposes of this Section
            8.2.7,
            an
“authorized representative” is any person or entity acting on behalf of the
            Member and with the Member’s written consent. A Provider may be an authorized
            representative. 

           

          The
            HMO
            must resolve Complaints within 30 days from the date the Complaint is
            received.
            The HMO is subject to remedies, including liquidated damages, if at least
            98
            percent of Member Complaints are not resolved within 30 days of receipt
            of the
            Complaint by the HMO. Please see the Uniform
            Managed Care Contract Terms & Conditions and
            Attachment B-5, Deliverables/Liquidated Damages Matrix.
            The
            Complaint procedure must be the same for all Members under the Contract.
            The
            Member or Member’s authorized representative may file a Complaint either orally
            or in writing. The HMO must also inform Members how to file a Complaint
            directly
            with HHSC, once the Member has exhausted the HMO’s complaint process.

           

          The
            HMO
            must designate an officer of the HMO who has primary responsibility for
            ensuring
            that Complaints are resolved in compliance with written policy and within
            the
            required timeframe. For purposes of Section
            8.2.7.2,
            an
“officer” of the HMO means a president, vice president, secretary, treasurer, or
            chairperson of the board for a corporation, the sole proprietor, the
            managing
            general partner of a partnership, or a person having similar executive
            authority
            in the organization. 

           

          The
            HMO
            must have a routine process to detect patterns of Complaints. Management,
            supervisory, and quality improvement staff must be involved in developing
            policy
            and procedure improvements to address the Complaints. 

           

          The
            HMO’s
            Complaint procedures must be provided to Members in writing and through
            oral
            interpretive services. A written description of the HMO’s Complaint procedures
            must be available in prevalent non-English languages for Major Population
            Groups
            identified by HHSC, at no more than a 6th grade reading level. 

           

          The
            HMO
            must include a written description of the Complaint process in the Member
            Handbook. The HMO must maintain and publish in the Member Handbook, at
            least one
            local and one toll-free telephone number with TeleTypewriter/Telecommunications
            Device for the Deaf (TTY/TDD) and interpreter capabilities for making
            Complaints. 

           

          The
            HMO’s
            process must require that every Complaint received in person, by telephone,
            or
            in writing must be acknowledged and recorded in a written record and
            logged with
            the following details: 

           

          
            	 	 	
                    1.
                      Date; 

                  

          

           

          
            	 	 	
                    2.
                      Identification of the individual filing the Complaint;
                      

                  

          

           

          
            	 	 	
                    3.
                      Identification of the individual recording the Complaint;
                      

                  

          

           

          
            	 	 	
                    4.
                      Nature of the Complaint; 

                  

          

           

          
            	 	 	
                    5.
                      Disposition of the Complaint (i.e., how the HMO resolved the
                      Complaint);
                      

                  

          

           

          
            	 	 	
                    6.
                      Corrective action required; and 

                  

          

           

          
            	 	 	
                    7.
                      Date resolved. 

                  

          

           

          The
            HMO
            is prohibited from discriminating or taking punitive action against a
            Member or
            his or her representative for making a Complaint. 

           

          If
            the
            Member makes a request for disenrollment, the HMO must give the Member
            information on the disenrollment process and direct the Member to the
            HHSC
            Administrative Services Contractor. If the request for disenrollment
            includes a
            Complaint by the Member, the Complaint will be processed separately from
            the
            disenrollment request, through the Complaint process. 

           

          The
            HMO
            will cooperate with the HHSC’s Administrative Services Contractor and HHSC or
            its designee to

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          resolve
            all Member Complaints. Such cooperation may include, but is not limited
            to,
            providing information or assistance to internal Complaint committees.
            

           

          The
            HMO
            must provide designated Member Advocates to assist Members in understanding
            and
            using the HMO’s Complaint system as described in Section
            8.2.7.9.
            The
            HMO’s Member Advocates must assist Members in writing or filing a Complaint
            and
            monitoring the Complaint through the HMO’s Complaint process until the issue is
            resolved. 

           

          8.2.7.2
            Medicaid Standard Member Appeal Process 

           

          The
            HMO
            must develop, implement and maintain an Appeal procedure that complies
            with
            state and federal laws and regulations, including 42 C.F.R.§ 431.200 and 42
            C.F.R. Part 438, Subpart F, “Grievance System.” An Appeal is a disagreement with
            an HMO Action as defined in HHSC’s
            Uniform Contract Terms and Conditions.
            The
            Appeal procedure must be the same for all Members. When a Member or his
            or her
            authorized representative expresses orally or in writing any dissatisfaction
            or
            disagreement with an Action, the HMO must regard the expression of
            dissatisfaction as a request to Appeal an Action. 

           

          A
            Member
            must file a request for an Appeal with the HMO within 30 days from receipt
            of
            the notice of the Action. The HMO is subject to remedies, including liquidated
            damages, if at least 98 percent of Member Appeals are not resolved within
            30
            days of receipt of the Appeal by the HMO. Please see the Uniform
            Managed Care Contract Terms & Conditions and Attachment B-5,
            Deliverables/Liquidated Damages Matrix.
            To
            ensure continuation of currently authorized services, however, the Member
            must
            file the Appeal on or before the later of 10 days following the HMO’s mailing of
            the notice of the Action, or the intended effective date of the proposed
            Action.
            The HMO must designate an officer who has primary responsibility for
            ensuring
            that Appeals are resolved in compliance with written policy and within
            the
            30-day time limit. 

           

          The
            provisions of Article 21.58A, Texas Insurance Code, (to be recodified
            as Texas
            Insurance Code, Title 14, Chapter 4201), relating to a Member’s right to Appeal
            an Adverse Determination made by the HMO or a utilization review agent
            to an
            independent review organization, do not apply to a Medicaid recipient.
            Article
            21.58A is pre-empted by federal Fair Hearings requirements. 

           

          The
            HMO
            must have policies and procedures in place outlining the Medical Director’s role
            in an Appeal of an Action. The Medical Director must have a significant
            role in
            monitoring, investigating and hearing Appeals. In accordance with 42
            C.F.R.§
438.406, the HMO’s policies and procedures must require that individuals who
            make decisions on Appeals are not involved in any previous level of review
            or
            decision-making, and are health care professionals who have the appropriate
            clinical expertise in treating the Member’s condition or disease. 

           

          The
            HMO
            must provide designated Member Advocates, as described in Section
            8.2.7.9,
            to
            assist Members in understanding and using the Appeal process. The HMO’s Member
            Advocates must assist Members in writing or filing an Appeal and monitoring
            the
            Appeal through the HMO’s Appeal process until the issue is resolved.

           

          The
            HMO
            must have a routine process to detect patterns of Appeals. Management,
            supervisory, and quality improvement staff must be involved in developing
            policy
            and procedure improvements to address the Appeals. 

           

          The
            HMO’s
            Appeal procedures must be provided to Members in writing and through
            oral
            interpretive services. A written description of the Appeal procedures
            must be
            available in prevalent non-English languages identified by HHSC, at no
            more than
            a 6th grade reading level. The HMO must include a written description
            of the
            Appeals process in the Member Handbook. The HMO must maintain and publish
            in the
            Member Handbook at least one local and one toll-free telephone number
            with
            TTY/TDD and interpreter capabilities for requesting an Appeal of an Action.
            

           

          The
            HMO’s
            process must require that every oral Appeal received must be confirmed
            by a
            written, signed Appeal by the Member or his or her representative, unless
            the
            Member or his or her representative requests an expedited resolution.
            All
            Appeals must be recorded in a written record and logged with the following
            details: 

           

          
            	 	 	
                    1)
                      Date notice is sent; 

                  

          

           

          
            	 	 	
                    2)
                      Effective date of the Action; 

                  

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          
            	 	 	
                    3)
                      Date the Member or his or her representative requested the
                      Appeal;
                      

                  

          

           

          
            	 	 	
                    4)
                      Date the Appeal was followed up in writing;

                  

          

           

          
            	 	 	
                    5)
                      Identification of the individual filing;

                  

          

           

          
            	 	 	
                    6)
                      Nature of the Appeal; and 

                  

          

           

          
            	 	 	
                    7)
                      Disposition of the Appeal, and notice of disposition to Member.
                      

                  

          

           

          The
            HMO
            must send a letter to the Member within five (5) business days acknowledging
            receipt of the Appeal request. Except for the resolution of an Expedited
            Appeal
            as provided in Section
            8.2.7.3,
            the HMO
            must complete the entire standard Appeal process within 30 calendar days
            after
            receipt of the initial written or oral request for Appeal. The timeframe
            for a
            standard Appeal may be extended up to 14 calendar days if the Member
            or his or
            her representative requests an extension; or the HMO shows that there
            is a need
            for additional information and how the delay is in the Member’s interest. If the
            timeframe is extended, the HMO must give the Member written notice of
            the reason
            for delay if the Member had not requested the delay. The HMO must designate
            an
            officer who has primary responsibility for ensuring that Appeals are
            resolved
            within these timeframes and in accordance with the HMO’s written policies.

           

          During
            the Appeal process, the HMO must provide the Member a reasonable opportunity
            to
            present evidence and any allegations of fact or law in person as well
            as in
            writing. The HMO must inform the Member of the time available for providing
            this
            information and that, in the case of an expedited resolution, limited
            time will
            be available. 

           

          The
            HMO
            must provide the Member and his or her representative opportunity, before
            and
            during the Appeal process, to examine the Member’s case file, including medical
            records and any other documents considered during the Appeal process.
            The HMO
            must include, as parties to the Appeal, the Member and his or her representative
            or the legal representative of a deceased Member’s estate. 

           

          In
            accordance with 42 C.F.R.§ 438.420, the HMO must continue the Member’s benefits
            currently being received by the Member, including the benefit that is
            the
            subject of the Appeal, if all of the following criteria are met: 

           

          
            	 	 	
                    1.
                      The Member or his or her representative files the Appeal timely
                      as defined
                      in this Contract: 

                  

          

           

          
            	 	 	
                    2.
                      The Appeal involves the termination, suspension, or reduction
                      of a
                      previously authorized course of treatment;

                  

          

           

          
            	 	 	
                    3.
                      The services were ordered by an authorized provider;
                      

                  

          

           

          
            	 	 	
                    4.
                      The original period covered by the original authorization has
                      not expired;
                      and 

                  

          

           

          
            	 	 	
                    5.
                      The Member requests an extension of the benefits.
                      

                  

          

           

          If,
            at
            the Member’s request, the HMO continues or reinstates the Member’s benefits
            while the Appeal is pending, the benefits must be continued until one
            of the
            following occurs: 

           

          1.
            The
            Member withdraws the Appeal; 

           

          2.
            Ten
            (10) days pass after the HMO mails the notice resolving the Appeal against
            the
            Member, unless the Member, within the 10-day timeframe, has requested
            a Fair
            Hearing with continuation of benefits until a Fair Hearing decision can
            be
            reached; or

           

          3.
            A
            state Fair Hearing officer issues a hearing decision adverse to the Member
            or
            the time period or service limits of a previously authorized service
            has been
            met. 

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          In
            accordance with 42 C.F.R.§ 438.420(d), if the final resolution of the Appeal is
            adverse to the Member and upholds the HMO’s Action, then to the extent that the
            services were furnished to comply with the Contract, the HMO may recover
            such
            costs from the Member. 

           

          If
            the
            HMO or State Fair Hearing Officer reverses a decision to deny, limit,
            or delay
            services that were not furnished while the Appeal was pending, the HMO
            must
            authorize or provide the disputed services promptly and as expeditiously
            as the
            Member’s health condition requires. 

           

          If
            the
            HMO or State Fair Hearing Officer reverses a decision to deny authorization
            of
            services and the Member received the disputed services while the Appeal
            was
            pending, the HMO is responsible for the payment of services. 

           

          The
            HMO
            is prohibited from discriminating or taking punitive action against a
            Member or
            his or her representative for making an Appeal. 

           

          8.2.7.3
            Expedited Medicaid HMO Appeals 

           

          In
            accordance with 42 C.F.R. §438.410, the HMO must establish and maintain an
            expedited review process for Appeals, when the HMO determines (for a
            request
            from a Member) or the provider indicates (in making the request on the
            Member’s
            behalf or supporting the Member’s request) that taking the time for a standard
            resolution could seriously jeopardize the Member’s life or health. The HMO must
            follow all Appeal requirements for standard Member Appeals as set forth
            in
Section
            8.2.7.2),
            except
            where differences are specifically noted. The HMO must accept oral or
            written
            requests for Expedited Appeals. 

           

          Members
            must exhaust the HMO’s Expedited Appeal process before making a request for an
            expedited Fair Hearing. After the HMO receives the request for an Expedited
            Appeal, it must hear an approved request for a Member to have an Expedited
            Appeal and notify the Member of the outcome of the Expedited Appeal within
            3
            business days, except that the HMO must complete investigation and resolution
            of
            an Appeal relating to an ongoing emergency or denial of continued
            hospitalization: (1) in accordance with the medical or dental immediacy
            of the
            case; and (2) not later than one (1) business day after receiving the
            Member’s
            request for Expedited Appeal is received. 

           

          Except
            for an Appeal relating to an ongoing emergency or denial of continued
            hospitalization, the timeframe for notifying the Member of the outcome
            of the
            Expedited Appeal may be extended up to 14 calendar days if the Member
            requests
            an extension or the HMO shows (to the satisfaction of HHSC, upon HHSC’s request)
            that there is a need for additional information and how the delay is
            in the
            Member’s interest. If the timeframe is extended, the HMO must give the Member
            written notice of the reason for delay if the Member had not requested
            the
            delay. 

           

          If
            the
            decision is adverse to the Member, the HMO must follow the procedures
            relating
            to the notice in Section
            8.2.7.5.
            The HMO
            is responsible for notifying the Member of his or her right to access
            an
            expedited Fair Hearing from HHSC. The HMO will be responsible for providing
            documentation to the State and the Member, indicating how the decision
            was made,
            prior to HHSC’s expedited Fair Hearing. 

           

          The
            HMO
            is prohibited from discriminating or taking punitive action against a
            Member or
            his or her representative for requesting an Expedited Appeal. The HMO
            must
            ensure that punitive action is neither taken against a provider who requests
            an
            expedited resolution or supports a Member’s request. 

           

          If
            the
            HMO denies a request for expedited resolution of an Appeal, it must:
            

           

          
            	 	 	
                    (1)
                      Transfer the Appeal to the timeframe for standard resolution,
                      and
                      

                  

          

           

          
            	 	 	
                    (2)
                      Make a reasonable effort to give the Member prompt oral notice
                      of the
                      denial, and follow up within two (2) calendar days with a written
                      notice.
                      

                  

          

           

           

          8.2.7.4
            Access to Fair Hearing for Medicaid Members 

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          The
            HMO
            must inform Members that they have the right to access the Fair Hearing
            process
            at any time during the Appeal system provided by the HMO. In the case
            of an
            expedited Fair Hearing process, the HMO must inform the Member that he
            or she
            must first exhaust the HMO’s internal Expedited Appeal process prior to filing
            an Expedited Fair Hearing. The HMO must notify Members that they may
            be
            represented by an authorized representative in the Fair Hearing process.
            

           

          8.2.7.5
            Notices of Action and Disposition of Appeals for Medicaid Members

           

          The
            HMO
            must notify the Member, in accordance with 1 T.A.C. Chapter 357, whenever
            the
            HMO takes an Action. The notice must, at a minimum, include any information
            required by 1 T.A.C. Chapter 357 that relates to a managed care organization’s
            notice of Action and any information required by 42 C.F.R. §438.404 as directed
            by HHSC, including but not limited to: 

           

          1.
            The
            Action the HMO has taken or intends to take; 

           

          2.
            The
            reasons for the Action; 

           

          3.
            The
            Member’s right to access the HMO’s Appeal process. 

           

          4.
            The
            procedures by which the Member may Appeal the HMO’s Action; 

           

          5.
            The
            circumstances under which expedited resolution is available and how to
            request
            it; 

           

          6.
            The
            circumstances under which a Member may continue to receive benefits pending
            resolution of the Appeal, how to request that benefits be continued,
            and the
            circumstances under which the Member may be required to pay the costs
            of these
            services; 

           

          7.
            The
            date the Action will be taken; 

           

          8.
            A
            reference to the HMO policies and procedures supporting the HMO’s Action;

           

          9.
            An
            address where written requests may be sent and a toll-free number that
            the
            Member can call to request the assistance of a Member representative,
            file an
            Appeal, or request a Fair Hearing; 

           

          10.
            An
            explanation that Members may represent themselves, or be represented
            by a
            provider, a friend, a relative, legal counsel or another spokesperson;
            

           

          11.
            A
            statement that if the Member wants a Fair Hearing on the Action, the
            Member must
            make the request for a Fair Hearing within 90 days of the date on the
            notice or
            the right to request a hearing is waived; 

           

          12.
            A
            statement explaining that the HMO must make its decision within 30 days
            from the
            date the Appeal is received by the HMO, or 3 business days in the case
            of an
            Expedited Appeal; and 

           

          13.
            A
            statement explaining that the hearing officer must make a final decision
            within
            90 days from the date a Fair Hearing is requested. 

           

          8.2.7.6
            Timeframe for Notice of Action 

           

          In
            accordance with 42 C.F.R.§ 438.404(c), the HMO must mail a notice of Action
            within the following timeframes: 

           

          
            	 	 	
                    1.
                      For termination, suspension, or reduction of previously authorized
                      Medicaid-covered services, within the timeframes specified
                      in 42 C.F.R.§§
                      431.211, 431.213, and 431.214; 

                  

          

           

          
            	 	 	
                    2.
                      For denial of payment, at the time of any Action affecting
                      the claim;
                      

                  

          

           

          
            	 	 	
                    3.
                      For standard service authorization decisions that deny or limit
                      services,
                      within the timeframe specified in 42 C.F.R.§ 438.210(d)(1);
                      

                  

          

           

          
            	 	 	
                    4.
                      If the HMO extends the timeframe in accordance with 42 C.F.R.
                      §438.210(d)(1), it must: 

                  

          

           

          
            	 	 	
                    5.
                      give the Member written notice of the reason for the decision
                      to extend
                      the timeframe and inform the Member of the right to file an
                      Appeal if he
                      or she disagrees with that decision; and

                  

          

           

          
            	 	 	
                    6.
                      issue and carry out its determination as expeditiously as the
                      Member’s
                      health condition requires and no later than the date the extension
                      expires; 

                  

          

           

          
            	 	 	
                    7.
                      For service authorization decisions not reached within the
                      timeframes
                      specified in 42 C.F.R.§ 438.210(d) (which constitutes a denial and is thus
                      an adverse Action), on the date that the timeframes expire;
                      and
                      

                  

          

           

          
            	 	 	
                    8.
                      For expedited service authorization decisions, within the timeframes
                      specified in 42 C.F.R. 438.210(d). 

                  

          

           

          8.2.7.7
            Notice of Disposition of Appeal 

           

          In
            accordance with 42 C.F.R.§ 438.408(e), the HMO must provide written notice of
            disposition of all Appeals including Expedited Appeals. The written resolution
            notice must include the results and date of the Appeal resolution. For
            decisions
            not wholly in the Member’s favor, the notice must contain: 

           

          
            	 	 	
                    1.
                      The right to request a Fair Hearing;

                  

          

           

          
            	 	 	
                    2.
                      How to request a Fair Hearing; 

                  

          

           

          
            	 	 	
                    3.
                      The circumstances under which the Member may continue to receive
                      benefits
                      pending a Fair Hearing; 

                  

          

           

          
            	 	 	
                    4.
                      How to request the continuation of benefits;

                  

          

           

          
            	 	 	
                    5.
                      If the HMO’s Action is upheld in a Fair Hearing, the Member may be liable
                      for the cost of any services furnished to the Member while
                      the Appeal is
                      pending; and 

                  

          

           

          
            	 	 	
                    6.
                      Any other information required by 1 T.A.C. Chapter 357 that
                      relates to a
                      managed care organization’s notice of disposition of an Appeal.
                      

                  

          

           

          8.2.7.8
            Timeframe for Notice of Resolution of Appeals 

           

          In
            accordance with 42 C.F.R.§ 438.408, the HMO must provide written notice of
            resolution of Appeals, including Expedited Appeals, as expeditiously
            as the
            Member’s health condition requires, but the notice must not exceed the timelines
            as provided in this Section for Standard or Expedited Appeals. For expedited
            resolution of Appeals, the HMO must make reasonable efforts to give the
            Member
            prompt oral notice of resolution of the Appeal, and follow up with a
            written
            notice within the timeframes set forth in this Section for Expedited
            Appeals. If
            the HMO denies a request for expedited resolution of an Appeal, the HMO
            must
            transfer the Appeal to the timeframe for standard resolution as provided
            in this
            Section, and make reasonable efforts to give the Member prompt oral notice
            of
            the denial, and follow up within two calendar days with a written notice.
            

           

          8.2.7.9
            Medicaid Member Advocates 

           

          The
            HMO
            must provide Member Advocates to assist Members. Member Advocates must
            be
            physically located within the Service Area unless an exception is approved
            by
            HHSC. Member Advocates must inform Members of the following: 

           

          
            	 	 	
                    1.
                      Their rights and responsibilities, 

                  

          

           

          
            	 	 	
                    2.
                      The Complaint process, 

                  

          

           

          
            	 	 	
                    3.
                      The Appeal process, 

                  

          

           

          
            	 	 	
                    4.
                      Covered Services available to them, including preventive services,
                      and
                      

                  

          

           

          
            	 	 	
                    5.
                      Non-capitated Services available to them.

                  

          

           

          Member
            Advocates must assist Members in writing Complaints and are responsible
            for
            monitoring the Complaint through the HMO’s Complaint process. 

           

          Member
            Advocates are responsible for making recommendations to management on
            any
            changes needed to improve either the care provided or the way care is
            delivered.
            Member Advocates are also responsible for helping or referring Members
            to
            community resources available to meet Member needs that are not available
            from
            the HMO as Medicaid Covered Services. 

           

          8.2.8
            Additional Medicaid Behavioral Health Provisions 

           

          8.2.8.1
            Local Mental Health Authority (LMHA) 

           

          Assessment
            to determine eligibility for rehabilitative and targeted DSHS case management
            services is a function of the LMHA. Covered Services must be provided
            to Members
            with severe and persistent mental illness (SPMI) and severe emotional
            disturbance (SED), when Medically Necessary, whether or not they are
            also
            receiving targeted case management or rehabilitation services through
            the LMHA.

           

          The
            HMO
            must enter into written agreements with all LMHAs in the Service Area
            that
            describe the process(es) that the HMO and LMHAs will use to coordinate
            services
            for Medicaid Members with SPMI or SED. The agreements will: 

           

          
            	 	 	
                    1.
                      Describe the Behavioral Health Services indicated in detail
                      in the
                      Provider
                      Procedures Manual
                      and in the Texas
                      Medicaid Bulletin,
                      include the amount, duration, and scope of basic and Value-added
                      Services,
                      and the HMO’s responsibility to provide these services;
                      

                  

          

           

          
            	 	 	
                    2.
                      Describe criteria, protocols, procedures and instrumentation
                      for referral
                      of Medicaid Members from and to the HMO and the LMHA;
                      

                  

          

           

          
            	 	 	
                    3.
                      Describe processes and procedures for referring Members with
                      SPMI or SED
                      to the LMHA for assessment and determination of eligibility
                      for
                      rehabilitation or targeted case management services;
                      

                  

          

           

          
            	 	 	
                    4.
                      Describe how the LMHA and the HMO will coordinate providing
                      Behavioral
                      Health Services to Members with SPMI or SED;

                  

          

           

          
            	 	 	
                    5.
                      Establish clinical consultation procedures between the HMO
                      and LMHA
                      including consultation to effect referrals and on-going consultation
                      regarding the Member’s progress; 

                  

          

           

          
            	 	 	
                    6.
                      Establish procedures to authorize release and exchange of clinical
                      treatment records; 

                  

          

           

          
            	 	 	
                    7.
                      Establish procedures for coordination of assessment, intake/triage,
                      utilization review/utilization management and care for persons
                      with SPMI
                      or SED; 

                  

          

           

          
            	 	 	
                    8.
                      Establish procedures for coordination of inpatient psychiatric
                      services
                      (including Court- ordered Commitment of Members under 21) in
                      state
                      psychiatric facilities within the LMHA’s catchment area;
                      

                  

          

           

          
            	 	 	
                    9.
                      Establish procedures for coordination of emergency and urgent
                      services to
                      Members; 

                  

          

           

          
            	 	 	
                    10.
                      Establish procedures for coordination of care and transition
                      of care for
                      new Members who are receiving treatment through the LMHA; and
                      

                  

          

           

          
            	 	 	
                    11.
                      Establish that when Members are receiving Behavioral Health
                      Services from
                      the Local Mental Health Authority that the HMO is using the
                      same UM
                      guidelines as those prescribed for use by local mental health
                      authorities
                      by DSHS which are published at: http://www.mhmr.state.tx.us/centraloffice/behavioralhealthservices/RDMClinGuide.html
                      .
                      

                  

          

           

          The
            HMO
            must offer licensed practitioners of the healing arts (defined in 25
            T.A.C.,
            Part 2, Chapter 419, Subchapter L), who are part of the Member’s treatment team
            for rehabilitation services, the opportunity to participate in the HMO’s
            Network. The practitioner must agree to accept the HMO’s Provider reimbursement
            rate, meet the credentialing requirements, and comply with all the terms
            and
            conditions of the HMO’s standard Provider contract. 

           

          Section
            8.2.8.1 modified by Version 1.1 

           

          HMOs
            must
            allow Members receiving rehabilitation services to choose the licensed
            practitioners of the healing arts who are currently a part of the Member’s
            treatment team for rehabilitation services to provide Covered Services.
            If the
            Member chooses to receive these services from licensed practitioners
            of the
            healing arts who are part of the Member’s rehabilitation services treatment team
            but are not part of the HMO’s Network, the HMO must reimburse the Local Mental
            Health Authority through Out-of-Network reimbursement arrangements.

           

          Nothing
            in this section diminishes the potential for the Local Mental Health
            Authority
            to seek best value for rehabilitative services by providing these services
            under
            arrangement, where possible, as specified is 25 T.A.C. §419.455. 

           

          8.2.9
            Third Party Liability and Recovery 

           

          Medicaid
            HMOs are responsible for establishing a plan and process for recovering
            costs
            for services that should have been paid through a third party in accordance
            with
            State and Federal law and regulations. To recognize this requirement,
            capitation
            payments to the HMOs are reduced by the projected amount of TPR that
            the HMO is
            expected to recover. 

           

          The
            HMOs
            must provide required reports as stated in Section
            8.1.17.2, Financial
            Reporting Requirements.  

           

          After
            120-days from the date of service on any claim, encounter, or other Medicaid
            related payment by the HMO subject to Third Party Recovery, HHSC may
            attempt
            recovery independent of any HMO action. HHSC will retain, in full, all
            funds
            received as a result of the state initiated recovery or subrogation action.
            

           

          HMOs
            shall provide a Member quarterly file, which contains the following information
            if available to the HMO: the Member name, address, claim submission address,
            group number, employer's mailing address, social security number, and
            date of
            birth for each subscriber or policyholder and each dependent of the subscriber
            or policyholder covered by the insurer. The file shall be used for the
            purpose
            of matching the Texas Medicaid eligibility file against the HMO Member
            file to
            identify Medicaid clients enrolled in the HMO, which may not be known
            the
            Medicaid Program. 

           

          8.2.10
            Coordination With Public Health Entities 

           

          8.2.10.1
            Reimbursed Arrangements with Public Health Entities 

           

          The
            HMO
            must make a good faith effort to enter into a subcontract for Covered
            Services
            with Public Health Entities. Possible Covered Services that could be
            provided by
            Public Health Entities include, but are not limited to, the following
            services:

           

          
            	 	 	
                    1.
                      Sexually Transmitted Diseases (STDs) services;

                  

          

           

          
            	 	 	
                    2.
                      Confidential HIV testing; 

                  

          

           

          
            	 	 	
                    3.
                      Immunizations; 

                  

          

           

          
            	 	 	
                    4.
                      Tuberculosis (TB) care; 

                  

          

           

          
            	 	 	
                    5.
                      Family Planning services; 

                  

          

           

          
            	 	 	
                    6.
                      THSteps medical checkups, and 

                  

          

           

          
            	 	 	
                    7.
                      Prenatal services. 

                  

          

           

          These
            subcontracts must be available for review by HHSC or its designated agent(s)
            on
            the same basis as all other subcontracts. If the HMO is unable to enter
            into a
            contract with Public Health Entities, the HMO must document efforts to
            contract
            with Public Health Entities, and make such documentation available to
            HHSC upon
            request. 

           

          HMO
            Contracts with Public Health Entities must specify the scope of responsibilities
            of both parties, the methodology and agreements regarding billing and
            reimbursements, reporting responsibilities, Member and Provider educational
            responsibilities, and the methodology and agreements regarding sharing
            of
            confidential medical record information between the Public Health Entity
            and the
            HMO or PCP. 

           

          The
            HMO
            must: 

           

          
            	 	 	
                    1.
                      Identify care managers who will be available to assist public
                      health
                      providers and PCPs in efficiently referring Members to the
                      public health
                      providers, specialists, and health-related service providers
                      either within
                      or outside the HMO’s Network; and 

                  

          

           

          
            	 	 	
                    2.
                      Inform Members that confidential healthcare information will
                      be provided
                      to the PCP, and educate Members on how to better utilize their
                      PCPs,
                      public health providers, emergency departments, specialists,
                      and
                      health-related service providers. 

                  

          

           

          8.2.10.2
            Non-Reimbursed Arrangements with Local Public Health Entities

           

          The
            HMO
            must coordinate with Public Health Entities in each Service Area regarding
            the
            provision of essential public health care services. In addition to the
            requirements listed above in Section 8.2.2, or otherwise required under
            state
            law or this contract, the HMO must meet the following requirements:

           

          
            	 	 	
                    1.
                      Report to public health entities regarding communicable diseases
                      and/or
                      diseases that are preventable by immunization as defined by
                      state law;
                      

                  

          

           

          
            	 	 	
                    2.
                      Notify the local Public Health Entity, as defined by state
                      law, of
                      communicable disease outbreaks involving Members;
                      

                  

          

           

          
            	 	 	
                    3.
                      Educate Members and Providers regarding WIC services available
                      to Members;
                      and 

                  

          

           

          
            	 	 	
                    4.
                      Coordinate with local public health entities that have a child
                      lead
                      program, or with DSHS regional staff when the local public
                      health entity
                      does not have a child lead program, for follow-up of suspected
                      or
                      confirmed cases of childhood lead exposure.

                  

          

           

          8.2.11
            Coordination with Other State Health and Human Services (HHS) Programs
            

           

          The
            HMO
            must coordinate with other state HHS Programs in each Service Area regarding
            the
            provision of essential public health care services. In addition to the
            requirements listed above in Section 8.2.2. or otherwise required under
            state
            law or this contract, the HMO must meet the following requirements:

           

          Section
            8.2.11 modified by Version 1.2 

           

          Section
            8.2.10.2 modified by Version 1.2 

           

          
            	 	 	
                    1.
                      Require Providers to use the DSHS Bureau of Laboratories for
                      specimens
                      obtained as part of a THSteps medical checkup, including THSteps
                      newborn
                      screens, lead testing, and hemoglobin/hematocrit tests;
                      

                  

          

           

          
            	 	 	
                    2.
                      Notify Providers of the availability of vaccines through the
                      Texas
                      Vaccines for Children Program; 

                  

          

           

          
            	 	 	
                    3.
                      Work with HHSC and Providers to improve the reporting of immunizations
                      to
                      the statewide ImmTrac Registry; 

                  

          

           

          
            	 	 	
                    4.
                      Educate Providers and Members about the Department of State
                      Health
                      Services (DSHS) Case Management for Children and Pregnant Women
                      (CPW)
                      services available; 

                  

          

           

          
            	 	 	
                    5.
                      Coordinate services with CPW specifically in regard to an HMO
                      Member’s
                      health care needs that are identified by CPW and referred to
                      the HMO;
                      

                  

          

           

          
            	 	 	
                    6.
                      Participate, to the extent practicable, in the community-based
                      coalitions
                      with the Medicaid-funded case management programs in the Department
                      of
                      Assistive and Rehabilitative Services (DARS), the Department
                      of Aging and
                      Disability Services (DADS), and DSHS;

                  

          

           

          
            	 	 	
                    7.
                      Cooperate with activities required of state and local public
                      health
                      authorities necessary to conduct the annual population and
                      community based
                      needs assessment; and 

                  

          

           

          
            	 	 	
                    8.
                      Report all blood lead results, coordinate and follow-up of
                      suspected or
                      confirmed cases of childhood lead exposure with the Childhood
                      Lead
                      Poisoning Prevention Program in DSHS.

                  

          

           

          8.2.12
            Advance Directives 

           

          Federal
            and state law require HMOs and providers to maintain written policies
            and
            procedures for informing all adult Members 18 years of age and older
            about their
            rights to refuse, withhold or withdraw medical treatment and mental health
            treatment through advance directives (see Social Security Act §1902(a)(57) and
§1903(m)(1)(A)). The HMO’s policies and procedures must include written
            notification to Members and comply with provisions contained in 42 C.F.R.
            §434.28 and 42 C.F.R. § 489, Subpart I, relating to advance directives for all
            hospitals, critical access hospitals, skilled nursing facilities, home
            health
            agencies, providers of home health care, providers of personal care services
            and
            hospices, as well as the following state laws and rules: 

           

          
            	 	 	
                    1.
                      A Member’s right to self-determination in making health care decisions;
                      

                  

          

           

          
            	 	 	
                    2.
                      The Advance Directives Act, Chapter 166, Texas Health and Safety
                      Code,
                      which includes: 

                  

          

           

          
            	 	 	
                    a.
                      A Member’s right to execute an advance written directive to physicians
                      and
                      family or surrogates, or to make a non-written directive to
                      administer,
                      withhold or withdraw life-sustaining treatment in the event
                      of a terminal
                      or irreversible condition; 

                  

          

           

          
            	 	 	
                    b.
                      A Member’s right to make written and non-written out-of-hospital
                      do-not-resuscitate (DNR) orders; 

                  

          

           

          
            	 	 	
                    c.
                      A Member’s right to execute a Medical Power of Attorney to appoint an
                      agent to make health care decisions on the Member’s behalf if the Member
                      becomes incompetent; and 

                  

          

           

          
            	 	 	
                    3.
                      The Declaration for Mental Health Treatment, Chapter 137, Texas
                      Civil
                      Practice and Remedies Code, which includes: a Member’s right to execute a
                      Declaration for Mental Health Treatment in a document making
                      a declaration
                      of preferences or instructions regarding mental health treatment.
                      

                  

          

           

          The
            HMO
            must maintain written policies for implementing a Member’s advance directive.
            Those policies must include a clear and precise statement of limitation
            if the
            HMO or a Provider cannot or will not implement a Member’s advance directive.

           

          The
            HMO
            cannot require a Member to execute or issue an advance directive as a
            condition
            of receiving health care services. The HMO cannot discriminate against
            a Member
            based on whether or not the Member has executed or issued an advance
            directive.

           

          The
            HMO’s
            policies and procedures must require the HMO and subcontractors to comply
            with
            the requirements of state and federal law relating to advance directives.
            The
            HMO must provide education and training to employees and Members on issues
            concerning advance directives. 

           

          All
            materials provided to Members regarding advance directives must be written
            at a
            7th
            -
            8th
            grade
            reading comprehension level, except where a provision is required by
            state or
            federal law and the provision cannot be reduced or modified to a 7th
            -
            8th
            grade
            reading level because it is a reference to the law or is required to
            be included
“as written” in the state or federal law. 

           

          The
            HMO
            must notify Members of any changes in state or federal laws relating
            to advance
            directives within 90 days from the effective date of the change, unless
            the law
            or regulation contains a specific time requirement for notification.
            

           

          8.3
            Additional STAR+PLUS Scope of Work 

           

          8.3.1
            Covered Community-Based Long-Term Care Services 

           

          The
            HMO
            must ensure that STAR+PLUS Members needing Community Long-term Care Services
            are
            identified and that services are referred and authorized in a timely
            manner. The
            HMO must ensure that Providers of Community Long-term Care Services are
            licensed
            to deliver the service they provide. The inclusion of Community Long-term
            Care
            Services in a managed care model presents challenges, opportunities and
            responsibilities. 

           

          Community
            Long-term Care Services may be necessary as a preventative service to
            avoid more
            expensive hospitalizations, emergency room visits, or institutionalization.
            Community Long-term Care Services should also be made available to Members
            to
            assure maintenance of the highest level of functioning possible in the
            least
            restrictive setting. A Member’s need for Community Long-term Care Services to
            assist with the activities of daily living must be considered as important
            as
            needs related to a medical condition. HMOs must provide Functionally
            Necessary
            Covered Services to Community Long-term Care Service Members. 

           

          8.3.1.1
            Community Based Long-Term Care Services Available to All Members

           

          The
            HMO
            shall enter into written contracts with Providers of Personal Assistance
            Services and Day Activity and Health Services (DAHS) to make them available
            to
            all STAR+PLUS Members. These Providers must at a minimum, meet all of
            the
            following state licensure and certification requirements for providing
            the
            services in Attachment
            B-2.1, Covered Services.
            

           

          Section
            8..3 added by Version 1.1 

           

          
            	
                     

                    Community
                      Long-Term Care Services Available to All Members 

                     

                  
	
                     

                    Service
                      

                     

                  	
                     

                    Licensure
                      and Certification Requirements 

                     

                  
	
                     

                    Personal
                      Attendant Services 

                     

                  	
                     

                    The
                      Provider must be licensed by the Texas Department of Human
                      Services as a
                      Home and Community Support Services Agency. The level of licensure
                      required depends on the type of service delivered. NOTE: For
                      primary home
                      care and client managed attendant care, the agency may have
                      only the
                      Personal Assistance Services level of licensure. 

                  
	
                     

                    Day
                      Activity and Health Services (DAHS) 

                  	
                     

                    The
                      Provider must be licensed by the Texas Department of Human
                      Services, Long
                      Term Care Regulatory Division, as an adult day care provider.
                      To provide
                      DAHS, the Provider must provide the range of services required
                      for DAHS.
                      

                  

          

           

          8.3.1.2
            1915(c) Nursing Facility Waiver Services Available to Members Who Qualify
            for
            1915 (c) Nursing Facility Waiver Services 

           

          The
            1915(c) Nursing Facility Waiver provides Community Long-term Care Services
            to
            Medicaid Eligibles who are elderly and to adults with disabilities as
            a
            cost-effective alternative to living in a nursing facility. These Members
            must
            be age 21 or older, be a Medicaid recipient or be otherwise financially
            eligible
            for waiver services. To be eligible for 1915(c) Nursing Facility Waiver
            Services, a Member must meet income and resource requirements for Medicaid
            nursing facility care, and receive a determination from HHSC on the medical
            necessity of the nursing facility care. The HMO must make available to
            STAR+PLUS
            Members who meet the eligibility requirements the array of services allowable
            through HHSC’s CMS-approved 1915(c) Nursing Facility Waiver (see Appendix
            B-2.1, STAR+PLUS Covered Services).
            

           

          
            	
                     

                    Community
                      Long-Term Care Services Under the 1915(c) Nursing Facility
                      Waiver 

                     

                  
	
                     

                    Service
                      

                     

                  	
                     

                    Licensure
                      and Certification Requirements 

                     

                  
	
                     

                    Personal
                      Attendant Services 

                     

                  	
                     

                    The
                      Provider must be licensed by the Texas Department of Human
                      Services as a
                      Home and Community Support Services Agency. The level of licensure
                      required depends on the type of service delivered. For Primary
                      Home Care
                      and Client Managed Attendant Care, the agency may have only
                      the Personal
                      Assistance Services level of licensure. 

                  
	
                     

                    Assisted
                      Living 

                     

                  	
                     

                    The
                      Provider must be licensed by the Texas Department of Aging
                      and Disability
                      Services, Long Term Care Regulatory Division. The type of licensure
                      determines what services may be provided. 

                  
	
                     

                    Emergency
                      Response Service Provider 

                     

                  	
                     

                    Texas
                      Department of Aging and Disability Services (DADS) Standards
                      for Emergency
                      Response Services at 40 T.A.C. §52.201(a), and be licensed by the Texas
                      Board of Private Investigators and Private Security Agencies,
                      unless
                      exempt from licensure. 

                  
	
                     

                    Adult
                      Foster Home 

                     

                  	
                     

                    TDSHS
                      Provider standards for Adult Foster Care and TDSHS Rules at
                      40 T.A.C.
                      §48.6032. Four bed homes also licensed under TDSHS Rules at
                      40 T.A.C.
                      §481.8906. 

                     

                     

                    DFPS
                      licensure in accordance with 24-hour Care Licensing requirements
                      found in
                      T.A.C., Title 40, Part 19, Chapter 720. 

                     

                  
	
                    Home
                      Delivered 

                    Meals
                      

                  	
                     

                    T.A.C.,
                      Title 40, Part 1, Chapter 55. 

                     

                  
	
                    Physical
                      

                    Therapy
                      

                  	
                     

                    Licensed
                      Physical Therapist through the Texas Board of Physical Therapy
                      Examiners,
                      Chapter 453. 

                     

                  
	
                    Occupational
                      

                    Therapy
                      

                  	
                     

                    Licensed
                      Occupational Therapist through the Texas Board of Occupational
                      Therapy
                      Examiners, Chapter 454. 

                     

                  
	
                    Speech
                      Therapy 

                  	
                     

                    Licensed
                      Speech Therapist Through the Department of State Health Services.
                      

                     

                  
	
                     

                    Consumer
                      Directed Services 

                     

                  	
                     

                    Home
                      and Community Support Services Agency (HCSSA) 

                     

                  
	
                     

                    Transition
                      Assistance Services 

                     

                  	
                     

                    No
                      licensure or certification requirements. 

                     

                  
	
                     

                    Minor
                      Home Modification 

                     

                  	
                     

                    No
                      licensure or certification requirements. 

                     

                  
	
                     

                    Adaptive
                      Aids and Medicaid Equipment 

                     

                  	
                     

                    No
                      licensure or certification requirements. 

                     

                  
	
                     

                    Medical
                      supplies 

                     

                  	
                     

                    No
                      licensure or certification requirements. 

                     

                  

          

          

           

          8.3.2
            Service Coordination 

           

          The
            HMO
            must furnish a Service Coordinator to all STAR+PLUS Members who request
            one. The
            HMO should also furnish a Service Coordinator to a STAR+PLUS Member when
            the HMO
            determines one is required through an assessment of the Member’s health and
            support needs. The HMO must ensure that each STAR+PLUS Member has a qualified
            PCP who is responsible for overall clinical direction and, in conjunction
            with
            the Service Coordinator, serves as a central point of integration and
            coordination of Covered Services, including primary, Acute Care, long-term
            care
            and Behavioral Health Services. 

           

          The
            Service Coordinator must work as a team with the PCP, and coordinate
            all
            STAR+PLUS Covered Services and any applicable Non-capitated Services with the
            PCP. This requirement applies whether or not the PCP is in the HMO’s Network, as
            some STAR+PLUS Members dually eligible for Medicare may have a PCP that
            is not
            in the HMO’s Provider Network. In order to integrate the Member’s Acute Care and
            primary care, and stay abreast of the Member’s needs and condition, the Service
            Coordinator must also actively involve and coordinate with the Member’s primary
            and specialty care providers, including Behavioral Health Service providers,
            and
            providers of Non-capitated Services. 

           

          STAR+PLUS
            Members dually eligible for Medicare will receive most prescription drug
            services through Medicare rather than Medicaid. The Texas Vendor Drug
            Program
            will pay for a limited number of medications not covered by Medicare.
            

           

          The
            HMO
            must identify and train Members or their families to coordinate their
            own care,
            to the extent of the Member’s or the family’s capability and willingness to
            coordinate care. 

           

          8.3.2.1
            Service Coordinators 

           

          The
            HMO
            must employ as Service Coordinators persons experienced in meeting the
            needs of
            vulnerable populations who have Chronic or Complex Conditions. Such Service
            Coordinators are Key HMO Personnel as described in Attachment
            A,
            HHSC’s
            Uniform Managed Care Contract Terms and Conditions, Section
            4.02,
            and must
            meet the requirements set forth in Section
            4.04.1
            of
            HHSC’s Uniform Managed Care Contract Terms and Conditions.
            

           

          8.3.2.2
            Referral to Community Organizations 

           

          The
            HMO
            must provide information about and referral to community organizations
            that may
            not be providing STAR+PLUS Covered Services, but are otherwise important
            to the
            health and well being of Members. These organizations include, but are
            not
            limited to: 

           

          
            	 	 	
                    1.
                      State/federal agencies (e.g., those agencies with jurisdiction
                      over aging,
                      public health, substance abuse, mental health/retardation,
                      rehabilitation,
                      developmental disabilities, income support, nutritional assistance,
                      family
                      support agencies, etc.); 

                  

          

           

          
            	 	 	
                    2.
                      social service agencies (e.g., Area Agencies on Aging, residential
                      support
                      agencies, independent living centers, supported employment
                      agencies,
                      etc.); 

                  

          

           

          
            	 	 	
                    3.
                      city and county agencies (e.g., welfare departments, housing
                      programs,
                      etc.); 

                  

          

           

          
            	 	 	
                    4.
                      civic and religious organizations; and

                  

          

           

          
            	 	 	
                    5.
                      consumer groups, advocates, and councils (e.g., legal aid offices,
                      consumer/family support groups, permanency planning, etc.).
                      

                  

          

           

          8.3.2.3
            Discharge Planning 

           

          The
            HMO
            must have a protocol for quickly assessing the needs of Members discharged
            from
            a Hospital or other care or treatment facility. 

           

          The
            HMO’s
            Service Coordinator must work with the Member’s PCP, the hospital discharge
            planner(s), the attending physician, the Member, and the Member’s family to
            assess and plan for the Member’s discharge. When long-term care is needed, the
            HMO must ensure that the Member’s discharge plan includes arrangements for
            receiving community-based care whenever possible. The HMO must ensure
            that the
            Member, the Member’s family, and the Member’s PCP are all well informed of all
            service options available to meet the Member’s needs in the community.

           

          8.3.2.4
            Transition Plan for New STAR+PLUS Members 

           

          The
            HMO
            must provide a transition plan for Members enrolled in the STAR+PLUS
            Program.
            HHSC, and/or the previous STAR+PLUS HMO contractor, will provide the
            HMO with
            detailed Care Plans, names of current providers, etc., for newly enrolled
            Members already receiving long-term care services at the time of enrollment.
            The
            HMO must ensure that current providers are paid for Medically Necessary
            Covered
            Services that are delivered in accordance with the Member’s existing
            treatment/long-term care services plan after the Member has become enrolled
            in
            the HMO and until the transition plan is developed. 

           

          The
            transition planning process must include, but is not limited to, the
            following:

           

          
            	 	 	
                    1.
                      review of existing DADS long-term care services plans;
                      

                  

          

           

          
            	 	 	
                    2.
                      preparation of a transition plan that ensures continuous care
                      under the
                      Member’s existing Care Plan during the transfer into the HMO’s Network
                      while the HMO conducts an appropriate assessment and development
                      of a new
                      plan, if needed; 

                  

          

           

          
            	 	 	
                    3.
                      if durable medical equipment or supplies had been ordered prior
                      to
                      enrollment but have not been received by the time of enrollment,
                      coordination and follow-through to ensure that the Member receives
                      the
                      necessary supportive equipment and supplies without undue delay;
                      and
                      

                  

          

           

          
            	 	 	
                    4.
                      payment to the existing provider of service under the existing
                      authorization until the HMO has completed the assessment and
                      service plans
                      and issued new authorizations. 

                  

          

           

          The
            HMO
            must review any existing care plan and develop a transition plan within
            30 days
            of receiving the Member’s enrollment. The transition plan will remain in place
            until the HMO contacts the Member and coordinates modifications to the
            Member’s
            current treatment/long-term care services plan. The HMO must ensure that
            the
            existing services continue and that there are no breaks in services.
            For initial
            implementation of the STAR+PLUS program in a Service Area, the HMO must
            complete
            this process within 90-days of the Member’s enrollment. 

           

          The
            HMO
            must ensure that the Member is involved in the assessment process and
            fully
            informed about options, is included in the development of the care plan,
            and is
            in agreement with the plan when completed. 

           

          8.3.2.5
            Centralized Medical Record and Confidentiality 

           

          The
            Service Coordinator shall be responsible for maintaining a centralized
            record
            related to Member contacts, assessments and service authorizations. The
            HMO
            shall ensure that the organization of and documentation included in the
            centralized Member record meets all applicable professional standards
            ensuring
            confidentiality of Member records, referrals, and documentation of information.
            

           

          The
            HMO
            must have a systematic process for generating or receiving referrals
            and sharing
            confidential medical, treatment, and planning information across providers.
            

           

          Section
            8.3.2.4 Modified by Version 1.5 

           

          8.3.2.6
            Nursing Facilities 

           

          Nursing
            facility care, although a part of the care continuum, presents a challenge
            for
            managed care. Because of the process for becoming eligible for Medicaid
            assistance in a nursing facility, there is frequently a significant time
            gap
            between entry into the nursing home and determination of Medicaid eligibility.
            During this gap from entry to Medicaid eligibility, the resident has
“nested” in
            the facility and many of the community supports are no longer available.
            To
            require participation of all nursing facility residents would result
            in the HMO
            maintaining a Member in the nursing facility without many options for
            managing
            their health. For this reason, persons who qualify for Medicaid as a
            result of
            nursing facility residency are not enrolled in STAR+PLUS. 

           

          The
            STAR+PLUS HMO must participate in the Promoting Independence initiative
            for such
            individuals. Promoting Independence (PI) is a philosophy that aged and
            disabled
            individuals remain in the most integrated setting to receive long-term
            care
            services. PI is Texas' response to the U.S. Supreme Court ruling in Olmstead
            v. L.C.
            that
            requires states to provide community-based services for persons with
            disabilities who would otherwise be entitled to institutional services,
            when:

           

          
            	 	 	
                    •
                      the state's treatment professionals determine that such placement
                      is
                      appropriate; 

                  

          

           

          
            	 	 	
                    •
                      the affected persons do not oppose such treatment; and
                      

                  

          

           

          
            	 	 	
                    •
                      the placement can be reasonably accommodated, taking into account
                      the
                      resources available to the state and the needs of others who
                      are receiving
                      state supported disability services.

                  

          

           

          In
            accordance with legislative direction, the HMO must designate a point
            of contact
            to receive referrals for nursing facility residents who may potentially
            be able
            to return to the community through the use of 1915(c) Nursing Facility
            Waiver
            services. To be eligible for this option, an individual must reside in
            a nursing
            facility until a written plan of care for safely moving the resident
            back into a
            community setting has been developed and approved. 

           

          A
            STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS
            Member
            for a total of four months. The nursing facility will bill the state
            directly
            for covered nursing facility services delivered while the Member is in
            the
            nursing facility. See Section
            8.3.2.7
            for
            further information. 

           

          The
            HMO
            is responsible for the Member at the time of nursing facility entry and
            must
            utilize the Service Coordinator staff to complete an assessment of the
            Member
            within 30 days of entry in the nursing facility, and develop a plan of
            care to
            transition the Member back into the community if possible. If at this
            initial
            review, return to the community is possible, the Service Coordinator
            will work
            with the resident and family to return the Member to the community using
            1915(c)
            Waiver Services. 

           

          If
            the
            initial review does not support a return to the community, the Service
            Coordinator will conduct a second assessment 90 days after the initial
            assessment to determine any changes in the individual’s condition or
            circumstances that would allow a return to the community. The Service
            Coordinator will develop and implement the transition plan. 

           

          The
            HMO
            will provide these services as part of the Promoting Independence initiative.
            The HMO must maintain the documentation of the assessments completed
            and make
            them available for state review at any time. 

           

          It
            is
            possible that the STAR+PLUS HMO will be unaware of the Member’s entry into a
            nursing facility. It is the responsibility of the nursing facility to
            review the
            Member’s Medicaid card upon entry into the facility and notify the HMO. The
            nursing facility is also required to notify HHSC of the entry of a new
            resident.
 

           

          8.3.2.7
            HMO Four-Month Liability for Nursing Facility Care 

           

          A
            STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS
            Member
            for a total of four months. The four months do not have to be consecutive.
            Upon
            completion of four months of nursing facility care, the individual will
            be
            disenrolled from the STAR+PLUS Program and the Medicaid Fee-for-Service
            program
            will provide Medicaid benefits. A STAR+PLUS Member may not change HMOs
            while in
            a nursing facility. 

           

          Tracking
            the four months of liability is done through a counter system. The four-month
            counter starts with the Medicaid admission or on the 21st day of a Medicare
            stay. A partial month counts as a full month. In other words, the month
            in which
            the Medicaid admission occurs or the month on which the 21st day of the
            Medicare
            stay occurs, is counted as one of the four months. 

           

          An
            amount
            will be included in the capitation rates to cover the cost of four months
            of
            nursing facility services (based upon experience from STAR+PLUS in Harris
            County) for the historical average number of admissions to nursing facilities.
            Nursing facility costs for STAR+PLUS in Harris County have accounted
            for less
            than one percent of premiums in recent years. HHSC believes that these
            costs
            will not deviate substantially from this experience. 

           

          The
            HMO
            will be liable for the cost of care in a nursing facility care and, for
            Medicaid-only Members, the cost of all other Covered Services. The HMO
            will not
            maintain nursing facilities in its Network and will not reimburse the
            nursing
            facilities directly. Nursing facilities will use the traditional Fee-for-Service
            system of billing HHSC rather than billing the HMO. The HMO's liability
            will be
            established based on the amount paid through the Fee-for-Service billing
            system
            on behalf of the Member. HHSC will recoup those costs from the HMO by
            an offset
            to the monthly Capitation Payment. The offset will be recognized as a
            nursing
            facility expense.. The HMO will record the nursing facility liability
            recoupment
            as nursing facility expense on its Financial-Statistical Reports (FSR).
            The HMO
            will be responsible for direct payment of all non-nursing facility Medicaid
            expenses on behalf of the Member. 

           

          8.3.3
            STAR+PLUS Assessment Instruments 

           

          The
            HMO
            must have and use functional assessment instruments to identify Members
            with
            significant health problems, Members requiring immediate attention, and
            Members
            who need or are at risk of needing long-term care services. The HMO,
            a
            subcontractor, or a Provider may complete assessment instruments, but
            the HMO
            remains responsible for the data recorded. 

           

          HMOs
            must
            use the DHS Form 2060, as amended or modified, to assess a Member’s need for
            Functionally Necessary Personal Attendant Services. The HMO may adapt
            the form
            to reflect the HMO’s name or distribution instructions, but the elements must be
            the same and instructions for completion must be followed without amendment.
            

           

          The
            DHS
            Form 2060 must be completed if a need or a change in Personal Attendant
            Services
            is warranted at the initial contact, at the annual reassessment, and
            anytime a
            Member requests the services or requests a change in services. The DHS
            Form 2060
            must also be completed if the HMO determines the Member requires the
            services or
            requires a change in the Personal Attendant Services that are authorized.
            

           

          For
            Members and applicants seeking or needing the 1915(c) Nursing Facility
            Waiver
            services, the HMOs must use the DADS CARE Form 3652, as amended or modified,
            to
            assess Members and to supply current medical information for Medical
            Necessity
            determinations. The HMO must also complete the Individual Service Plan
            (ISP),
            Form 3671 for each Member receiving 1915(c) Nursing Facility Waiver Services.
            The ISP is established for a one-year period. After the initial ISP is
            established, the ISP must be completed on an annual basis and the end
            date or
            expiration date does not change. Both of these forms (Form 3652 and Form
            3671)
            must be completed annually at reassessment. The HMO is responsible for
            tracking
            the end dates of the ISP to ensure that the Member is reassessed prior
            to the
            expiration date. Note that the DADS CARE Form 3652 cannot be submitted
            earlier
            than 90 days prior to the expiration date of the ISP. 

           

          HHSC
            has
            adopted a Minimum Data Set for Home Care (MDS-HC), which can be found
            in the
            HHSC Uniform Managed Care Manual. HHSC may adopt new versions of this
            instrument
            as appropriate or as directed by CMS. The MDS-HC instrument must be completed
            and electronically submitted to HHSC in the specified format within 30
            days of
            enrollment for every Member receiving Community-based Long-term Care
            Services,
            and then each year by the anniversary of the Member’s date of enrollment.

           

          The
            MDS-HC instrument must be completed and electronically submitted to HHSC
            in the
            specified format within 30 days of enrollment for every Member receiving
            Community-based Long-term Care Services. Because of the large number
            of Members
            the HMOs will be receiving initially during the implementation period
            of the
            STAR+PLUS Program, HHSC is allowing the following: 

           

          
            	 	 	
                    •
                      For the 1915(c) Nursing Facility Waiver Members, the MDS-HC
                      instrument
                      must be completed in conjunction with the annual reassessment.
                      The MDS-HC
                      instrument must be completed annually at the time of reassessment
                      for
                      these Members. 

                  

          

           

            •
For
            the non-1915(c)
            Nursing Facility Waiver Members that are receiving Community-based Long-term
            Care Services, the HMO must submit a schedule for HHSC’s approval that provides
            a plan of how the MDS-HC instruments will be completed for these Members
            over a
            twelve-month period beginning on February 1, 2007. 

           

          In
            addition to submitting the MDS-HC instrument to HHSC, the HMO may also
            submit
            other supplemental assessment instruments it elects to use. As specialized
            MDS
            instruments are developed or adopted by HHSC for other living arrangements
            (e.g., assisted living), HHSC will notify HMO of the availability of
            the
            instrument and the date the HMO is required to begin using such instrument
            in
            the HHSC Uniform Managed Care Manual. Any additional assessment instruments
            used
            by the HMO must be approved by HHSC. 

           

          Section
            8.3.3 Modified by Version 1.5 

           

          Section
            8.3.3 Modified by Version 1.6 

           

          8.3.4
            1915(c) Nursing Facility Waiver Service Eligibility 

           

          Recipients
            of 1915(c) Nursing Facility Waiver services must meet nursing facility
            criteria
            for participation in the waiver and must have a plan of care at initial
            determination of eligibility in which the plan’s annualized cost is equal to or
            less than the annualized cost of care if the individual were to enter
            a nursing
            facility. 

           

          8.3.4.1
            For Members 

           

          The
            HMO
            must notify HHSC when it initiates 1915(c) Nursing Facility Waiver eligibility
            testing on a STAR+PLUS Member. The HMO must apply risk criteria, complete
            the
            Form 3652 for Medical Necessity determination, complete the assessment
            documentation, and prepare a 1915(c) Nursing Facility Waiver Individual
            Service
            Plan (ISP) for each Member requesting 1915(c) Nursing Facility Waiver
            services
            and for Members the HMO has identified as needing 1915(c) Nursing Facility
            Waiver services. The HMO must provide HHSC the results of the assessment
            activities within 45 days of initiating the assessment process. 

           

          HHSC
            will
            notify the Member and the HMO of the eligibility determination, which
            will be
            based on the information provided by the HMO. If the STAR+PLUS Member
            is
            eligible for 1915(c) Nursing Facility Waiver services, HHSC will notify
            the
            Member of the effective date of eligibility. If the Member is not eligible
            for
            1915(c) Nursing Facility Waiver services, HHSC will provide the Member
            information on right to Appeal the Adverse Determination. Regardless
            of the
            1915(c) Nursing Facility Waiver eligibility determination, HHSC will
            send a copy
            of the Member notice to the HMO. 

           

          8.3.4.2
            For Medical Assistance Only (MAO) Non-Member Applicants 

           

          Non-Member
            persons who are not eligible for Medicaid in the community may apply
            for
            participation in the 1915(c) Nursing Facility Waiver program under the
            financial
            and functional eligibility requirements for MAO. HHSC will inform the
            applicant
            that services are provided through an HMO and allow the applicant to
            select the
            HMO. HHSC will authorize the selected HMO to initiate pre-enrollment
            assessment
            services required under the 1915(c) Nursing Facility Waiver for the non-member.
            The HMO must complete Form 3652 for Medical Necessity determination,
            complete
            the assessment documentation, and prepare a 1915(c) Nursing Facility
            Waiver
            service plan for each applicant referred by HHSC. The initial home visit
            with
            the applicant must occur within 14 days of the receipt of the referral.
            The HMO
            must provide HHSC the results of the assessment activities within 45
            days of the
            receipt of the referral. 

           

          HHSC
            will
            notify the applicant and the HMO of the results of its eligibility
            determination. If the applicant is eligible, HHSC will notify the applicant
            and
            the HMO will be notified of the effective date of eligibility, which
            will be the
            first day of the month following the determination of eligibility. The
            HMO must
            initiate the Individual Service Plan (ISP) on the date of enrollment.
            

           

          Section
            8.3.4 modified by Version 1.5 

           

          If
            the
            applicant is not eligible, the HHSC notice will provide information on
            the
            applicant’s right to Appeal the Adverse Determination. HHSC will also send
            notice to the HMO if the applicant is not eligible for 1915(c) Nursing
            Facility
            Waiver services. 

           

          8.3.4.3
            Annual Reassessment 

           

          Prior
            to
            the end date of the annual ISP, the HMO must initiate an annual reassessment
            to
            determine and validate continued eligibility for 1915(c) Nursing Facility
            Waiver
            services for each Member receiving such services. The HMO will be expected
            to
            complete the same activities for the annual reassessment as required
            for the
            initial eligibility determination, with the following exception: the
            HMO does
            not need to obtain a physician’s signature on the Form 3652 for the annual
            reassessment. . Existing 1915(c) Nursing Facility Waiver clients may
            not be
            denied 1915(c) Nursing Facility Waiver services solely on the basis that
            the
            proposed cost of the ISP will exceed the cost of care if the Member were
            in a
            nursing home if the following conditions are met: 

           

            1.
            those services are
            required for that individual to live in the most integrated setting appropriate
            to his or her needs; 

           

          
            	 	 	
                    2.
                      the cost for the needed services, averaged and excluding the
                      cost of minor
                      home modifications and adaptive aids, does not exceed 133.3%
                      of the
                      Nursing Facility Cost Ceiling; and 

                  

          

           

          
            	 	 	
                    3.
                      HHSC continues to comply with the cost-effectiveness requirements
                      from the
                      CMS. 

                  

          

           

          If
            an
            ongoing client has a change in needs that would cause the cost for needed
            services, under the client's ISP, to exceed 100% of the cost ceiling,
            the HMO
            with HHSC approval may consider the client's request if there is a change
            in:

           

          
            	 	 	
                    1.
                      the client's medical condition, functional needs, or environment;
                      

                  

          

           

          
            	 	 	
                    2.
                      the caregiver support or third-party resources that have been
                      providing
                      service to the client; or 

                  

          

           

          
            	 	 	
                    3.
                      the need for a service or support to adequately support the
                      client living
                      in the most integrated setting appropriate to his or her needs.
                      

                  

          

           

          If
            the
            client's needs cannot be met within the cost limit of 133% described
            above, then
            the client is no longer eligible for services, unless the client meets
            the
            criteria in the next paragraph. All available non-waiver support systems
            and
            resources must be accessed in the development of the ISP. 

           

          HMO
            will
            continue services to those individuals receiving services in a waiver
            program,
            when continuation of the services is necessary for the individual to
            live in the
            most integrated setting appropriate to his or her needs and HHSC continues
            to
            comply with CMS cost-effectiveness requirements. 

           

          Individuals
            receiving waiver services through the Medically Dependent Children Program
            are
            covered by the provisions in this Section when they apply for transition
            to the
            1915(c) waiver program at age 21. 

           

          8.3.5
            Personal Attendant Services 

           

          Section
            8.3.4.3 Modified by Version 1.5 

           

          There
            are
            three options available to STAR+PLUS Members desiring the delivery of
            Personal
            Attendant Services (PAS): 1) Self-Directed; 2) Agency Model, Self-Directed;
            and
            3) Agency Model. The HMO must provide information to all eligible Members
            on the
            three options and must provide Member orientation in the option selected
            by the
            Member. The HMO will provide the information to any STAR+PLUS Member
            receiving
            Personal Attendant Services: 

           

          
            	 	 	
                    •
                      at initial assessment; 

                  

          

           

          
            	 	 	
                    •
                      at annual reassessment or annual contact with the STAR+PLUS
                      Member;
                      

                  

          

           

          
            	 	 	
                    •
                      at any time when a STAR+PLUS Member receiving PAS requests
                      the
                      information; and 

                  

          

           

          
            	 	 	
                    •
                      in the Member Handbook. 

                  

          

           

          The
            HMO
            must contract with providers who are able to offer PAS and must also
            educate/train the HMO Network Providers regarding the three PAS options.
            To
            participate as a PAS Network Provider, the Provider must have a contract
            with
            DADS for the delivery of PAS. The HMO must assure compliance with the
            Texas
            Administrative Code in Title 40, Part 1, Chapter 41, Sections 41.101,
            41.103,
            and 41.105. The HMO must include the requirements in the Provider Manual
            and in
            the STAR+PLUS Provider training. 

           

          8.3.5.1
            Personal Attendant Services Delivery Option - Self-Directed
            Model 

           

          In
            the
            Self-Directed Model, the Member or the Member’s legal guardian is the employer
            of record and retains control over the hiring, management, and termination
            of an
            individual providing Personal Attendant Services. The Member is responsible
            for
            assuring that the employee meets the requirements for Personal Attendant
            Services, including the criminal history check. The Member uses a Home
            and
            Community Support Services (HCSS) agency to handle the employer-related
            administrative functions such as payroll, substitute (back-up), and filing
            tax-related reports of Personal Attendant Services. 

           

          8.3.5.2
            Personal Attendant Services Delivery Option - Agency Model,
            Self-Directed  

           

          In
            the
            Agency Model, Self-Directed, the Member or the Member’s legal guardian chooses a
            Home and Community Support Services (HCSS) agency in the HMO Provider
            Network
            who is the employer of record. In this model, the Member selects the
            personal
            attendant from the HCSS agency’s personal attendant employees. The personal
            attendant’s schedule is set up based on the Member input, and the Member manages
            the Personal Attendant Services. The Member retains the right to supervise
            and
            train the personal attendant. The Member may request a different personal
            attendant and the HCSS agency would be expected to honor the request.
            The HCSS
            agency establishes the payment rate, benefits, and provides all administrative
            functions such as payroll, substitute (back-up), and filing tax-related
            reports
            of personal attendant services. 

           

          8.3.5.3
            Personal Attendant Services Delivery Option - Agency Model 

           

          In
            the
            Agency Model, the Member chooses a Home and Community Support Services
            (HCSS)
            agency to hire, manage, and terminate the individual providing Personal
            Attendant Services. The HCSS agency is selected by the Member from the
            HCSS
            agencies in the HMO Provider Network. The Service Coordinator and Member
            develop
            the schedule and send it to the HCSS agency. The Member retains the right
            to
            supervise and train the personal attendant. The Member may request a
            different
            personal attendant and the HCSS agency would be expected to honor the
            request.
            The HCSS agency establishes the payment rate, benefits, and provides
            all
            administrative functions such as payroll, substitute (back-up), and filing
            tax-related reports of personal attendant services. 

           

          Section
            8.3.5 replaced by Version 1.5 

           

          8.3.6
            Community Based Long-term Care Service Providers 

           

          8.3.6.1
            Training 

           

          The
            HMO
            must comply with Section 8.1.4.6 regarding Provider Manual and Provider
            training
            specific to the STAR+PLUS Program. The HMO must train all Community Long-term
            Care Service Providers regarding the requirements of the Contract and
            special
            needs of STAR+PLUS Members. The HMO must establish ongoing STAR+PLUS
            Provider
            training addressing the following issues at a minimum: 

           

          
            	 	 	
                    1.
                      Covered Services and the Provider’s responsibilities for providing such
                      services to STAR+PLUS Members and billing the HMO for such
                      services. The
                      HMO must place special emphasis on Community Long-term Care
                      Services and
                      STAR+PLUS requirements, policies, and procedures that vary
                      from Medicaid
                      Fee-for-Service and commercial coverage rules, including payment
                      policies
                      and procedures. 

                  

          

           

          
            	 	 	
                    2.
                      Inpatient Stay hospital services and the authorization and
                      billing of such
                      services for STAR+PLUS Members. 

                  

          

           

          
            	 	 	
                    3.
                      Relevant requirements of the STAR+PLUS Contract, including
                      the role of the
                      Service Coordinator; 

                  

          

           

          
            	 	 	
                    4.
                      Processes for making referrals and coordinating Non-capitated
                      Services;
                      

                  

          

           

          
            	 	 	
                    5.
                      The HMO’s quality assurance and performance improvement program and
                      the
                      Provider’s role in such programs; and

                  

          

           

          
            	 	 	
                    6.
                      The HMO’s STAR+PLUS policies and procedures, including those relating
                      to
                      Network and Out-of-Network referrals.

                  

          

           

          8.3.7.2
            LTC Provider Billing 

           

          Long-term
            care providers are not required to utilize the billing systems that most
            medical
            facilities use on a regular basis. For this reason, the HMO must make
            accommodations to the claims processing system for such providers to
            allow for a
            smooth transition from traditional Medicaid to Managed Care Medicaid.
            

           

          HHSC
            will
            meet with HMOs to develop a standardized method long-term care billing.
            All
            STAR+PLUS HMOs will be required to utilize the standardized method, which
            will
            be incorporated into the HHSC
            Uniform Managed Care Manual.
            

           

          8.3.7.3
            Rate Enhancement Payments for Agencies Providing Attendant Care

           

          All
            HMOs
            participating in the STAR+PLUS program must allow their Long-term Support
            Services (LTSS) Providers to participate in the STAR+PLUS Attendant Care
            Enhancement Program if the providers are currently participating in the
            enhanced
            payment program with the Department of Aging and Disability Services
            (DADS).
            HMOs may choose not to offer participation to DADS-contracted providers
            who do
            not currently participate in the enhancement program. Additionally, HMOs
            may
            choose to include Providers in the network who do not participate in
            the
            enhanced payment program. 

           

          Section
            8.3.7.3 modified by Version 1.5 

           

          Attachment
            B-7,
            STAR+PLUS Attendant Care Enhanced Payment Methodology explains the methodology
            that the STAR+PLUS HMO will use to implement and pay the enhanced payments,
            including a description of the timing of the payments, in accordance
            with the
            requirements in the Uniform
            Managed Care Manual
            and the
            intent of the 2000-01 General Appropriations Act (Rider 27, House Bill
            1,
            76th
            Legislature, Regular Session, 1999) and T.A.C. Title 1, Part 15, Chapter
            355.

           

          8.3.7.4
            Payment for 1915(c) Nursing Facility Waiver Services for Non-Members
            

           

          Disenrolled
            Members:
            Occasionally, the Social Security Administration will place SSI recipients
            on
            hold for a short period of time, usually due failure to provide timely
            updates
            required for the continuation of SSI benefits. During this period, the
            recipients will not appear to be eligible for Medicaid or 1915(c) Nursing
            Facility Waiver services. Often the Social Security Administration reinstates
            these Medicaid Eligibles retroactively without a break in Medicaid coverage.
            To
            deal with this situation, for at least thirty (30) days after disenrollment,
            the
            HMO will continue to authorize and pay for 1915(c) Nursing Facility Waiver
            services for disenrolled STAR+PLUS Members who appear to lose eligibility
            due to
            an administrative problem related to SSI. If at the end of the thirty
            (30) days,
            the Medicaid Eligible’s 1915(c) Nursing Facility Waiver eligibility is
            reinstated, the Medicaid Eligible will be manually enrolled into the
            STAR+PLUS
            HMO back to the date of disenrollment and the retroactive adjustment
            system will
            properly reimburse the HMO. If after thirty (30) days, the former STAR+PLUS
            Member continues to be ineligible for Medicaid, the individual will not
            be
            retroactively enrolled, and the HMO will bill HHSC for 1915(c) Nursing
            Facility
            Waiver services rendered during this time. 

           

          8.4
            Additional CHIP Scope of Work 

           

          The
            following provisions only apply to HMOs participating in CHIP. 

           

          8.4.1
            CHIP Provider Network 

           

          In
            each
            Service Area, the HMO must seek to obtain the participation in its Provider
            Network of CHIP Significant Traditional Providers (STPs), defined by
            HHSC as PCP
            Providers currently serving the CHIP population and DSH hospitals. The
            Procurement Library includes CHIP STPs by Service Area. 

           

          The
            HMO
            must give STPs the opportunity to participate in its Network if the STPs:
            

           

          
            	 	 	
                    1.
                      Agree to accept the HMO’s Provider reimbursement rate for the provider
                      type; and 

                  

          

           

          
            	 	 	
                    2.
                      Meet the standard credentialing requirements of the HMO, provided
                      that
                      lack of board certification or accreditation by the Joint Commission
                      on
                      Accreditation of Health Care Organizations (JCAHO) is not the
                      sole grounds
                      for exclusion from the Provider Network.

                  

          

           

          8.4.2
            CHIP Provider Complaint and Appeals 

           

          CHIP
            Provider Complaints and Appeals are subject to disposition consistent
            with the
            Texas Insurance Code and any applicable TDI regulations. The HMO must
            resolve
            Provider Complaints within 30 days from the date the Complaint is
            received.

           

          8.4.3
            CHIP Member Complaint and Appeal Process 

           

          CHIP
            Member Complaints and Appeals are subject to disposition consistent with
            the
            Texas Insurance Code and any applicable TDI regulations. HHSC will require
            the
            HMO to resolve Complaints and Appeals (that are not elevated to TDI)
            within 30
            days from the date the Complaint or Appeal is received. The HMO is subject
            to
            remedies, including liquidated damages, if at least 98 percent of Member
            Complaints or Member Appeals are not resolved within 30 days of receipt
            of the
            Complaint or Appeal by the HMO. Please see the Uniform
            Managed Care Contract Terms & Conditions and
            Attachment B-5, Deliverables/Liquidated Damages Matrix. Any
            person, including those dissatisfied with a HMO’s resolution of a Complaint or
            Appeal, may report an alleged violation to TDI. 

           

          8.4.4
            Dental Coverage for CHIP Members 

           

          The
            HMO
            is not responsible for reimbursing dental providers for preventive and
            therapeutic dental services obtained by CHIP Members. However, medical
            and/or
            hospital charges, such as anesthesia, that are necessary in order for
            CHIP
            Members to access standard therapeutic dental services, are Covered Services
            for
            CHIP Members. The HMO must provide access to facilities and physician
            services
            that are necessary to support the dentist who is providing dental services
            to a
            CHIP Member under general anesthesia or intravenous (IV) sedation. 

           

          The
            HMO
            must inform Network facilities, anesthesiologists, and PCPs what authorization
            procedures are required, and how Providers are to be reimbursed for the
            preoperative evaluations by the PCP and/or anesthesiologist and for the
            facility
            services. For dental-related medical Emergency Services, the HMO must
            reimburse
            in-network and Out-of-Network providers in accordance with federal and
            state
            laws, rules, and regulations. 

           

          8.5
            Additional CHIP Perinatal Scope of Work 

           

          The
            following provisions only apply to HMOs participating in CHIP Perinatal Program.

           

          8.5.1
            CHIP Perinatal Provider Network 

           

          In
            each
            Service Area, the CHIP Perinatal HMO must seek to obtain the participation
            of
            Providers for CHIP Perinate Members. CHIP Perinatal HMOs are encouraged
            to
            obtain the participation of Obstetricians/Gynecologists (OB/GYNs), Family
            Practice Physicians with experience in prenatal care, or other qualified
            health
            care Providers as CHIP Perinate Providers. 

           

          Section
            8.4.2 modified by Version 1.2 

           

          Section
            8.5 added by Version 1.3 

           

          See
            Sections 8.1.3.2, Access to Network Providers, and 8.1.4.2, Primary Care
            Providers, regarding distinctions in the provider networks for CHIP Perinates
            and CHIP Perinate Newborns. 

           

          8.5.2
            CHIP Perinatal Program Provider Complaint and Appeals 

           

          CHIP
            Perinatal Program Provider Complaints and Appeals are subject to disposition
            consistent with the Texas Insurance Code and any applicable TDI regulations.
            The
            HMO must resolve Provider Complaints within 30 days from the date the
            Complaint
            is received. 

           

          8.5.3
            CHIP Perinatal Program Member Complaint and Appeal Process

           

          CHIP
            Perinatal Program Member Complaints and Appeals are subject to disposition
            consistent with the Texas Insurance Code and any applicable TDI regulations.
            HHSC will require the HMO to resolve Complaints and Appeals (that are
            not
            elevated to TDI) within 30 days from the date the Complaint or Appeal
            is
            received. Any person, including those dissatisfied with a HMO’s resolution of a
            Complaint or Appeal, may report an alleged violation to TDI. 

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          Responsible
            Office: HHSC Office of General Counsel (OGC) Subject:
            Attachment B-1 - HHSC Joint Medicaid/CHIP HMO RFP, Section 9 Version
            1.6 

          

          
            	
                    DOCUMENT
                      HISTORY LOG 

                  
	
                    STATUS1

                  	
                    DOCUMENT
                      

                    REVISION2

                  	
                    EFFECTIVE
                      

                    DATE
                      

                  	
                    DESCRIPTION3

                  
	
                     

                    Baseline
                      

                     

                  	
                     

                    n/a
                      

                     

                  	
                     

                     

                     

                  	
                     

                    Initial
                      version Attachment B-1, Section 7 

                     

                  
	
                    Revision
                      

                  	
                    1.1
                      

                  	
                    June
                      30, 2006 

                  	
                    Contract
                      amendment to include STAR+PLUS program. No change to this Section.
                      

                     

                  
	
                    Revision
                      

                  	
                    1.2
                      

                  	
                    September
                      1, 2006 

                  	
                    Contract
                      amendment did not revise Attachment B-1 Section 9 - Turnover
                      Requirements
                      

                     

                  
	
                    Revision
                      

                  	
                    1.3
                      

                  	
                    September
                      1, 2006 

                  	
                    Contract
                      amendment did not revise Attachment B-1 Section 9 - Turnover
                      Requirements
                      

                     

                  
	
                    Revision
                      

                  	
                    1.4
                      

                  	
                    September
                      1, 2006 

                  	
                    Contract
                      amendment did not revise Attachment B-1 Section 9 - Turnover
                      Requirements
                      

                     

                  
	
                    Revision
                      

                  	
                    1.5
                      

                  	
                    January
                      1, 2007 

                  	
                    Contract
                      amendment did not revise Attachment B-1 Section 9 - Turnover
                      Requirements
                      

                     

                  
	
                    Revision
                      

                  	
                    1.6
                      

                  	
                    February
                      1, 2007 

                  	
                    Contract
                      amendment did not revise Attachment B-1 Section 9 - Turnover
                      Requirements
                      

                     

                  
	
                     

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

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

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

                     

                  

          

           

          

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          9.
            Turnover Requirements  

           

          9.1
            Introduction  

           

          This
            section presents the Turnover Requirements to which the HMO must agree.
            Turnover
            is defined as those activities that are required for the HMO to perform
            upon
            termination of the Contract in situations in which the HMO must transition
            Contract operations to HHSC or a subsequent Contractor. 

           

          9.2
            Transfer of Data  

           

          The
            HMO
            must transfer all data regarding the provision of Covered Services to
            Members to
            HHSC or a new HMO, at the sole discretion of HHSC and as directed by
            HHSC. All
            transferred data must be compliant with HIPAA. 

           

          All
            relevant data must be received and verified by HHSC or the subsequent
            Contractor. If HHSC determines that not all of the data regarding the
            provision
            of Covered Services to Members was transferred to HHSC or the subsequent
            Contractor, as required, or the data is not HIPAA compliant, HHSC reserves
            the
            right to hire an independent contractor to assist HHSC in obtaining and
            transferring all the required data and to ensure that all the data are
            HIPAA
            compliant. The reasonable cost of providing these services will be the
            responsibility of the HMO. 

           

          9.3
            Turnover Services  

           

          Six
            months prior to the end of the Contract Period, including any extensions
            to such
            Period, the HMO must propose a Turnover Plan covering the possible turnover
            of
            the records and information maintained to either the State or a successor
            HMO.
            The Turnover Plan must be a comprehensive document detailing the proposed
            schedule, activities, and resource requirements associated with the turnover
            tasks. The Turnover Plan must be approved by HHSC. 

           

          As
            part
            of the Turnover Plan, the HMO must provide HHSC with copies of all relevant
            Member and service data, documentation, or other pertinent information
            necessary, as determined by the HHSC, for HHSC or a subsequent Contractor
            to
            assume the operational activities successfully. This includes correspondence,
            documentation of ongoing outstanding issues, and other operations support
            documentation. The plan will describe the HMO’s approach and schedule for
            transfer of all data and operational support information, as applicable.
            The
            information must be supplied in media and format specified by the State
            and
            according to the schedule approved by the State. 

           

          HHSC
            is
            not limited or restricted in the ability to require additional information
            from
            the HMO or modify the turnover schedule as necessary. 

           

          9.4
            Post-Turnover Services  

           

          Thirty
            (30) days following turnover of operations, the HMO must provide HHSC
            with a
            Turnover Results report documenting the completion and results of each
            step of
            the Turnover Plan. Turnover will not be considered complete until this
            document
            is approved by HHSC. 

           

          If
            the
            HMO does not provide the required relevant data and reference tables,
            documentation, or other pertinent information necessary for HHSC or the
            subsequent Contractor to assume the operational activities successfully,
            the HMO
            agrees to reimburse the State for all reasonable costs, including, but
            not
            limited to, transportation, lodging, and subsistence for all state and
            federal
            representatives, or their agents, to carry out their inspection, audit,
            review,
            analysis, reproduction and transfer functions at the location(s) of such
            records. 

           

          The
            HMO
            also agrees to pay any and all additional costs incurred by the State
            that are
            the result of the HMO’s failure to provide the requested records, data or
            documentation within the time frames agreed to in the Turnover Plan.
            

           

          The
            HMO
            must maintain all files and records related to Members and Providers
            for five
            years after the date of final payment under the Contract or until the
            resolution
            of all litigation, claims, financial management review or audit pertaining
            to
            the Contract, whichever is longer. The HMO agrees to repay any valid,
            undisputed
            audit exceptions taken by HHSC in any audit of the Contract. 

           

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        

          Contractual
            Document (CD) Responsible Office: HHSC Office of General Counsel (OGC)
            

          Subject:
            Attachment B-2 - Covered Services 

          Version
            1.6 

          
             

            
              	
                      DOCUMENT
                        HISTORY LOG 

                    
	
                      STATUS1

                    	
                      DOCUMENT
                        

                      REVISION2

                    	
                      EFFECTIVE
                        

                      DATE
                        

                    	
                      DESCRIPTION3

                    
	
                       

                      Baseline
                        

                       

                    	
                       

                      n/a
                        

                       

                    	
                       

                       

                       

                    	
                       

                      Initial
                        version Attachment B-2, Covered Services 

                       

                    
	
                       

                      Revision
                        

                    	
                       

                      1.1
                        

                    	
                       

                      June
                        30, 2006 

                    	
                       

                      Revised
                        Attachment B-2, Covered Services, by adding Attachment B-2.1,
                        STAR+PLUS
                        Covered Services. 

                       

                       

                    
	
                       

                      Revision
                        

                    	
                       

                      1.2
                        

                    	
                       

                      September
                        1. 2006 

                    	
                       

                      Revised
                        Attachment B-2 to include provisions applicable to MCOs participating
                        in
                        the STAR and CHIP Programs. 

                       

                      STAR
                        Covered Services, Services Included under the HMO Capitation
                        Payment, is
                        modified to clarify the STAR covered services related to
“optometry” and
                        “vision.” 

                       

                      CHIP
                        Covered Services is modified to correct services related
                        to artificial
                        aids including surgical implants. 

                    
	
                       

                      Revision
                        

                    	
                       

                      1.3
                        

                    	
                       

                      September
                        1, 2006 

                    	
                       

                      Contract
                        amendment did not revise Attachment B-2, Covered Services.
                        

                    
	
                       

                      Revision
                        

                    	
                       

                      1.4
                        

                    	
                       

                      September
                        1, 2006 

                    	
                       

                      Contract
                        amendment did not revise Attachment B-2, Covered Services.
                        

                    
	
                       

                      Revision
                        

                    	
                       

                      1.5
                        

                    	
                       

                      January
                        1, 2007 

                    	
                       

                      Contract
                        amendment did not revise Attachment B-2, Covered Services.
                        

                    
	
                       

                      Revision
                        

                    	
                       

                      1.6
                        

                    	
                       

                      February
                        1, 2007 

                    	
                       

                      Contract
                        amendment did not revise Attachment B-2, Covered Services.
                        

                    
	
                       

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

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

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

                    

            

            

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

            STAR
              Covered Services 

             

            The
              following is a non-exhaustive, high-level listing of Acute Care Covered
              Services
              included under the STAR Medicaid managed care program. 

             

            Medicaid
              HMO Contractors are responsible for providing a benefit package to
              Members that
              includes all medically necessary services covered under the traditional,
              fee-for-service Medicaid programs except for Non-capitated Services
              provided to
              STAR Members outside of the HMO capitation and listed in Attachment
              B-1,
Section
              8.2.2.8.
              Medicaid HMO Contractors must coordinate care for Members for these
              Non-capitated Services so that Members have access to a full range
              of medically
              necessary Medicaid services, both capitated and non-capitated. A Contractor
              may
              elect to offer additional acute care Value-added Services. 

             

            The
              STAR
              Members are provided with three enhanced benefits compared to the traditional,
              fee-for-service Medicaid coverage: 

            
              	 	 	
                      1)
                        waiver of the three-prescription per month limit;
                        

                    

            

            
              	 	 	
                      2)
                        waiver of the 30-day spell-of-illness limitation under fee-for-services;
                        and 

                    

            

            
              	 	 	
                      3)
                        inclusion of an annual adult well check for patients 21 years
                        of age and
                        over. 

                    

            

            

            Medicaid
              HMO Contractors are responsible for providing a benefit package to
              Members that
              includes the waiver of the 30-day spell-of-illness limitation under
              fee-for-service and the inclusion of an annual adult well check for
              patients 21
              years of age and over. Prescription drug benefits to Medicaid HMO Members
              are
              provided outside of the HMO capitation. 

             

            Bidders
              and Contractors should refer to the current Texas
              Medicaid Provider Procedures Manual
              and the
              bi-monthly Texas
              Medicaid Bulletin
              for a
              more inclusive listing of limitations and exclusions that apply to
              each Medicaid
              benefit category. (These documents can be accessed online at: http://www.tmhp.com
              .)

             

            The
              services listed in this Attachment are subject to modification based
              on Federal
              and State laws and regulations and Programs policy updates. 

             

            Services
              included under the HMO capitation payment 

            
              	 	 	
                      •
                        Ambulance services 

                    

            

            
              	 	 	
                      •
                        Audiology services, including hearing aids for adults (hearing
                        aids for
                        children are provided through the PACT program and are a
                        non-capitated
                        service) 

                    

            

            
              	 	 	
                      •
                        Behavioral Health Services, including:

                    

            

            §  Inpatient
              and outpatient mental health services for children (under age 21) 

            §  Outpatient
              chemical dependency services for children (under age 21) 

            §  Detoxification
              services 

            §  Psychiatry
              services 

            §  Counseling
              services for adults (21 years of age and over) 

            
              	 	 	
                      •
                        Birthing center services 

                    

            

            
              	 	 	
                      •
                        Chiropractic services 

                    

            

            
              	 	 	
                      •
                        Dialysis 

                    

            

            
              	 	 	
                      •
                        Durable medical equipment and supplies

                    

            

            
              	 	 	
                      •
                        Emergency Services 

                    

            

            
              	 	 	
                      •
                        Family planning services 

                    

            

            
              	 	 	
                      •
                        Home health care services 

                    

            

            
              	 	 	
                      •
                        Hospital services, including inpatient and outpatient
                        

                    

            

            
              	 	 	
                      •
                        Laboratory 

                    

            

            
              	 	 	
                      •
                        Medical check-ups and Comprehensive Care Program (CCP) Services
                        for
                        children (under age 21) through the Texas Health Steps Program
                        

                    

            

            
              	 	 	
                      •
                        Podiatry 

                    

            

            
              	 	 	
                      •
                        Prenatal care 

                    

            

            
              	 	 	
                      •
                        Primary care services 

                    

            

            
              	 	 	 

            

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

            •
              Radiology, imaging, and X-rays 

            
              	 	 	
                      •
                        Specialty physician services 

                    

            

            
              	 	 	
                      •
                        Therapies - physical, occupational and speech

                    

            

            

            •
              Transplantation of organs and tissues 

            
              	 	 	
                      •
                        Vision (Includes optometry and glasses. Contact lenses are
                        only covered if
                        they are medically necessary for vision correction, which
                        can not be
                        accomplished by glasses.)  

                    

            

             

            Modified
              by Version 1.2 

             

            CHIP
              Covered Services 

             

            Covered
              CHIP services must meet the CHIP definition of Medically Necessary
              Covered
              Services as defined in this
              Contract.
              There
              is no lifetime maximum on benefits; however, 12-month period, enrollment
              period
              (a 6-month period), or lifetime limitations do apply to certain services,
              as
              specified in the following chart. Please note that if services with
              a 12-month
              annual limit are all used within one 6-month enrollment period, these
              particular
              services are not available during the second 6-month enrollment period
              within
              that annual period. Co-pays apply until a family reaches its specific
              cost-sharing maximum. 

             

            
              	
                      Covered
                        Benefit 

                    	
                      Description
                        

                    
	
                      Inpatient
                        General Acute and Inpatient Rehabilitation Hospital Services
                        

                       

                       

                    	
                      Services
                        include, but are not limited to, the following: 

                      §  Hospital-provided
                        Physician or Provider services 

                      § Semi-private
                        room and board (or private if medically necessary as certified
                        by
                        attending) 

                      §  General
                        nursing care 

                      §  Special
                        duty nursing when medically necessary 

                      §  ICU
                        and services 

                      §  Patient
                        meals and special diets 

                      §  Operating,
                        recovery and other treatment rooms 

                      §  Anesthesia
                        and administration (facility technical component) 

                      §  Surgical
                        dressings, trays, casts, splints 

                      §  Drugs,
                        medications and biologicals 

                      § Blood
                        or blood products that are not provided free-of-charge to
                        the patient and
                        their administration 

                      §  X-rays,
                        imaging and other radiological tests (facility technical
                        component)
                        

                      §  Laboratory
                        and pathology services (facility technical component) 

                      §  Machine
                        diagnostic tests (EEGs, EKGs, etc.) 

                      §  Oxygen
                        services and inhalation therapy 

                      §  Radiation
                        and chemotherapy 

                      § Access
                        to DSHS-designated Level III perinatal centers or Hospitals
                        meeting
                        equivalent levels of care 

                      § In-network
                        or out-of-network facility and Physician services for a mother
                        and her
                        newborn(s) for a minimum of 48 hours following an uncomplicated
                        vaginal
                        delivery and 96 hours following an uncomplicated delivery
                        by caesarian
                        section. 

                      § Hospital,
                        physician and related medical services, such as anesthesia,
                        associated
                        with dental care 

                      §  Surgical
                        implants 

                      §  Other
                        artificial aids including surgical implants 

                      § Implantable
                        devices are covered under Inpatient and Outpatient services
                        and do not
                        count towards the DME 12-month period limit 

                    
	
                      Skilled
                        Nursing 

                      Facilities
                        

                      (Includes
                        Rehabilitation 

                      Hospitals)
                        

                       

                       

                    	
                      Services
                        include, but are not limited to, the following: 

                      §  Semi-private
                        room and board 

                      §  Regular
                        nursing services 

                       

                      §  Rehabilitation
                        services 

                      § Medical
                        supplies and use of appliances and equipment furnished by
                        the
                        facility 

                    
	
                      Outpatient
                        Hospital, Comprehensive Outpatient Rehabilitation Hospital,
                        Clinic
                        (Including Health Center) and Ambulatory Health Care Center
                        

                       

                    	
                      Services
                        include, but are not limited to, the following services provided
                        in a
                        hospital clinic or emergency room, a clinic or health center,
                        hospital-based emergency department or an ambulatory health
                        care setting:
                        

                      §  X-ray,
                        imaging, and radiological tests (technical component) 

                      §  Laboratory
                        and pathology services (technical component) 

                      §  Machine
                        diagnostic tests 

                      §  Ambulatory
                        surgical facility services 

                      §  Drugs,
                        medications and biologicals 

                      §  Casts,
                        splints, dressings 

                      §  Preventive
                        health services 

                      §  Physical,
                        occupational and speech therapy 

                      §  Renal
                        dialysis 

                      §  Respiratory
                        services 

                      §  Radiation
                        and chemotherapy 

                      § Blood
                        or blood products that are not provided free-of-charge to
                        the patient and
                        the administration of these products 

                      § Facility
                        and related medical services, such as anesthesia, associated
                        with dental
                        care, when provided in a licensed ambulatory surgical facility.
                        

                      §  Surgical
                        implants 

                      §  Other
                        artificial aids including surgical implants 

                      § Implantable
                        devices are covered under Inpatient and Outpatient services
                        and do not
                        count towards the DME 12-month period limit 

                    
	
                      Physician/Physician
                        

                      Extender
                        Professional Services 

                       

                    	
                      Services
                        include, but are not limited to, the following: 

                      § American
                        Academy of Pediatrics recommended well-child exams and preventive
                        health
                        services (including, but not limited to, vision and hearing
                        screening and
                        immunizations) 

                      §  Physician
                        office visits, in-patient and out-patient services 

                      § Laboratory,
                        x-rays, imaging and pathology services, including technical
                        component
                        and/or professional interpretation 

                      §  Medications,
                        biologicals and materials administered in Physician’s office 

                      §  Allergy
                        testing, serum and injections 

                      §  Professional
                        component (in/outpatient) of surgical services, including:

                      -
                        Surgeons and assistant surgeons for surgical procedures including
                        appropriate follow-up care 

                      -
                        Administration of anesthesia by Physician (other than surgeon)
                        or CRNA
                        

                      -
                        Second surgical opinions 

                      -
                        Same-day surgery performed in a Hospital without an over-night
                        stay
                        

                      -
                        Invasive diagnostic procedures such as endoscopic examinations 

                      § Hospital-based
                        Physician services (including Physician-performed technical
                        and
                        interpretive components) 

                      § In-network
                        and out-of-network Physician services for a mother and her
                        newborn(s) for
                        a minimum of 48 hours following an uncomplicated vaginal
                        delivery and 96
                        hours following an uncomplicated delivery by caesarian section.
                        

                      § Physician
                        services medically necessary to support a dentist providing
                        dental
                        services to a CHIP member such as general anesthesia or intravenous
                        (IV)
                        sedation. 

                    
	
                      Durable
                        Medical Equipment (DME), Prosthetic Devices and 

                      Disposable
                        Medical Supplies 

                       

                       

                    	
                      $20,000
                        12-month period limit for DME, prosthetics, devices and disposable
                        medical
                        supplies (diabetic supplies and equipment are not counted
                        against this
                        ccap). Services include DME (equipment which can withstand
                        repeated use
                        and is primarily and customarily used to serve a medical
                        purpose,
                        generally is not useful to a person in the absence of Illness,
                        Injury, or
                        Disability, and is appropriate for use in the home), including
                        devices and
                        supplies that are medically necessary and necessary for one
                        or more
                        activities of daily living and appropriate to assist in the
                        treatment of a
                        medical condition, including: 

                      §  Orthotic
                        braces and orthotics 

                      §  Prosthetic
                        devices such as artificial eyes, limbs, and braces 

                      § Prosthetic
                        eyeglasses and contact lenses for the management of severe
                        ophthalmologic
                        disease 

                      § Hearing
                        aids 

                      § Diagnosis-specific
                        disposable medical supplies, including diagnosis-specific
                        prescribed
                        specialty formula and dietary supplements. (See attachment
                        A)

                    
	
                       

                      Home
                        and Community Health Services 

                       

                       

                    	
                       

                      Services
                        that are provided in the home and community, including, but
                        not limited
                        to: 

                      §  Home
                        infusion 

                      §  Respiratory
                        therapy 

                      §  Visits
                        for private duty nursing (R.N., L.V.N.) 

                      § Skilled
                        nursing visits as defined for home health purposes (may include
                        R.N. or
                        L.V.N.). 

                      § Home
                        health aide when included as part of a plan of care during
                        a period that
                        skilled visits have been approved. 

                      §  Speech,
                        physical and occupational therapies. 

                      § Services
                        are not intended to replace the CHILD'S caretaker or to provide
                        relief for
                        the caretaker 

                      § Skilled
                        nursing visits are provided on intermittent level and not
                        intended to
                        provide 24-hour skilled nursing services 

                    
	
                      Inpatient
                        Mental Health Services 

                    	
                       Mental
                        health services, including for serious mental illness, furnished
                        in a
                        free-standing psychiatric hospital, psychiatric units of
                        general acute
                        care hospitals and state-operated facilities, including,
                        but not limited
                        to: 

                      §  Neuropsychological
                        and psychological testing. 

                      §  Inpatient
                        mental health services are limited to: 

                      §  45
                        days 12-month inpatient limit 

                      § Includes
                        inpatient psychiatric services, up to 12-month period limit,
                        ordered by a
                        court of competent jurisdiction under the provisions of Chapters
                        573 and
                        574 of the Texas Health and Safety Code, relating to court
                        ordered
                        commitments to psychiatric facilities. Court order serves
                        as binding
                        determination of medical necessity. Any modification or termination
                        of
                        services must be presented to the court with jurisdiction
                        over the matter
                        for determination 

                      § 25
                        days of the inpatient benefit can be converted to residential
                        treatment,
                        therapeutic foster care or other 24-hour therapeutically
                        planned and
                        structured services or sub-acute outpatient (partial hospitalization
                        or
                        rehabilitative day treatment) mental health services on the
                        basis of
                        financial equivalence against the inpatient per diem cost

                      §  20
                        of the inpatient days must be held in reserve for inpatient
                        use only
                        

                      § Does
                        not require PCP referral

                    
	
                      Outpatient
                        Mental Health Services 

                    	
                      Mental
                        health services, including for serious mental illness, provided
                        on an
                        outpatient basis, including, but not limited to: 

                      §  Medication
                        management visits do not count against the outpatient visit
                        limit.
                        

                      § The
                        visits can be furnished in a variety of community-based settings
                        (including school and home-based) or in a state-operated
                        facility
                        

                      §  Up
                        to 60 days 12-month period limit for rehabilitative day treatment
                        

                      §  60
                        outpatient visits 12-month period limit 

                      § 60
                        rehabilitative day treatment days can be converted to outpatient
                        visits on
                        the basis of financial equivalence against the day treatment
                        per diem cost
                        

                      § 60
                        outpatient visits can be converted to skills training (psycho
                        educational
                        skills development) or rehabilitative day treatment on the
                        basis of
                        financial equivalence against the outpatient visit cost 

                      § Includes
                        outpatient psychiatric services, up to 12-month period limit,
                        ordered by a
                        court of competent jurisdiction under the provisions of Chapters
                        573 and
                        574 of the Texas Health and Safety Code, relating to court
                        ordered
                        commitments to psychiatric facilities. Court order serves
                        as binding
                        determination of medical necessity. Any modification or termination
                        of
                        services must be presented to the court with jurisdiction
                        over the matter
                        for determination 

                      § Inpatient
                        days converted to sub-acute outpatient services are in addition
                        to the
                        outpatient limits and do not count towards those limits 

                      § A
                        Qualified Mental Health Professional (QMHP), as defined by
                        and
                        credentialed through Texas Department of State Health Services
                        (DSHS)
                        standards (TAC Title 25, Part II, Chapter 412), is a Local
                        Mental Health
                        Authorities provider. A QMHP must be working under the authority
                        of an
                        DSHS entity and be supervised by a licensed mental health
                        professional or
                        physician. QMHPs are acceptable providers as long as the
                        services would be
                        within the scope of the services that are typically provided
                        by QMHPs.
                        Those services include individual and group skills training
                        (which can be
                        components of interventions such as day treatment and in-home
                        services),
                        patient and family education, and crisis services

                      § Does
                        not require PCP referral 

                    
	
                      Inpatient
                        Substance Abuse Treatment Services 

                    	
                      Services
                        include, but are not limited to: 

                      § Inpatient
                        and residential substance abuse treatment services including
                        detoxification and crisis stabilization, and 24-hour residential
                        rehabilitation programs 

                      §  Does
                        not require PCP referral 

                      § Medically
                        necessary detoxification/stabilization services, limited
                        to 14 days per
                        12-month period. 

                      § 24-hour
                        residential rehabilitation programs, or the equivalent, up
                        to 60 days per
                        12-month period 

                      § 30
                        days may be converted to partial hospitalization or intensive
                        outpatient
                        rehabilitation, on the basis of financial equivalence against
                        the
                        inpatient per diem cost 

                      § 30
                        days must be held in reserve for inpatient use only 

                    
	
                      Outpatient
                        Substance Abuse Treatment Services 

                    	
                      Services
                        include, but are not limited to, the following: 

                      § Prevention
                        and intervention services that are provided by physician
                        and non-physician
                        providers, such as screening, assessment and referral for
                        chemical
                        dependency disorders. 

                      § Intensive
                        outpatient services is defined as an organized non-residential
                        service
                        providing structured group and individual therapy, educational
                        services,
                        and life skills training which consists of at least 10 hours
                        per week for
                        four to 12 weeks, but less than 24 hours per day 

                      § Outpatient
                        treatment service is defined as consisting of at least one
                        to two hours
                        per week providing structured group and individual therapy,
                        educational
                        services, and life skills training 

                      §  Outpatient
                        treatment services up to a maximum of: 

                      §  Intensive
                        outpatient program (up to 12 weeks per 12-month period) 

                      §  Outpatient
                        services (up to six-months per 12-month period) 

                    
	
                      Rehabilitation
                        Services 

                       

                    	
                       Services
                        include, but are not limited to, the following: 

                      § Habilitation
                        (the process of supplying a child with the means to reach
                        age-appropriate
                        developmental milestones through therapy or treatment) and
                        rehabilitation
                        services include, but are not limited to the following: 

                      §  Physical,
                        occupational and speech therapy

                      § 
                        Developmental assessment

                    
	
                      Hospice
                        Care Services 

                    	
                       Services
                        include, but are not limited to: 

                      § Palliative
                        care, including medical and support services, for those children
                        who have
                        six months or less to live, to keep patients comfortable
                        during the last
                        weeks and months before death 

                      §  Treatment
                        for unrelated conditions is unaffected 

                      §  Up
                        to a maximum of 120 days with a 6 month life expectancy 

                      § Patients
                        electing hospice services waive their rights to treatment
                        related to their
                        terminal illnesses; however, they may cancel this election
                        at
                        anytime 

                      § Services
                        apply to the hospice diagnosis

                    
	
                      Emergency
                        Services, including Emergency Hospitals, Physicians, and
                        Ambulance
                        Services 

                    	
                       HMO
                        cannot require authorization as a condition for payment for
                        emergency
                        conditions or labor and delivery. 

                      Covered
                        services include, but are not limited to, the following:

                      § Emergency
                        services based on prudent lay person definition of emergency
                        health
                        condition 

                      § Hospital
                        emergency department room and ancillary services and physician
                        services 24
                        hours a day, 7 days a week, both by in-network and out-of-network
                        providers 

                      §  Medical
                        screening examination  

                      §  Stabilization
                        services 

                      § Access
                        to DSHS designated Level 1 and Level II trauma centers or
                        hospitals
                        meeting equivalent levels of care for emergency services 

                      §  Emergency
                        ground, air and water transportation 

                      § Emergency
                        dental services, limited to fractured or dislocated jaw,
                        traumatic damage
                        to teeth, and removal of cysts.

                    
	
                      Transplants
                        

                    	
                      Services
                        include, but are not limited to, the following: 

                      § Using
                        up-to-date FDA guidelines, all non-experimental human organ
                        and tissue
                        transplants and all forms of non-experimental corneal, bone
                        marrow and
                        peripheral stem cell transplants, including donor medical
                        expenses

                    
	
                      Vision
                        Benefit 

                       

                       

                       

                    	
                      The
                        health plan may reasonably limit the cost of the frames/lenses.
                        

                      Services
                        include: 

                      § One
                        examination of the eyes to determine the need for and prescription
                        for
                        corrective lenses per 12-month period, without authorization

                      § One
                        pair of non-prosthetic eyewear per 12-month period

                    
	
                      Chiropractic
                        Services 

                    	
                       Services
                        do not require physician prescription and are limited to
                        spinal
                        subluxation

                    
	
                      Tobacco
                        Cessation 

                      Program 

                    	
                      Covered
                        up to $100 for a 12- month period limit for a plan- approved
                        program
                        

                      §  Health
                        Plan defines plan-approved program

                      § May
                        be subject to formulary requirements 

                    
	
                      [Value-added
                        services]

                    	
                      See
                        Attachment B-3

                    

            

             

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

             

            CHIP
              EXCLUSIONS FROM COVERED SERVICES 

             

            
              	 	
                      §

                    	
                      Inpatient
                        and outpatient infertility treatments or reproductive services
                        other than
                        prenatal care, labor and delivery, and care related to disease,
                        illnesses,
                        or abnormalities related to the reproductive system
                        

                    

            

            
              	 	
                      §

                    	
                      Personal
                        comfort items including but not limited to personal care
                        kits provided on
                        inpatient admission, telephone, television, newborn infant
                        photographs,
                        meals for guests of patient, and other articles which are
                        not required for
                        the specific treatment of sickness or injury

                    

            

            
              	 	
                      §

                    	
                      Experimental
                        and/or investigational medical, surgical or other health
                        care procedures
                        or services which are not generally employed or recognized
                        within the
                        medical community 

                    

            

            
              	 	
                      §

                    	
                      Treatment
                        or evaluations required by third parties including, but not
                        limited to,
                        those for schools, employment, flight clearance, camps, insurance
                        or court
                        

                    

            

            §  Private
              duty nursing services when performed on an inpatient basis or in a
              skilled
              nursing facility. 

            §  Mechanical
              organ replacement devices including, but not limited to artificial
              heart

            
              	 	
                      §

                    	
                      Hospital
                        services and supplies when confinement is solely for diagnostic
                        testing
                        purposes, unless otherwise pre-authorized by Health Plan 

                    

            

            §  Prostate
              and mammography screening 

            §  Elective
              surgery to correct vision 

            §  Gastric
              procedures for weight loss 

            §  Cosmetic
              surgery/services solely for cosmetic purposes 

            
              	 	
                      §

                    	
                      Out-of-network
                        services not authorized by the Health Plan except for emergency
                        care and
                        physician services for a mother and her newborn(s) for a
                        minimum of 48
                        hours following an uncomplicated vaginal delivery and 96
                        hours following
                        an uncomplicated delivery by caesarian section

                    

            

            
              	 	
                      §

                    	
                      Services,
                        supplies, meal replacements or supplements provided for weight
                        control or
                        the treatment of obesity, except for the services associated
                        with the
                        treatment for morbid obesity as part of a treatment plan
                        approved by the
                        Health Plan 

                    

            

            §  Acupuncture
              services, naturopathy and hypnotherapy 

            §  Immunizations
              solely for foreign travel 

            §  Routine
              foot care such as hygienic care 

            
              	 	
                      §

                    	
                      Diagnosis
                        and treatment of weak, strained, or flat feet and the cutting
                        or removal
                        of corns, calluses and toenails (this does not apply to the
                        removal of
                        nail roots or surgical treatment of conditions underlying
                        corns, calluses
                        or ingrown toenails) 

                    

            

            
              	 	
                      §

                    	
                      Replacement
                        or repair of prosthetic devices and durable medical equipment
                        due to
                        misuse, abuse or loss when confirmed by the Member or the
                        vendor
                         

                    

            

            §  Corrective
              orthopedic shoes 

            §  Convenience
              items 

            §  Orthotics
              primarily used for athletic or recreational purposes 

            
              	 	
                      §

                    	
                      Custodial
                        care (care that assists a child with the activities of daily
                        living, such
                        as assistance in walking, getting in and out of bed, bathing,
                        dressing,
                        feeding, toileting, special diet preparation, and medication
                        supervision
                        that is usually self-administered or provided by a parent.
                        This care does
                        not require the continuing attention of trained medical or
                        paramedical
                        personnel.) This exclusion does not apply to hospice services.
                        

                    

            

            §  Housekeeping
              

            
              	 	
                      §

                    	
                      Public
                        facility services and care for conditions that federal, state,
                        or local
                        law requires be provided in a public facility or care provided
                        while in
                        the custody of legal authorities 

                    

            

            §  Services
              or supplies received from a nurse, which do not require the skill and
              training
              of a nurse 

            §  Vision
              training and vision therapy 

            §  Reimbursement
              for school-based physical therapy, occupational therapy, or speech
              therapy
              services are not covered except when ordered by a Physician/PCP 

            §  Donor
              non-medical expenses 

            §  Charges
              incurred as a donor of an organ when the recipient is not covered under
              this
              health plan 

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

            CHIP
              DME/SUPPLIES 

            
              	
                       SUPPLIES

                    	
                      COVERED

                    	
                      EXCLUDED

                    	
                      COMMENTS/MEMBER

                      CONTRACT
                        PROVISIONS 

                    
	
                      Ace
                        Bandages 

                    	
                       

                    	
                      X

                    	
                      Exception:
                        If provided by and billed through the clinic or home care
                        agency it is
                        covered as an incidental supply. 

                    
	
                      Alcohol,
                        rubbing 

                    	
                       

                    	
                      X

                    	
                      Over-the-counter
                        supply. 

                    
	
                      Alcohol,
                        swabs (diabetic) 

                    	
                      X
                        

                    	 	
                      Over-the-counter
                        supply not covered, unless RX provided at time of dispensing.
                        

                    
	
                      Alcohol,
                        swabs 

                    	
                      X
                        

                    	 	
                      Covered
                        only when received with IV therapy or central line kits/supplies.
                        

                    
	
                      Ana
                        Kit Epinephrine 

                    	
                      X
                        

                    	 	
                      A
                        self-injection kit used by patients highly allergic to bee
                        stings.
                        

                    
	
                      Arm
                        Sling 

                    	
                      X
                        

                    	 	
                      Dispensed
                        as part of office visit. 

                    
	
                      Attends
                        (Diapers) 

                    	
                      X
                        

                    	 	
                      Coverage
                        limited to children age 4 or over only when prescribed by
                        a physician and
                        used to provide care for a covered diagnosis as outlined
                        in a treatment
                        care plan 

                    
	
                      Bandages
                        

                    	
                       

                    	
                      X

                    	
                       

                    
	
                      Basal
                        Thermometer 

                    	
                       

                    	
                      X

                    	
                      Over-the-counter
                        supply. 

                    
	
                      Batteries
                        - initial 

                    	
                      X
                        

                    	
                      .

                    	
                      For
                        covered DME items 

                    
	
                      Batteries
                        - replacement 

                    	
                      X
                        

                    	 	
                      For
                        covered DME when replacement is necessary due to normal use.
                        

                    
	
                      Betadine
                        

                    	
                       

                    	
                      X

                    	
                      See
                        IV therapy supplies. 

                    
	
                      Books
                        

                    	
                       

                    	
                      X

                    	
                       

                    
	
                      Clinitest
                        

                    	
                      X
                        

                    	 	
                      For
                        monitoring of diabetes. 

                    
	
                      Colostomy
                        Bags 

                    	
                       

                    	 	
                      See
                        Ostomy Supplies. 

                    
	
                      Communication
                        Devices 

                    	
                       

                    	
                      X

                    	
                       

                    
	
                      Contraceptive
                        Jelly 

                    	
                       

                    	
                      X

                    	
                      Over-the-counter
                        supply. Contraceptives are not covered under the plan. 

                    
	
                      Cranial
                        Head Mold 

                    	
                       

                    	
                      X

                    	 
	
                      Diabetic
                        Supplies 

                    	
                      X
                        

                    	 	
                      Monitor
                        calibrating solution, insulin syringes, needles, lancets,
                        lancet device,
                        and glucose strips. 

                    
	
                      Diapers/Incontinent
                        Briefs/Chux 

                    	
                      X
                        

                    	 	
                      Coverage
                        limited to children age 4 or over only when prescribed by
                        a physician and
                        used to provide care for a covered diagnosis as outlined
                        in a treatment
                        care plan 

                    
	
                      Diaphragm
                        

                    	
                       

                    	
                      X

                    	
                      Contraceptives
                        are not covered under the plan. 

                    
	
                      Diastix
                        

                    	
                      X
                        

                    	 	
                      For
                        monitoring diabetes. 

                    
	
                      Diet,
                        Special 

                    	
                       

                    	
                      X

                    	
                       

                    
	
                      Distilled
                        Water 

                    	
                       

                    	
                      X

                    	
                       

                    
	
                      Dressing
                        Supplies/Central Line 

                    	
                      X
                        

                    	 	
                      Syringes,
                        needles, Tegaderm, alcohol swabs, Betadine swabs or ointment,
                        tape. Many
                        times these items are dispensed in a kit when includes all
                        necessary items
                        for one dressing site change. 

                    
	
                      Dressing
                        Supplies/Decubitus 

                    	
                      X
                        

                    	 	
                      Eligible
                        for coverage only if receiving covered home care for wound
                        care.
                        

                    
	
                      Dressing
                        Supplies/Peripheral IV Therapy 

                    	
                      X
                        

                    	 	
                      Eligible
                        for coverage only if receiving home IV therapy. 

                    
	
                      Dressing
                        Supplies/Other 

                    	
                       

                    	
                      X

                    	
                       

                    
	
                      Dust
                        Mask 

                    	
                       

                    	
                      X

                    	
                       

                    
	
                      Ear
                        Molds 

                    	
                      X
                        

                    	 	
                      Custom
                        made, post inner or middle ear surgery 

                    
	
                      Electrodes
                        

                    	
                      X
                        

                    	 	
                      Eligible
                        for coverage when used with a covered DME. 

                    
	
                      Enema
                        Supplies 

                    	
                       

                    	
                      X

                    	
                      Over-the-counter
                        supply. 

                    

            

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

            

            
              	
                       SUPPLIES

                    	
                      COVERED

                    	
                      EXCLUDED

                    	
                      COMMENTS/MEMBER

                      CONTRACT
                        PROVISIONS 

                    
	
                      Enteral
                        Nutrition Supplies 

                    	
                      X
                        

                    	 	 
	
                      Eye
                        Patches 

                    	
                      X
                        

                    	
                       

                    	 
	
                      Formula

                    	 	
                      X
                        

                    	
                      Exception:
                        Eligible for coverage only for chronic hereditary metabolic
                        disorders a
                        non-function or disease of the structures that normally permit
                        food to
                        reach the small bowel; or malabsorption due to disease (expected
                        to last
                        longer than 60 days when prescribed by the physician and
                        authorized by
                        plan.) Physician documentation to justify prescription of
                        formula must
                        include: 

                       

                      •
                        Identification of a metabolic disorder, dysphagia that results
                        in a
                        medical need for a liquid diet, presence of a gastrostomy,
                        or disease
                        resulting in malabsorption that requires a medically necessary
                        nutritional
                        product 

                      Does
                        not include formula: 

                      § For
                        members who could be sustained on an age-appropriate diet.

                      § Traditionally
                        used for infant feeding 

                      § In
                        pudding form (except for clients with documented oropharyngeal
                        motor
                        dysfunction who receive greater than 50 percent of their
                        daily caloric
                        intake from this product) 

                      § For
                        the primary diagnosis of failure to thrive, failure to gain
                        weight, or
                        lack of growth or for infants less than twelve months of
                        age unless
                        medical necessity is documented and other criteria, listed
                        above, are met.
                        

                      Food
                        thickeners, baby food, or other regular grocery products
                        that can be
                        blenderized and used with an enteral system that are not
                        medically necessary, are not covered, regardless of whether
                        these regular
                        food products are taken orally or parenterally. 

                    
	
                      Gloves
                        

                    	
                       

                    	
                      X

                    	
                      Exception:
                        Central line dressings or wound care provided by home care
                        agency.
                        

                    
	
                      Hydrogen
                        Peroxide 

                    	
                       

                    	
                      X

                    	
                      Over-the-counter
                        supply. 

                    
	
                      Hygiene
                        Items 

                    	
                       

                    	
                      X

                    	
                       

                    
	
                      Incontinent
                        Pads 

                    	
                      X
                        

                    	 	
                      Coverage
                        limited to children age 4 or over only when prescribed by
                        a physician and
                        used to provide care for a covered diagnosis as outlined
                        in a treatment
                        care plan 

                    
	
                      Insulin
                        Pump (External) Supplies 

                    	
                      X
                        

                    	 	
                      Supplies
                        (e.g., infusion sets, syringe reservoir and dressing, etc.)
                        are eligible
                        for coverage if the pump is a covered item. 

                    
	
                      Irrigation
                        Sets, Wound Care 

                    	
                      X
                        

                    	 	
                      Eligible
                        for coverage when used during covered home care for wound
                        care.
                        

                    
	
                      Irrigation
                        Sets, Urinary 

                    	
                      X
                        

                    	 	
                      Eligible
                        for coverage for individual with an indwelling urinary catheter.
                        

                    
	
                      IV
                        Therapy Supplies 

                    	
                      X
                        

                    	 	
                      Tubing,
                        filter, cassettes, IV pole, alcohol swabs, needles, syringes
                        and any other
                        related supplies necessary for home IV therapy. 

                    
	
                      K-Y
                        Jelly 

                    	
                       

                    	
                      X

                    	
                      Over-the-counter
                        supply. 

                    
	
                      Lancet
                        Device 

                    	
                      X
                        

                    	 	
                      Limited
                        to one device only. 

                    
	
                      Lancets
                        

                    	
                      X
                        

                    	 	
                      Eligible
                        for individuals with diabetes. 

                    
	
                      Med
                        Ejector 

                    	
                      X
                        

                    	 	
                       

                    
	
                      Needles
                        and Syringes/Diabetic

                    	 	
                       

                    	
                      See
                        Diabetic Supplies 

                    
	
                      Needles
                        and Syringes/IV and Central Line

                    	 	
                       

                    	
                       See
                        IV Therapy and Dressing Supplies/Central Line.

                    
	
                      Needles
                        and Syringes/Other 

                    	
                      X
                        

                    	 	
                      Eligible
                        for coverage if a covered IM or SubQ medication is being
                        administered at
                        home. 

                    
	
                      Normal
                        Saline 

                    	
                       

                    	 	
                      See
                        Saline, Normal 

                    
	
                      Novopen
                        

                    	
                      X
                        

                    	
                      Novopen
                        

                    	
                       

                    
	
                      Ostomy
                        Supplies 

                    	
                      X
                        

                    	 	
                      Items
                        not eligible for coverage include: scissors, room deodorants,
                        cleaners,
                        rubber gloves, gauze, pouch covers, soaps, and lotions.

                    
	
                      Parenteral
                        Nutrition/Supplies 

                    	
                      X
                        

                    	 	
                      Necessary
                        supplies (e.g., tubing, filters, connectors, etc.) are eligible
                        for
                        coverage when the Health Plan has authorized the parenteral
                        nutrition.
                        

                    
	
                      Saline,
                        Normal 

                    	
                      X
                        

                    	 	
                      Eligible
                        for coverage:

                      a)
                        when used to dilute medications for nebulizer treatments;

                      b)
                        as part of covered home care for wound care;

                      c)
                        for indwelling urinary catheter irrigation. 

                    
	
                      Stump
                        Sleeve 

                    	
                      X
                        

                    	 	
                       

                    
	
                      Stump
                        Socks 

                    	
                      X
                        

                    	 	
                       

                    
	
                      Suction
                        Catheters 

                    	
                      X
                        

                    	 	
                       

                    
	
                      Syringes
                        

                    	
                       

                    	
                       

                    	
                      See
                        Needles/Syringes. 

                    
	
                      Tape
                        

                    	
                       

                    	
                       

                    	
                      See
                        Dressing Supplies, Ostomy Supplies, IV Therapy Supplies.
                        

                    
	
                      Tracheostomy
                        Supplies 

                    	
                      X
                        

                    	
                       

                    	
                      Cannulas,
                        Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for
                        coverage.
                        

                    
	
                      Under
                        Pads 

                    	
                       

                    	
                       

                    	
                      See
                        Diapers/Incontinent Briefs/Chux. 

                    
	
                      Unna
                        Boot 

                    	
                      X
                        

                    	
                       

                    	
                      Eligible
                        for coverage when part of wound care in the home setting.
                        Incidental
                        charge when applied during office visit. 

                    
	
                      Urinary,
                        External Catheter & Supplies 

                    	
                       

                    	
                      X
                        

                    	
                      Exception:
                        Covered when used by incontinent male where injury to the
                        urethra
                        prohibits use of an indwelling catheter ordered by the PCP
                        and approved by
                        the plan 

                    
	
                      Urinary,
                        Indwelling Catheter & Supplies 

                    	
                      X
                        

                    	
                       

                    	
                      Cover
                        catheter, drainage bag with tubing, insertion tray, irrigation
                        set and
                        normal saline if needed. 

                    
	
                      Urinary,
                        Intermittent 

                    	
                      X
                        

                    	
                       

                    	
                      Cover
                        supplies needed for intermittent or straight catherization.
                        

                    
	
                      Urine
                        Test Kit 

                    	
                      X
                        

                    	
                       

                    	
                      When
                        determined to be medically necessary. 

                    
	
                      Urostomy
                        supplies 

                    	
                       

                    	
                       

                    	
                      See
                        Ostomy Supplies. 

                    

            

            

            

             

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

             

            

              Contractual
                Document (CD) Responsible Office: HHSC Office of General Counsel
                (OGC)

              Subject:
                Attachment B-2.1 - STAR+PLUS Covered Services 

              Version
                1.6 

            

            

              

              
                	
                        DOCUMENT
                          HISTORY LOG 

                      
	
                        STATUS1

                      	
                        DOCUMENT
                          

                        REVISION2

                      	
                        EFFECTIVE
                          

                        DATE
                          

                      	
                        DESCRIPTION3

                      
	
                         

                        Baseline
                          

                         

                      	
                         

                        n/a
                          

                         

                      	
                         

                         

                      	
                         

                        Initial
                          version of Attachment B-2, Covered Services. 

                         

                      
	
                         

                        Revision
                          

                      	
                         

                        1.1
                          

                      	
                         

                        June
                          30, 2006 

                      	
                         

                        Revised
                          Attachment B-2, Covered Services, by adding Attachment
                          B-2.1, STAR+PLUS
                          Covered Services. This is the initial version of Attachment
                          B-2.1,
                          STAR+PLUS Covered Services, which lists the Acute Care
                          Services and the
                          Community Based Long Term Care Services. 

                         

                         

                      
	
                         

                        Revision
                          

                      	
                         

                        1.2
                          

                      	
                         

                        September
                          1, 2006 

                      	
                         

                        Contract
                          Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
                          Services.
                          

                         

                         

                      
	
                         

                        Revision
                          

                      	
                         

                        1.3
                          

                      	
                         

                        September
                          1, 2006 

                      	
                         

                        Contract
                          Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
                          Services.
                          

                         

                         

                      
	
                         

                        Revision
                          

                      	
                         

                        1.4
                          

                      	
                         

                        September
                          1, 2006 

                      	
                         

                        Contract
                          Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
                          Services.
                          

                         

                         

                      
	
                         

                        Revision
                          

                      	
                         

                        1.5
                          

                      	
                         

                        January
                          1, 2007 

                      	
                         

                        Revised
                          Attachment B-2.1, STAR+PLUS Covered Services, to include
                          inpatient and
                          outpatient mental health services for adults. 

                      
	
                         

                        Revision
                          

                      	
                         

                        1.6
                          

                      	
                         

                        February
                          1, 2007 

                      	
                         

                        Revised
                          Attachment B-2.1, STAR+PLUS Covered Services, to exclude
                          inpatient mental
                          health services for adults and children, and to establish
                          monetary limits
                          on Transition Assistance Services. 

                         

                        Personal
                          Attendant Services is clarified to include the three service
                          delivery
                          options described in Attachment B-1, Section 8.3.5. Consumer
                          Directed
                          Personal Attendant Services is deleted from the list since
                          it is one of
                          the three service delivery options under Personal Attendant
                          Services.
                          

                         

                         

                      
	
                         

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

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

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

                      

              

              

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

              STAR+PLUS
                Covered Services 

               

              Acute
                Care Services 

               

              The
                following is a non-exhaustive, high-level listing of Acute Care Covered
                Services
                included under the STAR+PLUS Medicaid managed care program. 

               

              Medicaid
                HMO Contractors are responsible for providing a benefit package to
                Members that
                includes all medically necessary services covered under the traditional,
                fee-for-service Medicaid programs except for Non-capitated Services
                provided to
                Medicaid Members outside of the HMO capitation and listed in Attachment
                B-1,
                Section 8.2.2.8. In addition to the non-capitated services listed
                in Attachment
                B-1, Section 8.2.2.8, Hospital Inpatient Stays are excluded from
                the capitation
                payment to STAR+PLUS HMOs and are paid through HHSC’s Administrative Contractor
                responsible for payment of Traditional Medicaid fee-for-service claims.
                Medicaid
                HMO Contractors must coordinate care for Members for these Non-capitated
                Services so that Members have access to a full range of medically
                necessary
                Medicaid services, both capitated and non-capitated. A Contractor
                may elect to
                offer additional acute care Value-added Services. 

               

              The
                STAR+PLUS Members are provided with two enhanced benefits compared
                to the
                traditional, fee-for-service Medicaid coverage: 

              
                	 	 	
                        1)
                          waiver of the three-prescription per month limit, for members
                          not covered
                          by Medicare; 

                      

              

              
                	 	 	
                        2)
                          inclusion of an annual adult well check for patients 21
                          years of age and
                          over. 

                      

              

              

              Medicaid
                HMO Contractors are responsible for providing a benefit package to
                Members that
                includes an annual adult well check for patients 21 years of age
                and over.
                Prescription drug benefits to HMO Members are provided outside of
                the HMO
                capitation. 

               

              STAR+PLUS
                HMO Contractors should refer to the current Texas
                Medicaid Provider Procedures Manual
                and the
                bi-monthly Texas
                Medicaid Bulletin
                for a
                more inclusive listing of limitations and exclusions that apply to
                each Medicaid
                benefit category. (These documents can be accessed online at: http://www.tmhp.com
                .)

               

              The
                services listed in this Attachment are subject to modification based
                on Federal
                and State laws and regulations and Programs policy updates. 

               

              Services
                included under the HMO capitation payment 

              
                	 	 	
                        •
                          Ambulance services 

                      

              

              
                	 	 	
                        •
                          Audiology services, including hearing aids for adults (hearing
                          aids for
                          children are provided through the PACT program and are
                          a non-capitated
                          service) 

                      

              

              
                	 	 	
                        •
                          Behavioral Health Services, including:

                      

              

              o
                Outpatient mental health services for Adults and Children 

              o
                Outpatient chemical dependency services for children (under age 21)
                

              o
                Detoxification services 

              o
                Psychiatry services 

              o
                Counseling services for adults (21 years of age and over) 

              
                	 	 	
                        •
                          Birthing center services 

                      

              

              
                	 	 	
                        •
                          Chiropractic services 

                      

              

              
                	 	 	
                        •
                          Dialysis 

                      

              

              
                	 	 	
                        •
                          Durable medical equipment and supplies

                      

              

              
                	 	 	
                        •
                          Emergency Services 

                      

              

              
                	 	 	
                        •
                          Family planning services 

                      

              

              
                	 	 	
                        •
                          Home health care services 

                      

              

              
                	 	 	
                        •
                          Hospital services, outpatient 

                      

              

              
                	 	 	
                        •
                          Laboratory 

                      

              

              
                	 	 	
                        •
                          Medical check-ups and Comprehensive Care Program (CCP)
                          Services for
                          children (under age 21) through the Texas Health Steps
                          Program
                          

                      

              

              
                	 	 	
                        •
                          Optometry, glasses, and contact lenses, if medically necessary
                          

                      

              

              
                	 	 	
                        •
                          Podiatry 

                      

              

              
                	 	 	 

              

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

                  •
Prenatal
                care 

              
                	 	 	
                        •
                          Primary care services 

                      

              

              
                	 	 	
                        •
                          Radiology, imaging, and X-rays 

                      

              

              
                	 	 	
                        •
                          Specialty physician services 

                      

              

              
                	 	 	
                        •
                          Therapies - physical, occupational and speech

                      

              

              
                	 	 	
                        •
                          Transplantation of organs and tissues

                      

              

              
                	 	 	
                        •
                          Vision 

                      

              

              

               

              Community
                Based Long Term Care Services 

               

              The
                following is a non-exhaustive, high-level listing of Community Based
                Long Term
                Care Covered Services included under the STAR+PLUS Medicaid managed
                care
                program. 

               

              
                	 	 	
                        •
                          Community
                          Based Long Term Care Services for all Members
                          

                      

              

              o
                Personal
                Attendant Services - All Members of a STAR+PLUS HMO may receive medically
                and
                functionally necessary personal attendant services (PAS). 

              o
                Day
                Activity and Health Services - All Members of a STAR+PLUS HMO may
                receive
                medically and functionally necessary Day Activity and Health Care
                Services
                (DAHS). 

              
                	 	 	
                        •
                          1915
                          (c) Nursing Facility Waiver Services for those Members
                          who qualify for
                          such services 

                      

              

              The
                state
                provides an enriched array of services to clients who would otherwise
                qualify
                for nursing facility care through a Home and Community Based Medicaid
                Waiver. In
                traditional Medicaid, this is known as the Community Based Alternatives
                (CBA)
                waiver. The STAR+PLUS HMO must also provide the services that are
                available to
                clients through the CBA waiver in traditional Medicaid to those clients
                that
                meet the functional and financial eligibility for the 1915 (c) Nursing
                Facility
                Waiver Services. 

              o
                Personal
                Attendant Services (including the three service delivery options:
                Self-Directed;
                Agency Model, Self-Directed; and Agency Model) 

              o
                Nursing
                Services (in home) 

              o
                Emergency
                Response Services (Emergency call button) 

              o
                Home
                Delivered Meals 

              o
                Minor
                Home Modifications 

              o
                Adaptive
                Aids and Medical Equipment 

              o
                Medical
                Supplies 

              o
                Physical
                Therapy, Occupational Therapy, Speech Therapy 

              o
                Adult
                Foster Care 

              o
                Assisted
                Living 

              o Transition
                Assistance Services (These services are limited to a maximum of $2,500.00.
                If
                the HMO determines that no other resources are available to pay for
                the basic
                services/items needed to assist a Member, who is leaving a nursing
                facility,
                with setting up a household, the HMO may authorize up to $2,500.00
                for
                Transition Assistance Services (TAS). The $2,500.00 TAS benefit is
                part of the
                expense ceiling when determining the Total Annual Individual Service
                Plan (ISP)
                Cost.) 

              

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

              

                Contractual
                  Document (CD) Responsible Office: HHSC Office of General Counsel
                  (OGC)

                Subject:
                  Attachment B-2.2 - CHIP Perinatal Covered Services 

                Version
                  1.6 

                

                   

                  
                    	
                            DOCUMENT
                              HISTORY LOG 

                          
	
                            STATUS1

                          	
                            DOCUMENT
                              

                            REVISION2

                          	
                            EFFECTIVE
                              

                            DATE
                              

                          	
                            DESCRIPTION3

                          
	
                             

                            Baseline
                              

                             

                          	
                             

                            n/a
                              

                             

                          	
                             

                             

                             

                          	
                             

                            Initial
                              version of Attachment B-2, Covered Services 

                             

                          
	
                             

                            Revision
                              

                          	
                             

                            1.1
                              

                          	
                             

                            June
                              30, 2006 

                          	
                             

                            Revised
                              Attachment B-2, Covered Services, by adding Attachment
                              B-2.1, STAR+PLUS
                              Covered Services. 

                             

                             

                          
	
                             

                            Revision
                              

                          	
                             

                            1.2
                              

                          	
                             

                            September
                              1, 2006 

                          	
                             

                            Revised
                              Attachment B-2, Covered Services, by updating provisions
                              applicable to
                              MCOs participating in the STAR and CHIP Programs. 

                             

                             

                          
	
                             

                            Revision
                              

                          	
                             

                            1.3
                              

                          	
                             

                            September
                              1, 2006 

                          	
                             

                            Revised
                              Attachment B-2, Covered Services, by adding Attachment
                              B-2.2, CHIP
                              Perinatal Covered Services. This is the initial version
                              of Attachment
                              B-2.2, which lists the CHIP Perinatal Covered Services,
                              exclusions
                              and DME/Supplies.
                              

                             

                             

                          
	
                             

                            Revision
                              

                          	
                             

                            1.4
                              

                          	
                             

                            September
                              1, 2006 

                          	
                             

                            Contract
                              Amendment did not revise Attachment B-2.2- CHIP Perinatal
                              Covered
                              Services. 

                             

                             

                          
	
                             

                            Revision
                              

                          	
                             

                            1.5
                              

                          	
                             

                            January
                              1, 2007 

                          	
                             

                            Contract
                              Amendment did not revise Attachment B-2.2- CHIP Perinatal
                              Covered
                              Services. 

                             

                             

                          
	
                             

                            Revision
                              

                          	
                             

                            1.6
                              

                          	
                             

                            February
                              1, 2007 

                          	
                             

                            Contract
                              Amendment did not revise Attachment B-2.2- CHIP Perinatal
                              Covered
                              Services. 

                             

                             

                          
	
                             

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

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

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

                          

                  

                  

                  

                    
                      
                        
                        

                      

                      
                        
                        

                        
                          

                        

                      

                      
                        
                        

                      

                    

CHIP
                    Perinatal Program Covered Services  

                  Covered
                    CHIP Perinatal Program services must meet the definition of Medically
                    Necessary
                    Covered Services as defined in this
                    Contract.
                    There
                    is no lifetime maximum on benefits; however, 12-month enrollment
                    period or
                    lifetime limitations do apply to certain services, as specified
                    in the following
                    chart. Co-pays do not apply to CHIP Perinatal Program Members.
                    CHIP Perinatal
                    Program Members are eligible for 12-months continuous coverage
                    following
                    enrollment in the program. 

                   

                  
                    	
                            Covered
                              Benefit 

                          	
                            CHIP
                              Perinate Newborn 

                          	
                            CHIP
                              Perinate 

                          
	
                            Inpatient
                              General Acute and Inpatient Rehabilitation Hospital
                              Services
                              

                             

                          	
                            For
                              CHIP Perinate Newborns in families with incomes at
                              or below 185% of the
                              Federal Poverty Level, the facility charges are not
                              a covered benefit for
                              the initial Perinate Newborn admission; however, facility
                              charges are a
                              covered benefit after the initial Perinate Newborn
                              admission. "Initial
                              Perinate Newborn admission" means the hospitalization
                              associated with the
                              birth.  

                             

                            For
                              CHIP Perinate Newborns in families with incomes at
                              or below 185% of the
                              Federal Poverty Level, professional service charges
                              are a covered benefit
                              for the initial Perinate Newborn admission and subsequent
                              admissions.
                              "Initial Perinate Newborn admission" means the hospitalization
                              associated
                              with the birth.  

                             

                            Services
                              include, but are not limited to, the following: 

                            § Hospital-provided
                              Physician or Provider services 

                            § Semi-private
                              room and board (or private if medically necessary as
                              certified by
                              attending) 

                            § General
                              nursing care 

                            § Special
                              duty nursing when medically necessary 

                            § ICU
                              and services 

                            § Patient
                              meals and special diets 

                            § Operating,
                              recovery and other treatment rooms 

                            § Anesthesia
                              and administration (facility technical component) 

                            § Surgical
                              dressings, trays, casts, splints 

                            § Drugs,
                              medications and biologicals 

                            § Blood
                              or blood products that are not provided free-of-charge
                              to the patient and
                              their administration 

                            § X-rays,
                              imaging and other radiological tests (facility technical
                              component)
                              

                            § Laboratory
                              and pathology services (facility technical component)

                            § Machine
                              diagnostic tests (EEGs, EKGs, etc.) 

                            § Oxygen
                              services and inhalation therapy 

                            § Radiation
                              and chemotherapy 

                            § Access
                              to DSHS-designated Level III perinatal centers or Hospitals
                              meeting
                              equivalentlevels of care 

                            § In-network
                              or out-of-network facility and Physician services for
                              a mother and her
                              newborn(s) for a minimum of 48 hours following an uncomplicated
                              vaginal
                              delivery and 96 hours following an uncomplicated delivery
                              by caesarian
                              section. 

                            § Hospital,
                              physician and related medical services, such as anesthesia,
                              associated
                              with dental care 

                            § Surgical
                              implants 

                            § Other
                              artificial aids including surgical implants 

                            § Implantable
                              devices are covered under Inpatient and Outpatient
                              services and do not
                              count towards the DME 12-month period limit 

                             

                          	
                            For
                              CHIP Perinates in families with incomes at or below
                              185% of the Federal
                              Poverty Level, the facility charges are not a covered
                              benefit; however,
                              professional services charges associated with labor
                              with delivery are a
                              covered benefit. 

                             

                            For
                              CHIP Perinates in families with incomes between 186%
                              and 200% of the
                              Federal Poverty Level, benefits are limited to professional
                              service
                              charges and facility charges associated with labor
                              with delivery.
                              

                             

                            Covered
                              medically necessary Hospital-provided services are
                              limited to labor with
                              delivery until birth. 

                             

                            Services
                              include: 

                            § Operating,
                              recovery and other treatment rooms 

                            § Anesthesia
                              and administration (facility technical component 

                            § Medically
                              necessary surgical services are limited to services
                              that directly relate
                              to the delivery of the unborn child. 

                          
	
                            Skilled
                              Nursing 

                            Facilities
                              

                            (Includes
                              Rehabilitation 

                            Hospitals)
                              

                             

                             

                          	
                            Services
                              include, but are not limited to, the following: 

                            § Semi-private
                              room and board 

                            § Regular
                              nursing services 

                             

                            § Rehabilitation
                              services 

                            § Medical
                              supplies and use of appliances and equipment furnished
                              by the
                              facility 

                          	
                            Not
                              a covered benefit. 

                          
	
                            Outpatient
                              Hospital, Comprehensive Outpatient Rehabilitation Hospital,
                              Clinic
                              (Including Health Center) and Ambulatory Health Care
                              Center
                              

                             

                          	
                            Services
                              include, but are not limited to, the following services
                              provided in a
                              hospital clinic or emergency room, a clinic or health
                              center,
                              hospital-based emergency department or an ambulatory
                              health care setting:
                              

                            § X-ray,
                              imaging, and radiological tests (technical component)

                            § Laboratory
                              and pathology services (technical component) 

                            § Machine
                              diagnostic tests 

                            § Ambulatory
                              surgical facility services 

                            § Drugs,
                              medications and biologicals 

                            § Casts,
                              splints, dressings 

                            § Preventive
                              health services 

                            § Physical,
                              occupational and speech therapy 

                            § Renal
                              dialysis 

                            § Respiratory
                              services 

                            § Radiation
                              and chemotherapy 

                            § Blood
                              or blood products that are not provided free-of-charge
                              to the patient and
                              the administration of these products 

                            § Facility
                              and related medical services, such as anesthesia, associated
                              with dental
                              care, when provided in a licensed ambulatory surgical
                              facility.
                              

                            § Surgical
                              implants 

                            § Other
                              artificial aids including surgical implants 

                            § Implantable
                              devices are covered under Inpatient and Outpatient
                              services and do not
                              count towards the DME 12-month period limit. 

                             

                          	
                            Services
                              include, the following services provided in a hospital
                              clinic or emergency
                              room, a clinic or health center, hospital-based emergency
                              department or an
                              ambulatory health care setting: 

                            § X-ray,
                              imaging, and radiological tests (technical component)

                            § Laboratory
                              and pathology services (technical component) 

                            § Machine
                              diagnostic tests 

                            § Drugs,
                              medications and biologicals that are medically necessary
                              prescription and
                              injection drugs. 

                             

                             

                            (1)
                              Laboratory and radiological services are limited to
                              services that directly
                              relate to ante partum care and/or the delivery of the
                              covered CHIP
                              Perinate until birth. 

                             

                            (2)
                              Ultrasound of the pregnant uterus is a covered benefit
                              when medically
                              indicated. Ultrasound may be indicated for suspected
                              genetic defects,
                              high-risk pregnancy, fetal growth retardation, or gestational
                              age
                              confirmation. 

                             

                            (3)
                              Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion
                              (FIUT) and
                              Ultrasonic Guidance for Cordocentesis, FIUT are covered
                              benefits with an
                              appropriate diagnosis. 

                             

                            (4)
                              Laboratory tests are limited to: nonstress testing,
                              contraction, stress
                              testing, hemoglobin or hematocrit repeated once a trimester
                              and at 32-36
                              weeks of pregnancy; or complete blood count (CBC),
                              urinanalysis for
                              protein and glucose every visit, blood type and RH
                              antibody screen; repeat
                              antibody screen for Rh negative women at 28 weeks followed
                              by RHO immune
                              globulin administration if indicated; rubella antibody
                              titer, serology for
                              syphilis, hepatitis B surface antigen, cervical cytology,
                              pregnancy test,
                              gonorrhea test, urine culture, sickle cell test, tuberculosis
                              (TB) test,
                              human immunodeficiency virus (HIV) antibody screen,
                              Chlamydia test, other
                              laboratory tests not specified but deemed medically
                              necessary, and
                              multiple marker screens for neural tube defects (if
                              the client initiates
                              care between 16 and 20 weeks); screen for gestational
                              diabetes at 24-28
                              weeks of pregnancy; other lab tests as indicated by
                              medical condition of
                              client. 

                          
	
                            Physician/
                              

                            Physician
                              

                            Extender
                              Professional Services 

                             

                          	
                            Services
                              include, but are not limited to, the following: 

                            § American
                              Academy of Pediatrics recommended well-child exams
                              and preventive health
                              services (including, but not limited to, vision and
                              hearing screening and
                              immunizations) 

                            § Physician
                              office visits, in-patient and out-patient services

                            § Laboratory,
                              x-rays, imaging and pathology services, including technical
                              component
                              and/or professional interpretation 

                            § Medications,
                              biologicals and materials administered in Physician’s office 

                            § Allergy
                              testing, serum and injections 

                            § Professional
                              component (in/outpatient) of surgical services, including:

                            § Surgeons
                              and assistant surgeons for surgical procedures including
                              appropriate
                              follow-up care 

                            § Administration
                              of anesthesia by Physician (other than surgeon) or
                              CRNA 

                            § Second
                              surgical opinions 

                            § Same-day
                              surgery performed in a Hospital without an over-night
                              stay 

                            § Invasive
                              diagnostic procedures such as endoscopic examinations 

                            § Hospital-based
                              Physician services (including Physician-performed technical
                              and
                              interpretive components) 

                            § In-network
                              and out-of-network Physician services for a mother
                              and her newborn(s) for
                              a minimum of 48 hours following an uncomplicated vaginal
                              delivery and 96
                              hours following an uncomplicated delivery by caesarian
                              section.
                              

                            § Physician
                              services medically necessary to support a dentist providing
                              dental
                              services to a CHIP member such as general anesthesia
                              or intravenous (IV)
                              sedation. 

                             

                          	
                            Services
                              include, but are not limited to the following: 

                            § Medically
                              necessary physician services are limited to prenatal
                              and postpartum care
                              and/or the delivery of the covered unborn child until
                              birth 

                            § Physician
                              office visits, in-patient and out-patient services

                            § Laboratory,
                              x-rays, imaging and pathology services including technical
                              component and
                              /or professional interpretation 

                            § Medically
                              necessary medications, biologicals and materials administered
                              in
                              Physician’s office 

                            § Professional
                              component (in/outpatient) of surgical services, including:

                            o
                              Surgeons
                              and assistant surgeons for surgical procedures directly
                              related to the
                              labor with delivery of the covered unborn child until
                              birth. 

                            o
                              Administration
                              of anesthesia by Physician (other than surgeon) or
                              CRNA 

                            o
                              Invasive
                              diagnostic procedures directly related to the labor with
                              delivery of the unborn child. 

                            § Hospital-based
                              Physician services (including Physician performed technical
                              and
                              interpretive components) 

                            § Professional
                              component of the ultrasound of the pregnant uterus
                              when medically
                              indicated for suspected genetic defects, high-risk
                              pregnancy, fetal growth
                              retardation, or gestational age confirmation. 

                            § Professional
                              component of Amniocentesis, Cordocentesis, Fetal Intrauterine
                              Transfusion
                              (FIUT) and Ultrasonic Guidance for Amniocentesis, Cordocentrsis,
                              and FIUT.
                              

                          
	
                            Prenatal
                              Care and Pre-Pregnancy Family Services and Supplies

                             

                             

                          	
                            Not
                              a covered benefit. 

                          	
                            Services
                              are limited to an initial visit and subsequent prenatal
                              (ante partum) care
                              visits that include: 

                             

                            (1)
                              One visit every four weeks for the first 28 weeks or
                              pregnancy;
                              

                            (2)
                              one visit every two to three weeks from 28 to 36 weeks
                              of pregnancy; and
                              

                            (3)
                              one visit per week from 36 weeks to delivery. 

                             

                            More
                              frequent visits are allowed as Medically Necessary.
                              Benefits are limited
                              to: 

                             

                            Limit
                              of 20 prenatal visits and 2 postpartum visits (maximum
                              within 60 days)
                              without documentation of a complication of pregnancy.
                              More frequent visits
                              may be necessary for high-risk pregnancies. High-risk
                              prenatal visits are
                              not limited to 20 visits per pregnancy. Documentation
                              supporting medical
                              necessity must be maintained in the physician’s files and is subject to
                              retrospective review. 

                             

                            Visits
                              after the initial visit must include: 

                            § interim
                              history (problems, marital status, fetal status); 

                            § physical
                              examination (weight, blood pressure, fundalheight,
                              fetal position and
                              size, fetal heart rate, extremities) and 

                            § laboratory
                              tests (urinanalysis for protein and glucose every visit;
                              hematocrit or
                              hemoglobin repeated once a trimester and at 32-36 weeks
                              of pregnancy;
                              multiple marker screen for fetal abnormalities offered
                              at 16-20 weeks of
                              pregnancy; repeat antibody screen for Rh negative women
                              at 28 weeks
                              followed by Rho immune globulin administration if indicated;
                              screen for
                              gestational diabetes at 24-28 weeks of pregnancy; and
                              other lab tests as
                              indicated by medical condition of client). 

                          
	
                            Durable
                              Medical Equipment (DME), Prosthetic Devices and 

                            Disposable
                              Medical Supplies 

                             

                             

                          	
                            $20,000
                              12-month period limit for DME, prosthetics, devices
                              and disposable medical
                              supplies (diabetic supplies and equipment are not counted
                              against this
                              cap). Services include DME (equipment which can withstand
                              repeated use and
                              is primarily and customarily used to serve a medical
                              purpose, generally is
                              not useful to a person in the absence of Illness, Injury,
                              or Disability,
                              and is appropriate for use in the home), including
                              devices and supplies
                              that are medically necessary and necessary for one
                              or more activities of
                              daily living and appropriate to assist in the treatment
                              of a medical
                              condition, including: 

                            § Orthotic
                              braces and orthotics 

                            § Prosthetic
                              devices such as artificial eyes, limbs, and braces

                            § Prosthetic
                              eyeglasses and contact lenses for the management of
                              severe ophthalmologic
                              disease 

                            § Hearing
                              aids 

                            § Diagnosis-specific
                              disposable medical supplies, including diagnosis-specific
                              prescribed
                              specialty formula and dietary supplements. (See Attachment
                              A)

                             

                          	
                            Not
                              a covered benefit. 

                          
	
                            Home
                              and Community Health Services 

                             

                             

                             

                          	
                            Services
                              that are provided in the home and community, including,
                              but not limited
                              to: 

                            § Home
                              infusion 

                            § Respiratory
                              therapy 

                            § Visits
                              for private duty nursing (R.N., L.V.N.) 

                            § Skilled
                              nursing visits as defined for home health purposes
                              (may include R.N. or
                              L.V.N.). 

                            § Home
                              health aide when included as part of a plan of care
                              during a period that
                              skilled visits have been approved. 

                            § Speech,
                              physical and occupational therapies. 

                            § Services
                              are not intended to replace the CHILD'S caretaker or
                              to provide relief for
                              the caretaker 

                            § Skilled
                              nursing visits are provided on intermittent level and
                              not intended to
                              provide 24-hour skilled nursing services 

                            § Services
                              are not intended to replace 24-hour inpatient or skilled
                              nursing facility
                              services 

                             

                          	
                            Not
                              a covered benefit. 

                          
	
                            Inpatient
                              Mental Health Services 

                             

                          	
                            Mental
                              health services, including for serious mental illness,
                              furnished in a
                              free-standing psychiatric hospital, psychiatric units
                              of general acute
                              care hospitals and state-operated facilities, including,
                              but not limited
                              to: 

                            § Neuropsychological
                              and psychological testing. 

                            Inpatient
                              mental health services are limited to: 

                            § 45
                              days 12-month inpatient limit 

                            § Includes
                              inpatient psychiatric services, up to 12-month period
                              limit, ordered by a
                              court of competent jurisdiction under the provisions
                              of Chapters 573 and
                              574 of the Texas Health and Safety Code, relating to
                              court ordered
                              commitments to psychiatric facilities. Court order
                              serves as binding
                              determination of medical necessity. Any modification
                              or termination of
                              services must be presented to the court with jurisdiction
                              over the matter
                              for determination 

                            § 25
                              days of the inpatient benefit can be converted to residential
                              treatment,
                              therapeutic foster care or other 24-hour therapeutically
                              planned and
                              structured services or sub-acute outpatient (partial
                              hospitalization or
                              rehabilitative day treatment) mental health services
                              on the basis of
                              financial equivalence against the inpatient per diem
                              cost 

                            § 20
                              of the inpatient days must be held in reserve for inpatient
                              use only
                              

                            § Does
                              not require PCP referral 

                             

                          	
                            Not
                              a covered benefit. 

                          
	
                            Outpatient
                              Mental Health Services 

                             

                          	
                            Mental
                              health services, including for serious mental illness,
                              provided on an
                              outpatient basis, including, but not limited to: 

                            § Medication
                              management visits do not count against the outpatient
                              visit limit.
                              

                            § The
                              visits can be furnished in a variety of community-based
                              settings
                              (including school and home-based) or in a state-operated
                              facility
                              

                            § Up
                              to 60 days 12-month period limit for rehabilitative
                              day treatment
                              

                            § 60
                              outpatient visits 12-month period limit 

                            § 60
                              rehabilitative day treatment days can be converted
                              to outpatient visits on
                              the basis of financial equivalence against the day
                              treatment per diem cost
                              

                            § 60
                              outpatient visits can be converted to skills training
                              (psycho educational
                              skills development) or rehabilitative day treatment
                              on the basis of
                              financial equivalence against the outpatient visit
                              cost 

                            § Includes
                              outpatient psychiatric services, up to 12-month period
                              limit, ordered by a
                              court of competent jurisdiction under the provisions
                              of Chapters 573 and
                              574 of the Texas Health and Safety Code, relating to
                              court ordered
                              commitments to psychiatric facilities. Court order
                              serves as binding
                              determination of medical necessity. Any modification
                              or termination of
                              services must be presented to the court with jurisdiction
                              over the matter
                              for determination 

                            § Inpatient
                              days converted to sub-acute outpatient services are
                              in addition to the
                              outpatient limits and do not count towards those limits

                            § A
                              Qualified Mental Health Professional (QMHP), as defined
                              by and
                              credentialed through Texas Department of State Health
                              Services (DSHS)
                              standards (TAC Title 25, Part II, Chapter 412), is
                              a Local Mental Health
                              Authorities provider. A QMHP must be working under
                              the authority of an
                              DSHS entity and be supervised by a licensed mental
                              health professional or
                              physician. QMHPs are acceptable providers as long as
                              the services would be
                              within the scope of the services that are typically
                              provided by QMHPs.
                              Those services include individual and group skills
                              training (which can be
                              components of interventions such as day treatment and
                              in-home services),
                              patient and family education, and crisis services 

                            § Does
                              not require PCP referral 

                             

                          	
                            Not
                              a covered benefit. 

                          
	
                            Inpatient
                              Substance Abuse Treatment Services 

                             

                          	
                            Services
                              include, but are not limited to: 

                            § Inpatient
                              and residential substance abuse treatment services
                              including
                              detoxification and crisis stabilization, and 24-hour
                              residential
                              rehabilitation programs 

                            § Does
                              not require PCP referral 

                            § Medically
                              necessary detoxification/stabilization services, limited
                              to 14 days per
                              12-month period. 

                            § 24-hour
                              residential rehabilitation programs, or the equivalent,
                              up to 60 days per
                              12-month period 

                            § 30
                              days may be converted to partial hospitalization or
                              intensive outpatient
                              rehabilitation, on the basis of financial equivalence
                              against the
                              inpatient per diem cost 

                            § 30
                              days must be held in reserve for inpatient use only.

                             

                          	
                            Not
                              a covered benefit. 

                          
	
                            Outpatient
                              Substance Abuse Treatment Services 

                             

                          	
                            Services
                              include, but are not limited to, the following: 

                            § Prevention
                              and intervention services that are provided by physician
                              and non-physician
                              providers, such as screening, assessment and referral
                              for chemical
                              dependency disorders. 

                            § Intensive
                              outpatient services is defined as an organized non-residential
                              service
                              providing structured group and individual therapy,
                              educational services,
                              and life skills training which consists of at least
                              10 hours per week for
                              four to 12 weeks, but less than 24 hours per day 

                            § Outpatient
                              treatment service is defined as consisting of at least
                              one to two hours
                              per week providing structured group and individual
                              therapy, educational
                              services, and life skills training 

                            § Outpatient
                              treatment services up to a maximum of: 

                            § Intensive
                              outpatient program (up to 12 weeks per 12-month period)

                            § Outpatient
                              services (up to six-months per 12-month period) 

                            § Does
                              not require PCP referral 

                             

                          	
                            Not
                              a covered benefit. 

                          
	
                            Rehabilitation
                              Services 

                             

                             

                          	
                            Services
                              include, but are not limited to, the following: 

                            § Habilitation
                              (the process of supplying a child with the means to
                              reach age-appropriate
                              developmental milestones through therapy or treatment)
                              and rehabilitation
                              services include, but are not limited to the following:

                            § Physical,
                              occupational and speech therapy 

                            § Developmental
                              assessment 

                             

                          	
                            Not
                              a covered benefit. 

                          
	
                            Hospice
                              Care Services 

                             

                          	
                            Services
                              include, but are not limited to: 

                            § Palliative
                              care, including medical and support services, for those
                              children who have
                              six months or less to live, to keep patients comfortable
                              during the last
                              weeks and months before death 

                            § Treatment
                              for unrelated conditions is unaffected 

                            § Up
                              to a maximum of 120 days with a 6 month life expectancy 

                            § Patients
                              electing hospice services waive their rights to treatment
                              related to their
                              terminal illnesses; however, they may cancel this election
                              at
                              anytime 

                            § Services
                              apply to the hospice diagnosis 

                             

                          	
                            Not
                              a covered benefit. 

                          
	
                            Emergency
                              Services, including Emergency Hospitals, Physicians,
                              and Ambulance
                              Services 

                             

                          	
                            HMO
                              cannot require authorization as a condition for payment
                              for emergency
                              conditions labor and delivery. 

                             

                            Covered
                              services include, but are not limited to, the following:

                            § Emergency
                              services based on prudent lay person definition of
                              emergency health
                              condition 

                            § Hospital
                              emergency department room and ancillary services and
                              physician services 24
                              hours a day, 7 days a week, both by in-network and
                              out-of-network
                              providers 

                            § Medical
                              screening examination  

                            § Stabilization
                              services 

                            § Access
                              to DSHS designated Level 1 and Level II trauma centers
                              or hospitals
                              meeting equivalent levels of care for emergency services 

                            § Emergency
                              ground, air and water transportation 

                            § Emergency
                              dental services, limited to fractured or dislocated
                              jaw, traumatic damage
                              to teeth, and removal of cysts. 

                             

                          	
                            HMO
                              cannot require authorization as a condition for payment
                              for emergency
                              conditions related to labor with delivery. 

                             

                            Covered
                              services are limited to those emergency services that
                              are directly related
                              to the delivery of the unborn child until birth. 

                            § Emergency
                              services based on prudent lay person definition of
                              emergency health
                              condition 

                            § Medical
                              screening examination to determine emergency when directly
                              related to the
                              delivery of the covered unborn child. 

                            § Stabilization
                              services related to the labor with delivery of the
                              covered unborn child.
                              

                            § Emergency
                              ground, air and water transportation for labor and
                              threatened labor is a
                              covered benefit 

                             

                            Benefit
                              limits: Post-delivery services or complications resulting
                              in the need for
                              emergency services for the mother of the CHIP Perinate
                              are not a covered
                              benefit. 

                          
	
                            Transplants
                              

                             

                          	
                            Services
                              include, but are not limited to, the following: 

                            § Using
                              up-to-date FDA guidelines, all non-experimental human
                              organ and tissue
                              transplants and all forms of non-experimental corneal,
                              bone marrow and
                              peripheral stem cell transplants, including donor medical
                              expenses.
                              

                             

                          	
                            Not
                              a covered benefit. 

                          
	
                            Vision
                              Benefit 

                             

                             

                             

                             

                          	
                            The
                              health plan may reasonably limit the cost of the frames/lenses.
                              

                            Services
                              include: 

                            § One
                              examination of the eyes to determine the need for and
                              prescription for
                              corrective lenses per 12-month period, without authorization

                            § One
                              pair of non-prosthetic eyewear per 12-month period

                             

                          	
                            Not
                              a covered benefit. 

                          
	
                            Chiropractic
                              Services 

                             

                          	
                            Services
                              do not require physician prescription and are limited
                              to spinal
                              subluxation. 

                             

                          	
                            Not
                              a covered benefit. 

                          
	
                            Tobacco
                              Cessation 

                            Program 

                             

                          	
                            Covered
                              up to $100 for a 12- month period limit for a plan-
                              approved program
                              

                            § Health
                              Plan defines plan-approved program. 

                            § May
                              be subject to formulary requirements. 

                             

                          	
                            Not
                              a covered benefit. 

                          
	
                            Case
                              Management and Care Coordination Services 

                             

                             

                          	
                            These
                              services include outreach informing, case management,
                              care coordination
                              and community referral. 

                          	
                            Covered
                              benefit. 

                             

                             

                          
	
                            Value-added
                              services 

                          	
                            See
                              Attachment B-3.2 

                          	
                             

                          

                  

                  

                   

                  
                    
                      
                      

                    

                    
                      
                      

                      
                        

                      

                    

                    
                      
                      

                    

                  

                   

                  CHIP
                    PERINATAL PROGRAM EXCLUSIONS FROM COVERED 

                  SERVICES
                    FOR CHIP PERINATES 

                   

                  For
                    CHIP
                    Perinates in families with incomes at or below 185% of the Federal
                    Poverty
                    Level, inpatient facility charges are not a covered benefit for
                    the initial
                    Perinatal Newborn admission. "Initial
                    Perinatal Newborn admission" means the hospitalization associated
                    with the
                    birth.  

                  
                    	
                            §

                          	
                            Inpatient
                              and outpatient treatments other than prenatal care,
                              labor with delivery,
                              and postpartum care related to the covered unborn child
                              until birth.
                              

                          

                  

                  
                    	
                            §

                          	
                             Inpatient
                              mental health services. 

                          

                  

                  
                    	
                            §

                          	
                             Outpatient
                              mental health services. 

                          

                  

                  
                    	
                            §

                          	
                             Durable
                              medical equipment or other medically related remedial
                              devices.
                              

                          

                  

                  
                    	
                            §

                          	
                             Disposable
                              medical supplies. 

                          

                  

                  
                    	
                            §

                          	
                             Home
                              and community-based health care services.

                          

                  

                  
                    	
                            §

                          	
                             Nursing
                              care services. 

                          

                  

                  
                    	
                            §

                          	
                             Dental
                              services. 

                          

                  

                  
                    	
                            §

                          	
                             Inpatient
                              substance abuse treatment services and residential
                              substance abuse
                              treatment services. 

                          

                  

                  
                    	
                            §

                          	
                             Outpatient
                              substance abuse treatment services.

                          

                  

                  
                    	
                            §

                          	
                            Physical
                              therapy, occupational therapy, and services for individuals
                              with speech,
                              hearing, and language disorders. 

                          

                  

                  
                    	
                            §

                          	
                             Hospice
                              care. 

                          

                  

                  
                    	
                            §

                          	
                             Skilled
                              nursing facility and rehabilitation hospital services.
                              

                          

                  

                  
                    	
                            §

                          	
                            Emergency
                              services other than those directly related to the labor
                              with delivery of
                              the covered unborn child. 

                          

                  

                  
                    	
                            §

                          	
                             Transplant
                              services. 

                          

                  

                  
                    	
                            §

                          	
                             Tobacco
                              Cessation Programs. 

                          

                  

                  
                    	
                            §

                          	
                             Chiropractic
                              Services. 

                          

                  

                  
                    	
                            §

                          	
                            Medical
                              transportation not directly related to the labor or
                              threatened labor
                              and/or delivery of the covered unborn child.

                          

                  

                  
                    	
                            §

                          	
                            Personal
                              comfort items including but not limited to personal
                              care kits provided on
                              inpatient admission, telephone, television, newborn
                              infant photographs,
                              meals for guests of patient, and other articles which
                              are not required for
                              the specific treatment related to labor with delivery
                              or post partum care.
                              

                          

                  

                  
                    	
                            §

                          	
                            Experimental
                              and/or investigational medical, surgical or other health
                              care procedures
                              or services which are not generally employed or recognized
                              within the
                              medical community 

                          

                  

                  
                    	
                            §

                          	
                            Treatment
                              or evaluations required by third parties including,
                              but not limited to,
                              those for schools, employment, flight clearance, camps,
                              insurance or court
                              

                          

                  

                  
                    	
                            §

                          	
                            Private
                              duty nursing services when performed on an inpatient
                              basis or in a skilled
                              nursing facility. 

                          

                  

                  
                    	
                            §

                          	
                             Mechanical
                              organ replacement devices including, but not limited
                              to artificial heart
                              

                          

                  

                  
                    	
                            §

                          	
                            Hospital
                              services and supplies when confinement is solely for
                              diagnostic testing
                              purposes and not a part of labor with delivery 

                          

                  

                  
                    	
                            §

                          	
                             Prostate
                              and mammography screening 

                          

                  

                  
                    	
                            §

                          	
                             Elective
                              surgery to correct vision 

                          

                  

                  
                    	
                            §

                          	
                             Gastric
                              procedures for weight loss 

                          

                  

                  
                    	
                            §

                          	
                             Cosmetic
                              surgery/services solely for cosmetic purposes

                          

                  

                  
                    	
                            §

                          	
                            Out-of-network
                              services not authorized by the Health Plan except for
                              emergency care
                              related to the labor with delivery of the covered unborn
                              child.
                              

                          

                  

                  
                    	
                            §

                          	
                            Services,
                              supplies, meal replacements or supplements provided
                              for weight control or
                              the treatment of obesity 

                          

                  

                  
                    	
                            §

                          	
                             Acupuncture
                              services, naturopathy and hypnotherapy

                          

                  

                  
                    	
                            §

                          	 Immunizations solely for foreign travel

                  

                  
                    
                      
                      

                    

                    
                      
                      

                      
                        

                      

                    

                    
                      
                      

                    

                  

                   

                  
                    	
                            §

                          	
                             Routine
                              foot care such as hygienic care 

                          

                  

                  
                    	
                            §

                          	
                            Diagnosis
                              and treatment of weak, strained, or flat feet and the
                              cutting or removal
                              of corns, calluses and toenails (this does not apply
                              to the removal of
                              nail roots or surgical treatment of conditions underlying
                              corns, calluses
                              or ingrown toenails)  

                          

                  

                  
                    	
                            §

                          	
                             Corrective
                              orthopedic shoes 

                          

                  

                  
                    	
                            §

                          	
                             Convenience
                              items 

                          

                  

                  
                    	
                            §

                          	
                             Orthotics
                              primarily used for athletic or recreational purposes
                              

                          

                  

                  
                    	
                            §

                          	
                            Custodial
                              care (care that assists with the activities of daily
                              living, such as
                              assistance in walking, getting in and out of bed, bathing,
                              dressing,
                              feeding, toileting, special diet preparation, and medication
                              supervision
                              that is usually self-administered or provided by a
                              caregiver. This care
                              does not require the continuing attention of trained
                              medical or
                              paramedical personnel.) 

                          

                  

                  
                    	
                            §

                          	
                             Housekeeping
                              

                          

                  

                  
                    	
                            §

                          	
                            Public
                              facility services and care for conditions that federal,
                              state, or local
                              law requires be provided in a public facility or care
                              provided while in
                              the custody of legal authorities 

                          

                  

                  
                    	
                            §

                          	
                             Services
                              or supplies received from a nurse, which do not require
                              the skill and
                              training of a nurse 

                          

                  

                  
                    	
                            §

                          	
                             Vision
                              training, vision therapy, or vision services

                          

                  

                  
                    	
                            §

                          	
                            Reimbursement
                              for school-based physical therapy, occupational therapy,
                              or speech therapy
                              services are not covered 

                          

                  

                  
                    	
                            §

                          	
                             Donor
                              non-medical expenses 

                          

                  

                  
                    	
                            §

                          	
                             Charges
                              incurred as a donor of an organ 

                          

                  

                  

                  CHIP
                    PERINATAL PROGRAM EXCLUSIONS FROM COVERED SERVICES 

                  FOR
                    CHIP PERINATE NEWBORNS 

                   

                  With
                    the
                    exception of the first bullet, all the following exclusions match
                    those found in
                    the CHIP Program. 

                  
                    	
                            §

                          	
                            For
                              CHIP Perinate Newborns in families with incomes at
                              or below 185% of the
                              Federal Poverty Level, inpatient facility charges are
                              not a covered
                              benefit for the initial Perinate Newborn admission.
                              "Initial Perinate
                              Newborn admission" means the hospitalization associated
                              with the birth.
                              

                          

                  

                  
                    	
                            §

                          	
                            Inpatient
                              and outpatient infertility treatments or reproductive
                              services other than
                              prenatal care, labor and delivery, and care related
                              to disease, illnesses,
                              or abnormalities related to the reproductive system
                              

                          

                  

                  
                    	
                            §

                          	
                            Personal
                              comfort items including but not limited to personal
                              care kits provided on
                              inpatient admission, telephone, television, newborn
                              infant photographs,
                              meals for guests of patient, and other articles which
                              are not required for
                              the specific treatment of sickness or injury

                          

                  

                  
                    	
                            §

                          	
                            Experimental
                              and/or investigational medical, surgical or other health
                              care procedures
                              or services which are not generally employed or recognized
                              within the
                              medical community 

                          

                  

                  
                    	
                            §

                          	
                            Treatment
                              or evaluations required by third parties including,
                              but not limited to,
                              those for schools, employment, flight clearance, camps,
                              insurance or court
                              

                          

                  

                  
                    	
                            §

                          	
                            Private
                              duty nursing services when performed on an inpatient
                              basis or in a skilled
                              nursing facility. 

                          

                  

                  
                    	
                            §

                          	
                            Mechanical
                              organ replacement devices including, but not limited
                              to artificial heart
                              

                          

                  

                  
                    	
                            §

                          	
                            Hospital
                              services and supplies when confinement is solely for
                              diagnostic testing
                              purposes, unless otherwise pre-authorized by Health
                              Plan 

                          

                  

                  
                    	
                            §

                          	
                            Prostate
                              and mammography screening 

                          

                  

                  
                    	
                            §

                          	
                            Elective
                              surgery to correct vision 

                          

                  

                  
                    	
                            §

                          	
                            Gastric
                              procedures for weight loss 

                          

                  

                  
                    	
                            §

                          	
                            Cosmetic
                              surgery/services solely for cosmetic purposes

                          

                  

                  
                    	
                            §

                          	
                            Out-of-network
                              services not authorized by the Health Plan except for
                              emergency care and
                              physician services for a mother and her newborn(s)
                              for a minimum of 48
                              hours following an uncomplicated vaginal delivery and
                              96 hours following
                              an uncomplicated delivery by caesarian section

                          

                  

                  
                    	
                            §

                          	
                            Services,
                              supplies, meal replacements or supplements provided
                              for weight control or
                              the treatment of obesity, except for the services associated
                              with the
                              treatment for morbid obesity as part of a treatment
                              plan approved by the
                              Health Plan 

                          

                  

                  
                    	
                            §

                          	 Acupuncture services, naturopathy and hypnotherapy
                            

                  

                  
                    
                      
                      

                    

                    
                      
                      

                      
                        

                      

                    

                    
                      
                      

                    

                  

                   

                  
                    	
                            §

                          	
                            Immunizations
                              solely for foreign travel 

                          

                  

                  
                    	
                            §

                          	
                            Routine
                              foot care such as hygienic care 

                          

                  

                  
                    	
                            §

                          	
                            Diagnosis
                              and treatment of weak, strained, or flat feet and the
                              cutting or removal
                              of corns, calluses and toenails (this does not apply
                              to the removal of
                              nail roots or surgical treatment of conditions underlying
                              corns, calluses
                              or ingrown toenails) 

                          

                  

                  
                    	
                            §

                          	
                            Replacement
                              or repair of prosthetic devices and durable medical
                              equipment due to
                              misuse, abuse or loss when confirmed by the Member
                              or the vendor
                               

                          

                  

                  
                    	
                            §

                          	
                            Corrective
                              orthopedic shoes 

                          

                  

                  
                    	
                            §

                          	
                            Convenience
                              items 

                          

                  

                  
                    	
                            §

                          	
                            Orthotics
                              primarily used for athletic or recreational purposes
                              

                          

                  

                  
                    	
                            §

                          	
                            Custodial
                              care (care that assists a child with the activities
                              of daily living, such
                              as assistance in walking, getting in and out of bed,
                              bathing, dressing,
                              feeding, toileting, special diet preparation, and medication
                              supervision
                              that is usually self-administered or provided by a
                              parent. This care does
                              not require the continuing attention of trained medical
                              or paramedical
                              personnel.) This exclusion does not apply to hospice
                              services.
                              

                          

                  

                  
                    	
                            §

                          	
                            Housekeeping
                              

                          

                  

                  
                    	
                            §

                          	
                            Public
                              facility services and care for conditions that federal,
                              state, or local
                              law requires be provided in a public facility or care
                              provided while in
                              the custody of legal authorities 

                          

                  

                  
                    	
                            §

                          	
                            Services
                              or supplies received from a nurse, which do not require
                              the skill and
                              training of a nurse 

                          

                  

                  
                    	
                            §

                          	
                            Vision
                              training and vision therapy 

                          

                  

                  
                    	
                            §

                          	
                            Reimbursement
                              for school-based physical therapy, occupational therapy,
                              or speech therapy
                              services are not covered except when ordered by a Physician/PCP
                              

                          

                  

                  
                    	
                            §

                          	
                            Donor
                              non-medical expenses 

                          

                  

                  
                    	
                            §

                          	
                            Charges
                              incurred as a donor of an organ when the recipient
                              is not covered under
                              this health plan 

                          

                  

                  
                    
                      
                      

                    

                    
                      
                      

                      
                        

                      

                    

                    
                      
                      

                    

                  

                  

                  CHIP
                    & CHIP PERINATAL PROGRAM DME/SUPPLIES 

                  Note:
                    DME/SUPPLIES are not a covered benefit for CHIP Perinate Members
                    but are a
                    benefit for CHIP Perinate Newborns. 

                  
                     

                    
                      	
                              SUPPLIES
                                

                            	
                              COVERED
                                

                            	
                              EXCLUDED
                                

                            	
                              COMMENTS/MEMBER
                                

                              CONTRACT
                                PROVISIONS 

                            
	
                              Ace
                                Bandages 

                            	
                               

                            	
                              X
                                

                            	
                              Exception:
                                If provided by and billed through the clinic or home
                                care agency it is
                                covered as an incidental supply. 

                            
	
                              Alcohol,
                                rubbing 

                            	
                               

                            	
                              X
                                

                            	
                              Over-the-counter
                                supply. 

                            
	
                              Alcohol,
                                swabs (diabetic) 

                            	
                              X
                                

                            	
                               

                            	
                              Over-the-counter
                                supply not covered, unless RX provided at time of
                                dispensing.
                                

                            
	
                              Alcohol,
                                swabs 

                            	
                              X
                                

                            	
                               

                            	
                              Covered
                                only when received with IV therapy or central line
                                kits/supplies.
                                

                            
	
                              Ana
                                Kit Epinephrine 

                            	
                              X
                                

                            	
                               

                            	
                              A
                                self-injection kit used by patients highly allergic
                                to bee stings.
                                

                            
	
                              Arm
                                Sling 

                            	
                              X
                                

                            	
                               

                            	
                              Dispensed
                                as part of office visit. 

                            
	
                              Attends
                                (Diapers) 

                            	
                              X
                                

                            	
                               

                            	
                              Coverage
                                limited to children age 4 or over only when prescribed
                                by a physician and
                                used to provide care for a covered diagnosis as outlined
                                in a treatment
                                care plan. 

                            
	
                              Bandages
                                

                            	
                               

                            	
                              X
                                

                            	
                               

                            
	
                              Basal
                                Thermometer 

                            	
                               

                            	
                              X
                                

                            	
                              Over-the-counter
                                supply. 

                            
	
                              Batteries
                                - initial 

                            	
                              X
                                

                            	
                              .
                                

                            	
                              For
                                covered DME items 

                            
	
                              Batteries
                                - replacement 

                            	
                              X
                                

                            	
                               

                            	
                              For
                                covered DME when replacement is necessary due to
                                normal use.
                                

                            
	
                              Betadine
                                

                            	
                               

                            	
                              X
                                

                            	
                              See
                                IV therapy supplies. 

                            
	
                              Books
                                

                            	
                               

                            	
                              X
                                

                            	
                               

                            
	
                              Clinitest
                                

                            	
                              X
                                

                            	
                               

                            	
                              For
                                monitoring of diabetes. 

                            
	
                              Colostomy
                                Bags 

                            	
                               

                            	
                               

                            	
                              See
                                Ostomy Supplies. 

                            
	
                              Communication
                                Devices 

                            	
                               

                            	
                              X
                                

                            	
                               

                            
	
                              Contraceptive
                                Jelly 

                            	
                               

                            	
                              X
                                

                            	
                              Over-the-counter
                                supply. Contraceptives are not covered under the
                                plan. 

                            
	
                              Cranial
                                Head Mold 

                            	
                               

                            	
                              X
                                

                            	
                               

                            
	
                              Diabetic
                                Supplies 

                            	
                              X
                                

                            	
                               

                            	
                              Monitor
                                calibrating solution, insulin syringes, needles,
                                lancets, lancet device,
                                and glucose strips. 

                            
	
                              Diapers/Incontinent
                                Briefs/Chux 

                            	
                              X
                                

                            	
                               

                            	
                              Coverage
                                limited to children age 4 or over only when prescribed
                                by a physician and
                                used to provide care for a covered diagnosis as outlined
                                in a treatment
                                care plan 

                            
	
                              Diaphragm
                                

                            	
                               

                            	
                              X
                                

                            	
                              Contraceptives
                                are not covered under the plan. 

                            
	
                              Diastix
                                

                            	
                              X
                                

                            	
                               

                            	
                              For
                                monitoring diabetes. 

                            
	
                              Diet,
                                Special 

                            	
                               

                            	
                              X
                                

                            	
                               

                            
	
                              Distilled
                                Water 

                            	
                               

                            	
                              X
                                

                            	
                               

                            
	
                              Dressing
                                Supplies/Central Line 

                            	
                              X
                                

                            	
                               

                            	
                              Syringes,
                                needles, Tegaderm, alcohol swabs, Betadine swabs
                                or ointment, tape. Many
                                times these items are dispensed in a kit when includes
                                all necessary items
                                for one dressing site change. 

                            
	
                              Dressing
                                Supplies/Decubitus 

                            	
                              X
                                

                            	
                               

                            	
                              Eligible
                                for coverage only if receiving covered home care
                                for wound care.
                                

                            
	
                              Dressing
                                Supplies/Peripheral IV Therapy 

                            	
                              X
                                

                            	
                               

                            	
                              Eligible
                                for coverage only if receiving home IV therapy. 

                            
	
                              Dressing
                                Supplies/Other 

                            	
                               

                            	
                              X
                                

                            	
                               

                            
	
                              Dust
                                Mask 

                            	
                               

                            	
                              X
                                

                            	
                               

                            
	
                              Ear
                                Molds 

                            	
                              X
                                

                            	
                               

                            	
                              Custom
                                made, post inner or middle ear surgery 

                            
	
                              Electrodes
                                

                            	
                              X
                                

                            	
                               

                            	
                              Eligible
                                for coverage when used with a covered DME. 

                            
	
                              Enema
                                Supplies 

                            	
                               

                            	
                              X
                                

                            	
                              Over-the-counter
                                supply. 

                            
	
                              Enteral
                                Nutrition Supplies 

                            	
                              X
                                

                            	
                               

                            	
                              Necessary
                                supplies (e.g., bags, tubing, connectors, catheters,
                                etc.) are eligible
                                for coverage. Enteral nutrition products are not
                                covered except for those
                                prescribed for hereditary metabolic disorders, a
                                non-function or disease
                                of the structures that normally permit food to reach
                                the small bowel, or
                                malabsorption due to disease 

                            
	
                              Eye
                                Patches 

                            	
                              X
                                

                            	
                               

                            	
                              Covered
                                for patients with amblyopia. 

                            
	
                              Formula
                                

                            	
                               

                            	
                              X
                                

                            	
                              Exception:
                                Eligible for coverage only for chronic hereditary
                                metabolic disorders a
                                non-function or disease of the structures that normally
                                permit food to
                                reach the small bowel; or malabsorption due to disease
                                (expected to last
                                longer than 60 days when prescribed by the physician
                                and authorized by
                                plan.) Physician documentation to justify prescription
                                of formula must
                                include: 

                                •
                                Identification of a metabolic disorder, dysphagia
                                that results in a
                                medical need for a liquid diet, presence of a gastrostomy,
                                or disease
                                resulting in malabsorption that requires a medically
                                necessary nutritional
                                product 

                               

                              Does
                                not include formula: 

                                •
                                For members who could be sustained on an age-appropriate
                                diet.
                                

                                •
                                Traditionally used for infant feeding 

                                •
                                In pudding form (except for clients with documented
                                oropharyngeal motor
                                dysfunction who receive greater than 50 percent of
                                their daily caloric
                                intake from this product) 

                                •
                                For the primary diagnosis of failure to thrive, failure
                                to gain weight, or
                                lack of growth or for infants less than twelve months
                                of age unless
                                medical necessity is documented and other criteria,
                                listed above, are met.
                                

                               

                               

                              Food
                                thickeners, baby food, or other regular grocery products
                                that can be
                                blenderized and used with an enteral system that
                                are not
                                medically necessary, are not covered, regardless
                                of whether these regular
                                food products are taken orally or parenterally. 

                            
	
                              Gloves
                                

                            	
                               

                            	
                              X
                                

                            	
                              Exception:
                                Central line dressings or wound care provided by
                                home care agency.
                                

                            
	
                              Hydrogen
                                Peroxide 

                            	
                               

                            	
                              X
                                

                            	
                              Over-the-counter
                                supply. 

                            
	
                              Hygiene
                                Items 

                            	
                               

                            	
                              X
                                

                            	
                               

                            
	
                              Incontinent
                                Pads 

                            	
                              X
                                

                            	
                               

                            	
                              Coverage
                                limited to children age 4 or over only when prescribed
                                by a physician and
                                used to provide care for a covered diagnosis as outlined
                                in a treatment
                                care plan 

                            
	
                              Insulin
                                Pump (External) Supplies 

                            	
                              X
                                

                            	
                               

                            	
                              Supplies
                                (e.g., infusion sets, syringe reservoir and dressing,
                                etc.) are eligible
                                for coverage if the pump is a covered item. 

                            
	
                              Irrigation
                                Sets, Wound Care 

                            	
                              X
                                

                            	
                               

                            	
                              Eligible
                                for coverage when used during covered home care for
                                wound care.
                                

                            
	
                              Irrigation
                                Sets, Urinary 

                            	
                              X
                                

                            	
                               

                            	
                              Eligible
                                for coverage for individual with an indwelling urinary
                                catheter.
                                

                            
	
                              IV
                                Therapy Supplies 

                            	
                              X
                                

                            	
                               

                            	
                              Tubing,
                                filter, cassettes, IV pole, alcohol swabs, needles,
                                syringes and any other
                                related supplies necessary for home IV therapy. 

                            
	
                              K-Y
                                Jelly 

                            	
                               

                            	
                              X
                                

                            	
                              Over-the-counter
                                supply. 

                            
	
                              Lancet
                                Device 

                            	
                              X
                                

                            	
                               

                            	
                              Limited
                                to one device only. 

                            
	
                              Lancets
                                

                            	
                              X
                                

                            	
                               

                            	
                              Eligible
                                for individuals with diabetes. 

                            
	
                              Med
                                Ejector 

                            	
                              X
                                

                            	
                               

                            	
                               

                            
	
                              Needles
                                and Syringes/Diabetic 

                            	
                               

                            	
                               

                            	
                              See
                                Diabetic Supplies 

                            
	
                              Needles
                                and Syringes/IV and Central Line 

                            	
                               

                            	
                               

                            	
                              See
                                IV Therapy and Dressing Supplies/Central Line. 

                            
	
                              Needles
                                and Syringes/Other 

                            	
                              X
                                

                            	
                               

                            	
                              Eligible
                                for coverage if a covered IM or SubQ medication is
                                being administered at
                                home. 

                            
	
                              Normal
                                Saline 

                            	
                               

                            	
                               

                            	
                              See
                                Saline, Normal 

                            
	
                              Novopen
                                

                            	
                              X
                                

                            	
                               

                            	
                               

                            
	
                              Ostomy
                                Supplies 

                            	
                              X
                                

                            	
                               

                            	
                              Items
                                eligible for coverage include: belt, pouch, bags,
                                wafer, face plate,
                                insert, barrier, filter, gasket, plug, irrigation
                                kit/sleeve, tape, skin
                                prep, adhesives, drain sets, adhesive remover, and
                                pouch deodorant.
                                

                              Items
                                not eligible for coverage include: scissors, room
                                deodorants, cleaners,
                                rubber gloves, gauze, pouch covers, soaps, and lotions.
                                

                            
	
                              Parenteral
                                Nutrition/Supplies 

                            	
                              X
                                

                            	
                               

                            	
                              Necessary
                                supplies (e.g., tubing, filters, connectors, etc.)
                                are eligible for
                                coverage when the Health Plan has authorized the
                                parenteral nutrition.
                                

                            
	
                              Saline,
                                Normal 

                            	
                              X
                                

                            	
                               

                            	
                              Eligible
                                for coverage: 

                              a)
                                when used to dilute medications for nebulizer treatments;

                              b)
                                as part of covered home care for wound care; 

                              c)
                                for indwelling urinary catheter irrigation. 

                            
	
                              Stump
                                Sleeve 

                            	
                              X
                                

                            	
                               

                            	
                               

                            
	
                              Stump
                                Socks 

                            	
                              X
                                

                            	
                               

                            	
                               

                            
	
                              Suction
                                Catheters 

                            	
                              X
                                

                            	
                               

                            	
                               

                            
	
                              Syringes
                                

                            	
                               

                            	
                               

                            	
                              See
                                Needles/Syringes. 

                            
	
                              Tape
                                

                            	
                               

                            	
                               

                            	
                              See
                                Dressing Supplies, Ostomy Supplies, IV Therapy Supplies.
                                

                            
	
                              Tracheostomy
                                Supplies 

                            	
                              X
                                

                            	
                               

                            	
                              Cannulas,
                                Tubes, Ties, Holders, Cleaning Kits, etc. are eligible
                                for coverage.
                                

                            
	
                              Under
                                Pads 

                            	
                               

                            	
                               

                            	
                              See
                                Diapers/Incontinent Briefs/Chux. 

                            
	
                              Unna
                                Boot 

                            	
                              X
                                

                            	
                               

                            	
                              Eligible
                                for coverage when part of wound care in the home
                                setting. Incidental
                                charge when applied during office visit. 

                            
	
                              Urinary,
                                External Catheter & Supplies 

                            	
                               

                            	
                              X
                                

                            	
                              Exception:
                                Covered when used by incontinent male where injury
                                to the urethra
                                prohibits use of an indwelling catheter ordered by
                                the PCP and approved by
                                the plan 

                            
	
                              Urinary,
                                Indwelling Catheter & Supplies 

                            	
                              X
                                

                            	
                               

                            	
                              Cover
                                catheter, drainage bag with tubing, insertion tray,
                                irrigation set and
                                normal saline if needed. 

                            
	
                              Urinary,
                                Intermittent 

                            	
                              X
                                

                            	
                               

                            	
                              Cover
                                supplies needed for intermittent or straight catherization.
                                

                            
	
                              Urine
                                Test Kit 

                            	
                              X
                                

                            	
                               

                            	
                              When
                                determined to be medically necessary. 

                            
	
                              Urostomy
                                supplies 

                            	
                               

                            	
                               

                            	
                              See
                                Ostomy Supplies. 

                            

                    

                    

                    	 	 

                  

                   

                  

                  
                    
                      
                      

                    

                    
                      
                      

                      
                        

                      

                    

                    
                      
                      

                    

                  

                  

                    Contractual
                      Document (CD) Responsible Office: HHSC Office of General Counsel
                      (OGC)

                    Subject:
                      Attachment B-3 - Value-added Services 

                    Version
                      1.6 

                  

                    

                    
                      	
                               

                              DOCUMENT
                                HISTORY LOG

                               

                            
	
                              STATUS1

                            	
                              DOCUMENT
                                

                              REVISION2

                            	
                              EFFECTIVE
                                

                              DATE
                                

                            	
                              DESCRIPTION3

                            
	
                               

                              Baseline
                                

                               

                               

                            	
                               

                              n/a
                                

                               

                               

                            	
                               

                               

                               

                               

                            	
                               

                              Initial
                                version of Attachment B-3, Value-added Services.

                               

                               

                            
	
                               

                              Revision
                                

                            	
                               

                              1.1
                                

                            	
                               

                              June
                                30, 2006 

                            	
                               

                              Contract
                                amendment did not revise Attachment B-3, Value-added
                                Services.
                                

                               

                               

                            
	
                               

                              Revision
                                

                            	
                               

                              1.2
                                

                            	
                               

                              September
                                1, 2006 

                            	
                               

                              Revised
                                the Physical Health Value-added Services to include
Home
                                Visits to New Mothers. Revised the certification
                                provision by changing the
                                start date for the 12-month provision of services.

                               

                               

                            
	
                               

                              Revision
                                

                            	
                               

                              1.3
                                

                            	
                               

                              September
                                1, 2006 

                            	
                               

                              Contract
                                amendment did not revise Attachment B-3, Value-added
                                Services. 

                            
	
                               

                              Revision
                                

                            	
                               

                              1.4
                                

                            	
                               

                              September
                                1, 2006 

                            	
                               

                              Contract
                                amendment removed the separate signature requirement
                                for Attachment B-3,
                                Value-added Services. By signing the Contract and/or
                                Contract Amendment,
                                the HMO certifies that it will provide the Value-added
                                Services from
                                September 1, 2006 through August 31, 2007. 

                            
	
                               

                              Revision
                                

                            	
                               

                              1.5
                                

                            	
                               

                              January
                                1, 2007 

                            	
                               

                              Contract
                                amendment did not revise Attachment B-3, Value-added
                                Services. 

                            
	
                               

                              Revision
                                

                            	
                               

                              1.6
                                

                            	
                               

                              February
                                1, 2007 

                            	
                               

                              Contract
                                amendment did not revise Attachment B-3, Value-added
                                Services. 

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

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

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

                            

                    

                     

                    
                      
                        
                        

                      

                      
                        
                        

                        
                          

                        

                      

                      
                        
                        

                      

                    

                    

                    ATTACHMENT
                      B-3: VALUE-ADDED SERVICES 

                    September
                      1, 2006 - August 31, 2007 

                     

                    HMO:
                      Superior HealthPlan, Inc. 

                     

                    HMO
                      PROGRAM: Medicaid 

                     

                    SERVICE
                      AREA(S):Bexar, El Paso, Lubbock, Nueces, and Travis  

                    

                      
                        	
                                Physical
                                  Health Value-added Services 

                                 

                              
	
                                 

                                 

                                Value-added
                                  Service 

                                 

                              	
                                 

                                 

                                Description
                                  of Value-added Services and Members Eligible to
                                  Receive the Services
                                  

                                 

                              	
                                 

                                 

                                 

                                 

                                Limitations
                                  or Restrictions 

                                 

                              	
                                Provider(s)
                                  responsible for providing this service 

                                 

                              
	
                                Vision
                                  

                                 

                              	
                                Members
                                  are allowed to purchase any prescription eyewear
                                  and apply a $100
                                  allowance toward the purchase of that eyewear.

                                 

                              	
                                Members
                                  are responsible for any charges that exceed the
                                  $100 allowance. Disposable
                                  contact lenses are excluded from this $100 allowance.
                                  This Value-Added
                                  benefit is only allowed one time per benefit period
                                  (i.e. 24-months).
                                  

                              	
                                TVHP
                                  contracted providers. 

                                 

                              
	
                                Pharmacy
                                  

                                 

                              	
                                Provides
                                  members with a $15.00 per household per quarter
                                  credit toward over the
                                  counter medications and supplies. 

                                 

                              	
                                Services
                                  must be sought from contracted pharmacies only.
                                  Items eligible for
                                  purchase under this benefit are over-the-counter,
                                  health related items
                                  only. 

                                 

                                 

                              	
                                Pharmacy
                                  Data Management contracted providers. 

                                 

                              
	
                                Transportation
                                  

                                 

                              	
                                HMO
                                  will offer tokens or vouchers for bus services
                                  to HMO members that have
                                  trouble accessing the State's Medical Transportation
                                  Program in a timely
                                  manner to ensure access to their provider appointments.
                                  In addition, HMO
                                  will provide transportation to non-medical services
                                  such as health
                                  education programs, nutrition classes, and birth
                                  preparation classes.
                                  HMO's member service staff will approve and coordinate
                                  the transportation
                                  service". 

                                 

                              	
                                Members
                                  in the Nueces Service Area. The Transportation
                                  Authority in this area will
                                  not agree to allow the plan to purchase bus vouchers
                                  or tokens.
                                  

                                The
                                  bus tokens must be requested in advance of a provider
                                  visit and authorized
                                  by Superior’s Member Services Department.  

                                 

                              	
                                Transit
                                  Authorities in applicable Service Area. 

                                 

                              
	
                                Adult
                                  Flu Shot 

                                 

                              	
                                During
                                  the flu season months of October through December,
                                  Members age 21 or older
                                  will be provided with a flu shot through their
                                  Primary Care Provider
                                  (PCP). 

                                 

                                 

                              	
                                This
                                  benefit is available to all STAR Adult Members
                                  age 21 and over. These
                                  services must be obtained from the Member’s Primary Care
                                  Provider. 

                                 

                                 

                              	
                                It
                                  is anticipated that the Member’s designated Primary Care Provider (PCP)
                                  will render this service. 

                                 

                              
	
                                NurseWise
                                  

                                 

                              	
                                Twenty-four
                                  hour nurse advice line 

                              	
                                Available
                                  to all members by calling the Member Services toll-free
                                  number
                                  

                              	
                                NurseWise,
                                  an affiliate of Centene Corporation 

                                 

                              
	
                                Home
                                  visits to New Mothers 

                                 

                              	
                                Superior
                                  Social Work and/or CONNECTIONS staff will make
                                  home visits to any Member
                                  with a new baby. This visit provides for resource
                                  and education
                                  coordination as identified in the visit, and ensures
                                  Members and the new
                                  babies are keeping all post natal and newborn doctor
                                  visits. This benefit
                                  is available to all Superior Members who have delivered
                                  a baby.
                                  

                                 

                              	
                                Only
                                  that a member consent to the home visit. 

                                 

                              	
                                Superior’s
                                  CONNECTIONS and Social Work staff provide this
                                  service. 

                                 

                                 

                              

                      

                      Benefit
                        added for Version 1.2

                      

                      

                       

                       

                      
                        	
                                 

                                Behavioral
                                  Health Value-added Services for Members Under
                                  21

                                 

                              
	
                                 

                                 

                                Value-added
                                  Service 

                                 

                              	
                                 

                                 

                                Description
                                  of Value-added Services and Members Eligible to
                                  Receive the Services
                                  

                                 

                              	
                                 

                                 

                                 

                                 

                                Limitations
                                  or Restrictions 

                                 

                              	
                                 

                                 

                                Provider(s)
                                  responsible for providing this service 

                                 

                              
	
                                Behavioral
                                  Health 

                              	
                                Rehabilitation/skills
                                  training.
                                  These are services provided to pregnant and parenting
                                  substance abusers at
                                  MHMR centers or in other treatment settings, focusing
                                  both on substance
                                  abuse and parenting issues. An augmentation of
                                  standard substance abuse
                                  treatment to focus on the special needs of this
                                  population. Authorized in
                                  increments of 15 minutes, with amount, duration,
                                  and scope based on
                                  medical necessity. This benefit is available to
                                  all Members. It is geared
                                  to pregnant women and parenting Members. 

                                 

                              	
                                Th
                                  These services must be authorized by Superior’s Behavioral Health
                                  Subcontractor. In addition, the service will be
                                  authorized for15-minute
                                  increments. The amount, duration, and scope are
                                  based on medical
                                  necessity. 

                                 

                                 

                              	
                                It
                                  is anticipated that Superior’s contracted MHMR providers specializing in
                                  Rehabilitation/Skills training in each Service
                                  Area will render this
                                  service. 

                                 

                              
	
                                Behavioral
                                  Health 

                                 

                              	
                                Superior’s
                                  Behavioral Health Subcontractor will authorize
                                  Behavioral Health
                                  practitioners in medical settings to provide health
                                  psychology
                                  interventions focused on the effective management
                                  of chronic medical
                                  conditions. These might include psycho-educational
                                  groups for chronic
                                  conditions, individual coaching for patients with
                                  chronic disease states,
                                  or skills training activities. 

                                 

                                 

                              	
                                These
                                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                                  The authorization will be tied to medical necessity.

                                 

                                 

                              	
                                It
                                  is anticipated that these services will be rendered
                                  by Superior’s
                                  behavioral health practitioners located in Superior’s contracted Federally
                                  Qualified Health Centers. 

                                 

                              
	
                                Behavioral
                                  Health 

                                 

                              	
                                Partial
                                  Hospitalization/Extended Day Treatment- An alternative
                                  to, or a step down
                                  from, inpatient care. 

                              	
                                These
                                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                                  Services are authorized for a minimum of five hours,
                                  but for less than
                                  24-hours per day. The amount, duration, and scope
                                  will be based on medical
                                  necessity. 

                                 

                              	
                                It
                                  is anticipated that Superior’s contracted Behavioral Health Providers such
                                  as its’ MHMR facilities and other contracted facilities
                                  in each Service
                                  Area will render this service. 

                                 

                              
	
                                Behavioral
                                  Health 

                                 

                              	
                                Intensive
                                  Outpatient Treatment/Day Treatment (IOP)- Used
                                  as an alternative to or
                                  step down from more restrictive levels of care.

                                 

                              	
                                These
                                  services must be authorized by Superior’s Behavioral Health Material
                                  Subcontractor. In addition, the service will be
                                  authorized for greater
                                  than one and one half hours, but less than five
                                  hours per day. Amount,
                                  duration, and scope are based on medical necessity. 

                                 

                              	
                                It
                                  is anticipated that Superior’s contracted Behavioral Health Providers such
                                  as the MHMR or other facilities in each Service
                                  Area will render this
                                  service. 

                                 

                              

                      

                      

                       

                      
                        
                           

                        

                        
                           

                          
                            

                          

                        

                        
                           

                        

                      

                      

                       

                      
                        	
                                 

                                Behavioral
                                  Health Value-added Services for Members 21
                                  and Over

                                 

                              
	
                                 

                                Value-added
                                  Service 

                              	
                                 

                                Description
                                  of Value-added Services and Members Eligible to
                                  Receive the Services
                                  

                              	
                                 

                                 

                                Limitations
                                  or Restrictions 

                              	
                                 

                                Provider(s)
                                  responsible for providing this service 

                              
	
                                Behavioral
                                  Health 

                                 

                              	
                                Rehabilitation/skills
                                  training.
                                  These are services provided to pregnant and parenting
                                  substance abusers at
                                  MHMR centers or in other treatment settings, focusing
                                  both on substance
                                  abuse and parenting issues. An augmentation of
                                  standard substance abuse
                                  treatment to focus on the special needs of this
                                  population. This benefit
                                  is available to all Members. It is geared to pregnant
                                  women and parenting
                                  Members. 

                                 

                              	
                                These
                                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                                  In addition, the service will be authorized for15-minute
                                  increments. The
                                  amount, duration, and scope are based on medical
                                  necessity. 

                                 

                                 

                              	
                                It
                                  is anticipated that Superior’s contracted MHMR providers specializing in
                                  Rehabilitation/Skills training in each Service
                                  Area will render this
                                  service. 

                                 

                              
	
                                Behavioral
                                  Health 

                                 

                              	
                                Partial
                                  Hospitalization/Extended Day Treatment- An alternative
                                  to, or a step down
                                  from, inpatient care. 

                                 

                              	
                                These
                                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                                  Services are authorized for a minimum of five hours,
                                  but for less than
                                  24-hours per day. The amount, duration, and scope
                                  will be based on medical
                                  necessity. 

                                 

                              	
                                It
                                  is anticipated that Superior’s contracted Behavioral Health Providers such
                                  as its’ MHMR facilities and other contracted facilities
                                  in each Service
                                  Area will render this service. 

                              
	
                                Behavioral
                                  Health 

                                 

                              	
                                Superior’s
                                  Behavioral Health Subcontractor, will authorize
                                  Behavioral Health
                                  practitioners in medical settings to provide health
                                  psychology
                                  interventions focused on the effective management
                                  of chronic medical
                                  conditions. These might include psycho-educational
                                  groups for chronic
                                  conditions, individual coaching for patients with
                                  chronic disease states,
                                  or skills training activities. 

                                 

                                 

                              	
                                These
                                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                                  The authorization will be tied to medical necessity.

                                 

                                 

                              	
                                It
                                  is anticipated that these services will be rendered
                                  by Superior’s
                                  behavioral health practitioners located in Superior’s contracted Federally
                                  Qualified Health Centers. 

                                 

                              
	
                                Behavioral
                                  Health 

                                 

                              	
                                Intensive
                                  Outpatient Treatment/Day Treatment (IOP)- Used
                                  as an alternative to or
                                  step down from more restrictive levels of care.

                                 

                              	
                                These
                                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                                  In addition, the service will be authorized for
                                  greater than one and one
                                  half hours, but less than five hours per day. Amount,
                                  duration, and scope
                                  are based on medical necessity. 

                                 

                              	
                                It
                                  is anticipated that Superior’s contracted Behavioral Health Providers such
                                  as the MHMR or other facilities in each Service
                                  Area will render this
                                  service. 

                                 

                              
	
                                Behavioral
                                  Health 

                                 

                              	
                                Off-site
                                  Services such as home-based services, , mobile
                                  crisis, intensive case
                                  management. It should be noted that staff must
                                  go off-site to provide such
                                  services. These services are provided to Members
                                  to help reduce or avoid
                                  inpatient admissions by a community based, mobile,
                                  multi-disciplinary team
                                  of licensed clinicians and trained, unlicensed
                                  workers working under the
                                  direction of a licensed professional. 

                                 

                              	
                                These
                                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                                  The amount, duration and scope are based on medical
                                  necessity. 

                                 

                              	
                                It
                                  is anticipated that Superior’s contracted Behavioral Health Providers such
                                  as the MHMR in each Service Area will render this
                                  service. 

                                 

                              

                      

                      
                        
                          
                          

                        

                        
                          
                          

                          
                            

                          

                        

                        
                          
                          

                        

                      

                      
 

                    

                    ADDITIONAL
                      INFORMATION:  

                     

                    1.
                      Explain how and when Providers and Members will be notified
                      about the
                      availability of the value-added services to be provided. 

                     

                    
                      	
                              Value
                                Added Services information will be included in the
                                Superior Provider
                                Manual and also during training sessions. Members
                                will receive this
                                information via the Plan Comparison Chart, in the
                                Member Handbook, with
                                New Member Packets and during orientations. Periodically,
                                Superior will
                                also highlight Value Added Services in the Provider
                                and Member
                                Newsletters. 

                               

                            

                    

                    

                    2.
                      Describe how a Member may obtain or access the value-added
                      services to be
                      provided. 

                     

                    
                      	
                              See
                                explanations provided above for accessing services.

                               

                              A
                                Member may access the Home Visits to New Mothers
                                service by accepting a
                                home visit appointment from a Superior Social Work
                                or CONNECTIONS staff
                                member.  

                            

                    

                     

                    Benefit
                      added for Version 1.2

                    

                    3.
                      Describe how the HMO will identify the Value-added Service
                      in administrative
                      (encounter) data. 

                     

                    
                      	
                               

                              Superior
                                will track the value added services through our claims
                                system for those
                                value-adds that HIPAA-compliant procedural codes
                                are available (vision,
                                behavioral health, flu shots). Superior will create
                                a specific benefit
                                category to track and report the value added services
                                'separately' from
                                our 'capitated' service data. In addition, Superior
                                will have the ability
                                to pass this information to the State utilizing the
                                encounter submission
                                process, as long as the State is able to segregate
                                the value adds data
                                from the capitated services data. 

                              For
                                pharmacy services, Superior will receive a data file
                                from the pharmacy
                                vendor to capture all utilization of the pharmacy
                                value-add benefit.
                                

                               

                              For
                                transportation services, Superior will maintain an
                                electronic file of
                                transportation services provided for Superior’s membership. 

                               

                              Home
                                visits to new mothers are tracked through Superior’s case management
                                system. Each staff member logs each member visit
                                and the outcome/findings
                                of the visit in Superior’s computer system. Superior will work with HHSC
                                to establish the most efficient transmission of the
                                data.
                                

                            

                    

                     

                    Benefit
                      added for Version 1.2

                    

                    4.
                      By
                      signing the Contract and/or Contract Amendment HMO certifies
                      that it will
                      provide the approved Value-added Services described herein
                      from September 1,
                      2006 through August 31, 2007. 

                     

                    
                      
                        
                        

                      

                      
                        
                        

                        
                          

                        

                      

                      
                        
                        

                      

                    

                  

                  

                  

                    Contractual
                      Document (CD) Responsible Office: HHSC Office of General Counsel
                      (OGC)

                    Subject:
                      Attachment B-3 - Value-added Services 

                    Version
                      1.6 

                  

                  

                    

                    
                      	
                              DOCUMENT
                                HISTORY LOG

                            
	
                              STATUS1

                            	
                              DOCUMENT
                                

                              REVISION2

                            	
                              EFFECTIVE
                                

                              DATE
                                

                            	
                              DESCRIPTION3

                            
	
                               

                              Baseline
                                

                               

                               

                            	
                               

                              n/a
                                

                               

                               

                            	
                               

                               

                               

                               

                            	
                               

                              Initial
                                version of Attachment B-3, Value-added Services.

                               

                               

                            
	
                               

                              Revision
                                

                            	
                               

                              1.1
                                

                            	
                               

                              June
                                30, 2006 

                            	
                               

                              Contract
                                amendment did not revise Attachment B-3, Value-added
                                Services.
                                

                               

                               

                            
	
                               

                              Revision
                                

                            	
                               

                              1.2
                                

                            	
                               

                              September
                                1. 2006 

                            	
                               

                              Revised
                                Physical Health Value-added Services to include Home
                                Visits to New Mothers. Revised the certification
                                provision by changing the
                                start date for the 12-month provision of services.

                               

                               

                            
	
                               

                              Revision
                                

                            	
                               

                              1.3
                                

                            	
                               

                              September
                                1, 2006 

                            	
                               

                              Contract
                                amendment did not revise Attachment B-3, Value-added
                                Services. 

                            
	
                               

                              Revision
                                

                            	
                               

                              1.4
                                

                            	
                               

                              September
                                1, 2006 

                            	
                               

                              Contract
                                amendment removed the separate signature requirement
                                for Attachment B-3,
                                Value-added Services. By signing the Contract and/or
                                Contract Amendment,
                                the HMO certifies that it will provide the Value-added
                                Services from
                                September 1, 2006 through August 31, 2007. 

                            
	
                               

                              Revision
                                

                            	
                               

                              1.5
                                

                            	
                               

                              January
                                1, 2007 

                            	
                               

                              Contract
                                amendment did not revise Attachment B-3, Value-added
                                Services. 

                            
	
                               

                              Revision
                                

                            	
                               

                              1.6
                                

                            	
                               

                              February
                                1, 2007 

                            	
                               

                              Contract
                                amendment did not revise Attachment B-3, Value-added
                                Services. 

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

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

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

                            

                    

                    

                    
                      
                        
                        

                      

                      
                        
                        

                        
                          

                        

                      

                      
                        
                        

                      

                    

                    

                    ATTACHMENT
                      B-3: VALUE-ADDED SERVICES 

                    September
                      1, 2006 - August 31, 2007 

                     

                    HMO:
                      Superior HealthPlan, Inc. 

                     

                    HMO
                      PROGRAM: CHIP 

                     

                    SERVICE
                      AREA(S):Bexar, El Paso, Lubbock, Nueces, and Travis 

                    

                      

                      
                        	
                                Physical
                                  Health Value-added Services 

                                 

                              
	
                                 

                                 

                                Value-added
                                  Service 

                                 

                              	
                                 

                                 

                                Description
                                  of Value-added Services and Members Eligible to
                                  Receive the Services
                                  

                                 

                              	
                                 

                                 

                                Limitations
                                  or Restrictions 

                                 

                              	
                                Provider(s)
                                  responsible for providing this service 

                                 

                              
	
                                Vision
                                  

                                 

                              	
                                20%
                                  discount off of Upgraded Hardware- The Member will
                                  receive a 20% discount
                                  on upgraded hardware. 

                                 

                              	
                                There
                                  is no limitation on the number of times the discount
                                  can be utilized.
                                   

                                 

                              	
                                TVHP
                                  contracted providers. 

                                 

                              
	
                                Pharmacy
                                  

                                 

                              	
                                Provides
                                  members with a $15.00 per household per quarter
                                  credit toward over the
                                  counter medications and supplies. 

                                 

                              	
                                Services
                                  must be sought from contracted pharmacies only.
                                  Items eligible for
                                  purchase under this benefit are over-the-counter,
                                  health related items
                                  only. 

                                 

                                 

                              	
                                Pharmacy
                                  Data Management contracted providers. 

                                 

                              
	
                                Transportation
                                  

                                 

                              	
                                For
                                  Members in need of transportation that cannot access
                                  transportation in a
                                  timely manner, Superior will provide bus tokens
                                  to ensure that Members
                                  have a means of accessing their provider appointment.

                                 

                              	
                                Members
                                  in the Nueces Service Area. The Transportation
                                  Authority in this area will
                                  not agree to allow the plan to purchase bus vouchers
                                  or tokens.
                                  

                                The
                                  bus tokens must be requested in advance of a provider
                                  visit and authorized
                                  by Superior’s Member Services Department.  

                                 

                              	
                                Transit
                                  Authorities in applicable Service Area. 

                                 

                              
	
                                NurseWise
                                  

                                 

                              	
                                Twenty-four
                                  hour nurse advice line 

                              	
                                Available
                                  to all members by calling the Member Services toll-free
                                  number
                                  

                              	
                                NurseWise,
                                  an affiliate of Centene Corporation 

                                 

                              
	
                                Home
                                  Visits to New Mothers 

                                 

                              	
                                Superior
                                  Social Work and/or CONNECTIONS staff will make
                                  home visits to any Member
                                  with a new baby. This visit provides for resource
                                  and education
                                  coordination as identified in the visit,[what does
                                  this mean?] and ensures
                                  Members and the new babies are keeping all post
                                  natal and newborn doctor
                                  visits. This benefit is available to all Superior
                                  Members who have
                                  delivered a baby. 

                                 

                              	
                                Only
                                  that a member consent to the home visit. 

                                 

                              	
                                Superior’s
                                  CONNECTIONS and Social Work staff provide this
                                  service. 

                                 

                                 

                              

                      

                    

                     

                    Benefit
                      added for Version 1.2 

                    

                     

                    
                      
                        
                        

                      

                      
                        
                        

                        
                          

                        

                      

                      
                        
                        

                      

                    

                    
                      
                        	 

                                Behavioral
                                  Health Value-added Services for Members Under
                                  21

                              
	
                                 Value-added
                                  Service 

                              	 

                                Description
                                  of Value-added Services and Members Eligible to
                                  Receive the Services
                                  

                              	 

                                Limitations
                                  or Restrictions 

                              	
                                 Provider(s)
                                  responsible for providing this
                                  service 

                              
	
                                 

                              	
                                 

                              	
                                 

                              	
                                 

                              
	
                                 

                              	
                                 

                              	
                                 

                              	
                                 

                              

                      

                    

                    
                       

                      
                        	
                                Behavioral
                                  Health Value-added Services for Members 21
                                  and Over

                              
	
                                 Value-added
                                  Service 

                              	 

                                Description
                                  of Value-added Services and Members Eligible to
                                  Receive the Services
                                  

                              	 

                                Limitations
                                  or Restrictions 

                              	
                                 Provider(s)
                                  responsible for providing this
                                  service 

                              
	
                                 

                              	
                                 

                              	
                                 

                              	
                                 

                              
	
                                 

                              	
                                 

                              	
                                 

                              	
                                 

                              

                        
                          
 

                        

                      

                    

                    ADDITIONAL
                      INFORMATION:  

                     

                    1.
                      Explain how and when Providers and Members will be notified
                      about the
                      availability of the value-added services to be provided. 

                     

                    

                    
                      	
                              Value
                                Added Services information will be included in the
                                Superior Provider
                                Manual and also during training sessions. Members
                                will receive this
                                information via the Plan Comparison Chart, in the
                                Member Handbook, with
                                New Member Packets and during orientations. Periodically,
                                Superior will
                                also highlight Value Added Services in the Provider
                                and Member
                                Newsletters. 

                               

                            

                    

                    

                    
                      
                        
                        

                      

                      
                        
                        

                        
                          

                        

                      

                      
                        
                        

                      

                    

                    2.
                      Describe how a Member may obtain or access the value-added
                      services to be
                      provided. 

                     

                    
                      	
                              See
                                explanations provided above for accessing services.

                               

                              A
                                Member may access the Home Visits to New Mothers
                                service by accepting a
                                home visit appointment from a Superior Social Work
                                or CONNECTIONS staff
                                member. 

                               

                            

                    

                     

                    Benefit
                      added for Version 1.2

                    

                    3.
                      Describe how the HMO will identify the Value-added Service
                      in administrative
                      (encounter) data. 

                     

                    
                      	
                               

                              Superior
                                will track the value added services through our claims
                                system for those
                                value-adds that HIPAA-compliant procedural codes
                                are available (vision,
                                behavioral health, flu shots). Superior will create
                                a specific benefit
                                category to track and report the value added services
                                'separately' from
                                our 'capitated' service data. In addition, Superior
                                will have the ability
                                to pass this information to the State utilizing the
                                encounter submission
                                process, as long as the State is able to segregate
                                the value adds data
                                from the capitated services data. 

                               

                              For
                                pharmacy services, Superior will receive a data file
                                from the pharmacy
                                vendor to capture all utilization of the pharmacy
                                value-add benefit.
                                

                               

                              For
                                transportation services, Superior will maintain an
                                electronic file of
                                transportation services provided for Superior’s membership.
                                

                               

                              Home
                                visits to new mothers are tracked through Superior’s case management
                                system. Each staff member logs each member visit
                                and the outcome/findings
                                of the visit in Superior’s computer system. Superior will work with HHSC
                                to establish the most efficient transmission of the
                                data. 

                               

                            

                    

                     

                    Benefit
                      added for Version 1.2

                    

                    4.
                      By
                      signing the Contract and/or Contract Amendment HMO certifies
                      that it will
                      provide the approved Value-added Services described herein
                      from September 1,
                      2006 through August 31, 2007. 

                     

                    
                      
                        
                        

                      

                      
                        
                        

                        
                          

                        

                      

                      
                        
                        

                      

                    

                    

                      Contractual
                        Document (CD) Responsible Office: HHSC Office of General
                        Counsel (OGC)

                      Subject:
                        Attachment B-3.1 - STAR+PLUS Value-added Services 

                      Version
                        1.6 

                    

                  

                  

                    

                    
                      	
                              DOCUMENT
                                HISTORY LOG

                            
	
                              STATUS1

                            	
                              DOCUMENT
                                

                              REVISION2

                            	
                              EFFECTIVE
                                

                              DATE
                                

                            	
                              DESCRIPTION3

                            
	
                               

                              Baseline

                            	
                               

                              1.0

                            	 	
                               

                              Initial
                                version of Attachment B-3, Value-added Services 

                               

                               

                            
	
                               

                              Revision
                                

                            	
                               

                              1.1
                                

                            	
                               

                              June
                                30, 2006 

                            	
                               

                              Revised
                                Attachment B-3, Value Added Services, by adding Attachment
                                B-3.1,
                                STAR+PLUS Value Added Services. This is the initial
                                version of Attachment
                                B-3.1, STAR+PLUS Value Added Services. 

                               

                               

                            
	
                               

                              Revision
                                

                            	
                               

                              1.2
                                

                            	
                               

                              September
                                1, 2006 

                            	
                               

                              Contract
                                amendment did not revise Attachment B-3.1, STAR+PLUS
                                Value Added Services
                                

                            
	
                               

                              Revision
                                

                            	
                               

                              1.3
                                

                            	
                               

                              September
                                1, 2006 

                            	
                               

                              Contract
                                amendment did not revise Attachment B-3.1, STAR+PLUS
                                Value Added Services
                                

                            
	
                               

                              Revision
                                

                            	
                               

                              1.4
                                

                            	
                               

                              September
                                1, 2006 

                            	
                               

                              Contract
                                amendment removed the separate signature requirement
                                for Attachment B-3.1,
                                STAR+PLUS Value-added Services. By signing the Contract
                                and/or Contract
                                Amendment, the HMO certifies that it will provide
                                the Value-added Services
                                from January 1, 2007 through August 31, 2007. 

                            
	
                               

                              Revision
                                

                            	
                               

                              1.5
                                

                            	
                               

                              January
                                1, 2007 

                            	
                               

                              Revised
                                Attachment B-3.1, STAR+PLUS Value Added Services
                                to state that only
                                non-dual members are eligible for dental benefits
                                and to clarify
                                description of Out-of-Home Respite. 

                            
	
                               

                              Revision
                                

                            	
                               

                              1.6
                                

                            	
                               

                              February
                                1, 2007 

                            	
                               

                              Revised
                                Attachment B-3.1, Value Added Services, to clarify
                                the coverage period for
                                the VAS. 

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

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

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

                            

                    

                    

                    
                      
                        
                        

                      

                      
                        
                        

                        
                          

                        

                      

                      
                        
                        

                      

                    

                    ATTACHMENT
                      B-3.1: STAR+PLUS VALUE-ADDED SERVICES 

                    February
                      1, 2007 through August 31, 2007 

                     

                    Modified
                      by Version1.6

                    HMO:
                      Superior HealthPlan, Inc. 

                     

                    SERVICE
                      AREA(S): Bexar & Nueces 

                     

                    
                      	
                               

                              Physical
                                Health Value-added Services 

                               

                            
	
                               

                              Value-added
                                Service 

                            	
                               

                              Description
                                of Value-added Services and Members Eligible to Receive
                                the Services
                                

                            	
                               

                               

                              Limitations
                                or Restrictions 

                            	
                              Provider(s)
                                responsible for providing this service 

                            
	
                              Pharmacy
                                

                               

                               

                               

                               

                               

                            	
                              Provides
                                members with a $15.00 per household quarter credit
                                toward over the counter
                                medications and supplies. 

                               

                            	
                              Services
                                must be sought from contracted pharmacies only. Items
                                eligible for
                                purchase under this benefit are over-the-counter
                                health related items
                                only. 

                               

                            	
                              Pharmacy
                                Data Management contracted providers. 

                               

                            
	
                              Dental
                                

                               

                               

                               

                               

                               

                               

                               

                            	
                              Basic
                                dental coverage, which includes the following CPT
                                codes: 0140- Emergency
                                Evaluation; 0120- Periodic Oral Evaluation; 0220-
                                Intra-oral Periapaical
                                First Film; 0230- Intraoral Periapical- Each Additional;
                                0240- Intra-oral
                                Occlusal Film; 0270- Bitewings- single film; 0272-
                                Bitewings- two films;
                                07110- Extraction- Single Tooth/Routine to Difficult;
                                and 07120
                                Extraction- Each Additional. 

                               

                            	
                              If
                                a Member receives services that are outside of the
                                scope of the CPT Codes
                                listed, the Member will be subject to a co-payment
                                of 75% of the dentists’
                                usual and customary charges for those services. 

                               

                              Only
                                non-dual members are eligible for dental benefits.

                               

                            	
                              OraQuest
                                Dental Network 

                               

                            
	
                              Adult
                                Flu Shot 

                               

                               

                               

                               

                               

                            	
                              During
                                the flu season months of October through December,
                                Members age 21 or older
                                will be provided with a flu shot through their Primary
                                Care Provider
                                (PCP). 

                               

                            	
                              This
                                benefit is limited to non-dual STAR+PLUS Adult members
                                age 21 and over.
                                Members may self-refer for this service. 

                               

                            	
                              Designated
                                Primary Care Provider 

                               

                            
	
                              NurseWise
                                

                               

                               

                               

                               

                               

                            	
                              Twenty-four
                                hour nurse advice line 

                               

                            	
                              Available
                                to all members by calling the Member Services toll-free
                                number
                                

                               

                            	
                              NurseWise,
                                an affiliate of Centene Corporation 

                               

                            

                    

                     

                    Modified
                      by Version 1.5

                    

                    
                      	
                               

                              Community
                                Based Long Term Care Value-added Services

                               

                            
	
                               

                              Value-added
                                Service 

                            	
                               

                              Description
                                of Value-added Services and 

                              Members
                                Eligible to Receive the Services 

                            	
                               

                               

                              Limitations
                                or Restrictions 

                            	
                              Provider(s)
                                responsible for providing this service 

                            
	
                              Out-of-Home
                                Respite 

                               

                               

                               

                               

                               

                            	
                              Respite
                                services for a caretaker who needs relief from their
                                care-giving
                                responsibilities because of severe physical or mental
                                stress or who is
                                temporarily unable to provide care because of illness,
                                hospitalization,
                                family emergency or other obligation. Services will
                                be provided in the
                                setting most appropriate to the Member's needs including
                                assisted living
                                facilities, adult foster care homes, or adult day
                                activity centers.
                                

                               

                            	
                              This
                                benefit is limited to non-dual Adult non-Waiver Members
                                age 21 and over.
                                Must be prior authorized. Limited to up to ten hours
                                per month of in home
                                respite services. 

                               

                            	
                              Network
                                providers. 

                               

                            

                    

                     

                    Modified
                      by Version 1.5

                     

                    
                      	
                               

                              Behavioral
                                Health Value-added Services for Members 21
                                and Over

                               

                            
	
                               

                              Value-added
                                Service 

                            	
                               

                              Description
                                of Value-added Services and Members Eligible to Receive
                                the Services
                                

                            	
                               

                               

                              Limitations
                                or Restrictions 

                            	
                              Provider(s)
                                responsible for providing this service 

                            
	
                              Behavioral
                                Health 

                               

                               

                               

                               

                               

                            	
                              Health
                                Psychology Interventions provided by a behavioral
                                health practitioner in a
                                medical setting that focuses on the effective management
                                of chronic
                                medical conditions. This might include psycho-educational
                                groups for
                                chronic conditions, individual coaching for patients
                                with chronic disease
                                states, or skills training activities. 

                               

                            	
                              Limited
                                to non-dual Members only. Services must be authorized
                                and is based on
                                medical necessity. 

                               

                            	
                              Network
                                Federally Qualified Health Centers (FQHCs) 

                               

                            
	
                              Behavioral
                                Health 

                               

                               

                               

                               

                               

                            	
                              Intensive
                                Outpatient Treatment/Day Treatment (IOP)- Used as
                                an alternative to step
                                down from more restrictive levels of care. 

                               

                            	
                              Limited
                                to non-dual Members only. Services must be authorized
                                and is based on
                                medical necessity. Services will be authorized for
                                greater than one and
                                one half hours, but less than five hours per day.

                               

                            	
                              It
                                is anticipated that behavioral health providers such
                                as the MHMR or other
                                facilities within the Service Area will render this
                                service. 

                               

                            
	
                              Behavioral
                                Health 

                               

                               

                               

                               

                               

                            	
                              Partial
                                Hospitalization/Extended Day Treatment- An alternative
                                to, or a step down
                                from, inpatient care. 

                               

                               

                            	
                              Limited
                                to non-dual Members only. Services must be authorized
                                and is based on
                                medical necessity. Services will be authorized for
                                a minimum of five
                                hours, but for less than 24-hours per day. 

                               

                            	
                              It
                                is anticipated that behavioral health providers such
                                as the MHMR or other
                                facilities within the Service Area will render this
                                service. 

                               

                            
	
                              Behavioral
                                Health 

                               

                               

                               

                               

                               

                            	
                              Off-site
                                services such as intensive case management. It should
                                be noted that staff
                                must go off-site to provide such services. These
                                services are provided to
                                Members to help reduce or avoid inpatient admissions
                                by a community based,
                                mobile, multi-disciplinary team of licensed clinicians
                                and trained,
                                unlicensed workers working under the direction of
                                a licensed professional.
                                

                               

                            	
                              Limited
                                to non-dual Members only. Services must be authorized
                                and is based on
                                medical necessity. 

                               

                            	
                              It
                                is anticipated that behavioral health providers such
                                as the MHMR or other
                                facilities within the Service Area will render this
                                service. 

                               

                            

                    

                    

                    ADDITIONAL
                      INFORMATION:  

                    
                      
                        
                        

                      

                      
                        
                        

                        
                          

                        

                      

                      
                        
                        

                      

                    

                     

                    1.
                      Explain how and when Providers and Members will be notified
                      about the
                      availability of the value-added services to be provided. 

                     

                    
                      	
                              Value
                                added services information will be included in the
                                Superior Provider
                                Manual and also during training sessions. Members
                                will receive this
                                information via the Plan Comparison Chart, in the
                                Member Handbook, with
                                New Member Packets and during orientations. Periodically,
                                Superior will
                                also highlight Value Added Services in the Provider
                                and member
                                Newsletters. 

                               

                            

                    

                    

                    2.
                      Describe how a Member may obtain or access the value-added
                      services to be
                      provided. 

                     

                    
                      	
                               

                              See
                                explanations provided above for accessing services.

                               

                               

                            

                    

                     

                    3.
                      Describe how the HMO will identify the Value-added Service
                      in administrative
                      (encounter) data. 

                    

                    
                      	
                              Superior
                                will track value added services through our claims
                                system for those value
                                -adds that are IIPAA-compliant procedural codes are
                                available (flu shots,
                                podiatry, etc.). Superior will create specific benefit
                                categories to track
                                and report the value added services “separately” from our “capitated”
                                service data. In addition, Superior will have the
                                ability to pass this
                                information to the State utilizing the encounter
                                submission process, as
                                long as the Sate is able to segregate the value adds
                                data from the
                                capitated services data. 

                              For
                                pharmacy services, Superior will receive a data file
                                from the pharmacy
                                vendor to capture all utilization of pharmacy value
                                added benefits. The
                                same is true for dental services. 

                               

                               

                            

                    

                     

                    4.
                      By
                      signing the Contract and/or Contract Amendment HMO certifies
                      that it will
                      provide the approved Value-added Services described herein
                      from February 1, 2007
                      through August 31, 2007. 

                     

                    Modified
                      by Version1.6

                     

                  

                

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

               

              Contractual
                Document (CD) Responsible Office: HHSC Office of General Counsel
                (OGC)

              Subject:
                Attachment B-3.2 - CHIP Perinatal Program Value-added Services 

              Version
                1.6 

              

              
                	
                        DOCUMENT
                          HISTORY LOG

                      
	
                         

                        STATUS1

                      	
                         

                        DOCUMENT
                          

                        REVISION2

                      	
                         

                        EFFECTIVE
                          

                        DATE
                          

                      	
                         

                        DESCRIPTION3

                      
	
                         

                        Baseline
                          

                      	
                         

                        1.0
                          

                      	
                         

                         

                      	
                         

                        Initial
                          version of Attachment B-3, Value-added Services 

                         

                         

                      
	
                         

                        Revision
                          

                      	
                         

                        1.1
                          

                      	
                         

                        June
                          30, 2006 

                      	
                         

                        Revised
                          Attachment B-3, Value Added Services, by adding Attachment
                          B-3.1,
                          STAR+PLUS Value Added Services. 

                         

                         

                      
	
                         

                        Revision
                          

                      	
                         

                        1.2
                          

                      	
                         

                        September
                          1, 2006 

                      	
                         

                        Contract
                          amendment did not revise Attachment B-3, Value Added Services
                          

                      
	
                         

                        Revision
                          

                      	
                         

                        1.3
                          

                      	
                         

                        September
                          1, 2006 

                      	
                         

                        Revised
                          Attachment B-3, Value Added Services, by adding Attachment
                          B-3.2, CHIP
                          Perinatal Program Value Added Services. This is the initial
                          version of
                          Attachment B-3.2, CHIP Perinatal Program Value Added Services.
                          

                      
	
                         

                        Revision
                          

                      	
                         

                        1.4
                          

                      	
                         

                        September
                          1, 2006 

                      	
                         

                        Contract
                          amendment removed the separate signature requirement for
                          Attachment B-3.2,
                          CHIP Perinatal Program Value-added Services. By signing
                          the Contract
                          and/or Contract Amendment, the HMO certifies that it will
                          provide the
                          Value-added Services from January 1, 2007 through August
                          31, 2007.
                          

                      
	
                         

                        Revision
                          

                      	
                         

                        1.5
                          

                      	
                         

                        January
                          1, 2007 

                      	
                         

                        Contract
                          amendment did not revise Attachment B-3.2, CHIP Perinatal
                          Program Value
                          Added Services. 

                      
	
                         

                        Revision
                          

                      	
                         

                        1.6
                          

                      	
                         

                        February
                          1, 2007 

                      	
                         

                        Contract
                          amendment did not revise Attachment B-3.2, CHIP Perinatal
                          Program Value
                          Added Services. 

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

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

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

                      

              

              

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

              

              

              ATTACHMENT
                B-3.2: CHIP PERINATAL PROGRAM VALUE-ADDED SERVICES 

              January
                1, 2007 through August 31, 2007 

               

              HMO:
                _________________________________________________________________________________
                

               

              SERVICE
                AREA(S):
                ______________________________________________________________________ 

               

              
                
                  	
                           

                          Physical
                            Health Value-added Services

                           

                        
	
                           

                           

                          Value-added
                            Service 

                           

                        	
                           

                           

                          Description
                            of Value-added Services and Members Eligible to Receive
                            the Services
                            

                           

                        	
                           

                           

                          Limitations
                            or Restrictions 

                           

                        	
                           

                           

                          Provider(s)
                            responsible for providing this service

                           

                        
	
                           

                           

                        	
                           

                           

                        	
                           

                           

                        	
                           

                           

                        
	
                           

                           

                        	
                           

                           

                        	
                           

                           

                        	
                           

                           

                        
	
                           

                           

                        	
                           

                           

                        	
                           

                           

                        	
                           

                        

                

              

               

               

               

              
                	
                         

                        Behavioral
                          Health Value-added Services for Members Under
                          21

                         

                      
	
                         

                         

                        Value-added
                          Service 

                         

                      	
                         

                         

                        Description
                          of Value-added Services and Members Eligible to Receive
                          the Services
                          

                         

                      	
                         

                         

                        Limitations
                          or Restrictions 

                         

                      	
                         

                         

                        Provider(s)
                          responsible for providing this service

                         

                      
	
                         

                         

                      	
                         

                         

                      	
                         

                         

                      	
                         

                         

                      
	
                         

                         

                      	
                         

                         

                      	
                         

                         

                      	
                         

                         

                      
	
                         

                         

                      	
                         

                         

                      	
                         

                         

                      	
                         

                         

                      

              

              

               

              
                	
                         

                        Behavioral
                          Health Value-added Services for Members 21
                          and Over

                         

                      
	
                         

                         

                        Value-added
                          Service 

                         

                      	
                         

                         

                        Description
                          of Value-added Services and Members Eligible to Receive
                          the Services
                          

                         

                      	
                         

                         

                         

                         

                        Limitations
                          or Restrictions 

                         

                      	
                        Provider(s)
                          responsible for providing this service

                         

                      
	
                         

                         

                      	
                         

                         

                      	
                         

                         

                      	
                         

                         

                      
	
                         

                         

                      	
                         

                         

                      	
                         

                         

                      	
                         

                         

                      
	
                         

                         

                      	
                         

                         

                      	
                         

                         

                      	
                         

                         

                      

              

              

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

               

              ADDITIONAL
                INFORMATION:  

               

              1.
                Explain how and when Providers and Members will be notified about
                the
                availability of the value-added services to be provided. 

              

              
                	
                         

                         

                         

                         

                         

                         

                         

                         

                      

              

              

               

              2.
                Describe how a Member may obtain or access the value-added services to be
                provided. 

              

              
                	
                         

                         

                         

                         

                         

                      

              

              

               

               

              3.
                Describe how the HMO will identify the Value-added Service in administrative
                (encounter) data. 

              

              
                	
                         

                         

                         

                         

                         

                      

              

              

               

              4.
                By
                signing the Contract and/or Contract Amendment HMO certifies that
                it will
                provide the approved Value-added Services described herein from January
                1, 2007
                through August 31, 2007. 

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

              Contractual
                Document (CD) Responsible Office: HHSC Office of General Counsel
                (OGC)

              Subject:
                Attachment B-4 -Performance Improvement Goals 

              Version
                1.6 

              

              
                	
                        DOCUMENT
                          HISTORY LOG 

                      
	
                        STATUS1

                      	
                        DOCUMENT
                          

                        REVISION2

                      	
                        EFFECTIVE
                          

                        DATE
                          

                      	
                        DESCRIPTION3

                      
	
                         

                        Baseline
                          

                         

                      	
                         

                        n/a
                          

                         

                      	
                         

                         

                         

                      	
                         

                        Initial
                          version Attachment B-4, Performance Improvement Goals.

                         

                      
	
                         

                        Revision
                          

                      	
                         

                        1.1
                          

                      	
                         

                        June
                          30, 2006 

                      	
                         

                        Contract
                          amendment to include STAR+PLUS program (Attachment B-4.1).
                          No change to
                          this Section. 

                      
	
                         

                        Revision
                          

                      	
                         

                        1.2
                          

                      	
                         

                        September
                          1, 2006 

                      	
                         

                        Revised
                          version of Attachment B-4 that includes provisions applicable
                          to MCOs
                          participating in the STAR and CHIP Programs. 

                         

                         

                        Updates
                          the attachment to reflect the changes made in Attachment
                          B-1, Section
                          8.1.1.1. 

                      
	
                         

                        Revision
                          

                      	
                         

                        1.3
                          

                      	
                         

                        September
                          1, 2006 

                      	
                         

                        Contract
                          amendment did not revise Attachment B-4, Performance Improvement
                          Goals.
                          

                         

                      
	
                         

                        Revision
                          

                      	
                         

                        1.4
                          

                      	
                         

                        September
                          1, 2006 

                      	
                         

                        Contract
                          amended to include Attachment B-4, Performance Improvement
                          Goals for
                          SFY2007 and format change. 

                         

                      
	
                         

                        Revision
                          

                      	
                         

                        1.5
                          

                      	
                         

                        January
                          1, 2007 

                      	
                         

                        Contract
                          amendment did not revise Attachment B-4, Performance Improvement
                          Goals.
                          

                         

                      
	
                         

                        Revision
                          

                      	
                         

                        1.6
                          

                      	
                         

                        February
                          1, 2007 

                      	
                         

                        Contract
                          amendment did not revise Attachment B-4, Performance Improvement
                          Goals.
                          

                         

                      
	
                         

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

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

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

                      

              

              

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

              

              Texas
                Health and Human Services Commission 

              STAR
                and CHIP HMO 

              Performance
                Improvement Goals 

              SFY
                2007 

              (September
                1, 2006 - August 31, 2007) 

               

              Modified
                by Versions 1.2 and 1.4

              

              A.
                Health
                Plan Information 

               

              Plan
                Name:
                Superior HealthPlan 

               

              HMO
                Program:  CHIP
                

               

              HMO
                Service Delivery Area:
                Bexar SDA 

               

              
                	
                        B.
                          Overarching Goal 

                      	
                        C.
                          Sub Goals: 

                      
	
                        Goal
                          1: 

                         

                        Improve
                          Access to Primary Care Services for Members 

                         

                      	
                         

                        §  90%
                          of Pediatricians will have open panels 

                         

                        § 90%
                          of initial credentialing of PCPs will be finalized within
                          90 days of
                          receipt of application 

                         

                      
	
                        Goal
                          2: 

                         

                        Improve
                          Access to Behavioral Health Services for Members 

                      	
                         

                        § Increase
                          urgent care appointment availability by 5 percentage points
                          over the
                          baseline 

                         

                        § Improve
                          the percent of psychiatrists accepting new member referrals
                          by 5
                          percentage points over the baseline 

                      
	
                        Goal
                          3: 

                         

                        Improve
                          Current Member Understanding About the CHIP Benefit Renewal
                          Processes
                          

                         

                      	
                         

                        § Member
                          Services staff will provide verbal reminders about re-enrollment
                          to 90% of
                          members 

                         

                        § Member
                          Services will research 100% of undelivered member mail
                          for updated and
                          valid demographic information 

                         

                      

              

              

              Additional
                information related to the Performance Improvement Goals can be found
                in
Attachment
                B-1, Section 8.1.1.1,
                to the
                Contract. 

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

              

              

              Texas
                Health and Human Services Commission 

              STAR
                and CHIP HMO 

              Performance
                Improvement Goals 

              SFY
                2007 

              (September
                1, 2006 - August 31, 2007) 

               

              Modified
                by Versions 1.2 and 1.4 

              

              A.
                Health
                Plan Information 

               

              Plan
                Name:
                Superior HealthPlan 

               

              HMO
                Program:  CHIP
                

               

              HMO
                Service Delivery Area:
                El Paso SDA 

               

              
                	
                        B.
                          Overarching Goal 

                      	
                        C.
                          Sub Goals: 

                      
	
                        Goal
                          1: 

                         

                        Improve
                          Access to Primary Care Services for Members 

                         

                      	
                         

                        §  90%
                          of Pediatricians will have open panels 

                         

                        § 90%
                          of initial credentialing of PCPs will be finalized within
                          90 days of
                          receipt of application 

                         

                      
	
                        Goal
                          2: 

                         

                        Improve
                          Access to Behavioral Health Services for Members 

                      	
                         

                        § Increase
                          urgent care appointment availability by 5 percentage points
                          over the
                          baseline 

                         

                        § Improve
                          the percent of psychiatrists accepting new member referrals
                          by 5
                          percentage points over the baseline 

                      
	
                        Goal
                          3: 

                         

                        Improve
                          Current Member Understanding About the CHIP Benefit Renewal
                          Processes
                          

                         

                      	
                         

                        § Member
                          Services staff will provide verbal reminders about re-enrollment
                          to 90% of
                          members 

                         

                        § Member
                          Services will research 100% of undelivered member mail
                          for updated and
                          valid demographic information 

                         

                      

              

              

              Additional
                information related to the Performance Improvement Goals can be found
                in
Attachment
                B-1, Section 8.1.1.1,
                to the
                Contract. 

               

              

                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              

              Texas
                Health and Human Services Commission 

              STAR
                and CHIP HMO 

              Performance
                Improvement Goals 

              SFY
                2007 

              (September
                1, 2006 - August 31, 2007) 

               

               

              Modified
                by Versions 1.2 and 1.4 

              

              A.
                Health
                Plan Information 

               

              Plan
                Name:
                Superior HealthPlan 

               

              HMO
                Program:  CHIP
                

               

              HMO
                Service Delivery Area:
                Lubbock SDA 

               

              
                	
                        B.
                          Overarching Goal 

                      	
                        C.
                          Sub Goals: 

                      
	
                        Goal
                          1: 

                         

                        Improve
                          Access to Primary Care Services for Members 

                         

                      	
                         

                        §  90%
                          of Pediatricians will have open panels 

                         

                        § 90%
                          of initial credentialing of PCPs will be finalized within
                          90 days of
                          receipt of application 

                         

                      
	
                        Goal
                          2: 

                         

                        Improve
                          Access to Behavioral Health Services for Members 

                      	
                         

                        § Increase
                          urgent care appointment availability by 5 percentage points
                          over the
                          baseline 

                         

                        § Improve
                          the percent of psychiatrists accepting new member referrals
                          by 5
                          percentage points over the baseline 

                      
	
                        Goal
                          3: 

                         

                        Improve
                          Current Member Understanding About the CHIP Benefit Renewal
                          Processes
                          

                         

                      	
                         

                        § Member
                          Services staff will provide verbal reminders about re-enrollment
                          to 90% of
                          members 

                         

                        § Member
                          Services will research 100% of undelivered member mail
                          for updated and
                          valid demographic information 

                         

                      

              

              

              Additional
                information related to the Performance Improvement Goals can be found
                in
Attachment
                B-1, Section 8.1.1.1,
                to the
                Contract. 

               

               

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

              

              Texas
                Health and Human Services Commission 

              STAR
                and CHIP HMO 

              Performance
                Improvement Goals 

              SFY
                2007 

              (September
                1, 2006 - August 31, 2007) 

               

              Modified
                by Versions 1.2 and 1.4 

              

              A.
                Health
                Plan Information 

               

              Plan
                Name:
                Superior HealthPlan 

               

              HMO
                Program:  CHIP
                

               

              HMO
                Service Delivery Area:
                Nueces SDA 

               

              
                	
                        B.
                          Overarching Goal 

                      	
                        C.
                          Sub Goals: 

                      
	
                        Goal
                          1: 

                         

                        Improve
                          Access to Primary Care Services for Members 

                         

                      	
                         

                        §  90%
                          of Pediatricians will have open panels 

                         

                        § 90%
                          of initial credentialing of PCPs will be finalized within
                          90 days of
                          receipt of application 

                         

                      
	
                        Goal
                          2: 

                         

                        Improve
                          Access to Behavioral Health Services for Members 

                      	
                         

                        § Increase
                          urgent care appointment availability by 5 percentage points
                          over the
                          baseline 

                         

                        § Improve
                          the percent of psychiatrists accepting new member referrals
                          by 5
                          percentage points over the baseline 

                      
	
                        Goal
                          3: 

                         

                        Improve
                          Current Member Understanding About the CHIP Benefit Renewal
                          Processes
                          

                         

                      	
                         

                        § Member
                          Services staff will provide verbal reminders about re-enrollment
                          to 90% of
                          members 

                         

                        § Member
                          Services will research 100% of undelivered member mail
                          for updated and
                          valid demographic information 

                         

                      

              

              

              Additional
                information related to the Performance Improvement Goals can be found
                in
Attachment
                B-1, Section 8.1.1.1,
                to the
                Contract. 

               

               

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

              

              Texas
                Health and Human Services Commission 

              STAR
                and CHIP HMO 

              Performance
                Improvement Goals 

              SFY
                2007 

              (September
                1, 2006 - August 31, 2007) 

               

              Modified
                by Versions 1.2 and 1.4

              

              A.
                Health
                Plan Information 

               

              Plan
                Name:
                Superior HealthPlan 

               

              HMO
                Program:  CHIP
                

               

              HMO
                Service Delivery Area:
                Travis SDA 

               

              
                	
                        B.
                          Overarching Goal 

                      	
                        C.
                          Sub Goals: 

                      
	
                        Goal
                          1: 

                         

                        Improve
                          Access to Primary Care Services for Members 

                         

                      	
                         

                        § 90%
                          of Pediatricians will have open panels 

                         

                        § 90%
                          of initial credentialing of PCPs will be finalized within
                          90 days of
                          receipt of application 

                         

                      
	
                        Goal
                          2: 

                         

                        Improve
                          Access to Behavioral Health Services for Members 

                      	
                         

                        § Increase
                          urgent care appointment availability by 5 percentage points
                          over the
                          baseline 

                         

                        § Improve
                          the percent of psychiatrists accepting new member referrals
                          by 5
                          percentage points over the baseline 

                      
	
                        Goal
                          3: 

                         

                        Improve
                          Current Member Understanding About the CHIP Benefit Renewal
                          Processes
                          

                         

                      	
                         

                        § Member
                          Services staff will provide verbal reminders about re-enrollment
                          to 90% of
                          members 

                         

                        § Member
                          Services will research 100% of undelivered member mail
                          for updated and
                          valid demographic information 

                         

                      

              

              

              Additional
                information related to the Performance Improvement Goals can be found
                in
Attachment
                B-1, Section 8.1.1.1,
                to the
                Contract. 

               

              

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

              

              Texas
                Health and Human Services Commission 

              STAR
                and CHIP HMO 

              Performance
                Improvement Goals 

              SFY
                2007 

              (September
                1, 2006 - August 31, 2007) 

               

              Modified
                by Versions 1.2 and 1.4

              

              A.
                Health
                Plan Information 

               

              Plan
                Name:
                Superior HealthPlan 

               

              HMO
                Program:  STAR
                

               

              HMO
                Service Delivery Area:
                Bexar SDA 

               

              
                	
                        B.
                          Overarching Goal 

                      	
                        C.
                          Sub Goals: 

                      
	
                        Goal
                          1: 

                         

                        Improve
                          Access to Primary Care Services for Members 

                         

                      	
                         

                        §  90%
                          of Pediatricians will have open panels 

                         

                        § 90%
                          of initial credentialing of PCPs will be finalized within
                          90 days of
                          receipt of application 

                         

                      
	
                        Goal
                          2: 

                         

                        Improve
                          Access to Behavioral Health Services for Members 

                      	
                         

                        § Increase
                          urgent care appointment availability by 5 percentage points
                          over the
                          baseline 

                         

                        § Improve
                          the percent of psychiatrists accepting new member referrals
                          by 5
                          percentage points over the baseline 

                      
	
                        Goal
                          3: 

                         

                        Improve
                          Access to Clinically Appropriate Alternatives to Emergency
                          Room Services
                          Outside of Regular Office Hours 

                         

                      	
                         

                        § Increase
                          the number of providers, including urgent care clinics
                          offering after hour
                          appointments, by 5% over baseline 

                         

                        § Target
                          outreach and education to 90% of members who have utilized
                          the emergency
                          room for primary care services ≥ 2 times 

                         

                         

                      

              

              

              Additional
                information related to the Performance Improvement Goals can be found
                in
Attachment
                B-1, Section 8.1.1.1,
                to the
                Contract. 

               

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

              

              Texas
                Health and Human Services Commission 

              STAR
                and CHIP HMO 

              Performance
                Improvement Goals 

              SFY
                2007 

              (September
                1, 2006 - August 31, 2007) 

               

              Modified
                by Versions 1.2 and 1.4

              

              A.
                Health
                Plan Information 

               

              Plan
                Name:
                Superior HealthPlan 

               

              HMO
                Program:  STAR
                

               

              HMO
                Service Delivery Area:
                El Paso SDA 

               

              
                	
                        B.
                          Overarching Goal 

                      	
                        C.
                          Sub Goals: 

                      
	
                        Goal
                          1: 

                         

                        Improve
                          Access to Primary Care Services for Members 

                         

                      	
                         

                        § 90%
                          of Pediatricians will have open panels 

                         

                        § 90%
                          of initial credentialing of PCPs will be finalized within
                          90 days of
                          receipt of application 

                         

                      
	
                        Goal
                          2: 

                         

                        Improve
                          Access to Behavioral Health Services for Members 

                      	
                         

                        § Increase
                          urgent care appointment availability by 5 percentage points
                          over the
                          baseline 

                         

                        § Improve
                          the percent of psychiatrists accepting new member referrals
                          by 5
                          percentage points over the baseline 

                      
	
                        Goal
                          3: 

                         

                        Improve
                          Access to Clinically Appropriate Alternatives to Emergency
                          Room Services
                          Outside of Regular Office Hours 

                         

                      	
                         

                        § Increase
                          the number of providers, including urgent care clinics
                          offering after hour
                          appointments, by 5% over baseline 

                         

                        § Target
                          outreach and education to 90% of members who have utilized
                          the emergency
                          room for primary care services ≥ 2 times 

                         

                      

              

              

              Additional
                information related to the Performance Improvement Goals can be found
                in
Attachment
                B-1, Section 8.1.1.1,
                to the
                Contract. 

              

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

              

              Texas
                Health and Human Services Commission 

              STAR
                and CHIP HMO 

              Performance
                Improvement Goals 

              SFY
                2007 

              (September
                1, 2006 - August 31, 2007) 

              Modified
                by Versions 1.2 and 1.4 

              

              A.
                Health
                Plan Information 

               

              Plan
                Name:
                Superior HealthPlan 

               

              HMO
                Program:  STAR
                

               

              HMO
                Service Delivery Area:
                Lubbock SDA 

               

              
                	
                        B.
                          Overarching Goal 

                      	
                        C.
                          Sub Goals: 

                      
	
                        Goal
                          1: 

                         

                        Improve
                          Access to Primary Care Services for Members 

                         

                      	
                         

                        §  90%
                          of Pediatricians will have open panels 

                         

                        § 90%
                          of initial credentialing of PCPs will be finalized within
                          90 days of
                          receipt of application 

                         

                      
	
                        Goal
                          2: 

                         

                        Improve
                          Access to Behavioral Health Services for Members 

                      	
                         

                        § Increase
                          urgent care appointment availability by 5 percentage points
                          over the
                          baseline 

                         

                        § Improve
                          the percent of psychiatrists accepting new member referrals
                          by 5
                          percentage points over the baseline 

                      
	
                        Goal
                          3: 

                         

                        Improve
                          Access to Clinically Appropriate Alternatives to Emergency
                          Room Services
                          Outside of Regular Office Hours 

                         

                      	
                         

                        § Increase
                          the number of providers, including urgent care clinics
                          offering after hour
                          appointments, by 5% over baseline 

                         

                        § Target
                          outreach and education to 90% of members who have utilized
                          the emergency
                          room for primary care services ≥ 2 times 

                         

                      

              

              

              Additional
                information related to the Performance Improvement Goals can be found
                in
Attachment
                B-1, Section 8.1.1.1,
                to the
                Contract. 

               

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

              

              

              Texas
                Health and Human Services Commission 

              STAR
                and CHIP HMO 

              Performance
                Improvement Goals 

              SFY
                2007 

              (September
                1, 2006 - August 31, 2007) 

              Modified
                by Versions 1.2 and 1.4 

               

              A.
                Health
                Plan Information 

               

              Plan
                Name:
                Superior HealthPlan 

               

              HMO
                Program:  STAR
                

               

              HMO
                Service Delivery Area:
                Nueces SDA 

               

              
                	
                        B.
                          Overarching Goal 

                      	
                        C.
                          Sub Goals: 

                      
	
                        Goal
                          1: 

                         

                        Improve
                          Access to Primary Care Services for Members 

                         

                      	
                         

                        §  90%
                          of Pediatricians will have open panels 

                         

                        § 90%
                          of initial credentialing of PCPs will be finalized within
                          90 days of
                          receipt of application 

                         

                      
	
                        Goal
                          2: 

                         

                        Improve
                          Access to Behavioral Health Services for Members 

                      	
                         

                        § Increase
                          urgent care appointment availability by 5 percentage points
                          over the
                          baseline 

                         

                        § Improve
                          the percent of psychiatrists accepting new member referrals
                          by 5
                          percentage points over the baseline 

                      
	
                        Goal
                          3: 

                         

                        Improve
                          Access to Clinically Appropriate Alternatives to Emergency
                          Room Services
                          Outside of Regular Office Hours 

                         

                      	
                         

                        § Increase
                          the number of providers, including urgent care clinics
                          offering after hour
                          appointments, by 5% over baseline 

                         

                        § Target
                          outreach and education to 90% of members who have utilized
                          the emergency
                          room for primary care services ≥ 2 times 

                         

                      

              

              

               

              Additional
                information related to the Performance Improvement Goals can be found
                in
Attachment
                B-1, Section 8.1.1.1,
                to the
                Contract. 

               

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

              Texas
                Health and Human Services Commission 

              STAR
                and CHIP HMO 

              Performance
                Improvement Goals 

              SFY
                2007 

              (September
                1, 2006 - August 31, 2007) 

              Modified
                by Versions 1.2 and 1.4 

               

              A.
                Health
                Plan Information 

               

              Plan
                Name:
                Superior HealthPlan 

               

              HMO
                Program:  STAR
                

               

              HMO
                Service Delivery Area:
                Travis SDA 

               

              
                	
                        B.
                          Overarching Goal 

                      	
                        C.
                          Sub Goals: 

                      
	
                        Goal
                          1: 

                         

                        Improve
                          Access to Primary Care Services for Members 

                         

                      	
                         

                        §  90%
                          of Pediatricians will have open panels 

                         

                        § 90%
                          of initial credentialing of PCPs will be finalized within
                          90 days of
                          receipt of application 

                         

                      
	
                        Goal
                          2: 

                         

                        Improve
                          Access to Behavioral Health Services for Members 

                      	
                         

                        § Increase
                          urgent care appointment availability by 5 percentage points
                          over the
                          baseline 

                         

                        § Improve
                          the percent of psychiatrists accepting new member referrals
                          by 5
                          percentage points over the baseline 

                      
	
                        Goal
                          3: 

                         

                        Improve
                          Access to Clinically Appropriate Alternatives to Emergency
                          Room Services
                          Outside of Regular Office Hours 

                         

                      	
                         

                        § Increase
                          the number of providers, including urgent care clinics
                          offering after hour
                          appointments, by 5% over baseline 

                         

                        § Target
                          outreach and education to 90% of members who have utilized
                          the emergency
                          room for primary care services ≥ 2 times 

                         

                      

              

              

              Additional
                information related to the Performance Improvement Goals can be found
                in
Attachment
                B-1, Section 8.1.1.1,
                to the
                Contract. 

               

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

              

              Contractual
                Document (CD) Responsible Office: HHSC Office of General Counsel
                (OGC)

              Subject:
                Attachment B-4.1 - FY2008 Performance Improvement Goals 

              Version
                1.6 

              

              
                	
                        DOCUMENT
                          HISTORY LOG 

                      
	
                        STATUS1

                      	
                        DOCUMENT
                          

                        REVISION2

                      	
                        EFFECTIVE
                          

                        DATE
                          

                      	
                        DESCRIPTION3

                      
	
                         

                        Baseline
                          

                      	
                         

                        1.0
                          

                      	
                         

                         

                      	
                         

                        Initial
                          version of Attachment B-4, Performance Improvement Goals.

                         

                         

                      
	
                         

                        Revision
                          

                      	
                         

                        1.1
                          

                      	
                         

                        June
                          30, 2006 

                      	
                         

                        Revised
                          Attachment B-4, Performance Improvement Goals Template,
                          by adding
                          Attachment B-4.1, FY2008 Performance Improvement Goals
                          Template. This is
                          the initial version of Attachment B-4.1, FY2008 Performance
                          Improvement
                          Goals. 

                      
	
                         

                        Revision
                          

                      	
                         

                        1.2
                          

                      	
                         

                        September
                          1, 2006 

                      	
                         

                        Contract
                          amendment did not revise Attachment B-4.1, FY2008 Performance
                          Improvement
                          Goals. 

                         

                         

                      
	
                         

                        Revision
                          

                      	
                         

                        1.3
                          

                      	
                         

                        September
                          1, 2006 

                      	
                         

                        Contract
                          amendment did not revise Attachment B-4.1, FY2008 Performance
                          Improvement
                          Goals. 

                         

                         

                      
	
                         

                        Revision
                          

                      	
                         

                        1.4
                          

                      	
                         

                        September
                          1, 2006 

                      	
                         

                        Contract
                          amendment did not revise Attachment B-4.1, FY2008 Performance
                          Improvement
                          Goals, but did change format. 

                      
	
                         

                        Revision
                          

                      	
                         

                        1.5
                          

                      	
                         

                        January
                          1, 2007 

                      	
                         

                        Contract
                          amendment did not revise Attachment B-4.1, FY2008 Performance
                          Improvement
                          Goals. 

                         

                         

                      
	
                         

                        Revision
                          

                      	
                         

                        1.6
                          

                      	
                         

                        February
                          1, 2007 

                      	
                         

                        Contract
                          amendment did not revise Attachment B-4.1, FY2008 Performance
                          Improvement
                          Goals. 

                         

                         

                      
	
                         

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

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

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

                      

              

              

              Additional
                information related to the Performance Improvement Goals can be found
                in
Attachment
                B-1, Section 8.1.1.1,
                to the
                Contract.

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

              

              Texas
                Health and Human Services Commission 

              HMO
                Performance Improvement Goal Template 

              for
                State Fiscal Year 2008 

              (September
                1, 2007 - August 31, 2008) 

               

               

              
                	
                         

                        A.
                          Health Plan Information 

                         

                         

                        Plan
                          Name: 

                        HMO
                          Program:  

                        HMO
                          Service Delivery Area: 

                         

                      
	
                        B.
                          Overarching Goal 

                      	
                        C.
                          Sub Goals: 

                      
	
                        Goal
                          1-5: 

                         

                        Three
                          to five Goals for all applicable HMO Programs to be determined
                          and
                          negotiated prior to FY2008. 

                         

                      	
                         

                        To
                          be determined for FY2008. 

                         

                      
	
                        Goal
                          6: 

                         

                        (STAR+PLUS
                          HMOs)
                          Increase the use of the Consumer Directed Services (CDS)
                          Program 

                         

                      	
                         

                        Increase
                          the percentage of enrollees receiving Personal Assistance
                          Services (PAS)
                          through the Consumer Directed Services (CDS) Program by
                          15% as compared to
                          the baseline rate of ____ 

                         

                      

              

              

               

              Specific
                percentages for Sub-Goals will be negotiated by HHSC and the HMO
                before the
                beginning of FY2008. 

               

              Additional
                information related to the Performance Improvement Goals can be found
                in
Attachment
                B-1, Section 8.1.1.1,
                to the
                Contract.

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

              Contractual
                Document (CD) Responsible Office: HHSC Office of General Counsel
                (OGC)

              Subject:
                Attachment B-5 -Deliverables/Liquidated Damages Matrix 

              Version
                1.6 

              

                

                
                  	
                          DOCUMENT
                            HISTORY LOG

                        
	
                          STATUS1

                        	
                          DOCUMENT
                            

                          REVISION2

                        	
                          EFFECTIVE
                            

                          DATE
                            

                        	
                          DESCRIPTION3

                        
	
                           

                          Baseline
                            

                           

                           

                        	
                           

                          n/a
                            

                           

                           

                        	
                           

                           

                           

                           

                        	
                           

                          Initial
                            version of Attachment B-5, Deliverables/Liquidated Damage
                            Matrix.
                            

                        
	
                           

                          Revision
                            

                        	
                           

                          1.1
                            

                        	
                           

                          June
                            30, 2006 

                        	
                           

                          Contract
                            amendment did not revise Attachment B-5, Deliverables/Liquidated
                            Damage
                            Matrix. 

                        
	
                           

                          Revision
                            

                        	
                           

                          1.2
                            

                        	
                           

                          September
                            1, 2006 

                        	
                           

                          Amended
                            Attachment B-5 Deliverables/Liquidated Damages Matrix
                            to add a footnote
                            clarifying the deliverable due dates. Also amended the
                            provisions
                            regarding Claims Processing Requirements and the Reporting
                            Requirements
                            for the Claims Summary Report. 

                        
	
                           

                          Revision
                            

                        	
                           

                          1.3
                            

                        	
                           

                          September
                            1, 2006 

                        	
                           

                          Amended
                            Attachment B-5 Deliverables/Liquidated Damages Matrix
                            performance standard
                            for Provider Directories for the CHIP Perinatal Program.
                            

                        
	
                           

                          Revision
                            

                        	
                           

                          1.4
                            

                        	
                           

                          September
                            1, 2006 

                        	
                           

                          Contract
                            amendment did not revise Attachment B-5, Deliverables/Liquidated
                            Damage
                            Matrix. 

                        
	
                           

                          Revision
                            

                        	
                           

                          1.5
                            

                        	
                           

                          January
                            1, 2007 

                        	
                           

                          Contract
                            amendment did not revise Attachment B-5, Deliverables/Liquidated
                            Damage
                            Matrix. 

                        
	
                           

                          Revision
                            

                        	
                           

                          1.6
                            

                        	
                           

                          February
                            1, 2007 

                        	
                           

                          Contract
                            amendment did not revise Attachment B-5, Deliverables/Liquidated
                            Damage
                            Matrix. 

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

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

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

                        

                

                

                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

                

                Deliverables/Liquidated
                  Damages Matrix 

                 

                
                  	
                           

                          Service/
                            

                           

                           

                          Component1

                           

                        	
                           

                          Performance
                            Standard2

                           

                        	
                           

                          Measurement
                            Period3

                           

                        	
                           

                          Measurement
                            Assessment4

                           

                        	
                           

                          Liquidated
                            Damages 

                           

                        
	
                           

                          Contract
                            Attachment B-1, RFP §7.3 --Transition Phase Schedule 

                           

                           

                           

                           

                           

                          Contract
                            Attachment B-1, RFP §7.3.1 -- Transition Phase Tasks 

                           

                           

                          Contract
                            Attachment B-1, RFP §8.1 -- General Scope 

                           

                        	
                           

                          The
                            HMO must be operational no later than the agreed upon
                            Operations Start
                            Date. HHSC, or its agent, will determine when the HMO
                            is considered to be
                            operational based on the requirements in Section 7 and
                            8 of Attachment
                            B-1. 

                           

                        	
                           

                          Operations
                            Start Date 

                           

                        	
                           

                          Each
                            calendar day of non-compliance, per HMO Program, per
                            Service Area (SA).
                            

                           

                        	
                           

                          HHSC
                            may assess up to $10,000 per calendar day for each day
                            beyond the
                            Operations Start date that the HMO is not operational
                            until the day that
                            the HMO is operational, including all systems. 

                           

                        
	
                           

                          Contract
                            Attachment B-1 RFP §7.3.1.5 -- Systems Readiness Review 

                           

                           

                           

                           

                        	
                           

                          The
                            HMO must submit to HHSC or to the designated Readiness
                            Review Contractor
                            the following plans for review, by December 14, 2005
                            for STAR and CHIP,
                            and by July 31, 2006 for STAR+PLUS: 

                           

                           

                          •
                            Joint Interface Plan; 

                           

                           

                          •
                            Disaster Recovery Plan; 

                           

                           

                          •
                            Business Continuity Plan; 

                           

                           

                          •
                            Risk Management Plan; and 

                           

                           

                          •
                            Systems Quality Assurance Plan. 

                           

                        	
                           

                          Transition
                            Period 

                           

                        	
                           

                          Each
                            calendar day of non-compliance, per report, per HMO Program,
                            and per SA.
                            

                           

                        	
                          HHSC
                            may assess up to $1,000 per calendar day for each day
                            a deliverable is
                            late, inaccurate or incomplete. 

                           

                           

                           

                           

                           

                           

                           

                           

                           

                          Modified
                            by Version 1.1

                        
	
                           

                          Contract
                            Attachment B-1 RFP §7.3.1.7 - Operations Readiness 

                           

                           

                           

                           

                        	
                           

                          Final
                            versions of the Provider Directory must be submitted
                            to the Administrative
                            Services Contractor no later than 95 days prior to the
                            Operational Start
                            Date for the CHIP, STAR, and STAR+PLUS HMOs, and no later
                            than 30 days
                            prior to the Operational Start Date for the CHIP Perinatal
                            HMOs.
                            

                           

                        	
                           

                          Transition
                            Period 

                           

                        	
                           

                          Each
                            calendar day of non-compliance, per directory, per HMO
                            Program and per SA.
                            

                           

                        	
                          HHSC
                            may assess up to $1,000 per calendar day for each day
                            the directory is
                            late, inaccurate or incomplete. 

                        
	
                           

                          Contract
                            Attachment B-1 RFP §§ 6, 7, 8 and 9 

                           

                           

                           

                           

                           

                          Uniform
                            Managed Care Manual 

                           

                        	
                           

                          All
                            reports and deliverables as specified in Sections 6,
                            7, 8 and 9 of
                            Attachment B-1 must be submitted according to the timeframes
                            and
                            requirements stated in the Contract (including all attachments)
                            and HHSC’s
                            Uniform Managed Care Manual. (Specific Reports or deliverables
                            listed
                            separately in this matrix are subject to the specified
                            liquidated
                            damages.) 

                           

                        	
                           

                          Transition
                            Period, Quarterly during Operations Period 

                           

                        	
                           

                          Each
                            calendar day of non-compliance, per HMO Program, per
                            SA. 

                           

                        	
                           

                          HHSC
                            may assess up to $250 per calendar day if the report/deliverable
                            is late,
                            inaccurate, or incomplete. 

                           

                        
	
                           

                          Contract
                            Attachment B-1 RFP §8.1.6 -- Marketing & Prohibited Practices
                            

                           

                           

                           

                           

                           

                          Uniform
                            Managed Care Manual 

                           

                        	
                           

                          The
                            HMO may not engage in prohibited marketing practices.

                           

                        	
                           

                          Transition,
                            Measured Quarterly during the Operations Period 

                           

                        	
                           

                          Per
                            incident of non-compliance. 

                           

                        	
                           

                          HHSC
                            may assess up to $1,000 per incident of non-compliance.

                           

                        
	
                          Contract
                            Attachment B-1 RFP §8.1.17.2 --Financial Reporting Requirements
                            

                           

                          Uniform
                            Managed Care Manual - Chapter 5 

                           

                        	
                           

                          Financial
                            Statistical Reports (FSR):
                            

                           

                           

                          For
                            each SA, the HMO must file quarterly and annual FSRs.
                            Quarterly reports
                            are due no later than 30 days after the conclusion of
                            each State Fiscal
                            Quarter (SFQ). The first annual report is due no later
                            than 120 days after
                            the end of each Contract Year and the second annual report
                            is due no later
                            than 365 days after the end of each Contract Year. 

                           

                        	
                           

                          Quarterly
                            during the Operations Period 

                           

                           

                           

                           

                        	
                           

                          Per
                            calendar day of non-compliance, per HMO Program, per
                            SA. 

                           

                        	
                           

                          HHSC
                            may assess up to $1,000 per calendar day a quarterly
                            or annual report is
                            late, inaccurate or incomplete. 

                           

                           

                           

                           

                        
	
                           

                          Contract
                            Attachment B-1 RFP §8.1.17.2 -- Financial Reporting Requirements:
                            

                           

                           

                           

                           

                           

                          Uniform
                            Managed Care Manual - Chapter 5 

                           

                        	
                           

                          Medicaid
                            Disproportionate Share Hospital (DSH) Reports:
                            The Medicaid HMO must submit, on an annual basis, preliminary
                            and final
                            DSH Reports. The Preliminary report is due no later than
                            June
                            1st
                            after each reporting year, and the final report is due
                            no later than July
                            15th
                            after each reporting year.
                            This
                            standard does not apply to CHIP HMOs. 

                           

                        	
                           

                          Measured
                            during 4th
                            Quarter of the Operations Period (6/1-8/31) 

                           

                        	
                           

                          Per
                            calendar day of non-compliance, per HMO Program, per
                            SA. 

                           

                        	
                           

                          HHSC
                            may assess up to $1,000 per calendar day, per program,
                            per service area,
                            for each day the report is late, incorrect, inaccurate
                            or incomplete.
                            

                           

                        
	
                           

                          Contract
                            Attachment B-1 RFP §8.1.18 - Management Information System (MIS)
                            Requirements 

                           

                        	
                           

                          The
                            HMO’s MIS must be able to resume operations within 72 hours
                            of employing
                            its Disaster Recovery Plan. 

                           

                        	
                           

                          Measured
                            Quarterly during the Operations Period 

                           

                        	
                           

                          Per
                            calendar day of non-compliance, per HMO Program, per
                            SA. 

                           

                        	
                           

                          HHSC
                            may assess up to $5,000 per calendar day of non-compliance

                           

                        
	
                           

                          Contract
                            Attachment B-1 RFP §8.1.18.3 - Management Information System (MIS)
                            Requirements: System-Wide Functions 

                           

                           

                           

                           

                        	
                           

                          The
                            HMO’s MIS system must meet all requirements in Section 8.1.18.3
                            of
                            Attachment B-1. 

                           

                        	
                           

                          Measured
                            Quarterly during the Operations Period 

                           

                        	
                           

                          Per
                            calendar day of non-compliance, per HMO Program, per
                            SA. 

                           

                        	
                           

                          HHSC
                            may assess up to $5,000 per calendar day of non-compliance.

                           

                        
	
                           

                          Contract
                            Attachment B-1 RFP §8.1.18.5 -- Claims Processing Requirements
                            

                           

                           

                           

                           

                           

                          Uniform
                            Managed Care Manual Chapter 2 

                           

                        	
                           

                          The
                            HMO must adjudicate all provider Clean Claims within
                            30 days of receipt by
                            the HMO. The HMO must pay providers interest at an 18%
                            per annum,
                            calculated daily for the full period in which the Clean
                            Claim remains
                            unadjudicated beyond the 30-day claims processing deadline.
 

                           

                        	
                           

                          Measured
                            Quarterly during the Operations Period 

                           

                        	
                           

                          Per
                            incident of non-compliance. 

                           

                        	
                          HHSC
                            may assess up to $1,000 per claim if the HMO fails to
                            timely pay interest.
                            

                           

                           

                           

                           

                           

                          Modified
                            by Version 1.2

                        
	
                           

                          Contract
                            Attachment B-1 RFP §8.1.18.5 -- Claims Processing Requirements
                            

                           

                           

                           

                           

                           

                          Uniform
                            Managed Care Manual - Chapter 2 

                           

                        	
                           

                          The
                            HMO must comply with the claims processing requirements
                            and standards as
                            described in Section 8.1.18.5 of Attachment B-1 and in
                            Chapter 2 of the
                            Uniform Managed Care Manual. 

                           

                           

                           

                           

                        	
                           

                          Measured
                            Quarterly during the Operations Period 

                           

                        	
                           

                          Per
                            quarterly reporting period, per HMO Program, per SA.

                           

                        	
                          HHSC
                            may assess liquidated damages of up to $5,000 for the
                            first quarter that
                            an HMO’s Claims Performance percentages by type and by Program
                            fall below
                            the performance standards. HHSC may assess up to $25,000
                            per quarter for
                            each additional quarter that the Claims Performance percentages
                            by type
                            and by Program fall below the performance standards.

                          Modified
                            by Version 1.2 

                        
	
                           

                          Contract
                            Attachment B-1 RFP §8.1.20.2-- Reporting Requirements 

                           

                           

                           

                           

                           

                          Uniform
                            Managed Care Manual Chapters 2 and 5 

                           

                        	
                           

                          Claims
                            Summary Report: 

                           

                          The
                            HMO must submit quarterly, Claims Summary Reports to
                            HHSC by HMO Program
                            and each SA and claims processing subcontractor by the
                            30th
                            day following the reporting period unless otherwise specified.
                            

                           

                        	
                           

                          Measured
                            Quarterly during the Operations Period 

                           

                        	
                           

                          Per
                            calendar day of non-compliance, per HMO Program, per
                            SA. 

                           

                           

                           

                           

                        	
                          HHSC
                            may assess up to $1,000 per calendar day the report is
                            late, inaccurate,
                            or incomplete. 

                           

                           

                           

                           

                           

                           

                          Modified
                            by Version 1.2

                        
	
                           

                          Contract
                            Attachment B-1 RFP §8.1.5.9-- Member Complaint and Appeal Process
                            

                           

                           

                          Contract
                            Attachment B-1 RFP §8.2.7.1 -- Member Complaint Process 

                           

                           

                          Contract
                            Attachment B-1 RFP §8.4.3 - CHIP Member Complaint and Appeal Process
                            

                           

                        	
                           

                          The
                            HMO must resolve at least 98% of Member Complaints within
                            30 calendar days
                            from the date the Complaint is received by the HMO. 

                           

                           

                           

                           

                        	
                           

                          Measured
                            Quarterly during the Operations Period 

                           

                        	
                           

                          Per
                            reporting period, per HMO Program, per SA. 

                           

                        	
                           

                          HHSC
                            may assess up to $250 per reporting period if the HMO
                            fails to meet the
                            performance standard. 

                           

                        
	
                           

                          Contract
                            Attachment B-1 RFP §8.3.3 - STAR+PLUS Assessment Instruments 

                           

                           

                          Uniform
                            Managed Care Manual 

                           

                        	
                           

                          The
                            MDS-HC instrument must be completed and electronically
                            submitted to HHSC
                            in the specified format within 30 days of enrollment
                            for every Member
                            receiving Community-based Long-term Care Services, and
                            then each year by
                            the anniversary of the Member’s date of enrollment. 

                           

                        	
                           

                          Operations,
                            Turnover 

                           

                        	
                           

                          Per
                            calendar day of non-compliance, per Service Area. 

                           

                        	
                          HHSC
                            may assess up to $500 per calendar day per Service Area,
                            for each day a
                            report is late, inaccurate or incomplete. 

                           

                           

                           

                          Added
                            by Version 1.1 

                        
	
                           

                          1
                            DeriveContract Attachment B-1 

                           

                           

                          RFP
                            §8.1.5.9—Member Complaint and Appeal Process 

                           

                           

                          Contract
                            Attachment B-1 RFP §8.2.7.2 -- Medicaid Standard Member Appeal Process
                            

                           

                           

                          Contract
                            Attachment B-1 RFP § 8.4.3 CHIP Member Complaint and Appeal Process
                            

                           

                        	
                           

                          the
                            Contract or HHSC’s Uniform ManThe HMO must resolve at least 98% of Member
                            Appeals within 30 calendar days from the date the Appeal
                            is filed with the
                            HMO. 

                           

                           

                           

                           

                        	
                           

                          Care
                            MMeasured Quarterly during the Operations Period 

                           

                        	
                           

                          Per
                            reporting period, per HMO Program, per SA. 

                           

                        	
                           

                          HHSC
                            may assess up to $500 per reporting period if the HMO
                            fails to meet the
                            performance standard. 

                           

                        
	
                           

                          Contract
                            Attachment B-1 RFP §9.2 -- Transfer of Data 

                           

                           

                           

                           

                           

                           

                           

                        	
                           

                          The
                            HMO must transfer all data regarding the provision of
                            Covered Services to
                            Members to HHSC or a new HMO, at the sole discretion
                            of HHSC and as
                            directed by HHSC. All transferred data must comply with
                            the Contract
                            requirements, including HIPAA. 

                           

                        	
                           

                          Measured
                            at Time of Transfer of Data and ongoing after the Transfer
                            of Data until
                            satisfactorily completed 

                           

                        	
                           

                          Per
                            incident of non-compliance (failure to provide data and/or
                            failure to
                            provide data in required format), per HMO Program, per
                            SA. 

                           

                        	
                           

                          HHSC
                            may assess up to $10,000 per calendar day the data is
                            late, inaccurate or
                            incomplete. 

                           

                           

                           

                           

                        
	
                           

                          Contract
                            Attachment B-1 RFP §9.3 -- Turnover Services 

                           

                           

                           

                           

                        	
                           

                          Six
                            months prior to the end of the contract period or any
                            extension thereof,
                            the HMO must propose a Turnover Plan covering the possible
                            turnover of the
                            records and information maintained to either the State
                            (HHSC) or a
                            successor HMO. 

                           

                        	
                           

                          Measured
                            at Six Months prior to the end of the contract period
                            or any extension
                            thereof and ongoing until satisfactorily completed 

                           

                        	
                           

                          Each
                            calendar day of non-compliance, per HMO Program, per
                            SA. 

                           

                        	
                           

                          HHSC
                            may assess up to $1,000 per calendar day the Plan is
                            late, inaccurate, or
                            incomplete. 

                           

                           

                           

                           

                        
	
                           

                          Contract
                            Attachment B-1 RFP §9.4 -- Post-Turnover Services 

                           

                           

                           

                           

                        	
                           

                          The
                            HMO must provide the State (HHSC) with a Turnover Results
                            report
                            documenting the completion and results of each step of
                            the Turnover Plan
                            30 days after the Turnover of Operations. 

                           

                        	
                           

                          Measured
                            30 days after the Turnover of Operations 

                           

                        	
                           

                          Each
                            calendar day of non-compliance, per HMO program, per
                            SA. 

                           

                        	
                           

                          HHSC
                            may assess up to $250 per calendar day the report is
                            late, inaccurate or
                            incomplete. 

                           

                        
	
                           

                          Contract
                            Attachment A HHSC Uniform Managed Care Contract Terms
                            and Conditions,
                            Section 4.08 Subcontractors 

                           

                        	
                           

                          The
                            HMO must notify HHSC in writing immediately upon making
                            a decision to
                            terminate a subcontract with a Material Subcontractor
                            or upon receiving
                            notification from the Material Subcontractor of its intent
                            to terminate
                            such subcontract. 

                           

                        	
                           

                          Transition,
                            Measured Quarterly during the Operations Period 

                           

                           

                           

                           

                        	
                           

                          Each
                            calendar day of non-compliance, per HMO Program, per
                            SA. 

                           

                        	
                           

                          HHSC
                            may assess up to $5,000 per calendar day of non-compliance.

                           

                        
	
                          Modified
                            by Version 1.2

                          1
                            Derived from the Contract or HHSC’s Uniform Managed Care
                            Manual.

                          2
                            Standard
                            specified in the Contract. Note: Where the due dates
                            states 30 days, the
                            HMO is to provide the deliverable by the last day of
                            the month following
                            the end of the reporting period. Where the due date states
                            45 days, the
                            HMO is to provide the deliverable by the 15th
                            day of the second month following the end of the reporting
                            period.
                            

                           
3
                            Period during which HHSC will evaluate service for purposes
                            of tailored
                            remedies.

                          4
                            Measure against which HHSC will apply
                            remedies.

                        

                

                

                 

                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

               

             

             

            

             

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

        

      

    

    

    

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

       

      

       

       

    

     

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel (OGC)

      Subject:
        Attachment B-7 - STAR+PLUS Attendant Care Enhanced Payments Methodology

      Version
        1.6 

      

        

        
          	
                   

                  DOCUMENT
                    HISTORY LOG

                   

                
	
                  STATUS1

                	
                  DOCUMENT
                    

                  REVISION2

                	
                  EFFECTIVE
                    

                  DATE
                    

                	
                  DESCRIPTION3

                
	
                   

                  Baseline
                    

                   

                	
                   

                  n/a
                    

                   

                	
                   

                  January
                    1, 2007 

                   

                	
                   

                  Initial
                    version of Attachment B-7, STAR+PLUS Attendant Care Enhanced
                    Payments
                    Methodology, was incorporated into Version 1.5 of the Contract.
                    

                   

                
	
                   

                  Revision
                    

                   

                   

                	
                   

                  1.6
                    

                   

                   

                	
                   

                  February
                    1, 2007 

                	
                   

                  Contract
                    amendment did not revise Attachment B-7, STAR+PLUS Attendant
                    Care Enhanced
                    Payments Methodology. 

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

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

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

                

        

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        

        ATTACHMENT
          B-7: STAR+PLUS ATTENDANT CARE ENHANCED PAYMENTS METHODOLOGY
 

         

        HMO:
          Superior Health Plan 

         

        SERVICE
          AREA(S): Bexar & Nueces 

        

          

            

             

            
              	
                       

                       

                      I.
                        Provider Contracting 

                       

                    	
                       

                       

                      (a)
                        Description of criteria the HMO will use to allow participation
                        in the
                        STAR+PLUS Attendant Care Enhanced Payments. Will the HMO
                        have a enrollment
                        period that corresponds to the DADS enrollment period to
                        allow new
                        providers to participate in the HMO's Attendant Care Enhanced
                        Payments, or
                        will the HMO have it's own enrollment period that is separate
                        and not tied
                        to the DADS enrollment? 

                       

                      (b)
                        Description of any limitations or restrictions. 

                       

                    
	 	
                       

                      Superior
                        HealthPlan will only allow those providers that are currently
                        participating in the DADS Attendant Compensation Rate Enhancements
                        to
                        participate in the STAR+PLUS Attendant Care Enhanced Payments.
                        SHP will
                        have an enrollment period corresponding to the DADS enrollment
                        period to
                        allow new providers to participate in the SHP Attendant Care
                        Enhanced
                        Payments.

                       

                    
	
                       

                       

                      II.
                        Payment for STAR+PLUS Attendant Care Enhanced Payments
                        

                       

                    	
                       

                       

                      Description
                        of methodology the HMO will use to pay for the Attendant
                        Care Enhanced
                        Payments. Provide sufficient detail to fully explain the
                        planned
                        methodology. 

                       

                    
	
                       

                       

                       

                       

                    	
                       

                       

                      Superior
                        will not use the DADS rates. SHP will establish an additional
                        amount to be
                        added on to the unit rate by type of service. 

                       

                       

                       

                    
	
                       

                       

                      III.
                        Timing of the Attendant Care Enhanced Payments  

                       

                    	
                       

                      Description
                        of when the payments will be made to the Providers and the
                        frequency of
                        payments. Also include timeframes for Providers complaints
                        and appeals
                        regarding enhanced payments. 

                    
	 	
                       

                      The
                        enhanced rate payment amount will be paid at the time of
                        claims payment so
                        the frequency will depend on the frequency with which providers
                        file their
                        claims. Provider complaints and appeals will be handled through
                        the normal
                        complaint and appeal process and finalized within 30 days
                        from receipt.
                        

                       

                    
	
                       

                       

                      IV.
                        Assurances from Participating Providers 

                       

                    	
                       

                       

                      Description
                        of how the HMO will ensure that the participating Providers
                        are using the
                        enhancement funds to compensate direct care workers as intended
                        by the
                        2000-01 General Appropriations Act (Rider 27, House Bill
                        1,
                        76th
                        Legislature, Regular Session, 1999) and by T.A.C. Title 1,
                        Part 15,
                        Chapter 355. 

                    
	
                       

                       

                       

                       

                       

                       

                       

                       

                       

                       

                    	
                       

                      Participating
                        Providers will be required by contract to complete and submit
                        an affidavit
                        annually stating they applied the enhancement funds to the
                        compensation
                        for direct care staff. Compensation may include increased
                        hourly rates,
                        bonuses, paid holidays or additional benefits such as employer
                        paid
                        insurance. 

                       

                       

                    
	
                      V.
                        Monitoring of Attendant Care Enhanced Payments 

                       

                    	
                       

                       

                      Explanation
                        of the Monitoring Process that the HMO will use to monitor
                        whether the
                        Attendant Care Enhanced Payments are used for the purposes
                        intended by the
                        Texas Legislature. 

                       

                    
	
                       

                       

                       

                       

                       

                       

                       

                       

                       

                       

                       

                       

                       

                       

                    	
                       

                      Each
                        Provider’s compliance with the attendant compensation spending requirement
                        for the reporting period will be monitored on an annual basis
                        via the
                        submission of the affidavit stating they applied the enhancement
                        funds to
                        the compensation for direct care staff. Compensation may
                        include increased
                        hourly rates, bonuses, paid holidays or additional benefits
                        such as
                        employer paid insurance. In addition, providers may be audited
                        on as
                        as-needed basis to ensure financial records support the pass
                        through of
                        the enhanced funds. Enhanced payments could potentially be
                        recouped for
                        those Providers who fail to pass the funds to their direct
                        care staff.
                        

                    

            

          

          

          By
            signing the Contract and/or Contract Amendment, HMO certifies that the
            approved
            STAR+PLUS Attendant Care Enhanced Payments Methodology described herein
            is the
            methodology the HMO will use to make the legislatively mandated payments
            to its
            Long Term Services and Support (LTSS) Providers participating in the
            Attendant
            Care Enhanced Payments. 

        

         

        Additional
          information related to the Attendant Care Enhanced Payments can be found
          in
          Attachment B-1, Section 8.3.7.3 of the Contract.SUMMARY OF COMPENSATORY ARRANGEMENTS WITH EXECUTIVE OFFICERS

    Exhibit
      10.23 

     

    Summary
      of Compensatory Arrangements with Executive Officers 

     

    The
      compensation committee of the board of directors approved a schedule of the
      following fiscal year 2007 base salaries for each of our named executive
      officers: 

     

    
      	 	 	 	 	 
	
              Name
                and Principal Position

            	
                

            	
                

            	
              2007

              Base Salary

            
	
              Michael
                F. Neidorff

                  Chairman
                and
                Chief Executive Officer

            	
                

            	
                

            	
              $

            	
              1,000,000

            
	
              J.
                Per Brodin

                  Senior
                Vice President and Chief Financial Officer

            	
                

            	
                

            	
              $

            	
              
                350,000

              

            
	
              Carol
                E. Goldman

                  Senior
                Vice President and Chief Administrative Officer

            	
                

            	
                

            	
              $

            	
              
                375,000

              

            
	
              William
                N. Scheffel

                  Senior
                Vice President, Specialty Business Unit

            	
                

            	
                

            	
              $

            	
              
                510,000

              

            
	
              Karey
                L. Witty

                  Senior
                Vice President, Health Plan Business Unit

            	
                

            	
                

            	
              $

            	
              
                500,000

              

            

    

     

    The
      basis
      for awarding bonuses, if any, to the executive officers named above shall
      be determined in accordance with the provisions of their respective employment
      agreements.

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