Document:

Exhibit 10.1

 

UTAH DEPARTMENT OF HEALTH

Box 143104

288 North 1460 West, Salt Lake City, Utah  84114- 3104

CONTRACT

 

	
  H0535503

  	
   

  	
   

  
	
  Department Log Number

  	
   

  	
  State
  Contract Number

  

 

1.                            CONTRACT NAME:

The name of this Contract is
Health Plan - Molina.

 

2.                            CONTRACTING PARTIES:

This Contract is between the
Utah Department of Health (DEPARTMENT), and Molina Healthcare of Utah (CONTRACTOR).

 

3.                            CONTRACT PERIOD:

The service period of this
Contract will be January 1, 2006 through June 30, 2006, unless terminated or
extended by agreement in accordance with the terms and conditions of this
Contract.  This Contract may be extended
annually 1 times, at the option of the DEPARTMENT, by means of an amendment to
this Contract.  Such extension must be in
writing.

 

4.                            CONTRACT AMOUNT:

The CONTRACTOR will be paid
up to a maximum amount of $90,000,000.00 in accordance with the provisions in
this Contract.  This Contract is funded
with 70.76% Federal funds and with 29.24% State funds.  The CFDA # is 93.778 and relates to the
federal funds provided.

 

5.                            CONTRACT INQUIRIES:

Inquiries regarding this
Contract shall be directed to the following individuals:

 

	
  CONTRACTOR

  	
   

  	
   

  	
   

  	
  DEPARTMENT

  	
   

  	
   

  
	
  Contact Person:

  	
   

  	
  Brian Monsen

  	
   

  	
  Program:

  	
   

  	
  Managed Health Care

  
	
  Business Address:

  	
   

  	
  7050 Union Park Ctr #200

  	
   

  	
  Contact Person:

  	
   

  	
  Julie Olson

  
	
   

  	
   

  	
  Salt Lake City, UT 84074

  	
   

  	
  Phone Number:

  	
   

  	
  (801) 538-6505

  
	
  Phone Number:

  	
   

  	
  (801) 587-6443

  	
   

  	
   

  	
   

  	
   

  

 

6.         REFERENCE TO ATTACHMENTS INCLUDED AS PART OF THIS CONTRACT:

 

	
  Attachment A: 

  	
  Utah Department of Health
  General Provisions

  
	
  Attachment B: 

  	
  Special Provisions

  
	
  Attachment C: 

  	
  Covered Services

  
	
  Attachment D: 

  	
  Utah’s Quality Assessment
  and Performance Improvement Plan

  
	
  Attachment E: 

  	
  Medicaid Enrollment (Table
  1), Cost Date (Table 2), Utilization Data (Table 3), Medicaid

  
	
   

  	
  Malpractice Information (Table 4)

  
	
  Attachment F: 

  	
  Payment Methodology

  

 

7.         PROVISIONS INCORPORATED INTO THIS CONTRACT BY REFERENCE, BUT NOT
ATTACHED HERETO:

 

A.                  All other governmental laws, rules,
regulations, or actions applicable to services provided herein.

 

B.                    If the
CONTRACTOR has provided the DEPARTMENT with Assurances, then the DEPARTMENT is
entering into this agreement based upon the Assurances provided by the
CONTRACTOR and the Assurances are incorporated by reference.

 

8.         If the CONTRACTOR is not a local public
procurement unit as defined by the Utah Procurement Code (UCA § 63-56-5),
this Contract must be signed by a representative of the State Division of
Finance and the State Division of Purchasing to bind the State and the
DEPARTMENT to this Contract.

 

9.        This Contract, its attachments, and all documents incorporated by
reference constitute the entire agreement between the parties and supercede all
prior negotiations, representations, or agreements, either written or oral between
the parties relating to the subject matter of this Contract.

 

 

IN WITNESS WHEREOF, the parties sign this Contract.

 

	
  CONTRACTOR:

  	
  Molina Healthcare of Utah

  	
   

  	
   

  	
  UTAH DEPARTMENT OF HEALTH

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  By:

  	
        /s/
  G. Kirk Olsen 

  	
   

  	
   

  	
  By:

  	
       /s/
  Shari A. Watkins 

  	
   

  
	
  Signature
  of Authorized Individual

  	
  Date
  

  	
   

  	
  Shari
  A. Watkins, C.P.A.

  	
  Date
  

  
	
   

  	
   

  	
  Director
  

  
	
  Print Name:

  	
      G.
  Kirk Olsen 

  	
   

  	
   

  	
  Office
  of Fiscal Operations  

  
	
   

  	
   

  	
   

  
	
  Title:

  	
  Chief Executive Officer

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  State Finance:

  	
  Date  

  
	
   

  	
   

  	
   

  	
   

  
	
       33-0617992

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Federal Tax Identification
  Number

  	
   

  	
  State Purchasing:

  	
  Date

  
																

 

1

 

ATTACHMENT
“A”

 

UTAH
DEPARTMENT OF HEALTH

 

General
Provisions

 

	
  I. CONTRACT DEFINITIONS 

  	
  1

  
	
   

  	
   

  
	
  II. AUTHORITY 

  	
  1

  
	
   

  	
   

  
	
  III. MISCELLANEOUS PROVISIONS 

  	
  2

  
	
   

  	
   

  
	
  IV. UTAH INDOOR CLEAN AIR ACT 

  	
  3

  
	
   

  	
   

  
	
  V. RELATED PARTIES & CONFLICTS OF INTEREST 

  	
  4

  
	
   

  	
   

  
	
  VI. OTHER CONTRACTS 

  	
  4

  
	
   

  	
   

  
	
  VII. SUBCONTRACTS & ASSIGNMENTS 

  	
  4

  
	
   

  	
   

  
	
  VIII. FURTHER WARRANTY 

  	
  4

  
	
   

  	
   

  
	
  IX. INFORMATION OWNERSHIP 

  	
  4

  
	
   

  	
   

  
	
  X. SOFTWARE OWNERSHIP 

  	
  4 

  
	
   

  	
   

  
	
  XI. INFORMATION PRACTICES 

  	
  5

  
	
   

  	
   

  
	
  XII. INDEMNIFICATION 

  	
  5

  
	
   

  	
   

  
	
  XIII. SUBMISSION OF REPORTS 

  	
  6

  
	
   

  	
   

  
	
  XIV. PAYMENT 

  	
  6

  
	
   

  	
   

  
	
  XV. RECORD KEEPING, AUDITS, & INSPECTIONS 

  	
  6

  
	
   

  	
   

  
	
  XVI. CONTRACT ADMINISTRATION REQUIREMENTS 

  	
  7

  
	
   

  	
   

  
	
  XVII. DEFAULT, TERMINATION, & PAYMENT ADJUSTMENT 

  	
  9

  
	
   

  	
   

  
	
  XVIII. FEDERAL REQUIREMENTS 

  	
  10

  

 

i

 

ATTACHMENT
“A”

 

UTAH
DEPARTMENT OF HEALTH GENERAL PROVISIONS

 

I. CONTRACT
DEFINITIONS

 

The following definitions apply in these general provisions:

 

“Assign” or “Assignment” means
the transfer of all rights and delegation of all duties in the contract to another
person.

 

“Business” means any corporation, partnership, individual, sole
proprietorship, joint stock company, joint venture, or any other private legal
entity.

 

“This Contract” means this agreement between the Department and
the Contractor, including both the General Provisions and the Special
Provisions.

 

“The Contractor” means the person who delivers the services or
goods described in this Contract, other than the state or the Department.

 

“The Department” means the Utah Department of Health.

 

“Director” means the Executive Director of the Department or
authorized representative.

 

“Equipment” means capital equipment which costs at least $1,000
and has a useful life of one year or more unless a different definition or
amount is set forth in the Special Provisions or specific Department Program
policy as described in writing to Contractor.

 

“Federal law” means the constitution, orders, case law,
statutes, rules, and regulations of the federal government.

 

“General provisions” means those provisions of this Contract
which are set forth under the heading “General Provisions.”

 

“Governmental entity” means a federal, state, local, or
federally-recognized Indian tribal government, or any subdivision thereof.

 

“Individual” means a living human being.

 

“Local health department” means a local health department as
defined in § 26A-1-102, Utah Code Annotated, 1953 as amended (UCA.).

 

“Non-governmental entity” means privately held non-profit or
for profit organization not classified as a “Governmental entity.”

 

“Person” means any governmental entity, business, individual,
union, committee, club, other organization, or group of individuals.

 

“Recipient” means an individual who is eligible for services
provided by the Department or by an authorized Contractor of the Department
under the terms of this Contract.

 

“Services” means the furnishing of labor, time, or effort by a
Contractor, not involving the delivery of a specific end product other than
reports which are merely incidental to the required performance.

 

“Special provisions” means those provisions of this Contract
which are in addition to the General Provisions and which more fully describe
the goods or services covered by this Contract.

 

“State” means the State of Utah.

 

“State law” means the constitution, orders, case law, statutes,
and rules, of the state.

 

“Subcontract” means any signed agreement between the Contractor
and a third party to provide goods or services for which the Contractor is
obligated, except purchase orders for standard commercial equipment, products,
or services.

 

“Subcontractor” means the person who performs the services or
delivers the goods described in a subcontract.

 

II.
AUTHORITY

 

1. The Department’s authority to enter into this Contract is derived
from Chapter 56, Title 63, UCA; Titles 26 and 26A, UCA; and from related
statutes.

 

2. The Contractor represents that it has the institutional, managerial,
and financial capability to ensure proper planning, management, and completion
of the project or services described in this Contract.

 

1

 

III. MISCELLANEOUS PROVISIONS

 

1. For reference clarity, as used in
these General Provisions: “ARTICLE” refers to a major topic designated by capitalized
roman numerals; “SECTION” refers to the next lower numbered heading designated
by arabic numerals, and “SUBSECTIONS” refers to the next two lower headings
designated by lower case letters and lower case roman numerals.

 

2. If the General Provisions and the
special provisions of this Contract conflict, the special provisions govern.

 

3. These provisions distinguish
between two Contractor types: Governmental and Non-governmental. Unspecified text
applies to both types. Type-specific statements appear in bold print (e.g., Non-governmental entities only).

 

4. Once signed by the Director and
the State Division of Finance, when applicable, and the State Division of Purchasing,
when applicable, this Contract becomes effective on the date specified in this
Contract. Changes made to the unsigned Contract document shall be initialed by
both persons signing this Contract on page one. Changes made to this Contract
after the signatures are made on page one may only be made by a separate
written amendment signed by persons authorized to amend this Contract.

 

5. Neither party may enlarge,
modify, or reduce the terms, scope of work, or dollar amount in this Contract,
except by written amendment as provided in section 4.

 

6. This Contract and the contracts
that incorporate its provisions contain the entire agreement between the Department
and the Contractor. Any statements, promises, or inducements made by either
party or the agent of either party which are not contained in the written
Contract or other contracts are not valid or binding.

 

7. The Contractor shall comply with
all applicable laws regarding federal and state taxes, unemployment insurance, disability
insurance, and workers’ compensation.

 

8. The Contractor is an independent
Contractor, having no authorization, express or implied, to bind the Department
to any agreement, settlement, liability, or understanding whatsoever, and
agrees not to perform any acts as agent for the Department unless expressly set
forth herein. Compensation stated herein shall be the total amount payable to the
Contractor by the Department. The Contractor shall be responsible for the
payment of all income tax and social security amounts due as a result of
payments received from the Department for these contract services. 

 

9. The Contractor shall maintain all
licenses, permits, and authority required to accomplish its obligations under
this Contract.

 

10. The Contractor shall obtain
prior written Department approval before purchasing any equipment with contract
funds.

 

11. Notice shall be in writing,
directed to the contact person on page one of this Contract, and delivered by
certified mail or by hand to the other party’s most currently known address.
The notice shall be effective when placed in the U.S. mail or hand-delivered.

 

12. The Department and the
Contractor shall attempt to resolve contract disputes through available
administrative remedies prior to initiating any court action.

 

13. This Contract shall be construed
and governed by the laws of the State of Utah. The Contractor submits to the jurisdiction
of the courts of the State of Utah for any dispute arising out of this Contract
or the breach thereof. The proper venue of any legal action arising under this
contract shall be in Salt Lake City, Utah.

 

14. Any court ruling or other
binding legal declaration which declares that any provision of this Contract is
illegal or void, shall not affect the legality and enforceability of any other
provision of this Contract, unless the provisions are mutually dependent.

 

15. The Contractor agrees to
maintain the confidentiality of records that it holds as agent for the
Department as required by the Government Records Access and Management Act,
Title 63, Chapter 2, UCA and the confidentiality of records requirements of
Title 26, UCA.

 

16. The Contractor agrees to abide
by the State of Utah’s executive order, dated March 17,1993, which prohibits sexual
harassment in the workplace.

 

17. The waiver by either party of
any provision, term, covenant or condition of this Contract shall not be deemed
to be a waiver of any other provision, covenant or condition of this Contract
nor any subsequent breach of the same or any other provision, term, covenant or
condition of this Contract.

 

18. The Contractor agrees to warrant
and assume responsibility for each hardware, firmware, and/or software product
(hereafter called the product) that it licenses, or sells, to the Department
under this Contract. The Contractor

 

2

 

acknowledges that the Uniform Commercial Code applies to this Contract.
In general, the Contractor warrants that:

 

(a) the product will do what the salesperson said it would do, (b) the
product will live up to all specific claims that the manufacturer makes in
their advertisements, (c) the product will be suitable for the ordinary
purposes for which such product is used, (d) the product will be suitable for
any special purposes  that
the Department has relied on the Contractor’s skill or judgement to consider
when it advised the Department about the product, (e) the product has been
properly designed and manufactured, and (f) the product is free of significant
defects or unusual problems about which the Department has not been warned.

 

19. The State of Utah’s sales and use tax exemption number is E33399.
The tangible personal property or services being purchased are being paid for
from State funds and used in the exercise of that entity’s essential functions.
If the items purchased are construction materials, they will be converted into
real property by employees of this government entity, unless otherwise stated
in the contract.

 

20. The Contractor agrees that the Contract will be a public document,
and may be available for distribution. Contractor gives the Department express
permission to make copies of the Contract and/or of the response to the solicitation
in accordance with State of Utah Government Records Access and Management Act.
The permission to make copies as noted will take precedence over any statements
of confidentiality, proprietary information, copyright information, or similar
notation.

 

21. This Contract may be amended, modified, or supplemented only by
written amendment to the Contract, executed by the parties hereto, and attached
to the original, signed copy of the Contract..

 

22. Unless otherwise specified in this Contract, all deliveries will be
F.O.B. destination with all transportation and handling charges paid by the
Contractor. Responsibility and liability for loss or damage will remain with
Contractor until final inspection and acceptance, when responsibility will pass
to the Department, except as to latent defects, fraud and Contractor’s warranty
obligations.

 

23. All orders will be shipped promptly in accordance with the delivery
schedule. The Contractor will promptly submit invoices (within 30 days of
shipment or delivery of services) to the Department. The State contract number and/or
the agency purchase order number shall be listed on all invoices, freight
tickets, and correspondence relating to the Contract order. The prices paid by
the Department will be those prices listed in the Contract. The Department has
the right to adjust or return any invoice reflecting incorrect pricing.

 

24. The Contractor will release, indemnify, and hold the State, its
officers, agents, and employees harmless from liability of any kind or nature,
including the Contractor’s use of any copyrighted or un-copyrighted
composition, secret process, patented or un-patented invention, article, or
appliance furnished or used in the performance of this Contract.

 

25. Neither party to this Contract will be held responsible for delay or
default caused by fire, riot, acts of God, and/or war which is beyond that
party’s reasonable control. The Department may terminate this Contract after determining
that such delay or default will reasonably prevent successful performance of
the Contract.

 

26. The Contractor understands that a person who is interested in any
way in the sale of any supplies, services, construction, or insurance to the
State of Utah is violating the law if the person gives or offers to give any compensation,
gratuity, contribution, loan, or reward, or any promise thereof to any person
acting as a procurement officer on behalf of the State, or who in any official
capacity participates in the procurement of such supplies, services,
construction, or insurance, whether it is given for their own use or for the
use or benefit of any other person or organization (63-56-73, Utah Code
Annotated, 1953 as amended).

 

27. Contractor Terms and Conditions that apply must be in writing and
attached to the Contract. No other Terms and Conditions will apply to this
Contract, including terms listed or referenced on a Contractor’s website, terms
listed in a Contractor quotation/sales order, etc. In the event of any conflict
in the contract terms and conditions, the order of precedence shall be: a.
Department General Provisions; b. Department Special Provisions; c. Contractor Terms
and Conditions.

 

IV. UTAH
INDOOR CLEAN AIR ACT

 

The Contractor, for all personnel operating within the State of Utah,
shall comply with the Utah Indoor Clean Air Act, Title 26, Chapter 38, UCA,
which prohibits smoking in public places.

 

3

 

V. RELATED
PARTIES & CONFLICTS OF INTEREST

 

1. The Contractor may not pay related parties for goods, services,
facilities, leases, salaries, wages, professional fees, or the like for
contract expenses without the prior written consent of the Department. The
Department may consider the payments to the related parties as disallowed
expenditures and accordingly adjust the Department’s payment to the Contractor
for all related party payments made without the Department’s consent. As used
in this section, “related parties” means any person related to the Contractor
by blood, marriage, partnership, common directors or officers, or 10% or
greater direct or indirect ownership in a common entity.

 

2. The Contractor shall comply with the Public Officers’ and Employees’
Ethics Act, § 67-16-10, UCA, which prohibits actions that may create or that
are actual or potential conflicts of interest. It also provides that “no person
shall induce or seek to induce any public officer or public employee to violate
any of the provisions of this act.” The Contractor represents that none of its officers
or employees are officers or employees of the State of Utah, unless disclosure
has been made in accordance with § 67-16-8, UCA.

 

VI. OTHER
CONTRACTS

 

1. The Department may perform additional work related to this Contract
or award other contracts for such work. The Contractor shall cooperate fully
with other contractors, public officers, and public employees in scheduling and
coordinating contract work. The Contractor shall give other contractors
reasonable opportunity to execute their work and shall not interfere with the
scheduled work of other contractors, public officers, and public employees.

 

2. The Department shall not unreasonably interfere with the Contractor’s
performance of its obligations under this Contract.

 

VII.
SUBCONTRACTS & ASSIGNMENTS

 

The Contractor shall not assign, sell, transfer, subcontract, or sublet
rights or delegate responsibilities under this Agreement, in whole or part,
without the prior written consent of the Department. The Department agrees that
the Contractor may partially subcontract services, provided that the Contractor
retains ultimate responsibility for performance of all terms, conditions and
provisions of this Agreement. When subcontracting, the Contractor agrees to use
written subcontracts that conform with Federal and State laws. The Contractor
shall request Department approval for any assignment at least 20 days prior to
its effective date.

 

VIII.
FURTHER WARRANTY

 

The Contractor warrants that (a) all services shall be performed in
conformity with the requirements of this Contract by qualified personnel in
accordance with generally recognized standards; and (b) all goods or products
furnished pursuant to this Contract shall be free from defects and shall
conform to contract requirements. For any item that the Department determines
does not conform with the warranty, the Department may arrange to have the item
repaired or replaced, either by the Contractor or by a third party at the
Department’s option, at the Contractor’s expense.

 

IX.
INFORMATION OWNERSHIP

 

Except for confidential medical records held by direct care providers,
the Department shall own exclusive title to all information gathered, reports
developed, and conclusions reached in performance of this Contract. The
Contractor may not use, except in meeting its obligations under this Contract,
information gathered, reports developed, or conclusions reached in performance
of this Contract without the express written consent of the Department.

 

X. SOFTWARE
OWNERSHIP

 

1. If the Contractor develops or pays to have developed computer
software exclusively with funds or proceeds from this Contract to perform its
obligations under this Contract, or to perform computerized tasks that it was
not previously performing to meet its obligations under this Contract, the computer
software shall be exclusively owned by or licensed to the Department. In the
case of software owned by the Department, the Department grants to the Contractor
a nontransferable, nonexclusive license to use the software in the performance
of this Contract. In the case of software licensed to the Department, the
Department grants to the Contractor permission to use the software in the
performance of this Contract. This license or permission, as the case may be,
terminates when the Contractor

 

4

 

has completed its work under this Contract.

 

2. If the Contractor develops or pays to have developed computer
software which is an addition to existing software owned by or licensed
exclusively with funds or proceeds from this Contract, or to modify software to
perform computerized tasks in a manner different than previously performed, to
meet its obligations under this Contract, the addition shall be exclusively
owned by or licensed to the Department. In the case of software owned by the Department,
the Department grants to the Contractor a nontransferable, nonexclusive license
to use the software in the performance of this Contract. In the case of
software licensed to the Department, the Department grants to the Contractor
permission to use the software in the performance of this Contract. This
license or permission, as the case may be, terminates when the Contractor has
completed its work under this Contract.

 

3. If the Contractor uses computer software licensed to it which it does
not modify or program to handle the specific tasks required by this Contract,
then to the extent allowed by the license agreement between the Contractor and
the owner of the software, the Contractor grants to the Department a continuing
nonexclusive license to use the software, either by the Department or by a
different Contractor, to perform work substantially identical to the work
performed by the Contractor under this Contract. If the Contractor cannot grant
the license as required by this section, then the Contractor shall reveal the
input screens, report formats, data structures, linkages, and relations used in
performing its obligations under this Contract in such a manner to allow the
Department or another Contractor to continue the work performed by the
Contractor under this Contract.

 

4. The Contractor shall deliver to the Department a copy of the software
or information required by this Article within 90 days after the commencement
of this Contract and thereafter immediately upon making a modification to any
of the software which is the subject of this Contract.

 

XI.
INFORMATION PRACTICES

 

1. (Governmental
entities only) The Contractor shall establish, maintain, and
practice information procedures and controls that comply with Federal and State
law. The Contractor assures that any information about an individual that it
receives or requests from the Department pursuant to this Contract is necessary
to the performance of its duties and functions and that the information will be
used only for the purposes set forth in this Contract. The Department shall
inform the Contractor of any non-public designation of any information it
provides to the Contractor.

 

2. (Non-governmental
entities only) The Contractor shall establish, maintain, and
practice information procedures and controls that comply with Federal and State
law. The Contractor may not release any information regarding any person from
any information provided by the Department, unless the Department first
consents in writing to the release.

 

XII.
INDEMNIFICATION

 

1. (Governmental
entities only) It is mutually agreed that each party assumes
liability for the negligent or wrongful acts committed by its own agents,
officials, or employees, regardless of the source of funding for this Contract.
Neither party waives any rights or defenses otherwise available under the
Governmental Immunity Act.

 

2. (Non-governmental entities only) To
the extent authorized by law, the Contractor shall indemnify and hold harmless
the Department and any of its agents, officers, and employees, from any claims,
demands, suits, actions, proceedings, loss, injury, death, and damages of every
kind and description, including any attorney’s fees and litigation expenses,
which may be brought, made against, or incurred by that party on account of
loss or damage to any property, or for injuries to or death of any person,
caused by, arising directly or indirectly out of, or contributed to in whole or
in part, by reason of any alleged act, omission, professional error, fault,
mistake, or negligence of the Contractor or its employees, agents, or
representatives, or subcontractors or their employees, agents, or representatives,
in connection with, incident to, or arising directly or indirectly out of this
Contract, or arising out of workers’ compensation claims, unemployment, or
claims under similar such laws or obligations.

 

5

 

XIII.
SUBMISSION OF REPORTS

 

If the Contractor is a Local Health Department, it shall submit monthly
expenditure reports to the Department in a format approved by the Department.
All other Contractors shall submit monthly summarized billing statements to the
Department. Expenditure reports and billing statements must be submitted to the
Department within 30 days following the last day of the month in which the
expenditures were incurred or the services provided.

 

XIV. PAYMENT

 

1. If a recipient, a recipient’s insurance, or any third-party is
responsible to pay for services rendered pursuant to this Contract, the
Contractor shall bill and collect for the goods or services provided to the
recipient. The Department shall reimburse total actual expenditures, less
amounts collected as required by this section.

 

2. Under no circumstances shall the Department authorize payment to the
Contractor that exceeds the amount specified in this Contract without an
amendment to the Contract.

 

3. The Department agrees to make every effort to pay for completed
services, and payments are conditioned upon receipt of applicable, accurate,
and completed reports prepared by the Contractor and delivered to the
Department. The Department may delay or deny payment for final expenditure
reports received more than 20 days after the Contractor has satisfied all
Contract requirements.

 

4. In the case that funds are not appropriated or are reduced, the
Department will reimburse Contractor for products delivered or services
performed through the date of cancellation or reduction, and the Department
will not be liable for any future commitments, penalties, or liquidated
damages.

 

XV. RECORD
KEEPING, AUDITS, & INSPECTIONS

 

1. The Contractor shall use an accrual or a modified accrual basis for
reporting annual fiscal data, as required by Generally Accepted Accounting
Principles (GAAP). Required monthly or quarterly reports may be reported using
a cash basis.

 

2. The Contractor and any subcontractors shall maintain financial and
operation records relating to contract services, requirements, collections, and
expenditures in sufficient detail to document all contract fund transactions.
The Contractor and any subcontractors shall maintain and make all records
necessary and reasonable for a full and complete audit, inspection, and
monitoring of services by state and federal auditors, and Department staff
during normal business hours or by appointment, until all audits and reviews
initiated by federal and state auditors are completed, or for a period of four
years from the date of termination of this Contract, whichever is longer, or
for any period required elsewhere in this Contract.

 

3. The Contractor shall retain all records which relate to disputes,
litigations, claim settlements arising from contract performance, or
cost/expense exceptions initiated by the Director, until all disputes,
litigations, claims, or exceptions are resolved.

 

4. The Contractor shall comply with federal and state regulations
concerning cost principles, audit requirements, and grant administration
requirements, cited in Table 1. Unless specifically exempted in this Contract’s
special provisions, the Contractor must comply with applicable federal cost
principles and grant administration requirements if state funds are received.
The Contractor shall also provide the Department with a copy of all reports
required by the State Legal Compliance Audit Guide (SLCAG) as defined in
Chapter 2, Title 51, UCA. All federal and state principles and requirements
cited in Table 1 are available for inspection at the Utah Department of Health
during normal business hours. A Contractor who receives $100,000 or more in a
year from all federal or from all state sources may be subject to federal and
state audit requirements. A Contractor who receives $500,000 for fiscal years ending
after December 31, 2003 or more per year from federal sources may be subject to
the federal single audit requirement. Counties, cities, towns, school
districts, and all non-profit corporations that receive 50 percent or more of
its funds from federal, state or local governmental entities are subject to the
State of Utah Legal Compliance Audit Guide. Copies of required audit reports
shall be sent to the Utah Department of Health, Bureau of Financial Audit, Box
144002, Salt Lake City, Utah 84114-4002.

 

6

 

Federal and
State Principles and Requirements

 

	
   

  	
   

  	
  Cost 

  	
   

  	
  Federal Audit 

  	
   

  	
  State Audit 

  	
   

  	
  Grant Admin. 

  
	
  Contractor 

  	
   

  	
  Principles 

  	
   

  	
  Requirements 

  	
   

  	
  Requirements 

  	
   

  	
  Requirements 

  
	
  State or Local Govt. & Indian Tribal Govts.

  	
   

  	
  OMB Circular A-87

  	
   

  	
  OMB Circular A-133

  	
   

  	
  SLCAG

  	
   

  	
  OMB Common Rule

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Hospitals

  	
   

  	
  45 CFR 74, App. E

  	
   

  	
  OMB Circular A-133

  	
   

  	
  SLCAG

  	
   

  	
  OMB Common Rule

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  or Circular A-110

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  College or University

  	
   

  	
  OMB Circular A-21

  	
   

  	
  OMB Circular A-133

  	
   

  	
  SLCAG

  	
   

  	
  OMB Circular A-110

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Non-Profit Organization

  	
   

  	
  OMB Circular A-122

  	
   

  	
  OMB Circular A-133

  	
   

  	
  SLCAG

  	
   

  	
  OMB Circular A-110

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  For-Profit Organization

  	
   

  	
  48 CFR 31

  	
   

  	
  n/a

  	
   

  	
  n/a

  	
   

  	
  OMB Circular A-110

  

 

	
  Documents

  	
   

  	
  Web Address

  
	
  OMB Circulars

  	
   

  	
  http://www.whitehouse.gov/omb/circulars/index.html

  
	
   

  	
   

  	
   

  
	
  OMB Common Rule

  	
   

  	
  http://www.whitehouse.gov/omb/grants/attach.html

  
	
   

  	
   

  	
   

  
	
  CFRs

  	
   

  	
  http://www.access.gpo.gov/nara/cfr/cfr-table-search.html

  
	
   

  	
   

  	
   

  
	
  SLCAG

  	
   

  	
  http://www.sao.state.ut.us/resources/resources-lg.htm

  

 

Table 1

 

XVI.
CONTRACT ADMINISTRATION REQUIREMENTS

 

The Contractor agrees to administer this Contract in compliance with
either OMB Common Rule or OMB Circular A-110 depending upon the legal status of
the of the Contractor as shown in Table 1. Financial management, procurement,
and affirmative step requirements specify that:

 

1. the Contractor must have
fiscal control and accounting procedures sufficient to: 

 

a. permit preparation of
reports required by this Contract, and

 

b. permit the tracing of
funds to a level of expenditures adequate to establish that such funds have not
been used in violation of the restrictions and prohibitions of applicable
statutes.

 

2. the Contractor’s financial
management systems must meet the following standards:

 

a. financial reporting. Accurate, current, and complete
disclosure of the financial results of financially assisted activities must be
made in accordance with the financial reporting requirements of this Contract. 

 

b. accounting records. The Contractor must maintain records
which adequately identify the source and application of funds provided for federally
financially-assisted activities. These records must contain information
pertaining to the Contract’s awards and authorizations, obligations,
unobligated balances, assets, liabilities, outlays or expenditures, and income.

 

c. internal control. Effective control and accountability must
be maintained for all Contract cash, real and personal property, and other
assets. The Contractor must adequately safeguard all such property and must assure
that it is used solely for authorized purposes.

 

d. budget control. Actual expenditures or outlays must be
compared with budgeted amounts for the Contract Financial information must be
related to performance or productivity data, including the development of unit cost
information whenever appropriate or specifically required in this Contract. If
unit cost data are required, estimates based on available documentation will be
accepted whenever possible.

 

3. Federal OMB cost
principles, federal agency program regulations, and the terms of grant and
subgrant, and contract agreements will be followed in determining the
reasonableness, allowability, and allocability of costs.

 

a. source documentation. Accounting records must be supported
by such source documentation as canceled checks, paid bills, payrolls, time and
attendance records, contract and subcontract award documents, etc.

 

b. cash management. Procedures for minimizing the time elapsing
between the transfer of funds from the U.S. Treasury and disbursement by the
Department and the Contractor must be followed whenever advance payment
procedures are used.

 

7

 

4. the Contractor shall use
its own procurement procedures which reflect applicable State and local laws,
rules, and regulations, provided that the procurements conform to applicable
Federal law and the standards identified in this Contract.

 

a. The Contractor will
maintain a contract administration system which ensures that subcontractors
perform in accordance with the terms, conditions, and specifications of its contracts
or purchase orders.

 

b. The Contractor will
maintain a written code of standards of conduct governing the performance of
its employees engaged in the award and administration of contracts. No
employee, officer or agent of the Department or the Contractor shall
participate in selection, or in the award or administration of a contract supported
by federal funds if a conflict of interest, real or apparent, would be
involved. Such a conflict would arise when:

 

i. the employee, officer or
agent,

ii. any member of his
immediate family,

iii. his or her partner; or

iv. an organization which
employs, or is about to employ, any of the above, has a financial or other interest
in the firm selected for award. The Department’s or the Contractor’s officer,
employees or agents will neither solicit nor accept gratuities, favors or
anything of monetary value from contractors, potential contractors, or parties
to subagreements. The Department and the Contractor may set minimum rules where
the financial interest is not substantial or the gift is an unsolicited item of
nominal intrinsic value. To the extent permitted by State or local law or
regulations, such standards or conduct will provide for penalties, sanctions,
or other disciplinary actions for violations of such standards by the
Department’s or the Contractor’s officers, employees, or agents, or by
subcontractors or their agents.

 

c. The Contractor’s
procedures will provide for a review of proposed procurements to avoid purchase
of unnecessary or duplicative items. Consideration should be given to
consolidating or breaking out procurements to obtain a more economical
purchase. Where appropriate, an analysis will be made of lease versus purchase
alternatives, and any other appropriate analysis to determine the most economical
approach.

 

d. To foster greater economy
and efficiency, the Contractor, if a governmental entity, is encouraged to
enter into State and local intergovernmental agreements for procurement or use
of common goods and services. 

 

e. If allowed by law, the
Contractor is encouraged to use Federal excess and surplus property in lieu of purchasing
new equipment and property whenever such use is feasible and reduces project
costs. 

 

f. The Contractor may
contract only with responsible contractors possessing the ability to perform successfully
under the terms and conditions of a proposed procurement.

 

g. The Contractor shall
maintain records sufficient to detail the significant history of a procurement.
These records shall include, but are not necessarily limited to the following:

 

i. the rationale for the
method of procurement,

ii. selection of contract
type,

iii. contractor selection or
rejection, and

iv. the basis for the
contract price.

 

h. The Contractor may use
time and material type contracts only:

i. after a determination that
no other contract is suitable, and

ii. if the Contract includes
a ceiling price that the Contractor exceeds at its own risk.

 

i. The Contractor alone will
be responsible, in accordance with good administrative practice and sound business
judgment, for the settlement of all contractual and administrative issues
arising out of procurements. These issues include, but are not limited to
source evaluation, protests, disputes, and claims. These standards do not
relieve the Contractor of any contractual responsibilities under its contracts.

 

j. The Contractor shall have
protest procedures to handle and resolve disputes relating to its procurements and
shall in all instances disclose information regarding the protest to the
federal funding agency. A protestor must exhaust all administrative remedies
with the Department and the Contractor before pursuing a protest with the
federal funding agency.

 

5. the Contractor shall take
all necessary affirmative steps to assure that minority firms, women’s business
enterprises, and labor surplus area firms are used when possible. Affirmative
steps shall include:

 

a. placing qualified small
and minority businesses and women’s business enterprises on solicitation lists;

 

b. assuring that small and
minority businesses, and women’s business enterprises are solicited whenever
they

 

8

 

are potential sources;

 

c. dividing total
requirements, when economically feasible, into smaller tasks or quantities to
permit maximum participation by small and minority business, and women’s
business enterprises;

 

d. establishing delivery
schedules, where the requirement permits, which encourage participation by
small and minority business, and women’s business enterprises;

 

e. using the services and
assistance of the Small Business Administration, and the Minority Business Development
Agency of the Department of Commerce; and

 

f. requiring the prime
contractor, if subcontracts are to be let, to take the affirmative steps listed
in Article XVI, section 5, subsections a - e.

 

XVII.
DEFAULT, TERMINATION, & PAYMENT ADJUSTMENT

 

1. Each party may terminate
this Contract with cause. If the cause for termination is due to the default of
a party, the non-defaulting party shall send a notice, which meets the notice
requirements of this Contract, citing the default and giving notice to the
defaulting party of its intent to terminate. The defaulting party may cure the
default within fifteen days of the notice. If the default is not cured within the
fifteen days, the party giving notice may terminate this Contract 45 days from
the date of the initial notice of default or at a later date specified in the
notice.

 

2. The Department may
terminate this Contract without cause, in advance of the specified termination
date, upon 30 days written notice.

 

3. The Department agrees to
use its best efforts to obtain funding for multi-year contracts. If continued
funding for this Contract is not appropriated or budgeted at any time
throughout the multi-year contract period, the Department may terminate this
Contract upon 30 days notice.

 

4. If funding to the
Department is reduced due to an order by the Legislature or the Governor, or is
required by federal or state law, the Department may terminate this Contract or
proportionately reduce the services and goods due and the amount due from the
Department upon 30 days written notice. If the specific funding source for the subject
matter of this Contract is reduced, the Department may terminate this Contract
or proportionately reduce the services and goods due and the amount due from
the Department upon 30 written notice being given to the Contractor.

 

5. If the Department
terminates this Contract, the Department may procure replacement goods or
services upon terms and conditions necessary to replace the Contractor’s
obligations. If the termination is due to the Contractor’s failure to perform,
and the Department procures replacement goods or services, the Contractor
agrees to pay the excess costs associated with obtaining the replacement goods
or services.

 

6. If the Contractor
terminates this Contract without cause, the Department may treat the Contractor’s
action as a default under this Contract.

 

7. The Department may
terminate this Contract if the Contractor becomes debarred, insolvent, files
bankruptcy or reorganization proceedings, sells 30% or more of the company’s
assets or corporate stock, or gives notice of its inability to perform its
obligations under this Contract.

 

8. If the Contractor defaults
in any manner in the performance of any obligation under this Contract, or if
audit exceptions are identified, the Department may, at its option, either
adjust the amount of payment or withhold payment until satisfactory resolution
of the default or exception. Default and audit exceptions for which payment may
be adjusted or withheld include disallowed expenditures of federal or state
funds as a result of the Contractor’s failure to comply with federal
regulations or state rules. In addition, the Department may withhold amounts
due the Contractor under this Contract, any other current contract between the
Department and the Contractor, or any future payments due the Contractor to
recover the funds. The Department shall notify the Contractor of the Department’s
action in adjusting the amount of payment or withholding payment. This Contract
is executory until such repayment is made.

 

9. The rights and remedies of
the Department enumerated in this article are in addition to any other rights
or remedies provided in this Contract or available in law or equity.

 

10. Upon termination of the
Contract, all accounts and payments for services rendered to the date of
termination will be processed according to the financial arrangements set forth
herein for approved services rendered to date of termination. If the Department
terminates this Contract, the Contractor shall stop all work as specified in
the notice of termination. The Department shall not be liable for work or
services performed beyond the termination date as specified in the notice of
termination.

 

9

 

11. Any of the following
events will constitute cause for the Department to declare Contractor in
default of the Contract: a. Nonperformance of contractual requirements; b. A material
breach of any term or condition of this contract. The Department will issue a
written notice of default providing a ten (10) day period in which Contractor will
have an opportunity to cure. Time allowed for cure will not diminish or
eliminate Contractor’s liability for damages. If the default remains, after
Contractor has been provided the opportunity to cure, the Department may do one
or more of the following: c. Exercise any remedy provided by law; d. Terminate
this Contract and any related Contracts or portions thereof; e. Impose
liquidated damages, if liquidated damages are listed in the Contract; f. Suspend
Contractor from receiving future solicitations.

 

XVIII.
FEDERAL REQUIREMENTS

 

The Contractor shall comply
with all applicable federal requirements. To the extent that the Department is
able, the Department shall give further clarification of federal requirements
upon the Contractor’s request. If the Contractor is receiving federal funds
under this Contract, certain federal requirements apply. The Contractor agrees
to comply with the federal requirements to the extent that they are applicable
to the subject matter of this Contract and are required by the amount of
federal funds involved in this Contract.

 

1. Civil Rights Requirements:

 

a. The Civil Rights Act of
1964, Title VI, provides that no person in the United States shall, on the
grounds of race, color, or national origin, be excluded from participation in,
be denied the benefits of, or be subjected to discrimination under any program
or activity receiving federal financial assistance. The Health and Human Services
regulation implementing this requirement is 45 CFR Part 80.

 

b. The Civil Rights Act of
1964, Title VII, (P.L. 88-352 & 42 U.S.C. § 2000e) prohibits employers from
discriminating against employees on the basis of race, color, religion,
national origin, and sex. Title VII applies to employers of fifteen or more
employees, and prohibits all discriminatory employment practices.

 

c. The Rehabilitation Act of
1973, as amended, section 504, provides that no otherwise qualified handicapped
individual in the United States shall, solely by reason of the handicap, be
excluded from participation in, be denied the benefits of, or be subjected to
discrimination under any program or activity receiving federal financial
assistance. The Health and Human Services regulation 45 CFR Part 84 implements
this requirement.

 

d. The Age Discrimination Act
of 1975, as amended (42 U.S.C. §§ 6101-6107), prohibits unreasonable discrimination
on the basis of age in any program or activity receiving federal financial
assistance. The Health and Human Services regulation implementing the
provisions of the Age Discrimination Act is 45 CFR Part 91.

 

e. The Education Amendments
of 1972, Title IX, (20 U.S.C. §§ 1681-1683 and 1685-1686), section 901, provides
that no person in the United States shall, on the basis of sex, be excluded
from participation in, be denied the benefits of, or be subjected to
discrimination under any educational program or activity receiving federal
financial assistance. Health and Human Services regulation 45 CFR Part 86
implements this requirement.

 

f. Executive Order No. 11246,
as amended by Executive Order 11375 relates to “Equal Employment Opportunity,”
(all construction contracts and subcontracts in excess of $10,000) 

 

g. Americans with
Disabilities Act of 1990, (P.L.101-336), section 504 of the Rehabilitation Act
of 1973, as amended (29 U.S.C. § 794), prohibits discrimination on the basis of
disability.

 

h. The Public Health Service
Act, as amended, Title VII, section 704 and TITLE VIII, section 855, forbids the
extension of federal support for health manpower and nurse training programs
authorized under those titles to any entity that discriminates on the basis of
sex in the admission of individuals to its training programs. Health and Human
Services regulation implementing this requirement is 45 CFR Part 83.

 

i. The Public Health Service
Act, as amended, section 526, provides that drug abusers who are suffering from
medical conditions shall not be discriminated against in admission or treatment
because of their drug abuse or drug dependence, by any private or public
general hospital that receives support in any form from any federally funded
program. This prohibition is extended to all outpatient facilities receiving or
benefitting from federal financial assistance by 45 CFR Part 84.

 

j. The Public Health Service
Act, as amended, section 522, provides that alcohol abusers and alcoholics who are
suffering from medical conditions shall not be discriminated against in
admission or treatment, solely because of their alcohol abuse or alcoholism, by
any private or public general hospital that receives support in

 

10

 

any form from any federally
funded program. This prohibition is extended to all outpatient facilities
receiving or benefitting from federal financial assistance by 45 CFR Part 84.

 

2. Confidentiality: The Public Health Service Act, as amended,
sections 301(d) and 543, require that certain records be kept confidential
except under certain specified circumstances and for specified purposes.
Confidential records include records of the identity, diagnosis, prognosis, or
treatment of any patient that are maintained in connection with the performance
of any activity or program relating to drug abuse prevention, i.e., drug abuse education,
training, treatment, or research, or alcoholism or alcohol abuse education,
training, treatment, rehabilitation, or research that is directly or indirectly
assisted by the federal government. Public Health Service regulations 42 CFR
Parts 2 and 2a implement these requirements.

 

3. Lobbying Restrictions: Lobbying restrictions as required by 31
U.S.C. § 1352, requires the Contractor to abide by this section and to place it’s
language in all of it’s contracts: 

 

a. No federal funds have been
paid or will be paid, by or on behalf of the Contractor, to any person for influencing
or attempting to influence an officer or employee of any federal agency, a
member of Congress, an officer or employee of Congress, or an employee of a
member of Congress in connection with the awarding of any federal contract, the
making of any federal grant, the making of any federal loan, the entering into
of any cooperative agreement, or the extension, continuation, renewal,
amendment, or modification of any federal contract, grant, loan, or cooperative
agreement.

 

b. If any funds other than
federal appropriated funds have been paid or will be paid to any person for influencing
or attempting to influence an officer or employee of any federal agency, a
member of Congress, an officer or employee of Congress, or an employee of a
member of Congress in connection with the federal contract, grant, loan, or
cooperative agreement, the Contractor shall complete and submit Federal
Standard Form LLL, “Disclosure Form to report Lobbying,” in accordance with its
instructions.

 

c. The Contractor shall
require that the language of this article be included in the award documents
for all subcontracts and that subcontractors shall certify and disclose
accordingly.

 

4. Debarment, suspension or other ineligibility: The Contractor
certifies that neither it nor its principals is presently debarred, suspended,
proposed for debarment, declared ineligible, or excluded from participation in
this Contract by any governmental department or agency. The Contractor must
notify the Department within 30 days in accordance with the notification
requirements specified in Article III, section 11 of this Contract if the Contractor
has been debarred by any governmental entity within the contract period.
Debarment regulations are stated in Health and Human Services regulation 45 CFR
Part 76.

 

5. Environmental Impact: The National Environmental Policy Act of
1969 (NEPA) (Public Law 91-190) establishes national policy goals and
procedures to protect and enhance the environment. NEPA applies to all federal
agencies and requires them to consider the probable environmental consequences
of any major federal activity, including activities of other organizations
operating with the concurrence or support of a federal agency.  This includes grant-supported activities under
this Contract if federal funds are involved. Additional environmental
requirements include:

 

a. the institution of
environmental quality control measures under the National Environmental Policy
Act of 1969 (P.L. 91-190) and Executive Order 11514;

 

b. the notification of
violating facilities pursuant to Executive Order 11738 (all contracts,
subcontracts, and subgrants in excess of $100,000);

 

c. the protection of wetlands
pursuant to Executive Order 11990;

 

d. the evaluation of flood
hazards in floodplains in accordance with Executive Order 11988;

 

e. the assurance of project
consistency with the approved State management program developed under the Coastal
Zone Management Act of 1972 (16 U.S.C. §§ 1451 et seq.);

 

f. the conformity of Federal
actions to State (Clear Air) Implementation Plans under Section 176 (c) of the Clear
Air Act of 1955, as amended (42 U.S.C. §§ 7401 et seq.);

 

g. the protection of
underground sources of drinking water under the Safe Drinking Water Act of
1974, as amended, (P.L. 93-523),

 

h. the protection of
endangered species under the Endangered Species Act of 1973, as amended, (P.L.
93- 205) and;

 

i. the protection of the
national wild and scenic rivers system under the Wild and Scenic Rivers Act of
1968 (16 U.S.C. §§ 1271 et seq.).

 

11

 

6. Human Subjects: The Public Health Service Act, section 474(a),
implemented by 45 CFR Part 46, requires basic protection for human subjects
involved in Public Health Service grant supported research activities. Human subject
is defined in the regulation as “a living individual about whom an investigator
(whether professional or student) conducting research obtains data through
intervention or interaction with the individual or identifiable private
information.” The regulation extends to the use of human organs, tissues, and
body fluids from individually identifiable human subjects as well as to
graphic, written, or recorded information derived from individually
identifiable human subjects. The regulation also specifies additional
protection for certain classes of human research involving fetuses, pregnant
women, human in vitro fertilization, and prisoners. However, the regulation
exempts certain categories of research involving human subjects which normally
involve little or no risk. The exemptions are listed in 45 CFR Part 46.101(b).
The protection of human subjects involved in research, development, and related
activities is found in P.L. 93-348.

 

7. Sterilization: Health and Human Services and Public Health
Service have established certain limitations on the performance of nonemergency
sterilizations by Public Health Service grant-supported programs or projects that
are otherwise authorized to perform such sterilizations. Public Health Service
has issued regulations that establish safeguards to ensure that such
sterilizations are performed on the basis of informed consent and that the solicitation
of consent is not based on the withholding of benefits. These regulations,
published at 42 CFR Part 50, Subpart B, apply to the performance of
nonemergency sterilizations on persons legally capable of consenting to the
sterilization. Federal financial participation is not available for any
sterilization procedure performed on an individual who is under the age of 21,
legally incapable of consenting to the sterilization, declared mentally incompetent,
or is institutionalized.

 

8. Abortions and Related Medical Services: Federal financial
participation is generally not available for the performance of an abortion in
a grant-supported health services project. For further information on this
subject, consult the regulation at 42 CFR Part 50, Subpart C. 

 

9. Recombinant DNA and Institutional Biosafety Committees: Each
institution where research involving recombinant DNA technology is being or
will be conducted must establish a standing Biosafety Committee. Requirements
for the composition of such a committee are given in Section IV of Guidelines for Research Involving Recombinant DNA
Molecules, (49 FR 46266 or latest revision), which also discusses
the roles and responsibilities of principal investigators and contractor
institutions. Guidelines for Research
Involving Recombinant DNA Molecules and Administrative Practices Supplement should
be consulted for complete requirements for the conduct of projects involving
recombinant DNA technology.

 

10. Animal Welfare: The Public Health Service Policy on Humane Care and Use
of Laboratory Animals By Awardee Institutions requires that
applicant organizations establish and maintain appropriate policies and procedures
to ensure the humane care and use of live vertebrate animals involved in
research activities supported by Public Health Service. This policy implements
and supplements the U.S. Government
Principles for the Utilization and Care of Vertebrate Animals Used in Testing,
Research, and Training and requires that institutions use the Guide for the Care and Use of Laboratory Animals as
a basis for developing and implementing an institutional animal care and use
program. This policy does not affect applicable State or local laws or
regulations which impose more stringent standards for the care and use of
laboratory animals. All institutions are required to comply, as applicable,
with the Animal Welfare Act as amended (7 U.S.C. 2131 et seq.) and other
federal statutes and regulations relating to animals. These documents are
available from the Office for Protection from Research Risks (OPRR), National
Institutes of Health, Bethesda, MD 20892, (301) 496-7005. 

 

11. Contract Provisions: The Contractor must
include the following provisions in its contracts, as limited by the statements
enclosed within the parentheses following each provision: 

 

a. administrative,
contractual, or legal remedies in instances where contractors violate or breach
contract terms, and provides for such sanctions and penalties as may be
appropriate. (Contracts other than small purchases. Small purchase involve
relatively simple and informal procurement methods that do not cost more than
$100,000 in aggregate.)

 

b. termination for cause and
for convenience by the contractor or subgrantee including the manner by which
it will be effected and the basis for settlement. (All contracts in excess of
$10,000) 

 

c. compliance with Executive
Order 11246 of September 24, 1965 entitled “Equal Employment Opportunity,” as
amended by Executive Order 11375 of October 13, 1967 and as supplemented in Department
of Labor regulations (41 CFR Chapter 60). (All construction contracts awarded
in excess of

 

12

 

$10,000 by the Contractor and
its contractors or subgrantees)

 

d. compliance with the
Copeland “Anti-Kickback” Act (18 U.S.C. 874) as supplemented in Department of Labor
regulations (29 CFR Part 3). (All contracts and subgrants for construction or
repair)

 

e. compliance with the
Davis-Bacon Act (40 U.S.C. 276a to a-7) as supplemented by Department of Labor regulations
(29 CFR Part 5). (Construction contracts in excess of $2,000 awarded when
required by Federal grant program legislation)

 

f. compliance with the
Contract Work Hours and Safety Standards Act, sections 103 and 107, (40 U.S.C. 327-330)
as supplemented by Department of Labor regulations (29 CFR Part 5).
(Construction contracts awarded in excess of $2,000, and in excess of $2,500
for other contracts which involve the employment of mechanics or laborers)

 

g. notice of the federal
awarding agency requirements and regulations pertaining to reporting. 

 

h. notice of federal awarding
agency requirements and regulations pertaining to patent rights with respect to
any discovery or invention which arises or is developed in the course of or
under such contract.

 

i. federal awarding agency
requirements and regulations pertaining to copyrights and rights in data.

 

j. access by the Department,
the Contractor, the Federal funding agency, the Comptroller General of the United
States, or any of their duly authorized representatives to any books,
documents, papers, and records of the Contractor which are directly pertinent
to that specific contract for the purpose of making audit, examination,
excerpts, and transcriptions.

 

k. compliance with all
applicable standards, orders, or requirements of the Clear Air Act, section
306, (42 U.S.C. 1857(h)), the Clean Water Act, section 508, (33 U.S.C. 1368),
Executive Order 11738, and Environmental Protection Agency regulations (40 CFR
Part 15). (Contracts, subcontracts, and subgrants of amounts in excess of
$100,000)

 

l. mandatory standards and
policies relating to energy efficiency which are contained in the state energy conservation
plan issued in compliance with the Energy Policy and Conservation Act (Pub. L.
94-163).

 

12. (Governmental entities only) Merit System Standards: The
Intergovernmental Personnel Act of 1970 (42 U.S.C. §§ 4728-4763), requires
adherence to prescribed standards for merit systems funded with federal funds.

 

13. Misconduct in Science: The United States
Public Health Service requires certain levels of ethical standards for all PHS
grant-supported projects and requires recipient institutions to inquire into,
investigate and resolve all instances of alleged or apparent misconduct in
science. Issues involving potential criminal violations must be promptly
reported to the HHS Office of Inspector General. (See regulations in 42 CFR
Part 50, Subpart A) 

 

END OF GENERAL PROVISIONS

 

13

 

ATTACHMENT B

SPECIAL PROVISIONS

 

TABLE OF CONTENTS

 

	
   

  	
   

  	
  Page

  
	
   

  	
   

  	
   

  
	
  Article I

  	
  Definitions

  	
  1

  
	
   

  	
   

  	
   

  
	
  Article II

  	
  Service Area

  	
  5

  
	
   

  	
   

  	
   

  
	
  Article III

  	
  Marketing,
  Enrollment, Orientation, Education, and Disenrollment

  	
  5

  
	
   

  	
   

  	
   

  
	
  A.

  	
  Marketing Activities

  	
  5

  
	
  B.

  	
  Enrollment Process

  	
  6

  
	
  C.

  	
  Member Orientation

  	
  9

  
	
  D.

  	
  Member Education

  	
  11

  
	
  E.

  	
  Disenrollment by Enrollee

  	
  15

  
	
  F.

  	
  Disenrollment by CONTRACTOR

  	
  17

  
	
  G.

  	
  Enrollee Transition Between Health Plans

  	
  19

  
	
  H.

  	
  Enrollee Transition from FFS to Health Plan or from Health Plan to
  FFS

  	
  19

  
	
   

  	
   

  	
   

  
	
  Article IV

  	
  Benefits

  	
  20

  
	
   

  	
   

  	
   

  
	
  A.

  	
  In General

  	
  20

  
	
  B.

  	
  Scope of Services

  	
  20

  
	
  C.

  	
  Clarification of Covered Services

  	
  21

  
	
   

  	
  1.

  	
  Emergency Services

  	
  21

  
	
   

  	
  2.

  	
  Care Provided in Skilled Nursery Facilities

  	
  24

  
	
   

  	
  3.

  	
  Hospice

  	
  25

  
	
   

  	
  4.

  	
  Inpatient Hospital Services for Scheduled Admissions

  	
  26

  
	
   

  	
  5.

  	
  Children in
  Custody of the Department of Human Services

  	
  26

  
	
   

  	
  6.

  	
  Organ Transplantations

  	
  28

  
	
   

  	
  7.

  	
  Mental
  Health Services

  	
  29

  
	
   

  	
  8.

  	
  Developmental
  and Organic Disorders

  	
  29

  
	
   

  	
  9.

  	
  Out-of-State Accessory Services

  	
  30

  
	
   

  	
  10.

  	
  Non-Contractor Prior Authorizations

  	
  30

  
	
  D.

  	
  Additional Services for Enrollees with Special Health Care Needs

  	
  31

  
	
   

  	
  1.

  	
  In General

  	
  31

  
	
   

  	
  2.

  	
  Identification

  	
  31

  
	
   

  	
  3.

  	
  Choosing a Primary Care Provider

  	
  31

  
	
   

  	
  4.

  	
  Referrals and Access to Specialty Providers

  	
  32

  
	
   

  	
  5.

  	
  Survey of Enrollees with Special Health Care Needs

  	
  32

  
	
   

  	
  6.

  	
  Collaboration with Other Programs

  	
  33

  
	
   

  	
  7.

  	
  Case Management and Coordination of Care Program

  	
  33

  
	
   

  	
  8.

  	
  Specific Requirements for Children with Special Health Care Needs

  	
  34

  

 

i

 

	
  Article V

  	
  Delivery
  Network

  	
  35

  
	
   

  	
   

  	
   

  
	
  A.

  	
  Availability of Services

  	
  35

  
	
  B.

  	
  Subcontracts and Assurances

  	
  36

  
	
  C.

  	
  Contractor’s Selection of Providers

  	
  39

  
	
   

  	
   

  	
   

  
	
  Article VI

  	
  Authorization
  of Services and Notices of Action

  	
  41

  
	
   

  	
   

  	
   

  
	
  A.

  	
  Service of Authorization and Notice of Action

  	
  41

  
	
  B.

  	
  Other Actions Requiring Notice of Action

  	
  46

  
	
  C.

  	
  Content of Notice of Action

  	
  47

  
	
  D.

  	
  Attachment to Notice of Actions - Written Appeal Request Form

  	
  49

  
	
  E.

  	
  Compensation for Utilization Management Activities

  	
  50

  
	
  F.

  	
  Medical Necessity Denials

  	
  50

  
	
   

  	
   

  	
   

  
	
  Article VII

  	
  Grievance
  Systems

  	
  50

  
	
   

  	
   

  	
   

  
	
  A.

  	
  Overall Grievance System

  	
  50

  
	
  B.

  	
  Special Requirements for Appeals

  	
  50

  
	
  C.

  	
  Standard Appeals Process

  	
  51

  
	
  D.

  	
  Process for Expedited Resolution of Appeals

  	
  54

  
	
  E.

  	
  Continuation of Benefits During Appeal or State Fair Hearing
  Processes

  	
  57

  
	
  F.

  	
  Duration of Continued or Reinstated Benefits

  	
  57

  
	
  G.

  	
  Reversed Appeal Resolutions

  	
  57

  
	
  H.

  	
  State Fair Hearings

  	
  58

  
	
  I.

  	
  Grievances

  	
  59

  
	
  J.

  	
  Documentation

  	
  61

  
	
   

  	
   

  	
   

  
	
  Article VIII

  	
  Enrollee
  Rights and Protections

  	
  62

  
	
   

  	
   

  	
   

  
	
  A.

  	
  Written Information on Enrollee Rights and Protections-General
  Requirements

  	
  62

  
	
  B.

  	
  Specific Enrollee Rights and Protections

  	
  62

  
	
  C.

  	
  Provider - Enrollee Communications

  	
  63

  
	
   

  	
   

  	
   

  
	
  Article IX

  	
  Contractor
  Assurances

  	
  64

  
	
   

  	
   

  	
   

  
	
  A.

  	
  Nondiscrimination

  	
  64

  
	
  B.

  	
  Member Services Function

  	
  64

  
	
  C.

  	
  Provider Services Function

  	
  65

  
	
  D.

  	
  Enrollee Liability

  	
  65

  
	
  E.

  	
  Access

  	
  65

  
	
  F.

  	
  Coordination and Continuity of Care

  	
  68

  
	
  G.

  	
  Billing Enrollees

  	
  71

  
				

 

ii

 

	
  H.

  	
  Survey Requirements

  	
  72

  

 

iii

 

	
  Article X

  	
  Measurement
  and Improvement Standards

  	
  73

  
	
   

  	
   

  	
   

  
	
  A.

  	
  Practice Guidelines

  	
  73

  
	
  B.

  	
  Quality Assessment and Performance Improvement Program

  	
  73

  
	
   

  	
   

  	
   

  
	
  Article XI

  	
  Other
  Requirements

  	
  75

  
	
   

  	
   

  	
   

  
	
  A.

  	
  Compliance with Public Health Service Act

  	
  75

  
	
  B.

  	
  Advance Directives

  	
  75

  
	
  C.

  	
  Fraud and Abuse Requirements

  	
  75

  
	
  D.

  	
  Disclosure of Ownership and Control Information

  	
  76

  
	
  E.

  	
  Safeguarding Confidential Information on Enrollees

  	
  76

  
	
  F.

  	
  Disclosure of Provider Incentive Plans

  	
  77

  
	
   

  	
   

  	
   

  
	
  Article XII

  	
  Payments

  	
  78

  
	
   

  	
   

  	
   

  
	
  A.

  	
  Non-Risk Contract

  	
  78

  
	
  B.

  	
  Payment Methodology

  	
  78

  
	
  C.

  	
  Contract Maximum

  	
  78

  
	
  D.

  	
  Medicare

  	
  78

  
	
  E.

  	
  Third Party Liability (Coordination of Benefits)

  	
  80

  
	
  F.

  	
  Third Party Responsibility (Including Worker’s Compensation)

  	
  82

  
	
  G.

  	
  Changes in Covered Services

  	
  83

  
	
  H.

  	
  Clarification of Payment Responsibilities

  	
  83

  
	
   

  	
   

  	
   

  
	
  Article XIII

  	
  Records and
  Reporting Requirements

  	
  87

  
	
   

  	
   

  	
   

  
	
  A.

  	
  Health Information Systems

  	
  87

  
	
  B.

  	
  Federally Required Reports

  	
  88

  
	
  C.

  	
  Periodic Reports

  	
  89

  
	
  D.

  	
  Data Certification

  	
  94

  
	
   

  	
   

  	
   

  
	
  Article XIV

  	
  Compliance/Monitoring

  	
  95

  
	
   

  	
   

  	
   

  
	
  A.

  	
  Audits

  	
  95

  
	
  B.

  	
  Quality Monitoring by the DEPARTMENT

  	
  95

  
	
  C.

  	
  External Quality Review

  	
  96

  
	
  D.

  	
  Corrective Action

  	
  98

  
	
   

  	
   

  	
   

  
	
  Article XV

  	
  Termination
  of the Contract

  	
  101

  
	
   

  	
   

  	
   

  
	
  A.

  	
  Automatic Termination

  	
  101

  
	
  B.

  	
  90-Day Termination Option

  	
  101

  

 

iv

 

	
  C.

  	
  Effect of
  Termination

  	
  101

  
	
  D.

  	
  Assignment

  	
  103

  
	
   

  	
   

  	
   

  
	
  Article XVI

  	
  Miscellaneous

  	
  103

  
	
   

  	
   

  	
   

  
	
  A.

  	
  Integration

  	
  103

  
	
  B.

  	
  Enrollees May Not Enforce Contract

  	
  103

  
	
  C.

  	
  Interpretation of Laws and Regulations

  	
  103

  
	
  D.

  	
  Adoption of Rules

  	
  103

  

 

v

 

Attachment B

Molina Healthcare of Utah

Effective January 1, 2006

 

For the purpose of the
Contract all article, section, and subsection headings in these Attachments B
and C are for convenience in referencing the provisions of the Contract. They
are not enforceable as part of the text of the Contract and may not be used to
interpret the meaning of the provisions that lie beneath them.

 

Special Provisions

 

Article I - Definitions

 

For the purpose of the
Contract:

 

A.                                   “Action” means:

(1)                                  the denial or limited authorization of a
requested 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 a service and the denial could result in the Enrollee liable for payment;

(4)                                  the failure to provide services in a timely
manner, as defined as failure to meet performance standards for appointment
waiting times (see Article IX - Contractor Assurances, Section E - Access,
Subsection 4.e. - Waiting Time Benchmarks); or

(5)                                  the failure of the CONTRACTOR to act within
the time frames established for resolution and notification of grievances and
appeals.

 

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

 

C.                                     “Appeal” means a request for review of an
Action.

 

D.                                    “Balance Bill” means the practice of billing
patients for charges that exceed the amount that the CONTRACTOR will pay.

 

E.                                      “CHEC Eligible” means any Medicaid recipient
under the age of 21 who is eligible to receive Early and Periodic Screening,
Diagnostic, and Treatment (EPSDT) services in accordance with 42 CFR Part 441,
Subpart B.

 

F.                                      “CHEC Program” or Child Health Evaluation and
Care program is Utah’s version of the federally mandated Early Periodic
Screening, Diagnosis and Treatment (EPSDT) program as defined in 42 CFR Part
441, Subpart B. Medicaid recipients who are eligible for the Non-Traditional
Medicaid Plan are not eligible to receive EPSDT services. (See Attachment C,
Covered Services, U.)

 

G.                                     “Child with Special Health Care Needs” means
a child under 21 years of age who has or is at increased risk for chronic
physical, developmental, behavioral, or emotional conditions and requires
health and related services of a type or amount beyond that required by
children generally, including a child who, consistent with 1932(a)(2)(A) of the
Social Security Act, 42 U.S.C., Section 1396u-2(a)(2)(A):

 

1

 

(1)                                  is blind or disabled or in a related
population (eligible for SSI under title XVI of the Social Security Act);

(2)                                  is in foster care or other out-of-home
placement;

(3)                                  is receiving foster care or adoption
assistance; or

(4)                                  is receiving services through a
family-centered, community-based coordinated care system that receives grant
funds described in section 501(a)(1)(D) of title V.

 

H.                                   “CMS” means the Centers for Medicare and Medicaid
Services, the federal Medicaid agency, within the Department of Health and
Human Services.

 

I.                                         “Covered Services” means services identified in Attachment C of
this Contract which the CONTRACTOR has agreed to provide and pay for under the
terms of this Contract.

 

J.                                      “Division of Health Care
Financing” or “DHCF” means the division within the
Department of Health responsible for the administration of the Utah Medicaid
program.

 

K.                                    “Emergency Medical Condition” means a medical condition manifesting itself
by acute symptoms of 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 attention to result
in:

(1)                                  Placing the health of the individual (or,
with respect to a pregnant woman, the health of a woman or her unborn child) in
serious jeopardy;

(2)                                  Serious impairment to bodily functions; or

(3)                                                                                                                                                                                                                                                                                                                                  Serious dysfunction of any bodily organ or
part.

 

L.                                     “Emergency Services” means covered inpatient and outpatient
services that are furnished by a provider that is qualified to furnish these
services and that are needed to evaluate or stabilize an emergency
medical condition.

 

M.                                  “Enrollee” means any Medicaid recipient who is currently
enrolled with this Health Plan and:

(1)                                  who, at the time of enrollment resides within
the geographical limits of the CONTRACTOR’s Service Area;

(2)                                  whose name appears on the DEPARTMENT’s
Eligibility Transmission as a new, reinstated, or retroactive Enrollee; and

(3)                                  who is accepted for enrollment by the
CONTRACTOR according to the conditions set forth in this Contract excluding
residents of the Utah State Hospital, Utah State Developmental Center, and
long-term care facilities except as defined in Attachment C.

 

N.                                    “Enrollees with
Special Health Care Needs”
means enrollees who have or are at increased risk for chronic physical,
developmental, behavioral, or emotional conditions and who also require health
and related services of a type or amount beyond that required by adults and
children generally.

 

O.                                    “Enrollment Area” or “Service
Area” means the counties enumerated in Article II.

 

P.                                     “External Quality Review” means the analysis and evaluation by an EQRO,
of 

 

2

 

aggregated information on
quality, timeliness, and access to the health care services that a Health Plan,
or its contractors, furnish to Medicaid recipients.

 

Q.                                   “External Quality Review
Organization (EQRO)” means
an entity under contract with the DEPARTMENT to conduct an external quality
review of the CONTRACTOR in accordance with Federal regulations governing
external quality reviews.

 

R.                                     “Family Member” means all Medicaid eligibles
who are members of the same family living at home.

 

S.                                      “Grievance” means an expression of
dissatisfaction about any matter other than an action (as defined in this
section). Possible subjects for grievances include, but are not limited to, the
quality of care or services provided, aspects of interpersonal relationships
such as rudeness of a provider or employee, or failure to respect the Enrollee’s
rights.

 

T.                                     “Grievance Process” means the CONTRACTOR’s
process for handling grievances that complies with the requirements including,
but not limited to, the procedural steps for an Enrollee to file a grievance,
the process for disposition of a grievance, and the timing and manner of
required notifications.

 

U.                                    “Grievance System” means an overall system
that includes a grievance process, an appeal process, and access to the State’s
fair hearing system.

 

V.                                     “Health Plan” means a federally defined
Prepaid Inpatient Health Plan, a federally defined Primary Care Case Management
system, or a federally defined Managed Care Organization under contract with
the DEPARTMENT to provide specified physical health care services to a specific
group of Medicaid clients.

 

W.                                 “Home and
Community-Based Services”
means services, not otherwise furnished under the State’s Medicaid plan, that
are furnished under a waiver of statutory requirements granted under the
provisions of CFR Part 441, subpart G. These services cover an array of Home
and Community-Based Services that are cost-effective and necessary for an
individual to avoid institutionalization.

 

X.                                    “Medically
Necessary” means any medical
service that is (1) reasonably calculated to prevent, diagnose, or cure
conditions in the Enrollee that endanger life, cause suffering or pain, cause
deformity or malfunction, or threaten to cause a handicap; and (2) there is no
equally effective course of treatment available or suitable for the Enrollee
requesting the service which is more conservative or substantially less costly.
Medical services will be of a quality that meets professionally recognized
standards of health care, and will be substantiated by records including
evidence of such medical necessity and quality. Those records will be made
available to the DEPARTMENT upon request. For CHEC Enrollees, “Medically
Necessary” means preventive screening services and other medical care,
diagnostic services, treatment, and other measures necessary to correct or
ameliorate defects and physical and mental illnesses and conditions, even if
the services are not included in the Utah State Medicaid Plan.

 

Y.                                     “Member Services” means a method of assisting
Enrollees in understanding CONTRACTOR policies and procedures, facilitating
referrals to participating specialists, and assisting in the resolution of
problems and member complaints. The purpose of Member Services is to 

3

 

improve
access to services and promote Enrollee satisfaction.

 

Z.                                     “Non-risk
Contract” means a
contract under which the CONTRACTOR is not at financial risk for changes in
utilization or for costs incurred under the Contract that do not exceed the
DEPARTMENT’s Payment Limit. The Payment Limit is the total amount Medicaid
would have paid, in aggregate, for the same services on a fee-for-service basis
net of third party payments.

 

AA.                           “Non-Traditional
Medicaid Plan” means the
reduced benefit plan provided to Medicaid eligibles age 19 through 64 who are
in certain TANF, Medically Needy, and Transitional Medicaid aid categories. Services
covered under the reduced benefit plan are similar to the Traditional Medicaid
Plan with some limitations and exclusions.

 

BB.                           “Notice of
Action” means written
notification to an Enrollee and written or verbal notification of a provider
when applicable, of an Action that will be taken by the CONTRACTOR.

 

CC.                           “Notice of
Appeal Resolution” means
written notification of an Enrollee, and a provider when applicable, of the
CONTRACTOR’s resolution of an Appeal.

 

DD.                           “Physician
Incentive Plan” means
any compensation between a contracting organization and a physician group that
may directly or indirectly have the effect of reducing or limiting services
provided with respect to Enrollees in the organization.

 

EE.                           “Post-stabilization
Services” means Covered
Services related to an Emergency Medical Condition that are provided after an
Enrollee is stabilized in order to maintain the stabilized condition, or to
improve or resolve the Enrollee’s condition.

 

FF.                           “Potential
Enrollee” means a
Medicaid recipient who is subject to mandatory enrollment or may voluntarily
elect to enroll in a given managed care program, but is not yet an enrollee of
a specific Health Plan.

 

GG.                           “Prepaid
Inpatient Health Plan”
means an entity that provides medical services to Enrollees under contract with
the DEPARTMENT, and on the basis of prepaid capitation payments, or other
payment arrangements that do not use State plan payment rates; provides,
arranges for, or otherwise has responsibility for the provision of inpatient
hospital or institutional services for its Enrollees; and does not have a
comprehensive risk contract.

 

HH.                           “Prepaid Mental Health Plan” means the mental health centers that
contract with the DEPARTMENT to provide inpatient and outpatient mental health
services to Medicaid clients living within each mental health center’s
jurisdiction.

 

II.                                     “Primary Care” means all health care services and
laboratory services customarily furnished by or through a general practitioner,
family physician, internal medicine physician, obstetrician/gynecologist, or
pediatrician, to the extent the furnishing of those services is legally
authorized in the State in which the practitioner furnishes them.

 

JJ.                               “Primary Care Case
Management” or “PCCM” means a system under which a PCCM
contracts with the DEPARTMENT to furnish case management services (which
include the location, coordination and monitoring of primary health care
services) to Medicaid

 

4

 

recipients.

 

KK.                           “Primary Care Provider” or “PCP”
means a health care provider the majority of whose practice is devoted to
internal medicine, family/general practice or pediatrics. The CONTRACTOR may
allow other specialists to be PCPs, when appropriate. PCPs are responsible for
delivering primary care services, coordinating and managing Enrollees’ overall
health, and authorizing referrals for other necessary care.

 

LL.                             “Restriction Program” means the Federally mandated program (42 CFR
431.54(e)) for Medicaid clients who over-utilize Medicaid services. If the
DEPARTMENT in conjunction with the CONTRACTOR finds that an Enrollee has
utilized Medicaid services at a frequency or amount that is not Medically
Necessary, as determined in accordance with utilization guidelines adopted by
the DEPARTMENT, the DEPARTMENT may place the Enrollee under the Restriction
Program for a reasonable period of time to obtain Medicaid services from
designated providers only.

 

MM.                       “State Plan” means the State Plan for organization and
operation of the Medicaid program as defined pursuant to Section 1902 of the
Social Security Act (42 U.S.C. 1396a).

 

NN.                           “Subcontract” means any written agreement between the
CONTRACTOR and another party to fulfill the requirements of this Contract. However,
such term does not include insurance purchased by the CONTRACTOR to limit its
loss with respect to an individual Enrollee.

 

OO.                         “Traditional Medicaid Plan” means the scope of services contained in the
State Plan provided to Medicaid eligibles who fall under one of the following
eligibility groups:

(1)                                  Section 1931 children and related poverty
level populations (TANF/AFDC);

(2)                                  Section 1931 pregnant women (TANF/AFDC);

(3)                                  Blind/disabled children and related
populations (SSI);

(4)                                  Blind/disabled adults and related populations
(SSI);

(5)                                  Aged and related populations (SSI, QMB and
Medicaid, Medicare and Medicaid);

(6)                                  Foster care children;

(7)                                  Individuals who qualify for Medicaid by
paying a spenddown and are under age 19 or are also aged or disabled;

(8)                                  Pregnant women (non-TANF/AFDC)

 

Article II - Service Area

 

The Service Area is limited
to the counties of Beaver, Box Elder, Cache, Davis, Garfield, Iron, Juan, Kane,
Millard, Morgan, Piute, Rich, Salt Lake, Sanpete, Sevier, Summit, Tooele, Utah,
Washington, Wayne, and Weber.

 

Article III - Marketing, Enrollment, Orientation, and
Disenrollment

 

A.                                   Marketing Activities

 

1.                                       The DEPARTMENT does not permit the CONTRACTOR
to conduct direct or indirect marketing as defined in this section. In this
Article III, Section A - Marketing 

 

5

 

Activities,
“CONTRACTOR” includes any of the CONTRACTOR’s employees, affiliated providers,
agents, or contractors.

 

2.                                       “Marketing” means any communication, from the
CONTRACTOR to a Potential Enrollee, that can reasonably be interpreted as
intended to influence the Potential Enrollee to enroll in the CONTRACTOR’s
Medicaid product, or either to not enroll in, or to disenroll from, another
Health Plan’s Medicaid product.

 

3.                                       “Marketing materials” means materials that
are produced in any medium, by or on behalf of the CONTRACTOR and can
reasonably be interpreted as intended to market to Potential Enrollees. The
CONTRACTOR cannot, either directly or indirectly, conduct door-to-door,
telephonic or other “cold call” marketing activities.

 

a.                                       These three marketing practices are
prohibited whether conducted by the CONTRACTOR itself (“directly”) or by an
agent or independent contractor (“indirectly”).

 

b.                                      Cold call marketing means any unsolicited
personal contact with a potential Enrollee for the purpose of marketing.

 

c.                                       All other non-requested marketing approaches
to Medicaid clients by the CONTRACTOR are also prohibited unless specifically
approved in advance by the DEPARTMENT.

 

4.                                       The CONTRACTOR may not influence enrollment
in conjunction with the sale or offering of any private insurance.

 

5.                                       The CONTRACTOR will not distribute any
materials that include statements that will be considered inaccurate, false, or
misleading including, but not limited to, any assertion or statement (whether
written or oral) that the Potential Enrollee must enroll in Healthy U in order
to obtain benefits or in order to not lose benefits; or that Healthy U is
endorsed by CMS, the Federal or State government, or similar entity.

 

B.                                    Enrollment Process

 

1.                                      Enrollee Choice

 

a.                                       The DEPARTMENT will offer Potential Enrollees
a choice among all Health Plans available in the Enrollment Area.

 

b.                                      The DEPARTMENT will inform Potential
Enrollees of Medicaid benefits.

 

c.                                       The Medicaid client’s intent to enroll is
established when the applicant selects the CONTRACTOR, either verbally or by
signing a choice of health care delivery form or equivalent. This initiates the
action to send an advance notification to the CONTRACTOR.

 

d.                                      Medicaid Enrollees made eligible for a
retroactive period prior to the current month are not eligible for CONTRACTOR
enrollment during the retroactive period.

 

6

 

2.                                      Period of
Enrollment

 

a.                                       Each Enrollee will be enrolled for the period
of the Contract or the period of Medicaid eligibility or until such person
disenrolls or is disenrolled, whichever is earlier.

 

b.                                      Until the DEPARTMENT notifies the CONTRACTOR
that an Enrollee is no longer Medicaid eligible, the CONTRACTOR may assume that
the Enrollee continues to be eligible.

 

c.                                       Each Enrollee will be automatically re-enrolled
at the end of each month unless that Enrollee notifies the DEPARTMENT’s Health
Program Representative of an intent not to re-enroll in the Health Plan
prior to the benefit issuance date.

 

3.                                      Open Enrollment

 

The CONTRACTOR will have a
continuous open enrollment period that meets the requirements of Section
1301(d) of the Public Health Service Act. The DEPARTMENT will certify, and the
CONTRACTOR agrees to accept individuals who are eligible to be enrolled in the
Health Plan under the provisions of this Contract:

 

a.                                       in the order in which they apply; and

 

b.                                      without restrictions unless authorized by the
DEPARTMENT.

 

4.                                      No Health
Screening

 

The DEPARTMENT and the
CONTRACTOR agree that no Potential Enrollee will be pre-screened or
selected by either party for enrollment on the basis of pre-existing
health problems or on the basis of race, color, national origin, disability or
age.

 

5.                                      Independent
Enrollment

 

Each Medicaid eligible can
be enrolled with or disenrolled from the Health Plan, independent of any other
Family Member’s enrollment or disenrollment.

 

6.                                      Representative
Population

 

The CONTRACTOR will service
a population representative of the categories of eligibility within the area it
serves.

 

7.                                      Eligibility
Transmission

 

a.                                      In general

 

(1)                                  Before the close of business each day, the
DEPARTMENT will provide to the CONTRACTOR an Eligibility Transmission which is
an electronic file that includes individuals which the DEPARTMENT certifies as
Medicaid eligible and who enrolled in the Health Plan. Eligibility
transmissions include new Enrollees, 

 

7

 

reinstated
Enrollees, retroactive Enrollees, terminated Enrollees and Enrollees whose
eligibility information results in a change to a critical field.

 

(2)                                  The Eligibility Transmission will be in
accordance with the Utah Health Information Network (UHIN) standard.

 

(3)                                  The DEPARTMENT represents and warrants to the
CONTRACTOR that the appearance of an individual’s name on the Eligibility
Transmission, other than a deleted Enrollee, will be conclusive evidence for
purposes of this Contract, that such person is enrolled in the program and
qualifies for medical assistance under Medicaid Title XIX.

 

b.                                      New Enrollees

 

(1)                                  New Enrollees are enrolled in this Health
Plan until otherwise specified; these Enrollees will not appear on future
transmissions unless there is a change in a critical field.

 

(2)                                  Critical fields are coverage dates, recipient
name, date of birth, date of death, sex, social security number, case
information, address, telephone number, payment code, coordination of benefits,
and the Enrollee’s provider under the Restriction Program.

 

(3)                                  Enrollees with a spenddown requirement will
appear on the eligibility transmission on a month by month basis after the
spenddown is met.

 

c.                                       Retroactive
Enrollees

 

Retroactive Enrollees are
those who were Enrollees previous to the current month. Retroactive Enrollees
include newborn Enrollees or Enrollees who have been reported in one payment
category in a previous month, but have been

 

8

 

changed to a new payment
category for that previous month when they are made eligible for the current
month.

 

d.                                      Reinstated
Enrollees

 

Reinstated Enrollees are
those who were enrolled for the previous month and also closed at the end of
the previous month. These Enrollees are eligible retroactively to the beginning
of the current month.

 

e.                                       Terminated
Enrollees

 

Terminated Enrollees are
those who are no longer eligible for Medicaid, were disenrolled from the Health
Plan, or had their premium retracted.

 

8.                                      Change of
Enrollment Procedures

 

a.                                       The CONTRACTOR will be advised of anticipated
changes in DEPARTMENT policies and procedures as they relate to the enrollment
process and their comments will be solicited.

 

b.                                      The CONTRACTOR agrees to be bound by such
changes in DEPARTMENT policies and procedures that are mutually agreed upon by
the CONTRACTOR and the DEPARTMENT.

 

C.                                    Member
Orientation

 

 

1.                                      Initial Contact
- General Orientation

 

a.                                       The CONTRACTOR will make a good faith effort
to ensure that each Enrollee or Enrollee’s family or guardian receives the
CONTRACTOR’s member handbook.

 

b.                                      The CONTRACTOR’s representative will make a
good faith effort, as evidenced in written or electronic records, to make an
initial contact with the Enrollee within 10 working days after the CONTRACTOR
has been notified through the Eligibility Transmission of the Enrollee’s
enrollment with this Health Plan.

 

(1)                                  If the CONTRACTOR’s representative cannot
contact the Enrollee within 10 working days or at all, the CONTRACTOR’s
representative will document its efforts to contact the Enrollee.

 

(2)                                  The initial contact will be in person or by
telephone (or in writing, but only if reasonable attempts have been made to
make the contact in person by telephone) and will inform the Enrollee of the
CONTRACTOR’s rules and policies.

 

c.                                       The CONTRACTOR will ensure that Enrollees are
provided interpreters, Telecommunication Device for the Deaf (TDD), and other
auxiliary aids to ensure that Enrollees understand their rights and
responsibilities.

 

9

 

d.                                      During the initial contact the CONTRACTOR’s
Representative will provide, at a minimum, the following information to the
Enrollee or Potential Enrollee appropriate to the Enrollee’s eligibility
(Traditional versus Non-Traditional Medicaid):

 

(1)                                  specific written and oral instructions on the
use of the CONTRACTOR’s Covered Services and procedures;

 

(2)                                  availability and accessibility of all Covered
Services, including the availability of family planning services and that the
Enrollee may obtain family planning services from Medicaid providers other than
providers affiliated with the CONTRACTOR;

 

(3)                                  the client’s rights and responsibilities as
an Enrollee of this Health Plan, including the right to file a grievance and
how to file a grievance;

 

(4)                                  the right to terminate enrollment with the
Health Plan; and

 

(5)                                  encouragement to make a medical appointment
with a provider.

 

2.                                      Identification
of Enrollees with Special Health Care Needs

 

a.                                       During the initial contact with each
Enrollee, the CONTRACTOR’s representative will use a process that will identify
children and adults with special health care needs.

 

b.                                      The CONTRACTOR’s representative will clearly
describe to each Enrollee during the initial contact the process for requesting
specialist care.

 

c.                                       When an Enrollee is identified as having
special health care needs, the CONTRACTOR’s Representative will forward this
information to a CONTRACTOR’s  individual
with knowledge of coordination of care and services necessary for such
Enrollees. The CONTRACTOR’s individual with knowledge of coordination of care
for Enrollees with special health care needs will make a good faith effort to
contact Enrollees within ten working days after identification to begin
coordination of health care needs, if necessary.

 

d.                                      The CONTRACTOR will not discriminate on the
basis of health status or the need for health care services.

 

e.                                       The DEPARTMENT’s Health Program
Representatives are responsible to forward information, including risk
assessments, that identify Enrollees with special health care needs and limited
language proficiency needs to the CONTRACTOR in a timely manner, coinciding
with the daily Eligibility Transmission as much as possible.

 

10

 

3.                                      Enrollees
Receiving Out-of-Plan Care Prior to Orientation

 

If the Enrollee receives
Covered Services by an out-of-plan provider after the first day of the month in
which the client’s enrollment became effective, and if a CONTRACTOR  orientation, either in-person or by telephone
(or in writing, but only if reasonable attempts have been made to make the
contact in person or by telephone), has not taken place prior to receiving such
services, the CONTRACTOR is responsible for payment of the services rendered
provided the DEPARTMENT informs the CONTRACTOR by the 20th of any
month prior to the month that enrollment with the Health Plan begins.

 

D.                                    Member Education

 

1.                                       Enrollee Information Requirements

 

a.                                       In General

 

(1)                                  The CONTRACTOR will write all Enrollee and
Potential Enrollee informational, instructional, and educational materials,
including the CONTRACTOR’s member handbook, in a manner and format that may be
easily understood; e.g. at no greater than a sixth grade reading level.

 

(2)                                  Once per year, the CONTRACTOR will notify all
Enrollees of their right ro request and obtain the CONTRACTOR’s member
handbook.

 

b.                                      Prevalent
Language

 

(1)                                  The CONTRACTOR will use the Eligibility
Transmission to determine  prevalent
non-English languages. A language is prevalent when it is spoken by five percent
or more of the CONTRACTOR’s enrolled population.

 

(2)                                  The CONTRACTOR will make available all
written Enrollee informational and instructional materials, including the
member handbook, in the prevalent non-English languages. Written materials
include vital documents such as applications, consent forms, release of
information forms, letters containing important information, etc.

 

c.                                       Alternative formats

 

The CONTRACTOR will make
Enrollee informational and instructional materials, including the member
handbook, available in alternative formats that take into consideration the
special needs of those who, for example, are visually limited or have limited
reading proficiency (e.g., audio tapes).

 

2.                                      Member Handbook

 

a.                                       The CONTRACTOR will produce a member handbook
that will be submitted 

 

11

 

to the DEPARTMENT for review
and approval before distribution. The DEPARTMENT will notify the CONTRACTOR in
writing of its approval or disapproval within ten working days after receiving
the member handbook unless the DEPARTMENT and CONTRACTOR agree to another time
frame. If the DEPARTMENT does not respond within the agreed upon time frame,
the CONTRACTOR may deem such materials are approved.

 

b.                                      If there are changes to the content of the
material in the handbook, the CONTRACTOR will update the member handbook and
submit a draft to the DEPARTMENT for review and approval before distribution to
its Enrollees.

 

c.                                       At a minimum, the member handbook will
explain in clear terms the following information:

 

(1)                                  The amount, duration, and scope of benefits
provided by the CONTRACTOR delineating Traditional versus Non-Traditional
Medicaid scopes of service in sufficient detail to ensure that enrollees
understand the benefits to which they are entitled;

 

(2)                                  Instructions on where and how to obtain
Covered Services, including any service authorization requirements; how and
under what circumstances out-of-area services are covered; policy on referrals
to speciality care and for other benefits not furnished by the Enrollee’s
primary care provider; and procedures for resolving Enrollee issues related to
authorization of coverage or payment for services;

 

(3)                                  The extent to which, and how, after-hours and
emergency coverage are provided, including:

 

(a)                                  What constitutes an emergency medical
condition, emergency services, and post-stabilization services, with reference
to definitions in 42 CFR 438.114(a);

 

(b)                                 The fact that prior authorization is not
required for emergency services;

 

(c)                                  The process and procedures for obtaining
emergency services, including use of the 911-telephone system or its local
equivalent;

 

(d)                                 The location of any emergency settings and
other locations at which providers and hospitals furnish emergency services and
poststabilization services covered under the Contract; and

 

(e)                                  The fact that the Enrollee has the right to
use any hospital or other setting for emergency care.

 

(4)                                  The post-stabilization care services rules
set forth at 42 CFR 422.113(c);

 

12

 

(5)                                  The extent to which, and how, Enrollees may
obtain benefits, including family planning services, from out-of-plan network
providers;

 

(6)                                  The importance of establishing a primary care
relationship with an affiliated provider, and processes for selecting or
changing primary care providers;

 

(7)                                  Description of Enrollee cost-sharing
requirements (if applicable);

 

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

 

(9)                                  A statement that the CONTRACTOR does not
discriminate against any Enrollee on the basis of race, color, national origin,
disability, sex, religion, or age in admission, treatment, or participation in
its programs, services and activities;

 

(10)                            The phone number of the nondiscrimination
coordinator for Enrollees to call if they have questions about the
nondiscrimination policy or desire to file a complaint or grievance alleging
violations of the nondiscrimination policy;

 

(11)                            Information on the availability of oral
interpretation, including the fact that it is available for any language and
that written information is available in prevalent languages, and includes a
statement on how to access these services;

 

(12)                            Information on the availability of written
materials in alternative formats and in an appropriate manner that takes into
consideration the special needs of those who, for example, are visually limited
or have limited reading proficiency, and a statement on how to access these
formats;

 

(13)                            Names, locations, telephone numbers of, and
non-English languages spoken by, current contracted providers in the Enrollee’s
service area, including identification of providers that are not accepting new
patients. This includes, at a minimum, information on primary care physicians,
specialists, and hospitals;

 

(14)                            Any restrictions on the Enrollee’s freedom of
choice among network providers;

 

(15)                            Enrollee rights and protections, as specified
in Article VIII of this Contract;

 

(16)                            Information on Grievance, Appeal, and State
fair hearing procedures and timeframes as provided in 438.400 through 438.424,
in a DEPARTMENT-approved description that will include the following:

 

13

 

(a)                                  the right to file Grievances and Appeals;

 

(b)                                 the requirements and timeframes for filing a
Grievance or Appeal;

 

(c)                                  the availability of assistance in the filing
process;

 

(d)                                 the toll-free numbers that the Enrollee can
use to file a Grievance or an Appeal by phone;

 

(e)                                  the fact that, when requested by the
Enrollee, benefits will continue if the Enrollee files an Appeal or a request
for a State fair hearing within the timeframes specified for filing, and the
Enrollee may be required to pay the cost of services furnished while the Appeal
is pending, if the final decision is adverse to the Enrollee;

 

(17)                            Information to adult Enrollees on Advance
Directives policies, including a description of applicable State law as set
forth in 42 CFR 422.128;

 

(18)                            A statement that additional information is
available upon an Enrollee’s request regarding structure and operation of the
center, including information on:

 

(a)                                  the CONTRACTOR’s policy for selection of
providers (staff and subcontractors) and what is required of them,

 

(b)                                 the CONTRACTOR’s grievance system,

 

(c)                                  the CONTRACTOR’s confidentiality policy,

 

(d)                                 that information is available on request
regarding the CONTRACTOR’s Physician Incentive Plan (if the CONTRACTOR has an
incentive plan), and

 

(e)                                  that a copy of the CONTRACTOR’s preferred
practice guidelines is also available to Enrollees on request;

 

(19)                            Circumstances in which the Enrollee may be
responsible for payment of services may include:

 

(a)                                  obtaining a service that is not a benefit of
the plan or

 

(b)                                 obtaining services not authorized by the
CONTRACTOR (in either situation, the Enrollee should be liable only if the
Enrollee gave advance written consent to the provider);

 

(c)                                  Appeal or State fair hearing decisions
adverse to the Enrollee when benefits (services) were continued during the
Appeal or State fair hearing process at the Enrollee’s request; or

 

14

 

(d)                                 ineligibility for Medicaid for any portion of
the time period during which services were provided;

 

(20)                            Description of Member Services function; and

 

(21)                            Reasons the CONTRACTOR may initiate
disenrollment of an Enrollee.

 

3.                                      Notification to
Enrollees of Policies and Procedures

 

a.                                      Changes to
Policies and Procedures

 

The CONTRACTOR will give
each Enrollee written notice at least 30 days before the intended effective
date of change to significant information in the CONTRACTOR’s member handbook.

 

b.                                      Annual Education
on Emergency Care and Grievance Procedures

 

The CONTRACTOR will annually
reinforce, in writing, to Enrollees how to access emergency and urgent services
and how to register an Appeal or Grievance.

 

4.                                      Notification  of Changes in Provider Network

 

The CONTRACTOR will make a
good faith effort to give written notice of termination of a contracted
provider, within 15 days after receipt or issuance of the termination notice,
to each Enrollee who received his or her primary care from, or was seen on a
regular basis by, the terminated provider.

 

E.                                    Disenrollment by
Enrollee

 

1.                                      Limited
Disenrollment Requirements

 

The DEPARTMENT has a
requirement that requires Health Plan Enrollees to stay with the same Health
Plan for up to twelve (12) months.

 

2.                                      Without Cause
Exception to 12 Month Enrollment with Same Health Plan Restriction

 

Enrollees are permitted to
transfer from one Health Plan to another without cause as follows:

 

a.                                       within the first three months of each
enrollment period with each Health Plan, or

 

b.                                      if no more than three months have passed
since the month the client’s Medicaid card has a Health Plan printed on it, or

 

c.                                       during the open enrollment period as defined
by the DEPARTMENT.

 

15

 

3.                                      With Cause
Exceptions to 12 Month Enrollment with Same Health Plan

 

Enrollees may request to
transfer from one Health Plan to another at any time during their twelve (12)
month restriction period for the following good cause reasons:

 

a.                                       Enrollee moves out of the Health Plan’s
service area;

 

b.                                      Current Health Plan is no longer available;

 

c.                                       Change in third party liability insurance
status;

 

d.                                      Health Plan choice not available when
Enrollee first made selection;

 

e.                                       Enrollee needs related services, some of
which are not available in the Health Plan’s network, and Enrollee’s provider determines
that receiving services separately would subject the enrollee to unnecessary
risk;

 

f.                                         Poor quality of care;

 

g.                                      Lack of access to Covered Services;

 

h.                                      Lack of access to providers experienced in
dealing with Enrollee’s health care needs;

 

i.                                          Enrollee becomes emancipated or is added to a
different Medicaid case;

 

j.                                          Difficulty getting continuity of care with
provider of choice (i.e., foster care Enrollee’s doctor switches Health Plans);
or

 

k.                                       Health Plan does not, because of moral or
religious objections, cover the service the Enrollee seeks.

 

16

 

4.                                      Process for
Requesting Health Plan Change

 

a.                                       The Enrollee may request to switch Health
Plans by submitting an oral or written request to the State. The Enrollee must
declare the Health Plan in which he or she wishes to enroll should the
disenrollment be approved.

 

b.                                      The DEPARTMENT will review each request to
determine if the request meets the criteria for cause and if so, will allow the
Enrollee to switch to another Health Plan. If the request does not meet the
criteria for cause, or if the concern is with a provider and not the Health
Plan, the DEPARTMENT will deny the disenrollment request and inform the
Enrollee of his or her rights to request a State fair hearing.

 

c.                                       If the DEPARTMENT fails to make a
determination within ten (10) calendar days after receiving the disenrollment
request, the disenrollment is considered approved. The effective date of an
approved disenrollment request will be no later than the first day of the
second month following the month in which the enrollee filed the request.

 

d.                                      The disenrollment will be effective once the
DEPARTMENT has been notified by the Enrollee, the DEPARTMENT issues a new
Medicaid card and the disenrollment is indicated on the Eligibility
Transmission.

 

5.                                      Enrollees in an
Inpatient Hospital Setting

 

The DEPARTMENT agrees that
if a new Enrollee is a patient in an inpatient hospital setting on the date the
new Enrollee’s name appears on the CONTRACTOR Eligibility Transmission, the
obligation of the CONTRACTOR to provide Covered Services to such person will
commence following discharge. If an Enrollee is a patient in an inpatient
hospital setting on the date that his or her name appears as a deleted Enrollee
on the CONTRACTOR Eligibility Transmission or he or she is otherwise
disenrolled under this Contract, the CONTRACTOR will remain financially
responsible for such care until discharge.

 

6.                                      Annual Study of
Enrollees who Disenrolled

 

Annually, the DEPARTMENT and
CONTRACTOR will work cooperatively to conduct an analysis of Enrollees who have
voluntarily disenrolled from this Health Plan. The results of the analysis will
include explanations of patterns of disenrollments and strategies or a
corrective action plan to address unusual rates or patterns of disenrollment. The
DEPARTMENT will inform the CONTRACTOR of such disenrollments.

 

F.                                    Disenrollment
Initiated by CONTRACTOR

 

1.                                      Cannot Disenroll
for Adverse Change in Enrollee’s Health

 

The CONTRACTOR may not
terminate enrollment because of an adverse change in the Enrollee’s health
status, or because of the Enrollee’s utilization of medical services,
diminished mental capacity, or uncooperative or disruptive behavior resulting
from his or her special needs (except when his or her continued enrollment 

 

17

 

in the health plan seriously
impairs the CONTRACTOR’s ability to furnish services to either this particular
Enrollee or other Enrollees).

 

2.                                      Valid Reasons
for Disenrollment

 

The CONTRACTOR may initiate
disenrollment of any Enrollee’s participation in the Health Plan upon one or
more of the following grounds:

 

a.                                       For reasons specifically identified in the
CONTRACTOR’s member handbook.

 

b.                                      When the Enrollee ceases to be eligible for
medical assistance under the State Plan, in accordance with Title 42 USCA,
1396, et. seq., and as finally determined by the DEPARTMENT.

 

c.                                       Upon termination or expiration of the
Contract.

 

d.                                      Death of the Enrollee.

 

e.                                       Confinement of the Enrollee in an institution
when confinement is not a Covered Service under this Contract.

 

f.                                         Violation of enrollment requirements
developed by the CONTRACTOR and approved by the DEPARTMENT but only after the
CONTRACTOR and/or the Enrollee has exhausted the CONTRACTOR’s applicable
internal grievance procedure.

 

3.                                      Approval by
DEPARTMENT Required

 

To initiate disenrollment of
an Enrollee’s participation with this Health Plan, the CONTRACTOR will provide
the DEPARTMENT with documentation justifying the proposed disenrollment. The
DEPARTMENT will approve or deny the disenrollment request in writing within
thirty (30) days of receipt of the request. Failure by the DEPARTMENT to deny a
disenrollment request within such thirty (30) day period will constitute
approval of such disenrollment requests.

 

4.                                      Enrollee’s Right
to File a Grievance

 

If the DEPARTMENT approves
the CONTRACTOR’s disenrollment request, the CONTRACTOR will give the Enrollee
thirty (30) days written notice of the proposed disenrollment, and will notify the
Enrollee of his or her opportunity to invoke the CONTRACTOR’s Grievance Process.
The CONTRACTOR will give a copy of the written notice to the DEPARTMENT at the
time the notice is sent to the Enrollee.

 

5.                                      Refusal of
Re-enrollment

 

If a person is disenrolled
because of violation of  responsibilities
included in the CONTRACTOR’s member handbook, the CONTRACTOR may refuse re-enrollment
of that Enrollee.

 

18

 

6.                                       Automatic Re-enrollment

 

An Enrollee who is disenrolled
from the Health Plan solely because he or she loses Medicaid eligibility will
be automatically re-enrolled if the Enrollee has not been Medicaid eligible for
two months or less.

 

G.                                    Enrollee
Transition Between Health Plans

 

1.                                      Will Accept
Pre-Enrollment Prior Authorizations

 

For Covered Services other
than inpatient, home health services, and medical equipment, if authorization
has been given for a Covered Service and an enrollee transitions between Health
Plans prior to the delivery of such Covered Service, the receiving Health Plan
will be bound by the relinquishing Health Plan’s prior authorization until the
receiving Health Plan has evaluated the medical necessity of the service and
agrees with the relinquishing Health Plan’s prior authorization or has made a
different determination. (See Article XII, Payments, Section H, Clarification
of Payment Responsibilities, Subsection 5, for inpatient, home health services,
and medical equipment explanations.)

 

2.                                      Will Provide
Medical Records to Enrollee’s New Health Plan

 

When enrollees are
transitioned between Health Plans the relinquishing Health Plan’s provider will
submit, upon request of the new Health Plan’s provider, any critical medical
information about the transitioning enrollee prior to the transition including,
but not limited to, whether the member is hospitalized, pregnant, involved in
the process of organ transplantation, scheduled for surgery or post-surgical
follow-up on a date subsequent to transition, scheduled for prior-authorized
procedures or therapies on a date subsequent to transition, receiving dialysis
or is chronically ill (e.g. diabetic, hemophilic, HIV positive).

 

H.                                    Enrollee Transition From FFS to Health Plan
or From Health Plan to FFS

 

1.                                       CONTRACTOR Will Accept Pre-Enrollment Prior
Authorizations

 

For Covered Services other
than inpatient, home health services, and medical equipment, if authorization
has been given for a Covered Service and a Medicaid client transitions from
Medicaid fee-for-service to enrollment with the CONTRACTOR’s health plan prior
to the delivery of such Covered Service, the CONTRACTOR will be bound by the
DEPARTMENT’s fee-for-service prior authorization until the CONTRACTOR has
evaluated the medical necessity of the service and agrees with the DEPARTMENT’s  fee-for-service prior authorization or has
made a different determination. (See Article XII, Payments, Section H,
Clarification of Payment Responsibilities, Subsection 6, for inpatient, home
health services, and medical equipment explanations.)

 

2.                                       DEPARTMENT Will Accept CONTRACTOR’s Prior
Authorization

 

For Covered Services other
than inpatient, home health services, and medical equipment, if authorization
has been given for a Covered Service and an Enrollee transitions to  Medicaid fee-for-service prior to the
delivery of such Covered Service, 

 

19

 

the DEPARTMENT will be bound
by the CONTRACTOR’s prior authorization until the DEPARTMENT has evaluated the
medical necessity of the service and agrees with the CONTRACTOR’s
fee-for-service prior authorization or has made a different determination. (See
Article XII, Benefits, Section H, Clarification of Payment Responsibilities,
Subsection 6, for inpatient, home health services, and medical equipment
explanations.)

 

3.                                      Will Provide
Medical Records to Enrollee’s Health Plan or to the DEPARTMENT

 

When enrollees are
transitioned from Health Plan to fee-for-service or from fee-for-service to
Health Plan, the relinquishing entity (Health Plan or DEPARTMENT) will submit, upon
request of the new entity, any critical medical information about the
transitioning Medicaid client prior to the transition including, but not
limited to, whether the member is hospitalized, pregnant, involved in the
process of organ transplantation, scheduled for surgery or post-surgical
follow-up on a date subsequent to transition, scheduled for prior-authorized
procedures or therapies on a date subsequent to transition, receiving dialysis
or is chronically ill (e.g. diabetic, hemophilic, HIV positive).

 

Article IV - Benefits

 

A.                                   In General

 

1.                                       The CONTRACTOR will provide to Enrollees
under this Contract, directly or through arrangements with subcontractors, all
Medically Necessary Covered Services described in Attachment C as promptly and
continuously as is consistent with generally accepted standards of medical
practice.

 

2.                                       The CONTRACTOR will ensure that all Covered
Services are furnished in an amount, duration, and scope that is no less than
the amount, duration, and scope for the same services furnished to
beneficiaries under fee-for-service Medicaid (as set forth in 440.230). The
CONTRACTOR will ensure that the services are sufficient in amount, duration, or
scope to reasonably be expected to achieve the purpose for which the services
are furnished.

 

3.                                       The CONTRACTOR may not arbitrarily deny or
reduce the amount, duration, or scope of a required service solely because of
diagnosis, type of illness, or condition of the Enrollee.

 

4.                                       The CONTRACTOR may place appropriate limits
on a service on the basis of criterion applied under the State plan, such as
medical necessity, or for the purpose of utilization control, provided the
services furnished can reasonably be expected to achieve their purpose.

 

5.                                       The subcontractors will follow generally
accepted standards of medical care in diagnosing Enrollees who request services
from the CONTRACTOR.

 

B.                                    Scope of
Services

 

1.                                      Responsible for
all Benefits in Attachment C (Covered Services)

 

20

 

Except as otherwise provided
for cases of Emergency Services, the CONTRACTOR has the exclusive right and
responsibility to arrange for all benefits listed in Attachment C. The
CONTRACTOR is responsible for payment of Emergency Services 24 hours a day and
7 days a week whether the service was provided by a network or out-of-network
provider and whether the service was provided in or out of the CONTRACTOR’s
Service Area.

 

2.                                      Changes to
Benefits

 

Amendments, revisions, or
additions to the State Plan or to State or Federal regulations, guidelines, or
policies and court or administrative orders will, insofar as they affect the
scope or nature of  benefits available to
Enrollees, be amendments to the Covered Services under Attachment C. The
DEPARTMENT will notify the CONTRACTOR, in writing, of any such changes and
their effective date.

 

C.                                     Clarification of Covered Services

 

1.                                      Emergency
Services

 

a.                                      In General

 

(1)                                  The CONTRACTOR will provide coverage for
Emergency Services without regard to prior authorizations or the emergency care
provider’s contractual relationship with the CONTRACTOR. The CONTRACTOR will
inform its Enrollees that access to Emergency Services is not restricted and
that if an Enrollee experiences a medical emergency, he or she may obtain
services from a non-plan physician or other qualified provider, without penalty.
An Enrollee who has an Emergency Medical Condition may not be held liable for
payment of subsequent screening and treatment needed to diagnose the specific
condition or stabilize the patient.

 

(2)                                  The CONTRACTOR may not limit what constitutes
an Emergency Medical Condition on the basis of lists of diagnoses or symptoms.

 

(3)                                  The CONTRACTOR will pay for services where
the presenting symptoms are of sufficient severity that a person with average
knowledge of health and medicine would reasonably expect the absence of
immediate medical attention to result in placing the health of the individual
(or, with respect to a pregnant woman, the health of a woman or her unborn
child) in serious jeopardy; serious impairment to bodily functions; or serious
dysfunction of any bodily organ or part.

 

(4)                                  The CONTRACTOR may not retroactively deny a
claim for an emergency screening examination because the condition, which
appeared to be an emergency medical condition under the prudent layperson
standard, turned out to be non-emergency in nature.

 

21

 

b.                                       Determining Liability for
Emergency Services

 

The CONTRACTOR may not deny
payment for treatment obtained when an Enrollee had an Emergency Medical
Condition, including cases in which the absence of immediate medical attention
would not have had the outcomes specified in the definition of Emergency
Medical Condition.

 

(1)                                  Presence of a clinical emergency

 

If the screening examination
leads to a clinical determination by the examining physician that an actual
emergency medical condition exists, the CONTRACTOR will pay for both the
services involved in the screening examination and the services required to
stabilize the Enrollee.

 

(2)                                  Emergency services continue until the
Enrollee can be safely discharged or transferred.

 

The CONTRACTOR will pay for
all Emergency Services that are Medically Necessary until the clinical
emergency is stabilized. This includes all treatment that may be necessary to
assure, within reasonable medical probability, that no material deterioration
of the Enrollee’s condition is likely to result from, or occur during,
discharge of the Enrollee or transfer of the Enrollee to another facility. If
there is a disagreement between a hospital and the CONTRACTOR concerning
whether the Enrollee is stable enough for discharge or transfer, or whether the
medical benefits of an unstabilized transfer outweigh the risks, the judgement
of the attending physician(s) actually caring for the Enrollee at the treating
facility prevails and is binding on the CONTRACTOR. The CONTRACTOR may
establish arrangements with hospitals whereby the CONTRACTOR may send one of
its own physicians with appropriate ER privileges to assume the attending
physician’s responsibilities to stabilize, treat, and transfer the Enrollee.

 

(3)                                  Absence of a clinical emergency

 

If the screening examination
leads to a clinical determination by the examining physician that an actual
emergency medical condition did not exist, then the determining factor for
payment liability should be whether the Enrollee had acute symptoms of
sufficient severity at the time of presentation. In these cases, the CONTRACTOR
will review the presenting symptoms of the Enrollee and will pay for all
services involved in the screening examination where the presenting symptoms
(including severe pain) were of sufficient severity to have warranted emergency
attention under the prudent layperson standard.

 

22

 

(4)                                  Referrals

 

When an Enrollee’s Primary
Care Physician or other plan representative instructs the Enrollee to seek
emergency care in or out of network, the CONTRACTOR is responsible for payment
of the medical screening examination and for other Medically Necessary
Emergency Services, without regard to whether the Enrollee meets the prudent
layperson standard.

 

(5)                                  Notification

 

The CONTRACTOR may not
refuse to cover Emergency Services because the emergency room provider,
hospital, or fiscal agent did not notify the CONTRACTOR of the Enrollee’s
screening and treatment within ten calendar days of presentation for Emergency
Services.

 

c.                                       Post-Stabilization Services

 

The CONTRACTOR will comply
with Medicare guidelines for post-stabilization of care as found in 42 CFR
422.113(c). Generally, Post-Stabilization Services begin when an Enrollee is
admitted for an inpatient hospital stay after Emergency Services to evaluate or
stabilize the Emergency Medical condition have been provided in the Emergency
Room.

 

However, in situations where
the hospital demonstrates the Enrollee received Emergency Services related to
an Emergency Medical Condition during the inpatient admission, the CONTRACTOR
will reimburse the hospital in accordance with regulations governing Emergency
Services as outlined in item b., Emergency Services, above.

 

(1)                                  Pre-approved
Post-Stabilization Services:  The CONTRACTOR is financially responsible for
Post-stabilization Services obtained within or outside the CONTRACTOR’s plan
that are pre-approved by a CONTRACTOR provider or representative.

 

(2)                                  Post-Stabilization Services
- Not Pre-Approved – but CONTRACTOR is Responsible:  The
CONTRACTOR is financially responsible for Post-stabilization Services obtained
within or outside the CONTRACTOR organization that are not pre-approved
by a CONTRACTOR provider or other CONTRACTOR representative, but are
administered to maintain the Enrollee’s stabilized condition within one hour
of a request to the CONTRACTOR for pre-approval of further post-stabilization
care services.

 

The CONTRACTOR is
financially responsible for Post-stabilization Services obtained within or
outside the CONTRACTOR organization that are not pre-approved by a
CONTRACTOR 

 

23

 

provider or other CONTRACTOR
representative, but are administered to maintain, improve or resolve the
Enrollee’s stabilized condition if:

 

(a)                                  the CONTRACTOR does not respond to a request
for pre-approval within one hour (of the request);

 

(b)                                 the CONTRACTOR cannot be contacted;

 

(c)                                  the CONTRACTOR representative and the
treating physician cannot reach an agreement concerning the Enrollee’s care and
a CONTRACTOR physician is not available for consultation. In this situation,
the CONTRACTOR will give the treating physician the opportunity to consult with
a CONTRACTOR physician and the treating physician may continue with the care of
the Enrollee until a CONTRACTOR physician is reached; or

 

one of the criteria outlined
in 42 CFR 422.113(c)(3) is met:

 

(i)  a CONTRACTOR physician with privileges at the
treating hospital assumes responsibility for the Enrollee’s care;

 

(ii) a CONTRACTOR physician
assumes responsibility for the Enrollee’s care through transfer;

 

(iii) a CONTRACTOR
representative and the treating physician reach an agreement concerning the
Enrollee’s care; or

 

(iv) the Enrollee is
discharged.

 

2.                                      Care Provided in Skilled
Nursing Facilities

 

a.                                       In General:  Stays Lasting 30 Days or Less

 

The CONTRACTOR may provide
long term care for Enrollees in skilled nursing facilities and then reimburse
such facilities when the plan of care includes a prognosis of recovery and
discharge within 30 days. It is the responsibility of a CONTRACTOR physician to
make the determination if the patient will require the services of a nursing
facility for fewer or greater than 30 days.

 

b.                                       Process for Stays Longer
than 30 Days

 

When the prognosis of an
Enrollee indicates that long term care greater than 30 days will be required,
the following process will occur:

 

24

 

(1)                                  The CONTRACTOR will notify the Enrollee,
hospital discharge planner, and nursing facility that the CONTRACTOR will not
be responsible for the services provided for the Enrollee during the stay at
the skilled nursing facility.

 

(2)                                  The CONTRACTOR will notify the DHCF, Bureau
of Managed Health Care (BMHC) of this determination and the BMHC will change
the status of the Enrollee to fee-for-service.

 

c.                                       Process for
Stays Less than 30 Days

 

When the prognosis of
skilled nursing facility services is anticipated to be less than 30 days, but
during the 30-day period the CONTRACTOR determines that the Enrollee will
require skilled nursing facility services for greater than 30 days, the
following process will be in effect:

 

(1)                                  The CONTRACTOR will notify the nursing
facility that a determination has been made that the Enrollee will require
services for more than 30 days.

 

(2)                                  The CONTRACTOR will notify the DHCF, Bureau
of Managed Health Care, of the determination that the Enrollee will require
services in a nursing facility for more than 30 days.

 

(3)                                  The CONTRACTOR will be responsible for
payment for three working days after the CONTRACTOR has notified the nursing
facility that skilled nursing care will be required for more than 30 days.

 

3.                                      Hospice

 

a.                                       If an Enrollee is receiving hospice services
at the time of enrollment in the Health Plan or if the Enrollee is already
enrolled in the Health Plan and has less than six months to live, the Enrollee
will be offered hospice services or the continuation of hospice services if he
or she is already receiving such services prior to enrollment in the Health
Plan.

 

b.                                      If the enrollee is admitted to a nursing
facility, ICF/MR, or a freestanding hospice facility, the Health Plan is
responsible to reimburse the hospice provider for both the hospice care and the
room and board until the Enrollee is disenrolled from the Health Plan by the
DEPARTMENT. At the point the Health Plan determines that the Enrollee will
require care in the hospice facility for greater than 30 days, the Health Plan
will notify the Enrollee, hospice agency, and hospice facility that the Health
Plan will no longer be responsible for hospice services. The CONTRACTOR will
also notify the DEPARTMENT’s Bureau of Managed Health Care (BMHC) of this
determination. The BMHC will change the status of the Enrollee to
fee-for-service.

 

c.                                       The CONTRACTOR is responsible for room and
board expenses of a hospice Enrollee receiving Medicare hospice care while the
Enrollee is a resident of a 

 

25

 

Medicare-certified nursing
facility, ICF/MR, or freestanding hospice facility until the Enrollee is
disenrolled from the Health Plan by the BMHC.

 

4.                                      Inpatient
Hospital Services for Scheduled Admissions

 

a.                                       If a CONTRACTOR’s provider admits an Enrollee
for inpatient hospital care and has followed the CONTRACTOR’s requirements for
the admission, the CONTRACTOR has the responsibility for all services needed by
the Enrollee during the hospital stay that are ordered by the CONTRACTOR’s
provider. Needed services include but are not limited to diagnostic tests,
pharmacy, and physician services, including services provided by psychiatrists.

 

b.                                      If diagnostic tests conducted during the
inpatient stay reveal that the Enrollee’s condition is outside the scope of the
CONTRACTOR’s responsibility, the CONTRACTOR remains financially responsible for
the Enrollee until the Enrollee is discharged or until responsibility is
transferred to another appropriate entity and the entity agrees to take
financial responsibility, including negotiating a payment for services.

 

c.                                       If the Enrollee is discharged and needs
further services, the admitting CONTRACTOR will coordinate with the other
appropriate entity to ensure continued care is provided. The CONTRACTOR and
appropriate entity will work cooperatively in the best interest of the Enrollee.
The appropriate entity includes, but is not limited to, a Prepaid Mental Health
Plan.

 

5.                                      Children in
Custody of the Department of Human Services

 

a.                                      In General

 

(1)                                  The CONTRACTOR will work with the Division of
Child and Family Services (DCFS) or the Division of Youth Corrections (DYC) in
the Department of Human Services (DHS) to ensure systems are in place to meet
the health needs of children in custody of the Department of Human Services. The
CONTRACTOR will ensure these children receive timely access to appointments
through coordination with DCFS or DYC. The CONTRACTOR will have available
providers who have experience and training in abuse and neglect issues.

 

(2)                                  The CONTRACTOR or its providers will make
every reasonable effort to ensure that a child who is in custody of the
Department of Human Services may continue to use the provider with whom the
child has an established professional relationship when the provider is part of
the CONTRACTOR’s network. The CONTRACTOR will facilitate timely appointments
with the provider of record to ensure continuity of care for the child.

 

(3)                                  While it is the CONTRACTOR’s responsibility
to ensure Enrollees who are children in the custody of DHS have access to
needed services, DHS personnel are primarily responsible to assist children in
custody 

 

26

 

in arranging for and getting
to medical appointments and evaluations with the CONTRACTOR’s network of
providers. DHS staff are primarily responsible for contacting the CONTRACTOR to
coordinate care for children in custody and informing the CONTRACTOR of the
special health care needs of these Enrollees. The Fostering Healthy Children
staff may assist the DHS staff in performing these functions by communicating
with the CONTRACTOR.

 

b.                                      Schedule of
Visits

 

(1)                                  Where physical and/or sexual abuse is
suspected

 

In cases where the child
protection worker suspects physical and/or sexual abuse, the CONTRACTOR will
ensure that the child has access to an appropriate examination within 24 hours
of notification that the child was removed from the home. If the CONTRACTOR
cannot provide an appropriate examination, the CONTRACTOR will ensure thechild
has access to a provider who can provide an appropriate examination within the
24 hour period.

 

(2)                                  All other cases

 

In all other cases, the
CONTRACTOR will ensure that the child has access to an initial health screening
within five calendar days of notification that the child was removed from the
home. The CONTRACTOR will ensure this exam identifies any health problems that
might determine the selection of a suitable placement, or require immediate
attention.

 

27

 

(3)                                  CHEC exams

 

In all cases, the CONTRACTOR
will ensure that the child has access to a Child Health Evaluation and Care
(CHEC) screening within 30 calendar days of notification that the child was
removed from the home. Whenever possible, the CHEC screening should be
completed within the five-day time frame. Additionally, the CONTRACTOR will
ensure the child has access to a CHEC screening according to the CHEC
periodicity schedule until age six, then annually thereafter.

 

6.                                      Organ
Transplantations

 

a.                                      In General

 

All organ transplantation
services are the responsibility of the CONTRACTOR for all Enrollees in
accordance with the criteria set forth in Rule R414-10A of the Utah
Administrative Code, unless amended under the provisions of Attachment B,
Article IV (Benefits), Section C, Subsection 7 of this Contract. The DEPARTMENT’s
criteria will be provided to the CONTRACTOR.

 

b.                                      Specific Organ
Transplantations Covered

 

The following
transplantations are covered for Enrollees under the Traditional Medicaid Plan as
described in Rule R414-10A: kidney, liver, cornea, bone marrow, stem cell,
heart, intestine, lung, pancreas, small bowel, combination heart/lung,
combination intestine/liver, combination kidney/pancreas, combination
liver/kidney, multi-visceral, and combination liver/small bowel. Transplantations
for Enrollees under the Non-Traditional Medicaid Plan are limited to kidney,
liver, cornea, bone marrow, stem cell, heart, and lung.

 

c.             Psychosocial Evaluation Required

 

(1)                                  Enrollees who have applied for organ
transplantations, except cornea or kidney, will undergo a comprehensive
psycho-social evaluation by a board-certified or board-eligible psychiatrist. The
evaluation will include a comprehensive history regarding substance abuse and
compliance with medical treatment. In addition, the parent(s) or guardian(s) of
Enrollees who are less than 18 years of age will undergo a psycho-social
evaluation that includes a comprehensive history regarding substance abuse, and
past and present compliance with medical treatment.

 

(2)                                  If a request is made for a transplantation
not listed above, the CONTRACTOR will contact the DEPARTMENT. Such requests
will be addressed as set forth in R414-10A-23.

 

28

 

d.                                      Out-of-State
Transplantations

 

When the CONTRACTOR arranges
the transplantation to be performed out-of- state, the CONTRACTOR is
responsible for coverage of food, lodging, transportation and airfare expenses
for the Enrollee and attendant. The CONTRACTOR will follow, at a minimum, the
DEPARTMENT’s criteria for coverage of food, lodging, transportation and airfare
expenses.

 

7.                                      Mental Health
Services

 

a.                                       When an Enrollee presents with a possible
mental health condition to his or her CONTRACTOR primary care physician, it is
the responsibility of the primary care provider to determine whether the
Enrollee should be referred to a psychologist, pediatric specialist,
psychiatrist, neurologist, or other specialist. Mental health conditions may be
handled by the CONTRACTOR primary care provider or referred to the Enrollee’s
Prepaid Mental Health Plan when more specialized services are required for the
Enrollee. CONTRACTOR primary care providers may seek consultation from the
Prepaid Mental Health Plan when the primary care provider chooses to manage the
Enrollee’s symptoms.

 

b.                                      An independent panel comprised of specialists
appropriate to the concern will be established by the DEPARTMENT with
representatives from the CONTRACTOR and Prepaid Mental Health Plan to
adjudicate disputes regarding which entity (the CONTRACTOR or Prepaid Mental
Health Plan) is responsible for payment and/or treatment of a condition. The
panel will be convened on a case-by-case basis. The CONTRACTOR and Prepaid
Mental Health Plan will adhere to the final decision of the panel.

 

8.                                      Developmental
and Organic Disorders

 

a.                                      Covered Services
for Child Enrollees through Age 20

 

(1)                                  The CONTRACTOR is responsible for all
inpatient and physician outpatient Covered Services for child Enrollees with
developmental (ICD-9 codes 299.0 through 299.11, developmental disorders
included within the range 299.8 through 299.91, and 317 through 319.9) and
organic diagnoses (ICD-9 codes 290 through 290.99, 293 through 294.99, and and
310 through 310.9) including, but not limited to, diagnostic work-ups and other
medical care such as medication management services related to the
developmental or organic disorder.

 

(2)                                  The CONTRACTOR is responsible for all
psychological services for child Enrollees with developmental or organic
disorders and all other diagnoses not covered by a Prepaid Mental Health Plan.

 

b.                                      Covered Services
for Adult Enrollees Age 21 and Older

 

The CONTRACTOR is
responsible for all inpatient and physician outpatient Covered Services for
adult Enrollees with developmental (ICD-9 codes 299.0 through 299.11,
developmental disorders included within the range 299.8 through 299.91, and 317
through 319.9) and organic diagnoses (ICD-9

 

29

 

codes 290 through 290.99,
293 through 294.99 and 310 through 310.9) including diagnostic work-ups and
other medical care such as medication management services related to the
developmental or organic disorder.

 

c.                                       Non-covered
Services

 

(1)                                  Psychological evaluations and testing
including neuropsychological evaluations and testing for adult Enrollees is not
the responsibility of the CONTRACTOR.

 

(2)                                  Habilitative and behavioral management
services are not the responsibility of the CONTRACTOR. If habilitative services
are required, the Enrollee should be referred to the Division of Services for
People with Disabilities (DSPD), the school system, the Early Intervention
Program, or similar support program or agency. The Enrollee should also be
referred to DSPD for consideration of other benefits and programs that may be
available through DSPD. Habilitative services are defined in Section
1915(c)(5)(a) of the Social Security Act as “services designed to assist
individuals in acquiring, retaining and improving the self-help, socialization
and adaptive skills necessary to reside successfully in home and community
based settings.”

 

d.                                      Responsibility
of the Prepaid Mental Health Plan

 

The Prepaid Mental Health
Plan is responsible for the treatment of the mental illness to individuals with
both an organic and a psychiatric diagnosis or with both a developmental and a
psychiatric diagnosis.

 

9.             Out-of-State Accessory Services

 

When the CONTRACTOR arranges
a Covered Service to be performed out-of-state, the CONTRACTOR is responsible
for coverage of airfare, food and lodging for the Enrollee and one attendant
during the stay at the out-of-state facility. Ground transportation costs only
from the airport to the hotel or hospital and back to the airport, one time
only are also the responsibility of the CONTRACTOR. The CONTRACTOR will follow,
at a minimum, the DEPARTMENT’s criteria for coverage of food, lodging,
transportation, and airfare expenses.

 

10.                               Non-Contractor
Prior Authorizations

 

a.                                      Prior
Authorizations - General

 

The CONTRACTOR will honor
prior authorizations for organ transplantations and any other ongoing services
initiated by the DEPARTMENT while the Enrollee was covered under Medicaid
fee-for-service until the Enrollee is evaluated by the CONTRACTOR and a new
plan of care is established.

 

30

 

b.                                      When the
CONTRACTOR has not Authorized the Service and the Provider is not a
Participating Provider

 

For services that require a
prior authorization, the CONTRACTOR will pay the provider of the service at the
Medicaid rate, if all of the following conditions are met:

 

(1)                                  the servicing provider is not a participating
provider under contract with the CONTRACTOR; and

 

(2)                                  the DEPARTMENT issued a prior authorization
for an Enrollee to the servicing provider; and

 

(3)                                  the provider filed an Appeal with the
CONTRACTOR within the required time frame for filing an Appeal; and

 

(4)                                  the servicing provider has completed the
CONTRACTOR’s appeals process without resolution of the claim, and has requested
a hearing with the State Formal Hearings Unit requesting payment for the
services rendered; and

 

(5)                                  in the hearing process it is determined that
the service rendered was a Medically Necessary service covered under this
Contract, and that the CONTRACTOR will be responsible for payment of the claim.

 

D.                                    Additional Services for Enrollees with
Special Health Care Needs

 

1.                                      In General

 

The CONTRACTOR will make
case management programs available to Enrollees identified with special health
care needs. The CONTRACTOR will ensure there is access to all Medically
Necessary Covered Services to meet the health needs of Enrollees with Special
Health Care Needs. Individuals with special health care needs are those who
have or are at increased risk for chronic physical, developmental, behavioral,
or emotional conditions and who also require health and related services of a
type or amount beyond that required by adults and children generally.

 

2.                                      Identification

 

The CONTRACTOR will identify
Enrollees with Special Health Care Needs using a process at the initial contact
made by the CONTRACTOR Representative to educate the client and will offer the
client care coordination or case management services. Care coordination
services are services to assist the client in obtaining Medically Necessary
Covered Services from the CONTRACTOR or another entity if the medical service
is not covered under the Contract.

 

3.                                      Choosing a Primary Care
Provider

 

The CONTRACTOR will have a
mechanism to inform caregivers and, when

 

31

 

appropriate, Enrollees with
Special Health Care Needs about primary care providers who have training in
caring for such Enrollees so that an informed selection of a provider can be
made. The CONTRACTOR will have primary care providers with skills and experience
to meet the needs of Enrollees with Special Health Care Needs. For Enrollees
determined to need a course of treatment or regular care monitoring, the
CONTRACTOR will have a mechanism in place to allow Enrollees to directly access
a specialist (for example, through standing referral or an approved number of
visits) as appropriate for the Enrollee’s condition and identified needs. The
CONTRACTOR will allow an appropriate specialist to be the primary care provider
but only if the specialist has the skills to monitor the Enrollee’s preventive
and primary care services.

 

4.                                      Referrals and Access to
Specialty Providers

 

(1)                                  The CONTRACTOR will ensure there is access to
appropriate specialty providers to provide Medically Necessary Covered Services
for adults and children with special health care needs. If the CONTRACTOR does
not employ or contract with a specialty provider to treat a special health care
condition at the time the Enrollee needs such Covered Services, the CONTRACTOR
will have a process to allow the Enrollee to receive Covered Services from a
qualified specialist who may not be affiliated with the CONTRACTOR. The
CONTRACTOR will reimburse the specialist for such care at no less than Medicaid’s
rate for the service when the service is rendered. The process for requesting
specialist’s care will be clearly described by the CONTRACTOR and explained to
each Enrollee during the initial contact with the Enrollee.

 

(2)                                  If the CONTRACTOR restricts the number of
referrals to specialists, the CONTRACTOR will not penalize those providers who
make such referrals for Enrollees with special health care needs.

 

5.                                      Survey of
Enrollees with Special Health Care Needs

 

At least every two years,
the CONTRACTOR in conjunction with the DEPARTMENT will survey a sample of Enrollees
with special health care needs using a national consumer assessment
questionnaire to evaluate their perceptions of services they have received. The
survey process, including the survey instrument, will be standardized and
developed collaboratively between the DEPARTMENT and all contracting Health
Plans. The DEPARTMENT will analyze the results of the surveys. The results and
analysis of

 

32

 

the surveys will be reviewed
by the CONTRACTOR’s quality assurance committee for action.

 

6.                                      Collaboration
with Other Programs

 

a.                                       The CONTRACTOR will implement procedures to
share with other PIHPs and PAHPs, serving Enrollees with Special health Care
Needs the results of its identification and assessment of each Enrollee’s needs
to prevent duplication of those activities.

 

b.                                      If the Enrollee with Special Health Care
Needs is enrolled in the Prepaid Mental Health Plan or is enrolled in any of
the Medicaid home and community-based waiver programs and is receiving case
management services through that program, or is covered by one of the other
Medicaid targeted case management programs, the CONTRACTOR care coordinator
will collaborate with the appropriate program person, i.e., the targeted case
manager, etc., for that program once the program person has contacted the
CONTRACTOR care coordinator. When necessary, the CONTRACTOR care coordinator
will make an effort to contact the program person of those Enrollees who have
medical needs that require such coordination.

 

c.                                       The CONTRACTOR will coordinate health care
needs for Enrollees with Special Health Care Needs with the services of other
agencies (e.g., mental and substance abuse, public health departments,
transportation, home and community based care, developmental disabilities,
Title V, local schools, IDA programs, and child welfare), and with families,
caregivers, and advocates.

 

7.                                      Case Management
and Coordination of Care Program

 

a.                                       The CONTRACTOR will have a basic system in
place to assure continuity and coordination of overall health care for all
Enrollees including a mechanism to ensure that each Enrollee has an ongoing
source of primary care. The CONTRACTOR’s case management (CM) program will be
designed around a collaborative process of assessment, planning, facilitation
and advocacy using available resources to promote quality, timely, safe and
cost effective outcomes. The CM program will have sufficient resources to meet
the needs of the enrolled population and anticipated enrollment as needs change.
The CONTRACTOR will use the information the DEPARTMENT provides on Enrollees
with Special Health Care Needs to coordinate care and determine case management
needs.

 

b.                                      case management program includes, but is not
limited to:

 

(1)                                  Methods used to identify Enrollees with
Special Health Care Needs and Enrollees needing case management or coordination
on enrollment and ongoing methods for existing enrollees; e.g. a mechanism to
perform health needs assessments upon enrollment for all Enrollees within the
time frames required by the contract, to identify Enrollees with Special Health
Care needs, to identify Enrollees needing case management services and to help
facilitate

 

33

 

care/services in accordance
with treatment plans

 

(2)                                  Methodologies to determine the frequency and
duration of CM services through application of established criteria.

 

(3)                                  Mechanism to refer to and coordinate with
other state agencies and community resources as necessary (i.e., coordination
of medical and mental health care, transportation, aging services, waiver
programs, CSHCN clinics, DSPD, dental, WIC, etc.) when needed.

 

(4)                                  Assisting with and the monitoring of
Enrollees follow up and specialty care (tracking of referrals) to ensure
compliance with treatment plan and ensure that members receive recommended
follow up and specialty care.

 

e.                                       Protocols to address Enrollees who are
non-compliant.

 

f.                                         Linkages to the CONTRACTOR’s disease
management programs.

 

g.                                      Methods for sharing the results of assessments
of Enrollees with Special Health Care Needs in order to prevent duplication of
those services and coordinate care. (Efforts to share information will be in
accordance with privacy requirements in 45 CFR parts 160 and 164 subparts A and
E, to the extent that they are applicable.)

 

8.                                      Specific
Requirements for Children with Special Health Care Needs

 

a.                                      DEPARTMENT’s
Identification

 

The DEPARTMENT will
implement mechanisms to identify Children with Special Health Care Needs as
defined in this Contract. These identification mechanisms are specified in the
DEPARTMENT’s Quality Assessment Performance Improvement Plan. (See Attachment
D.)

 

b.                                      Assessment

 

The CONTRACTOR will
implement mechanisms to assess each Child with Special Health Care Needs that
the DEPARTMENT has reported to the CONTRACTOR in order to identify any ongoing
special conditions of the Enrollee that require a course of treatment or
regular care monitoring. The assessment mechanisms will use appropriate health
care professionals.

 

34

 

Article V - Delivery Network

 

A.                                   Availability of Services

 

1.                                      Appropriate
Network

 

The CONTRACTOR will maintain
and monitor a network of appropriate providers that is supported by written
agreements and is sufficient to provide adequate access to all services covered
under this Contract. In establishing and maintaining the network of providers,
the CONTRACTOR will consider the following:

 

a.                                       the anticipated Medicaid enrollment;

 

b.                                      the expected utilization of services, taking
into consideration the characteristics and health care needs of specific
Medicaid populations represented in the CONTRACTOR’s Service Area;

 

c.                                       the numbers and types (in terms of training,
experience, and specialization) of providers required to furnish the contracted
Medicaid services; and

 

d.                                      the number of network providers who are not
accepting new Medicaid patients;

 

e.                                       the geographic locations of providers and
Enrollees, considering distance, travel time, the means of transportation
ordinarily used by Enrollees, and whether the location provides physical access
for Enrollees with disabilities.

 

2.                                      Direct Access

 

The CONTRACTOR will provide
female Enrollees with direct access to a women’s health specialist within the
network for covered care necessary to provide women’s routine and preventive
health care services. (This is in addition to the Enrollee’s designated source
of primary care if that source is not a women’s health specialist.)

 

3.                                       Second Opinion

 

The CONTRACTOR will provide
for a second opinion from a qualified health care professional within the
network, or arrange for the Enrollee to obtain one outside the network, at no
cost to the Enrollee.

 

4.                                       Out of Network

 

If the network is unable to
provide Necessary Covered Services under this Contract to a particular
Enrollee, the CONTRACTOR will adequately and timely cover these services out of
network for the Enrollee, for as long as the CONTRACTOR is unable to provide
them. The CONTRACTOR will require out-of-network providers to coordinate with the
CONTRACTOR with respect to payment and ensure that cost to the Enrollee is no
greater than it would be if the services were furnished within the network.

 

35

 

5.                                       Timely Access

 

The CONTRACTOR will require
that its network providers offer hours of operation that are no less than the
hours of operation offered to commercial enrollees or comparable to Medicaid
fee-for-service, if the provider serves only Medicaid enrollees. The CONTRACTOR
will ensure that all Covered Serices are available 24 hours a day, 7 days a
week, when medically necessary.

 

6.                                       Timely Access Monitoring

 

The CONTRACTOR will
establish mechanisms to ensure compliance by its network providers and will
monitor its providers regularly to determine compliance by providers. If there
is failure to comply, the CONTRACTOR will take corrective action.

 

B.                                     Subcontracts and Assurances

 

1.                                      General
Assurances

 

Any Covered Service may be
subcontracted. The CONTRACTOR will ensure that all subcontracts are in writing
and will include any general requirements of this Contract that are appropriate
to the service or activity delegated under the subcontract including
confidentiality requirements and will assure that all duties of the CONTRACTOR
under this Contract are performed. The CONTRACTOR will monitor the
subcontractor’s performance on an ongoing basis that will be subject to formal
review according to a periodic schedule established by the DEPARTMENT,
consistent with industry standards. If the CONTRACTOR identifies deficiencies
or areas for improvement, the CONTRACTOR and the subcontractor will take
corrective action. No subcontract terminates the legal responsibility of the
CONTRACTOR to the DEPARTMENT to assure that all activities under this Contract
are carried out. The CONTRACTOR will make all subcontracts available upon
request.

 

2.                                       Written Agreement

 

The CONTRACTOR will oversee
and be accountable for any functions and responsibilities that it delegates to
any subcontractor. Before any delegation, the CONTRACTOR will evaluate the
prospective subcontractor’s ability to perform the activities to be delegated. There
will be a written agreement between the CONTRACTOR and subcontractor that:

 

a.                                       specifies the activities and report
responsibilities delegated to the subcontractor;

 

b.                                      includes a provision for revoking delegation
or imposing other sanctions if the subcontractor’s performance is inadequate;

 

c.                                       includes a provision that if the
subcontractor becomes insolvent or bankrupt, Enrollees will not be liable for
the debt of the subcontractor; and

 

36

 

d.                                      specifies that the subcontractor, acting
within the lawful scope of his or her practice, will not be prohibited from
advising or advocating on behalf of an Enrollee who is his or her patient for
the following:

 

(1)                                  the Enrollee’s health status, medical care,
or treatment options, including any alternative treatment that may be
self-administered;

 

(2)                                  any information the Enrollee needs in order
to decide among all relevant treatment options;

 

(3)                                  the risks, benefits, and consequences of
treatment or non-treatment; and

 

(4)                                  the Enrollee’s right to participate in
decisions regarding his or her health care, including the right to refuse
treatment, and to express preferences about future treatment decisions.

 

3.                                       Practice Guidelines

 

a.                                       The CONTRACTOR and its subcontractors will
adopt practice guidelines that meet the following requirements:

 

(1)                                  are based on valid and reliable clinical
evidence or a consensus of health care professionals in the particular field;

 

(2)                                  consider the needs of the Enrollees in the
CONTRACTOR’s health plan;

 

(3)                                  are adopted in consultation with contracting
health care professionals; and

 

(4)                                  are reviewed and updated periodically as
appropriate.

 

b.                                      The CONTRACTOR will disseminate the practice
guidelines to all affected providers and, upon request, to Enrollees and
Potential Enrollees.

 

c.                                       The CONTRACTOR will ensure that decisions for
utilization management, Enrollee education, coverage of services, and other
areas to which the guidelines apply are consistent with the practice
guidelines.

 

4.                                       No Provisions to Reduce or Limit Medically
Necessary Services

 

The CONTRACTOR will ensure
that subcontractors abide by the requirements of Section 1128(b) of the Social
Security Act prohibiting the CONTRACTOR and other such providers from making
payments directly or indirectly to a physician or other provider as an
inducement to reduce or limit Medically Necessary services provided to
Enrollees.

 

37

 

5.                                       Domestic Violence

 

The CONTRACTOR will ensure
that providers and staff are knowledgeable about methods to detect domestic
violence, about mandatory reporting laws when domestic violence is suspected,
and about resources in the community to which patients can be referred.

 

6.                                       Requirement of 60 Days Written Notice Prior
to Termination of Contract

 

All subcontracts and
agreements will include a provision stating that if either party (the
subcontractor or CONTRACTOR) wishes to terminate the subcontract or agreement,
whichever party initiates the termination will give the other party written
notice of termination at least 60 calendar days prior to the effective
termination date. The CONTRACTOR will notify the DEPARTMENT of the termination
on the same day that the CONTRACTOR either initiates termination or receives
the notice of termination from the subcontractor.

 

7.                                       Compliance with CONTRACTOR’s Quality
Assurance Plan

 

All of the CONTRACTOR’s
providers will be aware of the CONTRACTOR’s Quality Assurance Plan and
activities. All subcontracts with the CONTRACTOR will include a requirement
securing cooperation with the CONTRACTOR’s Quality Assurance Plan and
activities and will allow the CONTRACTOR access to the subcontractor’s medical
records of its Enrollees.

 

8.                                      Unique
Identifier Required

 

All physicians who provide
services under this Contract will have a unique identifier in accordance with
the system established under section 1173(b) of the Social Security Act and in
accordance with the Health Insurance Portability and Accountability Act.

 

9.                                       Payment of Provider Claims

 

a.                                       The CONTRACTOR will pay its providers on a
timely basis consistent with the claims payment procedures described in section
1902(a)(37)(A) of the Social Security Act and the implementing Federal
regulation at 42 CFR 447.45 and 447.46, unless the CONTRACTOR and its provider
establish an alternative payment schedule. A claim means:  1) a bill for services, 2) a line item of
services, or 3) all services for one Enrollee within a bill.

 

b.                                      “Clean claim” means a claim that can be
processed without obtaining any additional information from the provider of the
service or from a third party. It includes a claim with errors originating from
the DEPARTMENT’s claims system. It does not include a claim from a provider who
is under investigation for fraud or abuse, or a claim under review for medical
necessity. The CONTRACTOR will pay 90 percent of all clean claims from
practitioners, who are in individual or group practice or who practice in
shared health facilities, within 90 days of receipt.

 

c.                                       The date receipt is the date the CONTRACTOR
receives the claim, as

 

38

 

indicated by its date stamp
on the claim, and the date of payment is the date of the check or other form of
payment.

 

C.                                     CONTRACTOR’s Selection of Providers

 

1.                                       Credentialing and Recredentialing of
Providers

 

The CONTRACTOR will maintain
written policies and procedures for selection and retention of providers. The
CONTRACTOR will establish and follow a documented credentialing and
recredentialing process for providers who have signed contracts or
participation agreements to: (1) assure that clinical staff are appropriately
credentialed, e.g. that the individual has a current license, is in good
standing with licensing boards, etc., and (2) review records for any adverse
actions or sanctioning of CONTRACTOR’s staff by other states or the federal
government.

 

2.                                       No Discrimination

 

a.                                       The CONTRACTOR’s subcontractor selection
policies and procedures cannot discriminate against particular providers who
serve high-risk populations or specialize in conditions that require costly
treatment.

 

b.                                      The CONTRACTOR will not discriminate against
subcontracting providers with respect to participation, reimbursement, or
indemnification as to any provider who is acting within the scope of that
provider’s license or certification under applicable State law solely on the
basis of the provider’s license or certification. This may not be construed to
mean that the DEPARTMENT requires the CONTRACTOR to contract with providers
beyond the number necessary to meet the needs of its Enrollees; nor does it
preclude the CONTRACTOR from using different reimbursement amounts for
different specialities or for different practitioners in the same speciality;
nor does it preclude the CONTRACTOR from establishing measures that are
designed to maintain quality of services and control costs and are consistent
with its responsibilities to Enrollees.

 

c.                                       If the CONTRACTOR declines to include
individual or groups of providers in its network, it will give the affected
providers written notice of the reason for its decision.

 

3.                                       Ownership or Controlling Interest -
Disclosure to the DEPARTMENT

 

The CONTRACTOR will notify
the DEPARTMENT of any person or corporation that has five percent or more
ownership or controlling interest in the entity.

 

4.                                       Excluded Entities and Providers

 

a.                                       The CONTRACTOR will not employ or subcontract
with any individual who is under a current federal debarment, suspension,
sanction or exclusion from participation in federal health care programs under
either section 1128 or section 1128A of the Social Security Act (the Act), or
who has had his or

 

39

 

her license suspended or
revoked by any state.

 

b.                                      The CONTRACTOR may not knowingly have a
relationship described in 4.c. with the following:

 

(1)                                  an individual who is debarred, suspended or
otherwise excluded from participating in procurement activities under the
Federal Acquisition Regulation or from participating in non-procurement
activities under regulations issued under Executive Order No.12549 or under
guidelines implementing Executive Order No.12549; or

 

(2)                                  an individual who is an affiliate, as defined
in the Federal Acquisition Regulation, of a person described in 4.b(1).

 

c.                                       The CONTRACTOR will not knowingly have a
relationship of the following types with individuals identified in 4.b. above:

 

(1)                                  a director, officer, or partner of the CONTRACTOR;

 

(2)                                  a person with beneficial ownership of five
percent or more of the CONTRACTOR’s equity;

 

(3)                                  a person with an employment, consulting or
other arrangement with the CONTRACTOR for the provision of items and services
that are significant and material to the CONTRACTOR’s obligations under this
Contract with the DEPARTMENT.

 

d.                                      Effect of Non-Compliance  –  If
the DEPARTMENT finds that the CONTRACTOR is not in compliance with these
requirements, the DEPARTMENT will notify the Secretary of the Department of
Health and Human Services of the noncompliance.

 

(1)                                  The DEPARTMENT may continue the Contract with
the CONTRACTOR unless the Secretary directs otherwise.

 

(2)                                  The DEPARTMENT may not renew or otherwise
extend the duration of an existing Contract with the CONTRACTOR unless the
Secretary provides to the DEPARTMENT and to Congress a written statement
describing compelling reasons that exist for renewing or extending the
Contract.

 

5.                                       Federally Qualified Health Centers (FQHCs)

 

If  the CONTRACTOR enters into a subcontract with
a Federally Qualified Health Center (FQHC), the CONTRACTOR will reimburse the
FQHC an amount not less than what the CONTRACTOR pays comparable providers that
are not FQHCs.

 

40

 

Article VI - Authorization of Services and Notices of Action

 

F.                                      Service Authorization and Notice of Action

 

1.                                       Policies and Procedures for Service
Authorizations

 

The CONTRACTOR will
establish and follow written policies and procedure for processing requests for
initial and continuing authorization of Covered Services.

 

a.                                       The CONTRACTOR will implement mechanisms to
ensure consistent application of review criteria for service authorization
decisions and consult with the requesting provider when appropriate.

 

b.                                      The CONTRACTOR will ensure that any decision
to deny a service authorization request or to authorize a service in an amount,
duration, or scope that is less than requested, be made by a health care
professional who has appropriate clinical expertise in treating the Enrollee’s
condition or disease.

 

c.                                       The CONTRACTOR will notify the requesting
provider, and give the Enrollee written notice of any decision to deny a
service authorization request, or to authorize a service in an amount,
duration, or scope that is less than requested. The notice to the provider
need not be in writing. (See Section III, Content of Notice of Action,
below.)

 

2.                                      Process for the CONTRACTOR
to Request Payment Authorization of Services

 

Since this is a Non-risk
Contract, the total payments the DEPARTMENT reimburses the CONTRACTOR may not
exceed the upper limit payments specified in 447.362 and may be reimbursed by
the State at the end of the Contract period based on the CONTRACTOR’s incurred
costs. The payment authorization process is to ensure services will be included
in the CONTRACTOR’s incurred costs and in the upper payment limit when the
DEPARTMENT determines whether payments it made to the CONTRACTOR are more or
less than the upper payment limit.

 

This process also ensures
the CONTRACTOR is appropriately applying practice guidelines, making
utilization management decisions and is covering services for Enrollees
requiring special consideration based on their special needs.

 

a.                                       The CONTRACTOR may submit a request for
payment of services to the Bureau of Managed Health Care. The BMHC will review
payment requests when:

 

(1)                                  Medicaid does not have criteria, criteria is
not clearly defined, criteria does not address the unique medical condition, or
a procedure is a newly approved FDA procedure. Examples are:

 

(a)                                  Medicaid does not have criteria and it is a
unique condition – in order to save the life of a pregnant mother and acardiac
twin, patient needs highly specialized procedure only performed at an
out-of-state center of excellence; and

 

41

 

(b)                                 new FDA-approved technology –
magnetoencephalography is used to diagnose and assist neurosurgeons when
performing corrective brain surgery for refractory epilepsy and gliomas.

 

(2)                                  the service is beyond the limits of the
covered benefit, but is medically necessary and is in lieu of more costly
services. Examples are:

 

(a)                                  in order to prevent hospitalization,
additional home health or physical therapy services are necessary;

 

(b)                                 in order to prevent infections leading to a
hospitalization, patient’s condition requires more tracheostomy supplies than
what Medicaid typically covers;

 

(c)                                  patient requires more insulin pump reservoirs
than Medicaid typically covers based on the type and amount of insulin patient
uses.

 

b.                                      The CONTRACTOR submits the necessary
information to a BMHC nurse for review.  The
CONTRACTOR must include the following information in a written request
outlining:

 

(1)                                  the services the CONTRACTOR is asking the
BMHC to review;

 

(2)                                  the Enrollee’s name and Medicaid ID number;

 

(3)                                  Medicaid’s fee-for-service policy governing
the service;

 

(4)                                  information documenting medical necessity;

 

(5)                                  a copy of the practice guideline or medical
pathway the CONTRACTOR used to review the case;

 

(6)                                  a cost/benefit analysis with an outline of
any alternative solutions and associated costs;

 

(7)                                  the short term and long term plan for the
service and Enrollee;

 

(8)                                  verification that the CONTRACTOR’s medical
director has reviewed the case (including his/her recommendations); and

 

(9)                                  any additional pertinent documentation the
CONTRACTOR feels is necessary for the BMHC’s review.

 

c.                                       Once the BMHC has all necessary information,
a BMHC nurse reviews the request for approval or denial of payment. The BMHC
nurse may consult with medical and non-medical DEPARTMENT staff to verify the

 

42

 

appropriate interpretation
of Medicaid coverage. The BMHC nurse makes a recommendation to a physician
consultant who then reviews the request for approval or denial based on medical
necessity. Appropriate DEPARTMENT staff reviews high cost requests before they
are authorized for payment. Once the DEPARTMENT has determined whether the
request is authorized for payment, the BMHC nurse notifies the CONTRACTOR of
the decision. The BMHC and CONTRACTOR track all requests.

 

3.                                      Time Frames for Service
Authorization Decisions

 

The CONTRACTOR will adhere
to the following time frames for making service authorization decisions and
mailing Notices of Action to Enrollees and providers:

 

a.                                       Standard Service
Authorization Approvals

 

(1)                                  The CONTRACTOR will make a decision and
provide notice to the Enrollee and provider as expeditiously as the Enrollee’s
health condition requires, but no later than 14 calendar days from
receipt of the request for Service Authorization.

 

(2)                                  Extensions— The CONTRACTOR may extend the time frame for making the decision by
up to 14 additional calendar days if:

 

(a)                                  the Enrollee or the provider requests
extension; or

 

(b)                                 the CONTRACTOR justifies (to the DEPARTMENT
upon request) a need for additional information and how the extension is in the
Enrollee’s interest.

 

b.                                      Standard Service
Authorization Decisions to Deny or Authorize Less Than Requested and Notice of
Action

 

(1)                                  If the CONTRACTOR denies a Service
Authorization request, or  authorizes a
requested service in an amount, duration or scope that is less than requested,
the CONTRACTOR will make the decision and give a Notice of Action to the
Enrollee as expeditiously as the Enrollee’s health condition requires, but no
later than 14 calendar days from receipt of the request for Service
Authorization.

 

2)                                      The CONTRACTOR will also notify the
requesting provider, although the notice need not be in writing.

 

(3)                                  Extensions— The CONTRACTOR may extend the time frame for making the decision by
up to 14 additional calendar days if:

 

(a)                                  the Enrollee or the provider requests
extension; or

 

43

 

(b)                                 the CONTRACTOR justifies (to the DEPARTMENT
upon request) a need for additional information and how the extension is in the
Enrollee’s interest.

 

c.                                       Extension of
Time Frames for Standard Service Authorization Decisions

 

If the CONTRACTOR extends
the time frame for making standard Service Authorization decisions in
accordance with Section A.2 a. and A.2.b. above, the CONTRACTOR will:

 

(1)                                  give the Enrollee written notice of
the reason for the decision to extend the time frame;

 

(2)                                  inform the Enrollee of his or her right to
file a Grievance, and how to do so, if the Enrollee disagrees with that
decision (See Article VII, Grievance System, Section I., Grievances); and

 

(3)                                  issue and carry out the determination as
expeditiously as the Enrollee’s health condition requires and no later than the
date the extension expires.

 

d.                                      Expedited
Service Authorization Decisions

 

(1)                                  For cases in which a provider indicates, or
the CONTRACTOR determines (on a request from an Enrollee), that following the
standard time frame above could seriously jeopardize the Enrollee’s life or
health or ability to attain, maintain, or regain maximum function, the
CONTRACTOR will make an expedited authorization decision and provide notice as
expeditiously as the Enrollee’s health condition requires, but no later than three
working days after receipt of the request for Service Authorization.

 

2)                                      The CONTRACTOR will follow notification
requirements outlined in  2. a. and 2.b.
above.

 

(3)                                  Extensions– The CONTRACTOR may extend the three working-day time period by up to
14 calendar days if:

 

(a)                                  the Enrollee requests an extension; or

 

(b)                                 the CONTRACTOR justifies (to the DEPARTMENT
upon request) a need for additional information and how the extension is in the
Enrollee’s interest.

 

e.                                       Service
Authorization Decisions Not Reached Within Required Time Frames

 

For Service Authorization
decisions not reached within the time frames specified in paragraphs 2.a, 2.b.
and 2.d above, which constitutes a denial and is thus an adverse Action, the
CONTRACTOR will give a Notice of Action on the date that the time frame
expires.

 

44

 

f.                                         Decisions to Terminate, Suspend or Reduce
Previously Authorized Medicaid-Covered Services

 

If the CONTRACTOR
terminates, suspends or reduces previously authorized Medicaid-covered
services, and the Enrollee informs the CONTRACTOR that he or she disagrees with
the change in his or her treatment plan, this constitutes an Action. The
CONTRACTOR will notify the requesting provider and mail a Notice of Action to
the Enrollee as expeditiously as the Enrollee’s health condition requires and
within the following time frames:

 

(1)                                  at least 10 days before the date of
the Action; or

 

(2)                                  5 days before the date of the Action if the
CONTRACTOR has facts indicating that Action should be taken because of probable
fraud by theEnrollee, and the facts have been verified, if possible, through
secondary sources; or

 

(3)                                  by the date of the Action if:

 

(a)                                  the CONTRACTOR has factual information
confirming the death of the Enrollee;

 

(b)                                 the CONTRACTOR receives a clear written
statement signed by the Enrollee that:

 

(i)                                     he no longer wishes services; or

 

(ii)                                  he gives information that requires
termination or reduction of services and indicates that he understands that
this will be the result of supplying that information;

 

(c)                                  the Enrollee has been admitted to an
institution where he is ineligible for further services;

 

(d)                                 the Enrollee’s whereabouts are unknown and
the post office returns mail directed to him indicating no forwarding address. In
this case any discontinued services will be reinstated if his whereabouts
become known during the time is eligible for services;

 

(e)                                  the Enrollee has been accepted for Medicaid
services by another local jurisdiction; or

 

(f)                                    the Enrollee’s physician prescribes the change
in the level of medical care.

 

45

 

B.                                     Other Actions Requiring Notice of Action

 

1.                                      Action to Deny
Payment in Whole or Part for a Service

 

a.                                       The CONTRACTOR will notify the requesting
provider of decisions to deny payment in whole or in part.

 

b.                                      The CONTRACTOR will also mail the Enrollee a
written Notice of Action at the time of the Action affecting a claim, if the
denial reason is that (1) the service was not authorized by the CONTRACTOR, as
the Enrollee could be liable for payment if the Enrollee gave advance written
consent to the provider that he or she would pay for the specific service; (2)
the Enrollee requested continued benefits (services ) during an Appeal or State
fair hearing and the appeal or State fair hearing decision was adverse to the
Enrollee, or (3) the Enrollee was not eligible for Medicaid when the service
was provided.

 

A Notice of Action to the
Enrollee is not necessary under the following circumstances:

 

(1)                                  the provider billed the CONTRACTOR in error
for a non-authorized service; or

 

(2)                                  the claim included a technical error
(incorrect data including procedure code, diagnosis code,  Enrollee name or Medicaid identification
number, date of service, etc.); or

 

(3)                                  the Enrollee became eligible after the first
of the month, but received a service during that month before becoming Medicaid
eligible.

 

2.                                      Action Due to
Failure to Provide Covered Services in a Timely Manner

 

Failure of the CONTRACTOR’s
subcontractors to provide services in a timely manner constitutes an Action. The
CONTRACTOR will provide a Notice of Action to the Enrollee at the time either
the Enrollee or provider informs the CONTRACTOR that the provider failed to
meet the performance benchmarks for appointment waiting times as defined in
Article IX - Contractor Assurances, Section E - Access,  Subsection 4.e. - Waiting Time Benchmarks.

 

3.                                      Action Due to
Failure to Resolve Appeals and Grievances Within Required Time Frames

 

a.                                       Failure of the CONTRACTOR to act within the
time frames provided for resolving and giving resolution notice for Appeals or
Grievances constitutes an Action. The CONTRACTOR will provide a Notice of
Action to the Enrollee at the time the CONTRACTOR determines the time frame for
resolving the Appeal or the Grievance will not be met. (See Article VII,
Grievance Systems.)

 

b.                                      If the CONTRACTOR does not resolve an Appeal
within the required time frame, the Enrollee has already gone through the
CONTRACTOR’s appeal process. Therefore, by declaring the CONTRACTOR’s failure
to provide resolution of the Appeal within the required time frame an Action,
the Enrollee may now file a request for a State fair hearing as the Enrollee
has

 

46

 

already exhausted the
CONTRACTOR’s internal appeals process. The Enrollee need not go through the
CONTRACTOR’s internal appeals process again.

 

c.                                       For Notice of Action due to failure to
resolve an Appeal within the required time frame, the CONTRACTOR will include
in the Notice of Action the information specified in Article VII, Grievance
System, Section C., #5, Format and Content of Notice of Appeal Resolution,
regarding procedures and time frames for filing a request for a State fair
hearing (rather than information on filing an Appeal). The CONTRACTOR will also
attach to the Notice of Action a copy of the “Request for a Hearing/Agency
Action” form that the Enrollee will submit to request a State fair hearing.

 

C.                                    Content of Notice of Action

 

1.                                       The CONTRACTOR’s Notice of Action to the Enrollee
will be in writing and meet the language and format requirements outlined in
Article III (Marketing ...), Section D (Member Services), Subsection 1
(Enrollee Information Requirements), to ensure ease of understanding. The
notice to the provider need not be in writing.

 

2.                                       The written Notice of Action will explain the
following:

 

a.                                       the Action the CONTRACTOR has taken or
intends to take;

 

b.                                      the reason for the Action;

 

c.                                       the date the Action will become effective
when the Action is to terminate, suspend, or reduce a previously authorized
Covered Service (see Section A.2. f., of this Article);

 

d.                                      the Enrollee’s or the provider’s right to
file an Appeal of the Action with the CONTRACTOR and that providers may file an
Appeal for the Enrollee only with the Enrollee’s written consent (see Article
VII, Grievance System, Section C. Standard Appeals Process, #1, Authority to
File, item b.);

 

e.                                       the procedures for filing an Appeal (See
Article VII, Grievance System, Section C. Standard Appeals Process, and Section
D., Process for Expedited Resolution of Appeals);

 

f.                                         the circumstances under which expedited
resolution of the Appeal is available and how to request an expedited Appeal
resolution (see Article VII, Grievance System, Section D., Process for
Expedited Resolution of Appeals);

 

g.                                      the Enrollee’s right to have benefits
continue pending resolution of the Appeal of an Action to terminate, suspend or
reduce a previously authorized course of treatment that was ordered by an
authorized provider;

 

h.                                      how to request that benefits be continued,
and the circumstances under which the Enrollee may be required to pay the cost
of these services if the

 

47

 

Appeal decision is adverse
to the Enrollee, to the extent that they were furnished solely because of this
Contract requirement which is based on federal regulation in 42 CFR 438.420;
and (438.404(b)(7), and 438.420(d).

 

i.                                          the time frames for filing an Appeal:

 

(1)                                  If the Enrollee is not  requesting continuation of benefits
pending resolution of an Appeal of an Action to terminate, suspend or reduce a
previously authorized course of treatment that was ordered by an authorized
provider, and the original period covered by the original authorization has not
expired, the Enrollee, or the provider with the Enrollee’s written consent,
will file the Appeal within 30 days from the date on the CONTRACTOR’s
Notice of Action; or

 

2)                                      If the Enrollee is requesting
continuation of benefits pending resolution of an Appeal of an Action to terminate,
suspend or reduce a previously authorized course of treatment that was ordered
by an authorized provider, and the original period covered by the original
authorization has not expired, the Enrollee or provider will file the
Appeal on or before the later of the following:

 

(a)                                  within 10 days of the CONTRACTOR mailing the notice of
Action; or

 

(b)                                 by the intended effective date of the CONTRACTOR’s proposed Action.

 

Also
see Article VII, Grievance Systems, Section C., Standard Appeals Process, #2.,
Timing, and #3, Procedures, item b., and Section E., Continuation of Benefits
During the Appeal or State Fair Hearing Process.

 

D.                                    Attachment to Notice of Action - Written
Appeal Request Form

 

1.                                      General
Requirements

 

The CONTRACTOR will develop
and include as an attachment to the Notice of Action an Appeal Request form
that Enrollees may use as the written Appeal request for standard Appeals. This
form may also be used for expedited Appeal requests if the Enrollee chooses to
submit a written request for an expedited Appeal resolution, even though an
oral request is all that is required. (See Article VI, Section D., 2.)

 

The CONTRACTOR will not
include this attachment if the Notice of Action is due to the circumstances in
Section B. 3. above. For the Action specified in Section B.3. above, the
CONTRACTOR will provide a Notice of Action that informs Enrollees of their
State fair hearing rights and how to request a State fair hearing.

 

48

 

2.                                       Specific Content of Written Appeal Request
Form

 

The
form will:

 

a.                                       provide a prompt (through use of check boxes
or other means) for Enrollees to:

 

(1)                                  request expedited Appeal resolution if they
choose to submit a written request for an expedited Appeal resolution; and

 

(2)                                  request 
continuation of benefits, if applicable;

 

b.                                      provide a statement that if continuation of
benefits is requested when a previously authorized service is terminated,
suspended or reduced, that the Enrollee agrees that the CONTRACTOR may recover
from the Enrollee the cost of the services furnished while the Appeal is
pending if the Appeal decision is adverse to the Enrollee, to the extent that
the services were furnished solely because of the requirements of this Contract
that are based on federal regulation in 42 CFR 438.420;

 

c.                                       summarize assistance the Enrollee may request
to complete the Appeal Request form and how to request the assistance (see
Article VII, Grievance System, Section C., Standard Appeals Process, #3
Procedures, item e.); and

 

d.                                      include a reminder that if the Enrollee is
not requesting an expedited Appeal resolution and the Enrollee files an Appeal
orally, that the oral Appeal will be followed by a  written Appeal request within five working
days from the date of the oral filing. (See Article VII, Grievance System,
Section C., Standard Appeals Process, #3., Procedures, item b.)

 

E.                                    Compensation for
Utilization Management Activities

 

The CONTRACTOR will ensure
compensation to individuals or entities that conduct utilization management
activities is not structured so as to provide incentives for the individual or
entity to deny, limit, or discontinue Medically Necessary Services to any
Enrollee.

 

F.                                    Medical
Necessity Denials

 

When the CONTRACTOR
determines that a service will not be covered due to the lack of medical
necessity, the CONTRACTOR will send all documentation supporting their decision
to the DEPARTMENT for its review before the CONTRACTOR’s determination is
deemed final, when the following conditions are met:

 

4.                                       there are no established national standards
for determining medical necessity, and

 

2.                                       the DEPARTMENT does not have medical
necessity criteria for the service.

 

The DEPARTMENT will review
the documentation and determine what the DEPARTMENT’s decision would be
regarding coverage for the service. The DEPARTMENT and the CONTRACTOR will work
collaboratively in making a final decision on whether the service is to be
covered by the CONTRACTOR.

 

49

 

Article VII - Grievance Systems

 

C.                                     Overall Grievance System

 

The CONTRACTOR will have a
Grievance System for Enrollees that includes (1) a grievance process whereby an
Enrollee, or provider acting on behalf of an Enrollee, may communicate a
Grievance, (2) an appeals process whereby an Enrollee, or provider acting on
behalf of the Enrollee with the Enrollee’s written consent, may file an Appeal
of an Action (see Article I, Definitions, definition of Action), and (3)
procedures for an Enrollee, or a provider acting on behalf of an Enrollee, to
access the State’s fair hearing system.

 

D.                                    Special Requirements for Appeals

 

The CONTRACTOR’s process for
appeals will:

 

1.                                       provide that oral inquiries seeking to appeal
an Action are treated as an Appeal, to establish the earliest possible filing
date for the Appeal;

 

2.                                       ensure that the Enrollee or provider
understands that the oral Appeal will be confirmed in writing, no later than five
working days from the date of the oral filing, unless the Enrollee or the
provider requests an expedited resolution to the Appeal. These requests do not
require a follow-up written request. (see Section C. regarding expedited
resolution of Appeals, and Section C., item #3.b., below.);

 

3.                                       provide the Enrollee reasonable opportunity
to present evidence, and allegations of fact or law, in person as well as in
writing. The CONTRACTOR will inform the Enrollee of the limited time available
for this in the case of an expedited Appeal resolution; and

 

4.                                       provide the Enrollee and his or her
authorized representative opportunity, before and during the appeals process,
to examine the Enrollee’s case file, including medical records, and any other
documents and records considered during the appeals process:

 

a.                                       include as parties to the Appeal the Enrollee
and his or her representative, or

 

b.                                      the legal representative of a deceased
Enrollee’s estate.

 

C.                                    Standard Appeals
Process

 

1.                                      Authority to
File

 

a.                                       An Enrollee or his or her legally authorized
representative may file an Appeal; or

 

b.                                      A provider, acting on behalf of the Enrollee
and with the Enrollee’s written consent, may file an Appeal.

 

50

 

2.                                      Timing

 

c.                                       The Enrollee or provider may file an Appeal
of a Notice of Action within 30 calendar days from the date on the
CONTRACTOR’s Notice of Action (See Article VI, Authorization of Services and
Notices of Action.); or

 

b.                                      If the Action being appealed is to terminate,
suspend or reduce a previously authorized course of treatment, the services
were ordered by an authorized provider and the original period covered by the
original authorization has not expired, and the Enrollee want benefits to
continue during the Appeal process, then the Enrollee will file the Appeal on
or before the later of the following:

 

(1)                                  within 10 days of the Notice of Action; or

 

(2)                                  the intended effective date of the CONTRACTOR’s
proposed Action.

(See Section E. of this
Article, Continuation of Benefits During the Appeal or State Fair Hearing
Process.)

 

3.                                      Procedures

 

a.                                       The Enrollee or the provider may file an
Appeal either orally or in writing.

 

b.                                      Unless the Enrollee or provider requests an
expedited resolution of the Appeal (which does not require a written follow-up
request), the oral Appeal will be followed with a written, signed Appeal. The
written, signed Appeal will be received within five working days from
the date of the oral Appeal. (See Section D regarding expedited Appeal
resolutions.)

 

c.                                       A provider may file the written, signed
Appeal on behalf of the Enrollee and will include the Enrollee’s signed written
consent.

 

d.                                      If an Enrollee or provider requests an Appeal
orally, the CONTRACTOR will inform or remind the Enrollee or provider of the
following:

 

(1)                                  that the oral filing of an Appeal will be
followed with a written, signed appeal within five working days from the
date of the oral Appeal;

 

(2)                                  if applicable, that the provider can file an
Appeal only with the Enrollee’s attached written consent;

 

(3)                                  of the standardized form that can be used to
submit the Appeal in writing;

 

(4)                                  that if the Enrollee wants continuation of
benefits when the Action is to terminate, suspend or reduce a previously
authorized course of treatment, that this will be requested; and

 

(5)                                  to whom or where to send the written, signed
Appeal.

 

51

 

e.                                       The CONTRACTOR will give Enrollees any
reasonable assistance in completing required forms for submitting a written
Appeal or taking other procedural steps. Reasonable assistance includes, but is
not limited to, providing interpreter services and toll-free numbers that have
adequate TTY/TTD and interpreter capability.

 

f.                                         The CONTRACTOR will acknowledge receipt of
the Appeal either orally or in writing and explain to the Enrollee the process
that will be followed to resolve the Appeal.

 

g.                                      As per Section B. 3. of this Article, provide
the Enrollee reasonable opportunity to present evidence, and allegations of
fact or law, in person as well as in writing. The CONTRACTOR will inform the
Enrollee of the limited time available for this in the case of an expedited
Appeal resolution.

 

h.                                      As per Section B.4. of this Article, provide
the Enrollee and his or her authorized representative opportunity, before and
during the appeals process, to examine the Enrollee’s case file, including
medical records, and any other documents and records considered during the
appeals process:

 

(1)                                  include as parties to the Appeal the Enrollee
and his or her representative, or

 

(2)                                  the legal representative of a deceased
Enrollee’s estate.

 

i.                                          The CONTRACTOR will ensure that the
individuals who make the decision on an Appeal are individuals who (1) were not
involved in any previous level of review or decision-making and (2) who, if
deciding any of the following, are health care professionals who have the
appropriate clinical expertise, as determined by the DEPARTMENT, in treating
the Enrollee’s condition or disease:

 

(1)                                  an Appeal of a denial that is based on lack
of medical necessity; or

 

(2)                                  an Appeal that involves clinical issues.

 

4.                                      Time Frames for
Appeal Resolution and Notification

 

a.                                       The CONTRACTOR will resolve each Appeal, and
provide notice of resolution to affected parties as expeditiously as the
Enrollee’s health condition requires, but no later than  30 calendar days from the day the
CONTRACTOR receives the Appeal whether orally or in writing.

 

b.                                      Extension of Time Frame – The CONTRACTOR may extend the time frame
for resolving the Appeal and providing notice by up to 14 calendar days if:

 

(1)                                  the Enrollee requests the extension; or

 

(2)                                  the CONTRACTOR shows that there is need for
additional

 

52

 

information and how the
delay is in the Enrollee’s interest (upon DEPARTMENT request).

 

c.                                       If the CONTRACTOR extends the time frame, and
the extension was not requested by the Enrollee, the CONTRACTOR will give the
Enrollee written notice of the reason for the delay.

 

5.                                      Format and
Content of Notice of Appeal Resolution

 

The CONTRACTOR will provide
a written Notice of Appeal Resolution to the affected parties. The written
Notice of Appeal Resolution will include the following:

 

a.                                       the results of the Appeal resolution process
and the date it was completed; and

 

b.                                      for Appeals not resolved wholly in favor of
the Enrollee, the CONTRACTOR will include the following in the written Notice
of Appeal Resolution:

 

(1)                                  the right to request a State fair hearing and
how to do so;

 

(2)                                  the right to request continuation of benefits
if the Appeal decision is to terminate, suspend or reduce a previously
authorized course of treatment that was ordered by an authorized provider and
the original period covered by the original authorization has not expired;

 

(3)                                  how to request continuation of benefits;

 

(4)                                  a statement that the Enrollee may be liable
for the cost of services provided if the State fair hearing decision upholds
the CONTRACTOR’s Action;

 

(5)                                  the time frame for requesting a State fair
hearing when continuation of benefits is not requested and when continuation of
benefits is requested (see Section F, Duration of Continued or Reinstated Benefits,
#2, and Section H, State Fair Hearings, #1 and #2, of this Article); and

 

(6)                                  a copy of either: (a) the “Request for a
Standard Sate Fair Hearing/Agency Action” form or (b) the “Request for an
Expedited State Fair Hearing/Agency Action form that the Enrollee must complete
and submit to the DHCF to request a State fair hearing, and continuation of
benefits, if applicable. The CONTRACTOR will include a copy of the “Request for
an Expedited State Fair Hearing/Agency Action” form if the Enrollee had an expedited
Appeal.

 

(See Section E.,
Continuation of Benefits During the Appeal or State Fair Hearing Process,
Section F., Duration of Continued or Reinstated Benefits, and Section H., State
Fair Hearings, of this Article, for additional information on all of the
above.)

 

53

 

D.                                    Process for
Expedited Resolution of Appeals

 

1.                                      General
Requirements

 

The CONTRACTOR will
establish and maintain an expedited review process for Appeals, when the
CONTRACTOR determines (from a request from the Enrollee) or a provider
indicates (in making the Appeal request on the Enrollee’s behalf or supporting
the Enrollee’s request) that the time for a standard resolution could seriously
jeopardize the Enrollee’s life or health or ability to attain, maintain, or
regain maximum function.

 

2.                                      Authority to
File

 

The Enrollee, or a provider
with the Enrollee’s written consent, may file an expedited Appeal request either
orally or in writing.

 

54

 

3.                                       Timing

 

a.                                       The Enrollee or provider may file an Appeal
of a Notice of Action within 30 days from the date on the CONTRACTOR’s
Notice of Action (See Article VI, 
Authorization of Services and Notices of Action.)

 

b.                                      If the Action being appealed is to terminate,
suspend or reduce a previously authorized course of treatment, the services
were ordered by an authorized provider and the original period covered by the
original authorization has not expired, and the Enrollee want benefits to
continue during the Appeal process, then the Enrollee will file the Appeal on
or before the later of the following:

 

(1)                                  within 10 days of the Notice of Action; or

 

(2)                                  the intended effective date of the CONTRACTOR’s
proposed Action.

(See Section E. of this
Article, Continuation of Benefits During the Appeal or State Fair Hearing
Process.)

 

4.                                      Procedures

 

a.                                       When an Enrollee or provider requests an
expedited resolution of an Appeal, the CONTRACTOR will inform the Enrollee or
provider of the limited timeavailable for the Enrollee to present evidence and
allegations of fact or law, in person and in writing.

 

b.                                      The CONTRACTOR will ensure that punitive
action is not taken against a provider who either requests an expedited
resolution to an Appeal or supports an Enrollee’s Appeal.

 

c.                                       The CONTRACTOR will give Enrollees any
reasonable assistance in taking procedural steps. Reasonable assistance
includes, but is not limited to, providing interpreter services and toll-free
numbers that have adequate TTY/TTD and interpreter capability.

 

d.                                      The CONTRACTOR will acknowledge receipt of
the request for expedited Appeal resolution either orally or in writing and
explain to the Enrollee the process that will be followed to resolve the
Appeal;

 

e.                                       The CONTRACTOR will ensure that the
individuals who make the decision on an Appeal are individuals who (1) were not
involved in any previous level of review or decision-making and (2) who, if
deciding any of the following, are health care professionals who have the
appropriate clinical expertise, as determined by the DEPARTMENT, in treating
the Enrollee’s condition or disease:

 

55

 

(1)                                  an Appeal of a denial that is based on lack
of medical necessity; or

 

(2)                                  an Appeal that involves clinical issues;

 

f.                                         Denial of a Request for Expedited Appeal
Resolution– If the
CONTRACTOR denies a request for an expedited resolution of an Appeal, the
CONTRACTOR will:

 

(1)                                  transfer the Appeal to the standard time
frame of no longer than 30 calendar days from the day the CONTRACTOR
receives the Appeal, with a possible 14-calendar day extension for resolving
the Appeal and providing Notice of Appeal Resolution to affected parties;

 

(2)                                  make reasonable effort to give the Enrollee
prompt oral notice of the denial; and

 

(3)                                  mail written notice within two calendar
days explaining the denial, specifying the standard time frame that will be
followed, and informing the affected parties that the Enrollee may file a
Grievance regarding this denial of expedited resolution of the Appeal.

 

5.                                      Time Frame for
Expedited Appeal Resolution and Notification

 

a.                                       The CONTRACTOR will resolve each expedited
Appeal and provide notice to affected parties, as expeditiously as the Enrollee’s
health condition requires, but no later than 
three working days after the CONTRACTOR receives the expedited
Appeal request.

 

b.                                      Extension of Time Frame– The CONTRACTOR may extend the time frame
for resolving the Appeal and providing notice by up to 14 calendar days if:

 

(1)                                  the Enrollee requests the extension; or

 

(2)                                  the CONTRACTOR shows that there is need for
additional information and how the delay is in the Enrollee’s interest (upon
DEPARTMENT request).

 

(3)                                  If the CONTRACTOR extends the time frame, and
the extension was not requested by the Enrollee, the CONTRACTOR will
give the Enrollee written notice of the reason for the delay.

 

6.                                      Format and
Content of Expedited Appeal Resolution Notice

 

a.                                       The CONTRACTOR will make reasonable effort to
provide oral notice of the expedited resolution in addition to providing a written
Notice of Appeal Resolution.

 

b.                                      The CONTRACTOR will provide a written Notice
of Appeal Resolution that meets the same format and content requirements
outlined in Section C.,

 

56

 

Standard Appeals Resolution,
#5., Format and Content of Notice of Appeal Resolution.

 

E.                                    Continuation of
Benefits During Appeal or State Fair Hearing Processes

 

The CONTRACTOR will continue
the Enrollee’s benefits during the Appeal process if:

 

1.                                       the Action being appealed is to terminate,
suspend or reduce a previously authorized course of treatment;

 

2.                                       the services were ordered by an authorized
provider;

 

3.                                       the original period covered by the original
authorization has not expired;

 

4.                                       the Enrollee files the Appeal timely, which
means filing the Appeal on or before the later of the following:

 

a.                                       within 10 days of the Notice of Action; or

 

b.                                      the intended effective date of the CONTRACTOR’s
proposed Action; and

 

5.                                       the Enrollee requests extension of benefits
in the Appeal.

 

F.                                    Duration of
Continued or Reinstated Benefits

 

If the CONTRACTOR continues
or reinstates the Enrollee’s benefits, the CONTRACTOR will continue benefits
until one of the following occurs:

 

5.                                       the Enrollee withdraws the Appeal;

 

2.                                       10 days pass after the CONTRACTOR mails the written Notice of Appeal
Resolution and within that 10-day time period, the Enrollee does not
request a State fair hearing with continuation of benefits until a State fair
hearing decision is reached;

 

3.                                       a State fair hearing officer issues a hearing
decision adverse to the Enrollee; or

 

4.                                       the time period or service limits of a
previously authorized service has been met.

 

G.                                    Reversed Appeal
Resolutions

 

1.                                      Services Not
Furnished While the Appeal is Pending

 

If the CONTRACTOR or State
fair hearing officer reverses an Action to deny, limit, or delay services that
were not furnished while the Appeal was pending, the CONTRACTOR will authorize
or provide the disputed services promptly, and as expeditiously as the Enrollee’s
health condition requires.

 

57

 

2.                                      Services
Furnished While the Appeal is Pending

 

If the CONTRACTOR or the
State fair hearing officer reverses a decision to deny authorization of
services and the Enrollee received the disputed services while the Appeal was
pending, the CONTRACTOR will pay for those services in accordance with State
policy and regulations.

 

H.                                    State Fair Hearings

 

When the Enrollee or
provider has exhausted the CONTRACTOR’s Appeal decision and a final decision
has been made, the CONTRACTOR will provide written notification to the party
who initiated the Appeal of the outcome and explain in clear terms a
detailed  reason for the denial.

 

The CONTRACTOR will provide
notification to Enrollees and providers that the final decision of the
CONTRACTOR may be appealed to the DEPARTMENT and will give to the Enrollee and
provider the DEPARTMENT’s form to request a State fair hearing. The Health Plan
will inform the Enrollee and provider the time frame for requesting a State
fair hearing.

 

1.                                       The DEPARTMENT will permit Enrollees and providers,
acting as an Enrollee’s authorized representative, to request a State fair
hearing within 30 days from the date of the CONTRACTOR’s Notice of Appeal
Resolution.

 

2.                                       However, if the Enrollee wants to continue
benefits pending the outcome of the State fair hearing, when a previously
authorized course of treatment has been terminated, suspended or reduced, the
services were ordered by an authorized provider and the original period covered
by the original authorization has not expired, the request for a State fair
hearing and continuation of benefits will be submitted within 10 days
after the CONTRACTOR mails the Notice of Appeal Resolution. (See Section E.,
Duration of Continued or Reinstated Benefits, above.)

 

3.                                       The parties to the State fair hearing include
the CONTRACTOR as well as the Enrollee and his or her representative which may
include legal counsel, a relative, a friend or other spokesman, or the
representative of a deceased Enrollee’s estate.

 

4.                                       The Enrollee or his or her representative, will
be given an opportunity to examine at a reasonable time before the date of the
hearing and during the hearing, the content of the Enrollee’s case file and all
documents and records to be used by the

 

58

 

CONTRACTOR.

 

5.                                       The Enrollee will also be given the
opportunity to:

 

a.                                       bring witnesses;

 

a.                                       establish all pertinent facts and
circumstances;

 

b.                                      present an argument without undue
interference; and

 

59

 

c.                                       question or refute any testimony or evidence,
including opportunity to confront and cross-examine adverse witnesses.

 

6.                                       The State fair hearing with the DEPARTMENT is
a de novo hearing. If the Enrollee or provider requests a State fair hearing
with the DEPARTMENT, all parties to the hearing are bound by the DEPARTMENT’s
decision until any judicial reviews are completed and are in the Enrollee’s or
provider’s favor. Any decision made by the DEPARTMENT pursuant to the hearing
will be subject to appeal rights as provided by State and Federal laws and
rules.

 

7.                                       The Enrollee will be notified in writing of
the State fair hearing decision and any appeal rights as provided by State and
Federal laws and rules.

 

8.                                       Standard resolution requests– The DEPARTMENT will reach its hearing
decision within 90 (calendar) days from the date the Enrollee filed the Appeal
with the CONTRACTOR.

 

9.                                       Expedited Appeal resolution requests – The DEPARTMENT will reach its hearing
decision within three working days from the date the DEPARTMENT receives a
State fair hearing request for a denial of a service that:

 

a.                                       meets the criteria for the expedited appeal
process but was not resolved using the CONTRACTOR’s required expedited Appeal
time frames; or

 

b.                                      was resolved wholly or partially adversely to
the Enrollee using the CONTRACTOR’s expedited Appeal time frames.

 

I.                                         Grievances

 

1.                                       Authority to File

 

b.                                      An Enrollee may file a Grievance; or

 

b.                                      A provider, acting on behalf of the Enrollee
as an authorized representative, may file a Grievance.

 

2.                                      Procedures

 

a.                                       The Enrollee or the provider may file a
Grievance either orally or in writing.

 

b.                                      The CONTRACTOR will give Enrollees any
reasonable assistance in completing required forms for submitting a written
Grievance or taking other procedural steps. Reasonable assistance includes, but
is not limited to providing interpreter services and toll-free numbers that
have adequate TTY/TTD and interpreter capability.

 

c.                                       The CONTRACTOR will acknowledge receipt of
the Grievance either orally or in writing.

 

d.                                      The CONTRACTOR will ensure that the
individuals who make the decision on a Grievance are individuals who (1) were
not involved in any previous

 

60

 

level of review or
decision-making, if applicable to the nature of the Grievance and (2) who, if
deciding any of the following, are health care professionals who have the
appropriate clinical expertise, as determined by the DEPARTMENT, in treating
the Enrollee’s condition or disease:

 

(1)                                  a Grievance regarding denial of a request for
an expedited resolution of an Appeal; or

 

(2)                                  a Grievance that involves clinical issues.

 

3.                                      Time Frames for
Grievance Disposition and Notification

 

a.                                       The CONTRACTOR will dispose of each Grievance
and provide notice to the affected parties as expeditiously as the Enrollee’s
health condition requires, but not to exceed 45 calendar days from the
day the CONTRACTOR receives the Grievance.

 

b.                                      For written Grievances, the CONTRACTOR will
notify the affected parties in writing of the disposition of the Grievance. For
Grievances received orally, the CONTRACTOR will notify the affected parties of
the disposition either orally or in writing.

 

c.                                       If the Enrollee, or a provider on behalf of
an Enrollee, files a Grievance with the DEPARTMENT, the DEPARTMENT will apprize
the Enrollee, or the provider on behalf of the Enrollee, of his or her right to
file the Grievance with the CONTRACTOR and how to do so.

 

1)                                      If the Enrollee or provider prefers, the
DEPARTMENT will promptly notify the CONTRACTOR both orally and in writing of
the Enrollee’s Grievance in his or her behalf.

 

2)                                      The CONTRACTOR will follow the procedures and
time frames outlined above for Grievances.

 

3)                                      The CONTRACTOR will notifying the affected
parties, including the DEPARTMENT, in writing of the disposition of the
grievance.

 

d.                                      Extension of Time Frame – The CONTRACTOR may
extend the time frame for disposing of the Grievance and providing notice by up
to 14 calendar days if:

 

(1)                                  the Enrollee requests the extension; or

 

(2)                                  the CONTRACTOR shows that there is need for
additional information and how the delay is in the Enrollee’s interest (upon
DEPARTMENT request).

 

(3)                                  If the CONTRACTOR extends the time frame, and
the extension was not requested by the Enrollee, the CONTRACTOR will give the
Enrollee written notice of the reason for the delay.

 

61

 

J.                                        Documentation

 

The CONTRACTOR will maintain
complete records of all Appeals and Grievances and submit semi-annual reports
summarizing Appeals and Grievances using DEPARTMENT-specified reporting
templates. The CONTRACTOR will separately track Grievances and Appeals that are
related to Children with Special Health Care Needs and those related to
Non-Traditional Medicaid Enrollees. (See Article XIII, Records and Reporting
Requirements, C.3.c.)

 

1.                                       Appeals

 

The CONTRACTOR will maintain
documentation including but not limited to:

 

a.                                       written Notices of Action;

 

b.                                      a log of all oral Appeals and oral requests
for expedited resolution of Appeals, including:

 

(1)                                  date of the oral requests;

 

(2)                                  date of acknowledgment of oral requests for
expedited resolution of Appeals and method of acknowledgment (i.e., orally or
in writing);

 

(3)                                  date of denials of requests for expedited
Appeal resolution; and

 

4)                                      date of attempt to give prompt oral notice;

 

c.                                       copies of written standard Appeal requests;

 

d.                                      copies of written notices of denial of
requests for expedited Appeal resolution;

 

e.                                       date of acknowledgment of  written standard Appeal requests and method
of acknowledgment (i.e., orally or in writing);

 

f.                                         copies of written notices when extending the
time frame for adjudicating standard or expedited Appeals when the CONTRACTOR
initiates the extension;

 

g.                                      copies of written Notices of Appeal
Resolution; and

 

h.                                      any other pertinent documentation needed to
maintain a complete record of all Appeals and to demonstrate that Appeals were
adjudicated according to the Contract provisions governing Appeals.

 

2.                                       Grievances

 

a.                                       Oral Grievances - Using its previously established verbal
complaint logging and tracking system, the CONTRACTOR will log all oral
Grievances and include the following:

 

(1)                                  date the Grievance was received;

 

62

 

(2)                                  date and method of acknowledgment (i.e.,
orally or in writing);

 

(3)                                  name of person taking the Grievance;

 

(4)                                  date of resolution and summary of the
resolution;

 

(5)                                  name of person resolving the Grievance; and

 

(6)                                  date the Enrollee was notified of the
resolution and how the Enrollee was notified (either orally or in writing). If
the Enrollee was notified of the disposition in writing, the CONTRACTOR will
maintain a copy of the written notification.

 

b.                                      Written Grievances - The CONTRACTOR will maintain all written
Grievances and copies of the written notices of resolution to the affected
parties.

 

Article VIII - Enrollee Rights and Protections

 

A.                                    Written Information on
Enrollee Rights and Protections - General Requirements

 

1.                                       The CONTRACTOR will develop and maintain
written policies regarding Enrollee rights and protections.

 

2.                                       The CONTRACTOR will comply with any
applicable Federal and State laws that pertain to Enrollee rights and ensure
that its staff and subcontracting providers take those rights into account when
furnishing services to Enrollees.

 

3.                                       The CONTRACTOR will ensure information on
Enrollee rights and protections is provided to all Enrollees by including its
Patient Rights statement in its member handbook. (See Article III, Marketing
...., Section D, Member Education, 2.o.)

 

4.                                       The CONTRACTOR will ensure Enrollees are free
to exercise their rights, and that the exercise of those rights will not
adversely affect the way the CONTRACTOR and its subcontractors treat Enrollees.

 

B.                                     Specific Enrollee Rights and Protections

 

The CONTRACTOR will include
all of the following Enrollee rights and protections in its written Patient
Rights statement:

 

1.                                       the right to receive information about this
Health Plan;

 

2                                          the right to be treated with respect and with
due consideration for his or her dignity and privacy;

 

3.                                       the right to receive information on available
treatment options and alternatives, presented in a manner appropriate to the
Enrollee’s condition and ability to

 

63

 

understand;

 

4.                                       the right to participate in treatment
decisions regarding his or her health care, including the right to refuse
treatment;

 

5.                                       the right to be free from any form of
restraint or seclusion used as a means of coercion, discipline, convenience, or
retaliation, as specified in other Federal regulations on the use of restraints
and seclusion;

 

6.                                       If the privacy rule, as set forth in 45 CFR
parts 160 and 164 subparts A and E, applies, the right to request and receive a
copy of his or her medical records, and to request that they be amended or
corrected, as specified in 45 CFR, sections 164.524 and 154.526;

 

7.                                       the right to be furnished health care
services in accordance with access and quality standards; and

 

8.                                       the right to be free to exercise all rights
and that by exercising those rights, the Enrollee will not be adversely treated
by the CONTRACTOR and its providers.

 

C.                                     Provider - Enrollee Communications

 

1.                                       General Rules

 

The CONTRACTOR will
communicate with its health care professionals that when acting within the lawful
scope of their practice, they will not be prohibited from advising or
advocating on behalf of an Enrollee for the following:

 

a.                                       the Enrollee’s health status, medical care,
or treatment options, including any alternative treatment that may be self-administered;

 

b.                                      any information the Enrollee needs in order
to decide among all relevant treatment options;

 

c.                                       the risks, benefits, and consequences of
treatment or non-treatment; and

 

d.                                      the Enrollee’s right to participate in
decisions regarding his or her health care, including the right to refuse
treatment, and to express preferences about future treatment decisions.

 

2.                                       Objection to Services on Moral or Religious
Grounds

 

Subject to the information
requirements below, if the CONTRACTOR that would otherwise be required to
provide, reimburse for, or provide coverage of, a counseling or referral
service because of the requirement  in
C.1 in this section, is not required to do so if the CONTRACTOR objects to the
service on moral or religious grounds. If the CONTRACTOR elects this option,
the CONTRACTOR will

 

a.                                       furnish information to the DEPARTMENT about
the services it does not cover prior to signing this Contract or whenever it
adopts the policy during

 

64

 

the
term of the Contract; and

 

b.                                      furnish the information to Potential
Enrollees, before and during enrollment and to Enrollees, within 90 days after
adopting the policy with respect to any service.

 

Article IX - Contractor Assurances

 

A.                                    Nondiscrimination

 

The CONTRACTOR will
designate a nondiscrimination coordinator who will 1) ensure the CONTRACTOR
complies with Federal Laws and Regulations regarding nondiscrimination, and 2)
take Grievances from Enrollees alleging nondiscrimination violations based on
race, color, national origin, disability, or age. The nondiscrimination
coordinator may also handle Grievances regarding the violation of other civil
rights (sex and religion) as other Federal laws and Regulations protect against
these forms of discrimination. The CONTRACTOR will develop and implement a
written method of administration to assure that the CONTRACTOR’s programs,
activities, services, and benefits are equally available to all persons without
regard to race, color, national origin, disability, or age.

 

B.                                    Member Services Function

 

The CONTRACTOR will operate
a Member Services function during regular business hours. Ongoing training, as
necessary, will be provided by the CONTRACTOR to ensure that the Member
Services staff is conversant in the CONTRACTOR’s policies and procedures as
they relate to Enrollees. At a minimum, Member Services staff will be
responsible for the following:

 

1.                                       Explaining the CONTRACTOR’s rules for
obtaining services;

 

2.                                       Assisting Enrollees to select or change
primary care providers;

 

3.                                       Fielding and responding to Enrollee questions
and the Grievance System.

 

The CONTRACTOR will conduct
ongoing assessment of its orientation staff to determine staff members’
understanding of the Health Plan and its Medicaid managed care policies and
provide training, as needed.

 

C.                                     Provider Services Function

 

The CONTRACTOR will operate
a Provider Services function during regular business hours. At a minimum,
Provider Services staff will be responsible for the following:

 

1.                                       Training, including ongoing training, of the
CONTRACTOR’s providers on Medicaid rules and regulations that will enable
providers to appropriately render services to Enrollees;

 

65

 

2.                                       Assisting providers to verify whether an individual
is enrolled with the Health Plan;

 

3.                                       Assisting providers with prior authorization
and referral protocols;

 

4.                                       Assisting providers with claims payment
procedures;

 

5.                                       Fielding and responding to provider questions
and the Grievance System.

 

D.                                    Enrollee
Liability

 

The CONTRACTOR will not hold
an Enrollee liable for the following:

 

1.                                       The debts of the CONTRACTOR if it should
become insolvent.

 

2.                                       Payment for services provided by the
CONTRACTOR if the CONTRACTOR has not received payment from the DEPARTMENT for
the services, or if the provider, under contract with the CONTRACTOR, fails to
receive payment from the CONTRACTOR.

 

3.                                       The payments to providers that furnish
Covered Services under a contract or other arrangement with the CONTRACTOR that
are in excess of the amount that normally would be paid by the Enrollee if the
service had been received directly from the CONTRACTOR.

 

E.                                    Access

 

1.                                       Basic Rule

 

The CONTRACTOR will provide
the DEPARTMENT adequate assurances and supporting documentation that demonstrates
the CONTRACTOR has the capacity to serve the expected enrollment in its Service
Area in accordance with the DEPARTMENT’s standards for access to care.

 

2.                                       Nature of Supporting Documentation

 

The CONTRACTOR will provide
the DEPARTMENT documentation, in a format specified by the DEPARTMENT that the
CONTRACTOR offers an appropriate range of preventive, primary care and
speciality services that is adequate for the anticipated number of Enrollees
for the Service Area, maintains a network of providers that is sufficient in
number, mix and geographic distribution to meet the anticipated number of
Enrollees in the Service Area.

 

3.                                       Timing of Documentation

 

The CONTRACTOR will submit
to the DEPARTMENT the documentation assuring adequate capacity and services in
the DEPARTMENT-specified format no less frequently than:

 

a.                                       at the time it enters into a contract with
the DEPARTMENT;

 

b.                                      at any time there has been a significant
change (as defined by the

 

66

 

DEPARTMENT) in the
CONTRACTOR’s operations that would affect adequate capacity and services
including changes in services, benefits, geographic Service Area or payments,
or enrollment of a new population in the Health Plan.

 

4.                                      Specific
Provisions

 

a.                                      Elimination of Access
Problems Caused by Geographic, Cultural and Language Barriers and Physical
Disabilities

 

The
CONTRACTOR will minimize, with a goal to eliminate, Enrollee’s access problems
due to geographic, cultural and language barriers, and physical disabilities. The
CONTRACTOR will provide assistance to Enrollees who have communication
impediments or impairments to facilitate proper diagnosis  and treatment. The CONTRACTOR will guarantee
equal access to services and benefits for all Enrollees by making available interpreters,
Telecommunication Devices for the Deaf (TDD), and other auxiliary aids to all
Enrollees as needed. The CONTRACTOR will accommodate Enrollees with physical
and other disabilities in accordance with the American Disabilities Act of 1990
(ADA), as amended. If the CONTRACTOR’s facilities are not accessible to
Enrollees with physical disabilities, the CONTRACTOR will provide services in
other accessible locations.

 

b.                                      Interpretive
Services

 

The CONTRACTOR will provide
oral interpretive services available free of charge for all non-English
languages, not just those the DEPARTMENT identifies as prevalent, on an as
needed basis. These requirements will extend to both in-person and telephone
communications to ensure that Enrollees are able to communicate with the
CONTRACTOR and CONTRACTOR’s providers and receive Covered Services. Professional
interpreters will be used when needed where technical, medical, or treatment
information is to be discussed, or where use of a Family Member or friend as
interpreter is inappropriate. A family member or friend may be used as an
interpreter if this method is requested by the patient, and the use of such a
person would not compromise the effectiveness of services or violate the
patient’s confidentiality, and the patient is advised that a free interpreter
is available.

 

c.                                       Cultural Competence Requirements

 

The CONTRACTOR will
participate in the DEPARTMENT’s efforts to promote

 

67

 

the delivery of services in
a culturally competent manner to all Enrollees, including those with limited
English proficiency and diverse cultural and ethnic backgrounds. The CONTRACTOR
will incorporate in its policies, administration, and delivery of services the
values of honoring Enrollee’s beliefs; being sensitive to cultural diversity;
and promoting attitudes and interpersonal communication styles with staff and
providers which respect Enrollees’ cultural backgrounds. The CONTRACTOR will
foster cultural competency among its providers. Culturally competent care is
care given by a provider who can communicate with the Enrollee and provide care
with sensitivity, understanding, and respect for the Enrollee’s culture,
background and beliefs. The CONTRACTOR will strive to ensure its providers
provide culturally sensitive services to Enrollees. These services will include
but are not limited to providing training to providers regarding how to promote
the benefits of health care services as well as training about health care
attitudes, beliefs, and practices that affect access to health care services.

 

d.                                      No Restrictions
of Provider’s Ability to Advise and Counsel

 

The CONTRACTOR may not
restrict a health care provider’s ability to advise and counsel Enrollees about
Medically Necessary treatment options. All contracting providers acting within
his or her scope of practice, will be permitted to freely advise an Enrollee
about his or her health status and discuss appropriate medical care or
treatment for that condition or disease regardless of whether the care or
treatment is a Covered Service.

 

e.                                       Waiting Time
Benchmarks

 

The CONTRACTOR will adopt
benchmarks for waiting times for physician appointments as follows:

 

Waiting Time for
Appointments

 

(1)                                  Primary Care Providers:

 

(a)                                  within 30 days for routine, non-urgent
appointments

 

(b)                                 within 60 days for school physicals

 

(c)                                  within 2 days for urgent, symptomatic, but
not life-threatening care (care that can be treated in the doctor’s office)

(2)                                  Specialists:

 

(a)                                  within 30 days for non-urgent care

 

(b)                                 within 2 days for urgent, symptomatic, but
not life-threatening care (care that can be treated in a doctor’s office)

 

68

 

These benchmarks do not
apply to appointments for regularly scheduled visits to monitor a chronic
medical condition if the schedule calls for visits less frequently than once
every month.

 

F.                                    Coordination and
Continuity of Care

 

1.                                      In General

 

The CONTRACTOR will ensure
access to a coordinated, comprehensive and continuous array of needed services through
coordination with other appropriate entities. The CONTRACTOR will implement
procedures to coordinate the services the CONTRACTOR furnishes to the Enrollee
with the services the Enrollee receives from any other MCO, PIHP, or PAHP. The
CONTRACTOR will ensure that in the process of coordinating care, each Enrollee’s
privacy is protected in accordance with the privacy requirements in 45 CFR
parts 160 and 164, subparts A and E, to the extent that they are applicable. The
CONTRACTOR’s providers are not responsible for rendering Home and
Community-Based Waiver services.

 

2.                                       Primary Care

 

a.                                       The CONTRACTOR will implement procedures to
deliver primary care to and coordinate health care services for all Enrollees. The
CONTRACTOR will implement procedures to ensure that each Enrollee has an
ongoing source of primary care appropriate to his or her needs and a person or
entity formally designated as primarily responsible for coordinating the health
care services furnished to the Enrollee.

 

b.                                      The CONTRACTOR will allow Enrollees the
opportunity to select a participating Primary Care Provider. This excludes
clients who are under the Restriction Program. If an Enrollee’s Primary Care
Provider ceases to participate in the CONTRACTOR’s network, the CONTRACTOR will
offer the Enrollee the opportunity to select a new Primary Care Provider.

 

3.                                       Prepaid Mental Health Plan

 

a.                                       When an Enrollee is also enrolled in a
Prepaid Mental Health Plan, the CONTRACTOR and Prepaid Mental Health Plan will
share appropriate information regarding the Enrollee’s health care to ensure
coordination of physical and mental health care services.

 

b.                                      The CONTRACTOR will educate its subcontracted
providers regarding an effective model of coordination such as the model
developed by the PMHP/Health Plan Coordination of Care Committee. The
CONTRACTOR will ensure its subcontracted providers coordinate the provision of
physical health care services with mental health care services as appropriate.

 

a.                                       When an Enrollee is also enrolled in a
Prepaid Mental Health Plan, the CONTRACTOR will not delay an Enrollee’s access
to needed services in disputes regarding responsibility for payment. Payment
issues should be

 

69

 

addressed only after needed
services are rendered. As described in Attachment B, IV (Benefits), Section E
(Clarification of Covered Services), Subsection 8 of this Contract, the
independent panel established by the DEPARTMENT will assist in adjudicating
such disputes when requested to do so by either party.

 

b.                                      Clients enrolled in the Health Plan and a
Prepaid Mental Health Plan who due to a psychiatric condition require lab,
radiology and similar outpatient services covered under this Contract, but
prescribed by the Prepaid Mental Health Plan physician, will have access to
such services in a timely fashion. The CONTRACTOR and Prepaid Mental Health
Plan will reduce or eliminate unnecessary barriers that may delay  the Enrollee’s access to these critical
services.

 

4.                                       Restriction Program

 

a.                                       The CONTRACTOR will provide care coordination
for its Restricted Enrollees. The CONTRACTOR will provide staff who will ensure
that all Enrollees who are on the Restriction Program have a contact person to
call when they have access problems, physician or pharmacy change request, or
other questions or problems. The CONTRACTOR will provide the following services
related to the Restriction Program:

 

(1)                                  Provide the Enrollee an initial orientation
about the Restriction Program and ongoing education on the appropriate use of
medical services;

 

(2)                                  Ensure access to necessary care, including
urgent care and emergent care;

 

(3)                                  Maintain a standardized care coordination
& Restriction plan in conjunction with the Enrollee’s Primary Care Provider
(PCP). Review and update as needed. When a personalized care plan is developed,
submit copies to the DEPARTMENT to be included in the Enrollee’s Restriction
case file;

 

(4)                                  Work with the Restriction pharmacy,
specialists, dentists, etc. by sharing pertinent information regarding the
Enrollee;

 

(5)                                  Provide information to the DEPARTMENT’s
Restriction staff that will help assess Restriction Enrollees’ progress and
that may include periodic written or telephonic evaluations when requested by
the Restriction staff;

 

(6)                                  Ensure a single point of contact for
restricted members to allow effective care coordination by the CONTRACTOR staff.
The CONTRACTOR is authorized to accept, approve or forward the following to the
DEPARTMENT’s Restriction Program staff:

 

(a)                                  Accept and forward requests for overrides on
pharmacy

 

70

 

claims according to DUR
regulations (i.e. cumulative, early refill, non-covered, non-concurrent
policies, etc.) to the DEPARTMENT.

 

(b)                                 Accept and approve PCP changes according to
program guidelines; contact the PCP for affirmation of his/her acceptance on
each individual enrollee prior to approving them as an Enrollee’s PCP; and
coordinate changes with the Restriction Program staff.

 

(c)                                  Accept and forward pharmacy change requests
to the DEPARTMENT’s Restriction staff and coordinate changes with the
Restriction Program staff.

 

b.                                      The CONTRACTOR will ensure that Enrollees who
are on the Restriction Program are linked to a PCP who agrees to serve as a
Restriction PCP. The Restriction PCP will agree to the following:

 

(1)                                  manage all of the Enrollee’s medical care;

 

(2)                                  educate the Enrollee regarding appropriate
use of medical services;

 

(3)                                  provide a referral to another physician when
needed care is not within the PCP’s field of expertise, or when for some other
reason the care cannot be provided by the PCP;

 

(4)                                  will be telephonically available 24 hours a
day, seven days a week (or make certain a provider of comparable specialty is
available) for urgent/emergent medical situations to assure the availability of
prompt, quality, medical services and continuity of care;

 

(5)                                  manage acute and/or chronic long term pain
through a variety of services or treatment options including office calls,
medication administration, physical therapy, counseling and mental health
referral with emphasis on teaching Enrollees to manage their pain by adapting
actions and behaviors;

 

(6)                                  approve or deny drugs prescribed by other
providers when contacted by the pharmacy to which the Enrollee is restricted;

 

(7)                                  work with the Restriction pharmacy,
specialists, dentists, etc. sharing pertinent information regarding the
Enrollee; and

 

(8)                                  provide information to the DEPARTMENT’s
Restriction staff that will help assess Restriction Enrollees’ progress and
that may include periodic written or telephonic evaluations when requested by
the Restriction staff.

 

c.                                       If the Restricted Enrollee’s PCP chooses to
no longer serve as the Enrollee’s PCP, the CONTRACTOR will assist the Enrollee
in finding a new PCP and

 

71

 

coordinate with the
DEPARTMENT’s Restriction staff.

 

d.                                      If a Restriction PCP ceases participation
with the CONTRACTOR, the CONTRACTOR will communicate this immediately to the
DEPARTMENT’s Restriction staff. The CONTRACTOR will assist all affected
Enrollees in finding a new PCP and notify the DEPARTMENT when the new PCP is
selected.

 

G.                                    Billing
Enrollees

 

1.                                      In General

 

Except as provided in this
Article IX, Section G,, Subsection 2, no claim for payment will be made at any
time by the CONTRACTOR or its providers to an Enrollee accepted by that
provider as an Enrollee for any Covered Service. When a provider accepts an
Enrollee as a patient he or she will look solely to the CONTRACTOR and any
third party coverage for reimbursement. If the provider fails to receive
payment from the CONTRACTOR, the Enrollee cannot be held responsible for these
payments.

 

2.                                      Circumstances
When an Enrollee May be Billed

 

An Enrollee may in certain
circumstances be billed by the provider for non-Covered Services and/or for
unpaid Medicaid co-payments or Medicaid co-insurance. A non-Covered Service is
one that is not covered under this Contract, or includes special features or
characteristics that are desired by the Enrollee, such as more expensive
eyeglass frames, hearing aids, custom wheelchairs, etc., but do not meet the
Medical Necessity criteria for amount, duration, and scope as set forth in the
Utah State Plan or is not authorized by the CONTRACTOR. The  DEPARTMENT will specify to the CONTRACTOR the
extent of Covered Services and items under the Contract, as well as services
not covered under the Contract but provided by Medicaid on a fee-for-service
basis that would effect the CONTRACTOR’s Covered Services. An Enrollee may be
billed for a service not covered under this Contract and/or for unpaid Medicaid
co-payment or co-insurance only when all of the following conditions are met:

 

a.                                       the provider has an established policy for
billing all patients for services not covered by a third party and/or for billing
all patients for unpaid co-payment or co-insurance (non-Covered Services cannot
be billed only to Enrollees.);

 

b.                                      the provider has informed the Enrollee of its
policy and the services and items that are not covered under this Contract
and/or Medicaid co-payment or co-insurance requirements and included this
information in the Enrollee’s member handbook;

 

c.                                       the provider has advised the Enrollee prior
to rendering the service that the service is not covered under this Contract
and/or that a Medicaid co-payment or co-insurance is required and that the
Enrollee will be personally responsible for making payment; and

 

72

 

d.                                      in the case of non-Covered Services, the
Enrollee agrees to be personally responsible for the payment of the non-Covered
Service and an agreement is made in writing between the provider and the
Enrollee which details the service and the amount to be paid by the Enrollee.

 

3.                                      CONTRACTOR May
Not Hold Enrollee’s Medicaid Card

 

The CONTRACTOR or its
providers will not hold the Enrollee’s Medicaid card as guarantee of payment by
the Enrollee, nor may any other restrictions be placed upon the Enrollee.

 

4.                                      Criminal
Penalties

 

Criminal penalties will be
imposed on Health Plan providers as authorized under section 1128B(d)(1)of the
Social Security Act if the provider knowingly and willfully charges an Enrollee
at a rate other than those allowed under this Contract.

 

H.                                    Survey Requirements

 

Surveys will be conducted of
the CONTRACTOR’s Enrollees that will include questions about  Enrollees’ perceptions of access to and the
quality of care received through the CONTRACTOR. The survey process, including
the survey instrument, will be standardized and developed collaboratively among
the DEPARTMENT and all contracting Health Plans. The DEPARTMENT will analyze
the results of the surveys. The CONTRACTOR’s quality assurance committee will
review the results of the surveys, identify areas needing improvement, outline
action steps to follow up on findings, and inform (at a minimum),
subcontractors, and member and provider services staff, when applicable.

 

9.                                       General Population Survey

 

At least every two years,
the CONTRACTOR in conjunction with the DEPARTMENT will survey a sample of its
general population Enrollees; i.e., Enrollees who do not meet the definition of
those with special health care needs.

 

2.                                       Special Needs Survey

 

At least every two years,
the CONTRACTOR, in conjunction with the DEPARTMENT, will survey a sample of
Enrollees with special health care needs.

 

Article X - Measurement and Improvement Standards

 

A.                                    Practice Guidelines

 

The CONTRACTOR and its
subcontractors will adopt practice guidelines that meet the following
requirements:

 

5.                                       are based on valid and reliable clinical
evidence or a consensus of health care professionals in the particular field;

 

73

 

6.                                       consider the needs of the CONTRACTOR’s Health
Plan’s Enrollees;

 

7.                                       are adopted in consultation with contracting
health care professionals; and

 

8.                                       are reviewed and updated periodically as
appropriate.

 

The CONTRACTOR will
disseminate the practice guidelines to all affected providers and, upon
request, to Enrollees and Potential enrollees.

 

The CONTRACTOR will ensure
that decisions for utilization management, Enrollee education, coverage of
services, and other areas to which the guidelines apply are consistent with the
practice guidelines.

 

B.                                    Quality
Assessment and Performance Improvement Program

 

1.                                      In General

 

a.                                       The Quality Assessment and Performance
Improvement Program will include a policymaking body which oversees the Quality
Assessment and Performance Improvement Program, a designated senior official
responsible for administration of the program, an interdisciplinary quality
assessment and performance improvement committee that has the authority to
report its findings and recommendations for improvement to the CONTRACTOR’s
executive director, and a mechanism for ongoing communication and collaboration
among the executive director, the policymaking body and other functional areas
of the organization.

 

b.                                      The CONTRACTOR will establish an ongoing
quality assessment and performance improvement program for the services it
furnished to its Enrollees. CMS, in consultation with States and other stakeholders,
may specify performance measures and topics for performance improvement
projects that would be required for the CONTRACTOR to implement. Prior to the
effective date of the Contract, all plans will be reviewed by the DEPARTMENT.

 

2.                                      Basic  Elements of Quality Assessment and
Performance Improvement Programs

 

At a minimum, the CONTRACTOR
will comply with the following requirements:

 

a.                                       Conduct performance improvement projects that
are designed to achieve, through ongoing measurements and intervention,
significant improvement, sustained over time, in clinical and nonclinical areas
that are expected to have a favorable effect on health outcomes and Enrollee
satisfaction.

 

b.                                      Submit performance measurement data.

 

c.                                       Have in effect mechanisms to detect both
underutilization and overutilization of services.

 

74

 

d.                                      Have in effect mechanisms to assess the
quality and appropriateness of care furnished to Enrollees with special health
care needs.

 

e.                                       Have in effect a process for evaluating the
impact and effectiveness of the quality assessment and performance improvement
program.

 

3.                                       Performance Measurement

 

Annually, the CONTRACTOR
will:

 

a.                                       Measure and report to the DEPARTMENT its
performance, using standard measures required by the DEPARTMENT and/or CMS;

 

b.                                      Submit to the DEPARTMENT, data specified by
the DEPARTMENT, that enables the DEPARTMENT to measure the CONTRACTOR’s
performance; or

 

c.                                       Perform a combination of the above
activities.

 

4.                                       Required areas and reporting of Performance
Improvement Projects

 

a.                                       The CONTRACTOR will have an ongoing program
of performance improvement projects that focus on clinical and non-clinical
areas, and that involve the following:

 

(1)                                  Measurement of performance using objective quality
indicators.

 

(2)                                  Implementation of system interventions to
achieve improvement in quality.

 

(3)                                  Evaluation of the effectiveness of the
interventions.

 

(4)                                  Planning and initiation of activities for
increasing or sustaining improvement.

 

b.                                      The CONTRACTOR will report the status and
results of each project, including those required by CMS, to the DEPARTMENT as
requested. Each performance improvement project will be completed in a
reasonable time period so as to generally allow information on the success of
performance improvement projects in the aggregate to produce new information on
quality of care every year.

 

Article XI - Other Requirements

 

A.                                    Compliance with Public
Health Service Act

 

The CONTRACTOR will comply
with all requirements of Section 1301 to and including 1318 of the Public
Health Service Act, as applicable. The CONTRACTOR will provide

 

75

 

verification of such
compliance to the DEPARTMENT upon the DEPARTMENT’s request.

 

B.                                    Advance Directives

 

The CONTRACTOR will comply
with the requirements of 42 CFR 434.28 relating to maintaining written Advance
Directives as outlined under Subpart I of 489.100 through 489.102.

 

C.                                    Fraud and Abuse Requirements

 

1.                                       In General

 

The CONTRACTOR will have
administrative and management arrangements or procedures, including a mandatory
compliance plan, that are designed to guard against fraud and abuse. The
CONTRACTOR will have a compliance program to identify and refer suspected fraud
and abuse activities.

 

2.                                       Components of arrangements or procedures

 

The arrangements or
procedures will include the following:

 

a.                                       Written policies, procedures, and standards
of conduct that articulate the CONTRACTOR’s commitment to comply with all
applicable Federal and State Standards;

 

b.                                      The designation of a compliance officer and a
compliance committee that are accountable to senior management;

 

c.                                       Effective training and education for the
compliance officer and the CONTRACTOR’s employees;

 

d.                                      Effective lines of communication between the
compliance officer and the CONTRACTOR’s employees;

 

e.                                       Enforcement of standards through
well-publicized disciplinary guidelines;

 

f.                                         Provision for internal monitoring and
auditing; and

 

g.                                      Provision for prompt response to detected
offenses, and for development of corrective action initiatives relating to this
Contract.

 

3.                                       Reporting requirements related to fraud and
abuse

 

The CONTRACTOR will:

 

a.                                       Refer in writing to the DEPARTMENT all
detected incidents of potential fraud or abuse on the part of providers of
services to Enrollees or to other patients.

 

76

 

b.                                      Refer in writing to the DEPARTMENT all
detected incidents of patient fraud or abuse involving Covered Services
provided which are paid for in whole, or in part, by the DEPARTMENT.

 

c.                                       Refer in writing to the DEPARTMENT the names
and Medicaid ID numbers of those Enrollees that the CONTRACTOR suspects of
inappropriate utilization of services, and the nature of the suspected
inappropriate utilization.

 

d.                                      Inform the DEPARTMENT in writing when a
provider is removed from the CONTRACTOR’s panel for reasons relating to
suspected fraud, abuse or quality of care concerns.

 

D.                                    Disclosure of
Ownership and Control Information

 

The CONTRACTOR agrees to
meet the requirements of 42 CFR 455, Subpart B related to disclosure by the
CONTRACTOR of ownership and control information and information related to
business transactions.

 

E.                                    Safeguarding
Confidential Information on Enrollees

 

The CONTRACTOR and the
CONTRACTOR’s subcontractors will follow all federal and state laws,
regulations, and policies governing confidential information including the
applicable requirements set forth in 42 CFR part 431, subpart F; and 45 CFR
parts 160 and 164, subparts A and E (Health Insurance Portability and
Accountability Act).

 

F.                                    Disclosure of
Provider Incentive Plans

 

1.                                       The CONTRACTOR will submit to the DEPARTMENT
information on its physician incentive plans as listed in 42 CFR 417.479(h)(1)
and summarized in this Article VII, Section F, Subsections 1 through 7, by May
1 of each year. The CONTRACTOR will provide to the DEPARTMENT the
enrollee/disenrollee survey results when beneficiary surveys are required as
specified in 42 CFR 417.479(g) by October 1 or three months after the end of the
Contract year. The CONTRACTOR will submit to the DEPARTMENT information on
capitation payments paid to primary care physicians as specified in 42 CFR
417.479(h)(1)(vi).

 

2.                                       Per 42 CFR 417.479(a), no specific payment
may be made directly or indirectly under a physician incentive plan to a
physician or physician group as an inducement to reduce or limit Medically
Necessary services furnished to an Enrollee.

 

3.                                       The CONTRACTOR may operate a physician
incentive plan only if the stop-loss protection, Enrollee survey, and
disclosure requirements are met. The CONTRACTOR will disclose to the DEPARTMENT
the following information on provider incentive plans in sufficient detail to
determine whether the incentive plan complies with the regulatory requirements.
The disclosure will contain:

 

a.                                       Whether services not furnished by the
physician or physician group are covered by the incentive plan. If only the
services furnished by the physician or physician group are covered by the
incentive plan, disclosure of

 

77

 

other aspects of the plan
need not be made.

 

b.                                      The type of incentive arrangement (i.e.,
withhold, bonus, capitation).

 

c.                                       If the incentive plan involves a withhold or
bonus, the percent of the withhold or bonus.

 

d.                                      Proof that the physician or physician group
has adequate stop-loss protection, including the amount and type of stop-loss
protection.

 

e.                                       The panel size and, if patients are pooled;
the method used.

 

f.                                         To the extent provided for in the Department
of Health and Human Services, Centers for Medicare and Medicaid Services’ (CMS’)
implementation guidelines, capitation payments paid to primary care physicians
for the most recent year broken down by percent for primary care services,
referral services to specialists, and hospital and other types of provider
services (i.e., nursing home and home health agency) for capitated physicians
or physician groups.

 

g.                                      In the case of those prepaid plans that are
required to conduct beneficiary surveys, the survey results. (The CONTRACTOR
will conduct a customer satisfaction of both Enrollees and disenrollees if any
physicians or physicians groups contracting with the CONTRACTOR are placed at
substantial financial risk for referral services. The survey will include
either all current  Enrollees and those
who have disenrolled in the past twelve months, or a sample of these same
Enrollees and disenrollees. Recognizing that different questions are asked of
the disenrollees than those asked of Enrollees, the same survey cannot be used
for both populations.)

 

4.                                       The CONTRACTOR will disclose this information
to the DEPARTMENT (1) prior to approval of its Contract or agreement and (2)
upon the Contract or agreements anniversary or renewal effective date. The
CONTRACTOR will provide the capitation data required (see 6 above) for the
previous Contract year to the DEPARTMENT three months after the end of the
Contract year. The CONTRACTOR will provide to the Enrollee upon request whether
the CONTRACTOR uses a physician incentive plan that affects the use of referral
services, the type of incentive arrangement, whether stop-loss protection is
provided, and the survey results of any enrollee/disenrollee surveys conducted.

 

Article XII - Payments

 

A.                                   Non-Risk Contract

 

This Contract is a non-risk
contract as described in 42 CFR 447.362. Aggregate payments made to the
CONTRACTOR may not exceed what the DEPARTMENT would have paid, on a
fee-for-service basis, in aggregate, for the services actually furnished to
recipients.

 

78

 

B.                                     Payment Methodology

 

The payment methodology is
described in Attachment F of this Contract.

 

C.                                    Contract Maximum

 

In no event will the
aggregate amount of payments to the CONTRACTOR exceed the Contract maximum
amount. If payments to the CONTRACTOR approach or exceed the Contract amount
before the renewal date of the Contract, the DEPARTMENT will make a good faith
effort to execute a Contract amendment to increase the Contract amount within
30 calendar days of the date the Contract amount is exceeded.

 

D.                                    Medicare

 

1.                                      Payment of
Medicare Part B Premiums

 

The DEPARTMENT will pay the
Medicare Part B premium for each Enrollee who is on Medicare. The Enrollee will
assign to the CONTRACTOR his or her Medicare reimbursement for benefits
received under Medicare. The Eligibility Transmission includes and identifies
those Enrollees who are covered under Medicare.

 

2.                                      Payment of
Medicare Deductible and Coinsurance

 

The CONTRACTOR is
responsible for payment of either the Medicare coinsurance and deductible
billed by Medicare or the Medicare deductible and coinsurance up to the
CONTRACTOR’s allowed amount for Enrollees, whichever is lower. When a service
is paid for by Medicare, the CONTRACTOR will pay whether or not the service is
covered under this Contract. The CONTRACTOR is responsible for payment whether
or not the Medicare covered service is rendered by a network provider or has
been authorized by the CONTRACTOR. Attachment E, Table 2, will be used to
identify the total cost to the CONTRACTOR of providing care for Enrollees who
are also covered by Medicare.

 

a.                                      The DEPARTMENT’s
financial obligation

 

The
DEPARTMENT’s financial obligation under this Contract for Enrollees who are
covered by both Medicare and the Health Plan is limited to the Medicare Part B
premium and the CONTRACTOR premium.

 

b.                                      When CONTRACTOR will pay up
to the Medicaid payment rate

 

For specified services, the
CONTRACTOR is responsible to pay the lower

 

79

 

of the allowed CONTRACTOR
payment rate less the amounts paid by Medicare and other payers, or the
Medicare coinsurance and deductibles. The specified services are billings from:

 

(1)                                  inpatient hospitals;

 

(2)                                  outpatient hospitals;

 

(3)                                  medical supplies defined as billings from
medical suppliers and pharmacies that bill medical supplies; and

 

(4)                                  physicians defined as all physician
specialists except anesthesiologists, osteopaths, podiatrists, independent
laboratories and independent radiology providers; and

 

(5)                                  certified nurse midwives and nurse
practitioners.

 

c.                                       When CONTRACTOR will pay the
Medicare coinsurance and deductibles

 

For crossover claims other
than those listed in 2.b above, the CONTRACTOR may choose when to pay either 1)
the lower of the allowed Medicaid payment rate less the amounts paid by
Medicare or other payors or the Medicare coinsurance and deductibles, or 2) the
coinsurance and deductibles billed by Medicare even if Medicaid’s allowed
amount is less than what Medicare paid.

 

 In the event Medicaid does not have a price
for a procedure code on a Medicare crossover claim, the CONTRACTOR will pay the
amount of coinsurance and deductible billed by Medicare.

 

3.                                      Will Not Balance Bill
Enrollees

 

The CONTRACTOR or its
providers will not Balance Bill the Enrollee and will consider  reimbursement from Medicare and from the
CONTRACTOR as payment in full. 

 

E.                                      Third Party Liability
(Coordination of Benefits)

 

The DEPARTMENT will provide
the CONTRACTOR a monthly listing of Enrollees covered under the Buy-out Program,
including the premium amount paid by the DEPARTMENT.

 

1.                                      TPL Collections

 

The CONTRACTOR will be
responsible to coordinate benefits and collect third party liability (TPL). The
CONTRACTOR will keep TPL collections. The DEPARTMENT’s  audit staff will monitor collections to
ensure the

 

80

 

CONTRACTOR is making a good
faith effort to pursue TPL.

 

2.                                      Duplication of Benefits

 

This provision applies when,
under another health insurance plan such as a prepaid plan, insurance contract,
mutual benefit association or employer’s self-funded group health and welfare
program, etc., an Enrollee is entitled to any benefits that would totally or
partially duplicate the benefits that the CONTRACTOR is obligated to provide under
this Contract. Duplication exists when (1) the CONTRACTOR has a duty to
provide, arrange for or pay for the cost of Covered Services, and (2) another
health insurance plan, pursuant to its own terms, has a duty to provide,
arrange for or pay for the same type of Covered Services regardless of whether
the duty of the CONTRACTOR is to provide the Covered Services and the duty of
the other health insurance plan is only to pay for the Covered Services. Under
State and Federal laws and regulations, Medicaid funds are the last dollar
source and all other health insurance plans as referred to above are primarily
responsible for the costs of providing Covered Services.

 

3.                                      Reconciliation of Other TPL

 

In order to assist the
CONTRACTOR in billing and collecting from other health insurance plans the
DEPARTMENT will include on the Eligibility Transmission other health insurance
plans of each Enrollee when it is known. The CONTRACTOR will review the
Eligibility Transmission and will report to the Office of Recovery Services or
the DEPARTMENT any TPL discrepancies identified within 30 working days of
receipt of the Eligibility Transmission. The CONTRACTOR’s report will include a
listing of

 

81

 

Enrollees that the CONTRACTOR
has independently identified as being covered by another health insurance plan.

 

4.                                      When TPL is Denied

 

On a monthly basis,  the CONTRACTOR will report to the Office of
Recovery Services (ORS) claims that have been billed to other health care plans
but have been denied which will include the following information:

 

a.                                       patient name and Medicaid identification
number;

 

b.                                      ICD-9-CM code;

 

c.             procedure codes; and

 

d.                                      insurance company.

 

5.                                      Notification of Personal
Injury Cases

 

The CONTRACTOR will be responsible
to notify ORS of all personal injury cases, as defined by ORS and agreed to by
the CONTRACTOR, no later than 30 days after the CONTRACTOR has received a “clean”
claim. A clean claim is a claim that is ready to adjudicate. The diagnosis
codes to identify personal injury cases include the ICD-9-CM codes 800 through
999 (regardless of any prefix, e.g. E800) except the following codes:
900-919.5, 931-939.9, 942.22, 944.20, 946.2, E950-958.8, 958.3, 960-979.9, 981,
986, 989.5, 990-995.89, 996-998.9, and 999.8.

 

The following data elements
will be provided by the CONTRACTOR to ORS:

 

a.                                       patient name and Medicaid identification
number;

 

b.                                      CONTRACTOR’s patient number;

 

c.                                       dates of service;

 

d.                                      provider billed amount;

 

e.                                       TPL collected amount;

 

f.                                         TPL name;

 

g.                                      amount paid by CONTRACTOR;

 

h.                                      amount paid by Medicaid;

 

i.                                          servicing provider name;

 

j.                                          specific type of injury by ICD-9-CM code; and

 

82

 

k.                                       procedure codes.

 

6.                                      ORS to Pursue
Collections

 

ORS will pursue collection
on all claims described in this Article XII (Payments), Section E, Subsections
4 and 5 of this Contract. The DEPARTMENT will retain, for administrative costs,
one third of the collections received for the period during which medical
services were provided by the CONTRACTOR, and remit the balance to the
CONTRACTOR.

 

7.                                      Insurance
Buy-Out Program

 

The Insurance Buy-out
Program is an optional program in which the DEPARTMENT purchases group health
insurance for a recipient who is eligible for Medicaid when it is determined
cost-effective for the Medicaid program to do so. The insurance buy-out process
will be coordinated by the DEPARTMENT in cooperation with the Office of
Recovery Services, and Medicaid eligibility workers. The CONTRACTOR will file
claims against group Health Plan’s first before claiming services against the
CONTRACTOR or other Health Plans.

 

8.                                      CONTRACTOR Will
Pay Provider Administrative Fee for Immunizations

 

When an Enrollee has third
party coverage for immunizations, the CONTRACTOR will pay the provider the
administrative fee for providing the immunization and not require the provider
to bill the third party as a cost avoidance method. The CONTRACTOR may choose
to pursue the third party amount for the administrative fee after payment has
been made to the provider.

 

F.                                    Third Party
Responsibility (Including Worker’s Compensation)

 

1.                                      CONTRACTOR to
Bill Usual and Customary Charges

 

When a third party has an
obligation to pay for Covered Services provided by the CONTRACTOR to an
Enrollee pursuant to this Contract, the CONTRACTOR will bill the third party
for the usual and customary charges for Covered Services provided and costs
incurred. Should any sum be recovered by the Enrollee or otherwise, from or on
behalf of the person responsible for payment for the service, the CONTRACTOR
will be paid out of such recovery for the charges for service provided and
costs incurred by the CONTRACTOR.

 

2.                                      Third Party’s
Obligation to Pay for Covered Services

 

Examples of situations where
a third party has an obligation to pay for Covered Services provided by the
CONTRACTOR are when (a) the Enrollee is injured by a person due to the
negligent or intentional acts (or omissions) of the person; or (b) the Enrollee
is eligible to receive payment through Worker’s Compensation Insurance. If the
Enrollee does not diligently seek such recovery, the CONTRACTOR may institute
such rights that it may have.

 

83

 

3.                                      First Dollar
Coverage for Accidents

 

In addition, both parties
agree that the following will apply regarding first dollar coverage for
accidents:  if the injured party has
additional insurance, primary coverage may be given to the motor insurance
effective at the time of the accident. Once the motor vehicle policy is
exhausted, the CONTRACTOR will be the secondary payer and pay for all of the
Enrollee’s Covered Services. If medical insurance does not exist, the
CONTRACTOR will be the primary payer for all Covered Services.

 

G.                                    Changes in
Covered Services

 

If Covered Services are
amended under the provisions of Attachment B, Article IV (Benefits),  rates may be renegotiated, if applicable.

 

H.                                   Clarification of
Payment Responsibilities

 

1.                                      Covered Services
Received Outside CONTRACTOR’s Network but Paid by CONTRACTOR

 

The CONTRACTOR will not be
required to pay for Covered Services, defined in Attachment C, which the
Enrollee receives from sources outside the CONTRACTOR’s network, not arranged
for and not authorized by, the CONTRACTOR except as follows:

 

a.                                       Emergency Services;

 

b.                                      Court ordered services that are Covered
Services defined in Attachment C and which have been coordinated with the
CONTRACTOR; or

 

c.                                       Cases where the Enrollee demonstrates that
such services are Medically Necessary Covered Services and were unavailable
from the CONTRACTOR.

 

2.                                      Payment to
Non-Network Providers and to Providers out of the Service Area

 

Payment by the CONTRACTOR to
an out-of-network provider for emergency services and/or to a provider out of
the Service Area for services that are approved for payment by the CONTRACTOR
will not exceed the lower of the following rates applicable at the time the
services were rendered to an Enrollee, unless there is a negotiated arrangement:

 

a.                                       The usual charges made to the general public
by the provider;

 

b.                                      The rate equal to the applicable Medicaid
fee-for-service rate; or

 

c.                                       The rate agreed to by the CONTRACTOR and the
provider.

 

3.                                       When Covered Services are not the CONTRACTOR’s
Responsibility

 

a.                                       The CONTRACTOR is not responsible for payment
when family planning

 

84

 

services are obtained by an
Enrollee from sources other than the CONTRACTOR.

 

b.                                      The CONTRACTOR will not be required to provide,
arrange for, or pay for Covered Services to Enrollees whose illness or injury
results directly from a catastrophic occurrence or disaster, including, but not
limited to, earthquakes or acts of war. The effective date of excluding such
Covered Services will be the date specified by the Federal Government or the
State of Utah that a Federal or State emergency exists or disaster has
occurred.

 

4.                                      The DEPARTMENT’s
Responsibility

 

Except as described in
Attachment F (Payment Methodologies) of this Contract, the DEPARTMENT will not
be required to pay for any Covered Services under Attachment C which the
Enrollee received from any sources outside the CONTRACTOR except for family
planning services.

 

5.                                      Covered Services
Provided by the Department of Health, Division of Community and Family Health
Services

 

a.                                       For Enrollees who qualify for special
services offered by or through the Department of Health, Division of Community
and Family Health Services (DCFHS), the CONTRACTOR agrees to reimburse DCFHS at
the standard Medicaid rate in effect at the time of service for one outpatient
team evaluation and one follow-up visit for each Enrollee upon each instance
that the Enrollee both becomes Medicaid eligible and selects the CONTRACTOR as
its provider.

 

(1)                                  The CONTRACTOR agrees to waive any prior
authorization requirement for one outpatient team evaluation and one follow-up
visit.

 

(2)                                  The services provided in the outpatient team
evaluation and follow-up visit for which the CONTRACTOR will reimburse DCFHS
are limited to the services that the CONTRACTOR is otherwise obligated to
provide under this Contract.

 

b.                                      If the CONTRACTOR desires a more detailed
agreement for additional services to be provided by or through DCFHS for
children with special health care needs, the CONTRACTOR may subcontract with
DCFHS. The CONTRACTOR agrees that the subcontract with DCFHS will acknowledge
and address the specific needs of DCFHS as a government provider.

 

6.                                      Enrollee
Transition Between Health Plans, or Between Fee-For-Service and CONTRACTOR

 

a.                                      Inpatient
Hospital

 

(1)                                  When an Enrollee is in an inpatient hospital
setting and selects another Health Plan or becomes fee-for-service anytime
prior to

 

85

 

discharge from the hospital, the CONTRACTOR is financially responsible
for the entire hospital stay including all services related to the hospital
stay (i.e. physician, etc.), unless responsibility is transferred to another
appropriate entity and the entity agrees to take financial responsibility,
including negotiating a payment for services (see Article IV, Benefits, Section
C.4., Inpatient Hospital Services for Scheduled Admissions).

 

(2)                                  The Health Plan in which the individual is
enrolled when discharged from the hospital is financially responsible for
services provided during the remainder of the month when the individual was
discharged.

 

(a)                                  If such individual is fee-for-service when
discharged from the hospital, the DEPARTMENT is financially responsible for the
remainder of the month when the individual was discharged.

 

(b)                                 If a Medicaid eligible is fee-for-service
when admitted to the hospital and selects a Health Plan anytime prior to
discharge from the hospital, the DEPARTMENT is financially responsible for the
entire hospital stay including all services related to the hospital stay, i.e.
physician, etc.

 

(3)                                  When an Enrollee is in an inpatient hospital
setting at the time the CONTRACTOR terminates this Contract and the Enrollee
selects another Health Plan anytime prior to discharge from the hospital, the
receiving Health Plan is financially responsible for the hospital stay
beginning 30 days after termination of the Contract.

 

b.                                      Home Health
Services

 

(1)                                  Medicaid clients who are under
fee-for-service or are enrolled in a Health Plan other than this Health Plan
and are receiving home health services from an agency not contracting with the
CONTRACTOR will be transitioned to the CONTRACTOR’s home health agency.

 

(2)                                  The CONTRACTOR is responsible for payment,
not to exceed Medicaid payment, for a period not to exceed seven calendar days,
unless the CONTRACTOR notifies the non-participating home health agency of the
change in status or the non-participating home health agency notifies the
CONTRACTOR that services are bing provided by its agency.

 

(3)                                  The CONTRACTOR will assess the needs of the
Enrollee at the time the CONTRACTOR provides the orientation to the Enrollee.

 

(4)                                  The CONTRACTOR will include the Enrollee in
developing the plan of care to be provided by the CONTRACTOR’s home health agency
before the transition is complete. The CONTRACTOR will address

 

86

 

Enrollee’s concerns regarding Covered Services provided by the
CONTRACTOR’s home health agency before the new plan of care is implemented.

 

c.                                       Medical
Equipment

 

(1)                                  When medical equipment is ordered for an
Enrollee by the CONTRACTOR and the Enrollee enrolls in a different Health Plan
or becomes fee-for-service before receiving the equipment, the CONTRACTOR is
responsible for payment of such equipment.

 

(2)                                  When medical equipment is ordered for a
Medicaid eligible by the DEPARTMENT and the Enrollee selects a Health Plan, the
DEPARTMENT is responsible for payment of such equipment.

 

(3)                                  Medical equipment includes, but is not
limited to, specialized wheelchairs or attachments, prostheses, and other
equipment designed or modified for an individual client. Any attachments to the
equipment, replacements, or new equipment is the responsibility of the Health
Plan in which the client is enrolled at the time such equipment is ordered.

 

7.                                      Surveys

 

e.                                       All surveys required under this Contract will
be funded by the CONTRACTOR unless funded by another source such as the Utah
Department of Health, Office of Health Care Statistics.

 

f.                                         The surveys will be conducted by an
independent vendor mutually agreed upon by the DEPARTMENT and CONTRACTOR.

 

g.                                      The DEPARTMENT or designee will analyze the
results of the surveys. Before publishing articles, data, reports, etc. related
to surveys, the DEPARTMENT will provide drafts of such material to the
CONTRACTOR for review and feedback.

 

h.                                      The CONTRACTOR will not be responsible for
the costs incurred for such publishing by the DEPARTMENT.

 

87

 

Article XIII - Records and Reporting Requirements

 

A.                                    Health Information Systems

 

The CONTRACTOR will retain
records in accordance with requirements of 45 CFR 74 (three years after the
final payment is made and all pending matters closed, plus additional time if
an audit, litigation, or other legal action involving the records is started
before or during the original three year period ends).

 

1.                                       General Rule

 

The CONTRACTOR will maintain
a health information system that collects, analyzes, integrates, and reports
data. The system will provide information on areas including, but not limited
to, utilization, Grievances and Appeals, and disenrollments for other than loss
of Medicaid eligibility.

 

2.                                       Basic Elements of a Health Information System

 

In accordance with Section
4752 of OBRA ‘90 (amended section 1903 (m)(2)(A) of the Social Security Act),
the CONTRACTOR agrees to maintain sufficient patient encounter data to identify
the physician who delivers Covered Services to Enrollees.

 

a.                                       The CONTRACTOR agrees to provide this
encounter data, upon request of the DEPARTMENT, within 30 days of the request.

 

b.                                      At a minimum, the CONTRACTOR will collect
data on Enrollee and provider characteristics as specified by the DEPARTMENT
and on services furnished to Enrollees through an encounter data system.

 

3.                                       Accuracy of Data

 

a.                                       The CONTRACTOR will ensure that data received
from providers is accurate and complete by:

 

(1)                                  verifying the accuracy of reported data;

 

(2)                                  screening the data for completeness, logic,
and consistency; and

 

(3)                                  collecting service information in
standardized formats to the extent feasible and appropriate.

 

b.                                      The CONTRACTOR will make all collected data
available to the DEPARTMENT and upon request to CMS.

 

88

 

4.                                       Medical Records

 

The CONTRACTOR agrees that
medical records are considered confidential information and agrees to follow
Federal and State confidentiality requirements.

 

a.                                       The CONTRACTOR will require that its
providers maintain a medical record keeping system through which all pertinent
information relating to the medical management of the Enrollee is maintained,
organized, and is readily available to appropriate professionals.

 

b.                                      Notwithstanding any other provision of this
Contract to the contrary, medical records covering Enrollees will remain the
property of the provider, and the provider will respect every Enrollee’s
privacy by restricting the use and disclosure of information in such records to
purposes directly connected with the Enrollee’s health care and administration of
this Contract.

 

c.                                       The CONTRACTOR will use and disclose
information pertaining to individual Enrollees and prospective Enrollees only
for purposes directly connected with the administration of the Medicaid Program
and this Contract.

 

B.                                     Federally Required Reports

 

1.                                       CHEC/EPSDT Reports

 

The CONTRACTOR agrees to act
as a continuing care provider for the CHEC/EPSDT program in compliance with
OBRA ‘89 and Social Security Act Sections 1902 (a)(43), 1905 (a)(4)(B) and 1905
(r).

 

a.                                       CHEC/EPSDT Screenings

 

(1)                                  Annually, the CONTRACTOR will submit to the
DEPARTMENT information on CHEC/EPSDT screenings to meet the Federal EPSDT
reporting requirements (Form CMS-416). The data will be in a mutually agreed
upon format.

 

(2)                                  The CHEC/EPSDT information is due December 31
for the prior federal fiscal year’s data (October 1 through September 30).

 

b.                                      Immunization
Data

 

The CONTRACTOR will submit
immunization data as part of the CHEC/EPSDT reporting. Enrollee name, Medicaid
ID, type of immunization identified by procedure code, and date of immunization
will be reported in the same format as the CHEC/EPSDT data.

 

89

 

1.                                       Disclosure of Physician Incentive Plans

 

a.                                       The CONTRACTOR will submit to the DEPARTMENT
information on its physician incentive plans as listed in 42 CFR 417.479(h)(1)
by May 1 of each year.

 

b.                                      The CONTRACTOR will provide to the DEPARTMENT
the enrollee/disenrollee survey results when beneficiary surveys are required
as specified in 42 CFR 417.479(g) by October 1 or three months after the end of
the Contract year.

 

c.                                       The CONTRACTOR will submit to the DEPARTMENT
information on capitation payments paid to primary care physicians as specified
in 42 CFR 417.479(h)(1)(vi).

 

C.                                    Periodic Reports

 

1.                                      Enrollment, Cost
and Utilization Reports (Attachment E)

 

a.                                       Enrollment, cost and utilization reports will
be submitted on diskettes or CDs in Excel and in the format specified in
Attachment E. A hard copy of the report will be submitted as well. The
DEPARTMENT will send to the CONTRACTOR a template of the Attachment E format on
a diskette, CD, or electronically.

 

b.                                      The CONTRACTOR may not customize or change
the report format. The financial information for these reports will be reported
as defined in CMS Publication 75, and if applicable, CMS 15-1.

 

c.                                       The CONTRACTOR will certify in writing the
accuracy and completeness, to the best of its knowledge, of all costs and
utilization data provided to the DEPARTMENT on Attachment E.

 

d.                                      Two Attachment E reports will be submitted
covering dates of service for each Contract year.

 

(1)                                  Attachment E is due May 1 for the preceding six-month reporting period (July
through December).

 

(2)                                  Attachment E 
is due November 1
for the preceding 12-month reporting period (July through June).

 

e.                                       If necessary, the CONTRACTOR may request, in
writing, an extension of the due date up to 30 days beyond the required due
date. The DEPARTMENT will approve or deny the extension request writing within
seven calendar days of receiving the request.

 

2.                                       Interpretive Services

 

Annually, on November 1, the
CONTRACTOR will submit summary information about the use of interpretive
services during the previous Contract year (July 1

 

90

 

through June 30). The
information will include the following:

 

a.                                       a list of all sources of interpreter
services;

 

b.                                      total expenditures for each language;

 

c.                                       total expenditures for clinical versus
administrative;

 

d.                                      number of Enrollees who used interpretive
services for each language; and

 

e.                                       number of services provided categorized by
clinical versus administrative.

 

3.                                      Semi-Annual
Reports

 

The following semi-annual
reports are due May 1
for the preceding six-month reporting period ending December 31 (July through
December) and are due November
1 for the preceding six month period ending June 30 (January
through June).

 

a.                                      Organ
Transplants: Report the
total number of organ transplants by type of transplant.

 

b.                                      Obstetrical
Information: Report
obstetrical information including:

 

(1)                                  total number of obstetrical deliveries by aid
category grouping;

 

(2)                                  total number of caesarean sections and total
number of vaginal deliveries;

 

(3)                                  total number low birth weight infants; and

 

(4)                                  total number of Enrollees requiring prenatal
hospital admission.

 

c.                                       Appeals and
Grievances

 

The CONTRACTOR will maintain
complete records of all Appeals and Grievances and submit semi-annual reports
summarizing Appeals and Grievances using DEPARTMENT-specified reporting
templates.

 

(1)                                  Separate reports of Appeals and Grievances
are required for adults and children; and for Traditional Medicaid Plan
Enrollees and Non-Traditional Plan Enrollees.

 

91

 

(2)                                  Each report will distinguish between those
Enrollees with special health care needs and the general population of
children.

 

(3)                                  Report summary information on the number of
Appeals and Grievances by type of Appeals and Grievance and indicate the number
that have been resolved. Include an analysis of the type and number of Appeals
and Grievances received by the CONTRACTOR.

 

d.                                      Aberrant
Physician Behavior

 

Report summary information
of corrective actions taken on physicians who have been identified by the
CONTRACTOR as exhibiting aberrant physician behavior and the names of physicians
who have been removed from the CONTRACTOR’s network due to aberrant behavior. The
summary will include the reasons for the corrective action or removal.

 

4.                                      Annual Quality
Improvement Program Documentation 

 

a.                                       Annually, the CONTRACTOR will submit to the
DEPARTMENT the following documents:

 

(1)                                  the CONTRACTOR’s quality improvement program
description;

 

(2)                                  the CONTRACTOR’s quality improvement work
plan;

 

(3)                                  the CONTRACTOR’s quality improvement work
plan evaluation for previous calendar year.

 

b.                                      These reports will be in the format developed
by the DEPARTMENT and include signature(s) of approval by the CONTRACTOR’s
designated authorizing authority. Reports will be on a Contract year basis and
will be due no later that October 1st of each year.

 

5.                                      Documents Due
Prior to Quality Monitoring Reviews

 

a.                                       The following documents are due at least 60
days prior to the DEPARTMENT’s quality assurance monitoring review, or earlier
on request, unless the DEPARTMENT has already received documents that are in
effect:

 

(1)                                  the CONTRACTOR’s most current (may be in
draft stage) written quality improvement program description;

 

(2)                                  the CONTRACTOR’s most current (may be in
draft stage) annual quality improvement work plan;

 

(3)                                  the CONTRACTOR’s most current (may be in draft
stage) quality improvement work plan evaluation for the previous calendar year;

 

(4)                                  documentation of the CONTRACTOR’s compliance
to standards 

 

92

 

defined in Utah’s Quality Assessment and Performance Improvement Plan
for contracted medical health plans (Attachment D).

 

(5)                                  all other information requested by the
DEPARTMENT to facilitate the DEPARTMENT’s review of the CONTRACTOR’s compliance
to standards defined in Utah’s Quality Assessment and Performance Improvement
Plan for contracted medical health plans (Attachment D).

 

b.                                      The above documents will show evidence of a
well defined, organized program designed to improve client care.

 

6.                                      Impact of
Co-payments

 

a.                                       The following semi-annual report is due May 1 for the preceding
six-month reporting period ending April 30 (November of previous year through
April of current year) and November
1 for the preceding six-month period ending October 31 (May
through October of the current year):

 

b.                                      Report will document all instances when
Enrollees have contacted the CONTRACTOR with a complaint about being denied
services because they did not pay their Medicaid co-payment or co-insurance. For
each instance, report the Enrollee’s name, Medicaid ID, provider, and the service
the Enrollee was scheduled to receive.

 

7.                                      HEDIS

 

Audited Health Plan Employer
Data and Information Set (HEDIS) performance measures will cover services
rendered to Enrollees and will be reported as set forth in State rules by the
Office of Health Data Analysis. For example, calendar year 2003 HEDIS measures
will be reported in 2004.

 

8.                                       Encounter Data

 

a.                                       Encounter data will be submitted in
accordance with the instructions detailed in the Encounter Records 837
Institutional Guide and Encounter Records 837, Professional Companion Guide,
for dates of service beginning July 1, 2002.

 

b.                                      The CONTRACTOR will receive certification
from an independent, credible vendor that their electronic submissions of
encounter data are compliant with the Health Insurance Portability and
Accountability Act (HIPAA) requirements.

 

c.                                       At a minimum, the CONTRACTOR will be
HIPAA-compliant in the first four levels of HIPAA compliance: Level 1 -
Integrity Testing, Level 2 - Requirement Testing, Level 3 - Balancing, and
Level 4 - Situation Testing.

 

93

 

9.                                      Audit of
Abortions, Sterilizations and Hysterectomies

 

a.                                      The CONTRACTOR will conduct an annual audit
of abortion, hysterectomy and sterilization procedures performed by the
CONTRACTOR’s providers. The purpose of the audit is to monitor compliance with
federal and state requirements for the reimbursement of these procedures under
Medicaid. The CONTRACTOR will audit all abortions and a sample of hysterectomy
and sterilization procedures as defined by the DEPARTMENT.

 

b.                                      On November 1 of each year, the CONTRACTOR
will submit to the DEPARTMENT the following information on the results of the
abortion, sterilization and hysterectomy audit for the previous calendar year.

 

c.                                       For the sterilization and hysterectomy audit,
submit documentation of the methodology used to pull the sample of
sterilization and hysterectomies and include the sampling proportions.

 

d.                                      In an Excel file, submit the following
information for all abortions, the sample of sterilizations, and the sample of
hysterectomies:

 

(1)                                  client name

(2)                                  Medicaid ID number

(3)                                  procedure code

(4)                                  date of service

(5)                                  history/physical (yes/no)

(6)                                  operative report (yes/no)

(7)                                  pathology report (yes/no)

(8)                                  consent form (yes/no)

(9)                                  medical necessity criteria - hysterectomies
only

 

e.                                       When information is submitted electronically,
the CONTRACTOR will use a secured electronic transmission process.

 

f.                                         The DEPARTMENT will evaluate the results of the CONTRACTOR’s audit and
identify the cases that will require medical record submission.

 

(1)                                  Medical record submission will be required
for all abortions and a random sample of hysterectomy and sterilization cases.

 

(2)                                 The DEPARTMENT will notify the CONTRACTOR in
writing of the cases that will require medical record submission and the time
line for the medical record submissions.

 

10.                                 Provider Network

 

The CONTRACTOR will submit a
monthly file of its provider network that meets the DEPARTMENT’s provider file
specifications and data element requirements.

 

11.                                 Case Management Reports

 

The CONTRACTOR will submit
quarterly case management reports due 30 days after the end of each quarter
being reported; i.e., data covering July through September is due November 1. (See
Utah’s Quality Assessment and Performance

 

94

 

Improvement Plan, Attachment
D).

 

12.                                 Development of New Reports

 

Any new reports/data
requirements mandated by the DEPARTMENT will be mutually developed by the
DEPARTMENT and the CONTRACTOR.

 

D.                                    Data Certification

 

1.                                      Certifications

 

The
CONTRACTOR will certify financial data that are submitted to the DEPARTMENT.

 

2.                                      Timing of Certification for Financial
Data and Reports 

 

a.                                       When submitting paper copies of the financial
data or reports, the CONTRACTOR may submit the written certification by using
the DEPARTMENT-developed data and reports cover sheet which includes a
certification statement.

 

b.                                      If the CONTRACTOR does not use the cover
sheet, the CONTRACTOR will attach a cover letter that includes the data
certification statement.

 

c.                                       When submitting data and reports
electronically, the CONTRACTOR will include a certification statement with the
submission.

 

3.                                       Content of Certification

 

In the certification, the
CONTRACTOR will attest to the completeness and truthfulness of the data and
documents based on best knowledge, information and belief.

 

4.                                      Authority to
Certify

 

The CONTRACTOR will ensure
one of the following certifies data and documents:

 

a.                                       the CONTRACTOR’s chief executive officer;

 

95

 

b.                                      the CONTRACTOR’s chief financial officer; or

 

96

 

c.                                       an individual who has delegated authority to
sign for, and who reports directly to the chief executive officer or chief
financial officer.

 

Article XIV - Compliance/Monitoring

 

A.                                    Audits

 

1.                                      Right of DEPARTMENT and CMS
to Audit

 

The DEPARTMENT and the
Department of Health and Human Services, Centers for Medicare and Medicaid
Services may audit and inspect any financial records of the CONTRACTOR or its
subcontractors relating (a) to the ability of the CONTRACTOR to bear the risk
of potential financial losses, or (b) to evaluate services performed or
determinations of amounts payable under the Contract.

 

2.                                      Information to Determine
Allowable Costs

 

The CONTRACTOR will make
available to the DEPARTMENT all reasonable and related financial, statistical,
clinical or other information needed for the determination of allowable costs
to the Medicaid program for “related party/home office” transactions as defined
in CMS 15-1. These records are to be made available in Utah or the CONTRACTOR
will pay the increased cost (incremental travel, per diem, etc.) of auditing at
the out-of-state location. The cost to the CONTRACTOR will include round-trip
travel and two days per diem/lodging. Additional travel costs of the site audit
will be shared equally by the CONTRACTOR and the DEPARTMENT.

 

3.                                      Management and Utilization
Audits

 

(1)                                  The CONTRACTOR will allow the DEPARTMENT and
the Department of Health and Human Services, Centers for Medicare and Medicaid
Services, to perform audits for identification and collection of management
data, including Enrollee satisfaction data, quality of care data, fraud-related
data, abuse-related data, patient outcome data, and cost and utilization data,
which will include patient profiles, exception reports, etc.

 

(2)                                  The CONTRACTOR will provide all data required
by the DEPARTMENT or the independent quality review examiners in performance of
these audits.

 

(3)                                  Prior to beginning any audit, the DEPARTMENT
will give the CONTRACTOR reasonable notice of audit, and the DEPARTMENT will be
responsible for costs of its auditors or representatives.

 

B.                                    Quality
Monitoring by the DEPARTMENT

 

1.                                       The DEPARTMENT will review, at least
annually, the impact and effectiveness of the CONTRACTOR’s quality assessment
and performance improvement program. The review will include:

 

97

 

a.                                       The CONTRACTOR’s performance on the standard
measures on which it is required by the DEPARTMENT to report.

 

b.                                      The results of the CONTRACTOR’s performance
improvement projects.

 

c.                                       The results of the CONTRACTOR’s evaluation of
the impact and effectiveness of its quality assessment and performance improvement
program.

 

1.                                       The DEPARTMENT will review the CONTRACTOR for
compliance to standards defined in Utah’s Quality Assessment and Performance
Improvement Plan (Attachment D).

 

C.                                    External Quality
Review

 

1.                                      In General

 

a.                                       Pursuant to 42 CFR Part 438 Subpart E -  External Quality Review (EQR), the DEPARTMENT
will provide for an annual external quality review conducted by an External
Quality Review Organization (EQRO) of the quality, timeliness, and access to
Covered Services. The CONTRACTOR will support the annual external quality
review.

 

b.                                      The DEPARTMENT will choose an agency to
perform an annual EQR pursuant to Federal law and will pay for such review.

 

(1)                                  The CONTRACTOR will maintain all clinical and
administrative records for use by the EQRO.

 

(2)                                  The CONTRACTOR agrees to support quality
assurance reviews, focused studies and other projects performed for the
DEPARTMENT by the EQRO.

 

(3)                                  The purpose of the reviews and studies is to
comply with Federal requirements for an annual EQR.

 

(4)                                  The external quality reviews are conducted by
the EQRO, with the advice, assistance, and cooperation of a planning team
composed of representatives from the CONTRACTOR, the EQRO and the DEPARTMENT
with final approval by the DEPARTMENT.

 

2.                                      Specific
Requirements

 

a.                                      Liaison for
Routine Communication

 

The CONTRACTOR will
designate an individual to serve as liaison with the EQRO for routine
communication with the EQRO.

 

b.                                      Representative
to Assist with Projects

 

98

 

(1)                                  The CONTRACTOR will designate a minimum of
two representatives (unless one individual can service both functions) to serve
on the planning team for each EQRO project.

 

(2)                                  Representatives will include a quality
improvement representative and a data representative.

 

(3)                                  The planning team is a joint collaborative
forum between DEPARTMENT staff, the EQRO and the CONTRACTOR.

 

(4)                                  The role of the planning team is to
participate in the process and completion of EQRO projects.

 

c.                                       Copies and
On-Site Access

 

(1)                                  The CONTRACTOR will be responsible for
obtaining copies of Enrollee information and facilitating on-site access to
Enrollee information as needed by the EQRO. Such information will be used to
plan and conduct projects and to investigate complaints and grievances.

 

(2)                                  Any associated copying costs are the
responsibility of the CONTRACTOR.

 

(3)                                  Enrollee information includes medical
records, administrative data such as, but not limited to, enrollment
information and claims, nurses’ notes, medical logs, etc. of the CONTRACTOR or
its providers.

 

d.                                      Format of
Enrollee Files

 

The CONTRACTOR will provide
Enrollee information in a mutually agreed upon format compatible for the EQRO’s
use, and in a timely fashion to allow the EQRO to select cases for its review.

 

e.                                       Time-frame for
Providing Data

 

(1)                                  The CONTRACTOR will provide data to the EQRO
within 15 working days of the written request from the EQRO and will provide
medical records within 30 working days of the written request from the EQRO.

 

(2)                                  Requests for extensions of these time frames
will be reviewed and approved or disapproved by the DEPARTMENT on a
case-by-case basis.

 

f.                                         Work Space for
On-Site Reviews

 

The CONTRACTOR will assure
that the EQRO staff and consultants have

 

99

 

adequate work space, access
to a telephone and copy machines at the time of review. The review will be
performed during agreed-upon hours.

 

g.                                      Staff Assistance
During On-Site Visits

 

The CONTRACTOR will assign
appropriate person(s) to assist the EQRO personnel conduct the reviews during
on-site visits and to participate in an informal discussion of screening
observations at the end of each on-site visit, if necessary.

 

D.                                    Corrective
Action

 

1.                                      When Corrective
Actions are Necessary

 

a.                                       The CONTRACTOR agrees to implement corrective
action as specified by the DEPARTMENT when quality assurance monitoring
including, but not limited to, site reviews, CONTRACTOR documentation reviews,
data analysis, medical audits, or complaints/grievances, determines the need
for such corrective action.

 

b.                                      In addition, if the DEPARTMENT determines
that the CONTRACTOR has not provided services in accordance with the Contract
or within expected professional standards, the DEPARTMENT will request in
writing that the CONTRACTOR correct deficiencies or identified problems by
developing a corrective action plan.

 

c.                                       If the corrective action is a result of
non-compliance with the DEPARTMENT’s Quality Assessment Improvement and
Performance Improvement Plan, the time frames below do not necessarily apply;
the time frames will be specified in a formal letter sent to the CONTRACTOR
from the DEPARTMENT if a corrective action is required.

 

2.                                      Initial Response
by CONTRACTOR

 

a.                                       The CONTRACTOR has 20 working days from the
date the DEPARTMENT mails, through certified mail, its written request for the
CONTRACTOR to respond to the problems identified and will either:

 

(1)                                  submit a corrective action plan,

 

(2)                                  submit a letter summarizing the CONTRACTOR’s
disagreements with the DEPARTMENT’s findings, or

 

(3)                                  request, in writing, an extension of the
20-day time frame. The CONTRACTOR may only request an extension if it
determines it will conduct a medical records review or there are other
extenuating circumstances.

 

b.                                      If the CONTRACTOR fails to respond in one of
the above ways, the CONTRACTOR will be subject the following sanction:

 

100

 

A $500 penalty for each working day, beginning on the first day after
the 20-day time period has expired, and continuing until the day a corrective
action plan is submitted to the DEPARTMENT.

 

3.                                      Submission of
Corrective Action to DEPARTMENT

 

a.                                       Acceptance of Corrective Action Plan

 

If the CONTRACTOR submits a
corrective action plan to the DEPARTMENT within 20 working days (or other
agreed upon time frame) and the DEPARTMENT accepts the corrective action plan,
the DEPARTMENT will send written notice to the CONTRACTOR officially approving
the corrective action plan.

 

b.                                      When Corrective Action Plan Requires
Revisions

 

(1)                                  If the CONTRACTOR submits a corrective action
plan, but the DEPARTMENT determines the corrective action plan requires
revisions, the CONTRACTOR will have 20 working days to submit a revised plan
from the date the DEPARTMENT mails, through certified mail, the request for a
revised plan. The DEPARTMENT’s letter will state the specific revisions to be
made in the corrective action plan.

 

(2)                                  If the CONTRACTOR is unable or unwilling to
submit to the DEPARTMENT within the established time frame, a revised corrective
action plan containing the DEPARTMENT’s requested revisions, the CONTRACTOR
will be subject to the following sanction:

 

A $500 penalty for each working day, beginning on the first day after
the 20-day time period has expired, and continuing until the day a corrective
action plan is submitted to the DEPARTMENT.

 

4.                                      Initial Appeal
of DEPARTMENT’s Findings

 

a.                                       If the CONTRACTOR disagrees with the
DEPARTMENT’s findings and wishes to appeal those findings, the CONTRACTOR will
submit a detailed explanation of the disagreement in writing to the DEPARTMENT
within the established time frame. If the DEPARTMENT agrees with the
CONTRACTOR, the DEPARTMENT will provide written notification of its decision
and will withdraw the request for a corrective action plan.

 

b.                                      If the DEPARTMENT upholds its request for a
corrective plan, the CONTRACTOR has 20 days from the date the DEPARTMENT mails,
through certified mail, a letter upholding its request for a corrective action
plan.

 

c.                                       If the CONTRACTOR does not submit a corrective
action plan within that

 

101

 

time frame, the CONTRACTOR will be subjected to the following sanction:

 

A $500 penalty for each working day, beginning on the first day after
the 20-day time period has expired, and continuing until the day a corrective
action plan is submitted.

 

5.                                      Formal Hearing

 

a.                                       If the DEPARTMENT upholds its decision that a
corrective action plan is required, the CONTRACTOR may file a request for a
formal hearing with the DEPARTMENT within 30 days from the date the DEPARTMENT
mails, through certified mail, a letter upholding its decision. If the $500
penalty has begun, it will discontinue once the DEPARTMENT receives the formal
hearing request from the CONTRACTOR.

 

b.                                      If the outcome of the formal hearing is in
favor of the CONTRACTOR, the DEPARTMENT will provide the CONTRACTOR with
written notification that a corrective action plan is no longer required. The
DEPARTMENT will reimburse the CONTRACTOR any penalties the CONTRACTOR has paid
to the DEPARTMENT that accrued beginning on day 21 from the date the DEPARTMENT
mails, through certified mail, the request for a corrective action plan and
ending on the day the request for a formal hearing is received by the
DEPARTMENT.

 

c.                                       If the outcome of the formal hearing is in
favor of the DEPARTMENT, the CONTRACTOR will submit a corrective action plan,
as determined by the formal hearing decision, within 20 days of the date of the
hearing decision, otherwise the CONTRACTOR will be subject to the following
sanction:

 

A $500 penalty for each working day, beginning on the first day after
the 20-day time period has expired, and continuing until the day a corrective
action plan that complies with the formal hearing decision is submitted to the
DEPARTMENT. If the DEPARTMENT determines that the corrective action plan
requires revisions, the CONTRACTOR will again be subject to a $500 penalty for
each working day beginning on the first day after the DEPARTMENT verbally
notifies the CONTRACTOR that the corrective action plan requires revisions and
continuing until the day the DEPARTMENT receives the corrective action plan
containing the DEPARTMENT’s required revisions.

 

6.                                      CONTRACTOR
Unwilling or Unable to Implement Corrective Action Plan

 

a.                                       If the CONTRACTOR is unwilling or unable to
implement the corrective action plan to the satisfaction of the DEPARTMENT, the
CONTRACTOR will be subject to the following sanction:

 

A $500 penalty for each working day, beginning on the first day after
the DEPARTMENT verbally notifies the CONTRACTOR that the corrective action plan
has not been implemented, and continuing

 

102

 

until the day the CONTRACTOR successfully demonstrates to the
DEPARTMENT that it has implemented the plan. Following the DEPARTMENT’s verbal
notification, the DEPARTMENT will mail, through certified mail, a letter
stating the penalty has been invoked.

 

b.                                      The CONTRACTOR will be apprized of its right
to request a formal hearing.

 

(1)                                  If the CONTRACTOR decides to formally appeal
the DEPARTMENT’s decision that the corrective action plan has not been
implemented, then the procedures detailed in number 2 above apply.

 

(2)                                  If the outcome of the formal hearing is in
favor of the DEPARTMENT, penalties will resume on the date of the formal
hearing decision and continue until the CONTRACTOR complies with the decision
of the formal hearing.

 

7.                                      Collection of
Financial Penalties

 

The DEPARTMENT may deduct
any financial penalties assessed by the DEPARTMENT from the monthly payment to
the CONTRACTOR.

 

Article XV - Termination of the Contract

 

A.                                    Automatic Termination

 

This Contract will
automatically terminate June 30, 2006. The parties agree to meet prior to the
end date of this Contract to discuss terms and conditions that may be
incorporated into the next Contract period, unless terminated by either party
as provided herein.

 

B.                                    90-Day Termination Option

 

Either party may terminate
the Contract without cause by giving the other party written notice of
termination at least 90 days prior to the termination date.

 

C.                                    Effect of Termination

 

1.                                      Coverage

 

Inasmuch as the CONTRACTOR
is paid on a monthly basis, the CONTRACTOR will continue providing the Covered
Services required by this Contract until midnight of the last day of the calendar
month in which the termination becomes effective. If an Enrollee is a patient
in a hospital setting during the month in which termination becomes effective,
the CONTRACTOR is responsible for the entire hospital stay including physician
charges until discharge or thirty days following termination, whichever occurs
first.

 

103

 

2.                                      Enrollee Not Liable for
Debts of CONTRACTOR or its Subcontractors

 

If the CONTRACTOR or one of
its subcontractors becomes insolvent or bankrupt, the Enrollees will not be
liable for the debts of the CONTRACTOR or its subcontractor. The CONTRACTOR
will include this term in all of its subcontracts.

 

3.                                      Information for
Claims Payment

 

The CONTRACTOR will promptly
supply to the DEPARTMENT all information necessary for the reimbursement of any
Medicaid claims not paid by the CONTRACTOR.

 

4.                                      Changes in
Enrollment Process

 

The CONTRACTOR will be
advised of anticipated changes in policies and procedures as they relate to the
enrollment process and their comments will be solicited. The CONTRACTOR agrees
to be bound by such changes in policies and procedures unless they are not
agreeable to the CONTRACTOR, in which case the CONTRACTOR may terminate the
Contract in accordance with the Contract termination provisions.

 

5.                                      Hearing Prior to
Termination

 

Regarding the General
Provisions, Article XVII (Default, Termination, & Payment Adjustment), item
3, if the CONTRACTOR fails to meet the requirements of the Contract, the
DEPARTMENT will give the CONTRACTOR a hearing prior to termination. Enrollees
will be informed of the hearing and will be allowed to disenroll from this
Health Plan without cause.

 

6.                                      CMS Consent
Required

 

If the Department of Health
and Human Services, Centers for Medicare and Medicaid (CMS) directs the
DEPARTMENT to terminate this Contract, the DEPARTMENT will not be permitted to
renew this Contract without CMS consent.

 

D.                                    Assignment

 

Assignment of any or all
rights or obligations under this Contract without the prior written consent of
the DEPARTMENT is prohibited. Sale of all or any part of the rights or
obligations under this Contract will be deemed an assignment. Consent may be
withheld in the DEPARTMENT’s sole and absolute discretion.

 

Article XVI - Miscellaneous

 

A.                                   Integration

 

This Contract contains the
entire agreement between the parties with respect to the subject matter of this
Contract. There are no representations, warranties, understandings, or
agreements other than those expressly set forth herein. Previous contracts
between the

 

104

 

parties hereto and conduct
between the parties which precedes the implementation of this Contract will not
be used as a guide to the interpretation or enforcement of this Contract or any
provision hereof. If there is a conflict between these Special Provisions
(Attachment B) or the General Provisions (Attachment A), then these Special
Provisions will control.

 

B.                                     Enrollees May Not Enforce Contract

 

Although this Contract
relates to the provision of benefits for Enrollees and others, no Enrollee is
entitled to enforce any provision of this Contract against the CONTRACTOR nor
will any

 

provision of this Contract
be constructed to constitute a promise by the CONTRACTOR to any Enrollee or
Potential Enrollee.

 

C.                                     Interpretation of Laws and Regulations

 

The DEPARTMENT will be
responsible for the interpretation of all Federal and State laws and
regulations governing or in any way affecting this Contract. When
interpretations are required, the CONTRACTOR will submit written requests to
the DEPARTMENT. The DEPARTMENT will retain full authority and responsibility
for the administration of the Medicaid program in accordance with the
requirements of Federal and State law.

 

D.                                    Adoption of Rules

 

Adoption of rules by the
DEPARTMENT which govern the Medicaid program, will be automatically
incorporated into this Contract upon receipt by the CONTRACTOR of written
notice thereof.

 

105

 

Attachment C

Molina Healthcare of Utah 

January 1, 2006

 

Covered Services

Limitations & Exclusions

Co-payment & Co-insurance Requirements

 

Covered Services are the same under both the Traditional and
Non-Traditional Medicaid Plans unless otherwise indicated. Co-payments and
co-insurances are listed if required. Pregnant
women and children under age 18 are exempt from all co-payment and co-insurance
requirements. Services related to family planning are excluded from all
co-payment and co-insurance requirements. Medicaid Provider Manuals
provide detailed information regarding covered services and are available to
the CONTRACTOR upon request.

 

A.                                   In
General

 

The CONTRACTOR will provide the following benefits to Enrollees in
accordance with Medicaid benefits as defined in the Utah State Plan subject to
the exception or limitations as noted below. The DEPARTMENT reserves the right
to interpret what is in the State plan. Medicaid services can only be limited
through utilization criteria based on Medical Necessity. The CONTRACTOR will
provide at least the following benefits to Enrollees.

 

The CONTRACTOR is responsible to provide or arrange for all Medically
Necessary Covered Services on an emergency basis 24 hours each day, seven days
a week. The CONTRACTOR is responsible for payment for all covered Emergency
Services furnished by providers that do not have arrangements with the
CONTRACTOR.

 

B.                                    Hospital
Services

 

1.                                      Inpatient
Hospital

 

Services furnished in a licensed, certified hospital are Covered
Services.

 

Non-Traditional Medicaid Plan excludes the
following revenue codes:

430 - 439 (Occupational Therapy)

380 - 382, and 391 (Whole Blood)

390 and 399 (Autologous or self blood storage for future use)

811 - 813 (Organ Donor charges)

 

CO-INSURANCE

Traditional Medicaid: $220.00
for non-emergency admissions. Limited to $220.00 per Enrollee per calender
year.

Non-Traditional Medicaid: $220.00
for each non-emergency admission per Enrollee. Counts toward total maximum
co-payment and co-insurance of $500.00 per Enrollee per calendar year.

 

1

 

2.                                      Outpatient
Hospital

 

Services provided to Enrollees at a licensed, certified hospital who
are not admitted to the hospital are Covered Services.

 

CO-PAYMENT

 

Traditional Medicaid:
$2.00 co-payment per visit. Limited to one co-payment per date of service per
provider. The facility fees associated with services provided in an outpatient
hospital or free-standing ambulatory surgical centers are subject to $2.00
co-payment per date of service per provider. Annual calendar year maximum for
any combination of physician, podiatry, outpatient hospital, and surgical
centers is $100.00 per Enrollee.

 

Non-Traditional Medicaid:
$3.00 co-payment per visit. Limited to one co-payment per date of service per
provider. The facility fees associated with services provided in an outpatient
hospital or a free standing ambulatory surgical centers are subject to $3.00
co-payment per date of service per provider. Counts toward total maximum
co-payment and co-insurance of $500.00 per Enrollee per calendar year.

 

3.                                      Emergency
Department Services

 

Emergency Services provided to Enrollees in designated hospital
emergency departments are Covered Services.

 

CO-PAYMENT

 

Traditional Medicaid: Co-payment
is $6.00 for non-emergency use of the emergency room.

 

Non-Traditional Medicaid:
Co-payment is $6.00 for non-emergency use of the emergency room. Counts toward
total maximum co-payment and co-insurance of $500.00 per Enrollee per calendar
year.

 

C.                                     Physician
Services

 

Services provided directly by licensed physicians or osteopaths, or by
other licensed professionals such as physician assistants, nurse practitioners,
or nurse midwives under the physician’s or osteopath’s supervision are covered
Services.

 

Non-Traditional Medicaid excludes office
visits in conjunction with allergy injections (CPT codes 95115 through 95134
and 95144 through 95199).

 

CO-PAYMENT

 

Traditional Medicaid:
Co-pay is $3.00 per visit. Limited to one co-payment per date of service per
provider. Annual calendar year maximum is $100.00 per Enrollee for any
combination of physician, osteopath, podiatry, outpatient hospital,
freestanding

 

2

 

emergency centers, and surgical centers. Co-payment required for
preventive services and immunizations.

 

Non-Traditional Medicaid:
Co-payment is $3.00 per visit. Limited to one co-payment per date of service
per provider. No co-payment for preventive services and immunizations. Counts
toward total maximum co-payment and co-insurance of $500.00 per Enrollee per
calendar year.

 

D.                                    General
Preventive Services

 

The CONTRACTOR must develop or adopt practice guidelines consistent
with current standards of care, as recommended by professional groups such as
the American Academy of Pediatric and the U.S. Task Force on Preventive Care.

 

A minimum of three screening programs for prevention or early
intervention (e.g. Pap Smear, diabetes, hypertension).

 

E.                                      Vision
Care

 

Services provided by licensed ophthalmologists or licensed optometrists,
and opticians within their scope of practice are Covered Services. Services
include, but are not limited to, the following:

 

1.                                       Eye examinations
and care to identify and treat medical problems

2.                                       Eye refractions,
examinations

3.                                       Laboratory work

4.                                       Lenses

5.                                       Eyeglass Frames

6.                                       Repair of Frames

7.                                       Repair or
Replacement of Lenses

8.                                       Contact Lenses
(when Medically Necessary)

 

Traditional Medicaid
Plan: Full coverage for all Non-Traditional clients.

 

Non-Traditional Medicaid Plan is limited to
the following services and limitations:Non-Traditional
Medicaid clients have coverage for vision screening in conjunction with
determining refractions. Providers may bill using procedure codes 92002, 92004,
92012, and 92014. There is a maximum Medicaid benefit of $31.21 for screening
services. Charges above the $31.21 are non-covered Medicaid services and are
considered the patient’s responsibility. Eye refraction/examination is limited
to one eye examination every 12 months.

 

Eyeglasses (lenses and frames) are not covered.

 

Services to identify and treat medical problems such as diabetic
retinopathy, glaucoma, cataracts, etc., may be billed by ophthalmologists and
optometrists using procedure codes

 

3

 

92020, 92083, 92135, 95930, 99201-99205, 99211-99215, 65210, 65220,
65222, 67820, 68761, and 68801. Ophthalmologists may bill additional procedure
codes within their scope of service that are covered by Medicaid. These
services are paid based on the Medicaid fee schedule and are considered payment
in full.

 

F.                                      Lab
and Radiology Services

 

Professional and technical laboratory and X-ray services furnished by
licensed and certified providers are Covered Services. All laboratory testing
sites, including physician office labs, providing services under this Contract
will have either a Clinical Laboratory Improvement Amendments (CLIA)
Certificate of Waiver or a certificate of registration along with a CLIA
identification number.

 

Those laboratories with certificates of waiver will provide only the
eight types of tests permitted under the terms of their waiver. Laboratories
with certificates of registration may perform a full range of laboratory tests.

 

G.                                    Physical
and Occupational Therapy

 

1.                                      Physical
Therapy

 

Treatment and services provided by a licensed physical therapist. Treatment
and services must be authorized by a physician and include services prescribed
by a physician or other licensed practitioner of the healing arts within the
scope of his or her practice under State law and provided to an Enrollee by or
under the direction of a qualified physical therapist. Necessary supplies and
equipment will be reviewed for medical necessity and follow the criteria of the
R414.12 rule.

 

2.                                      Occupational
Therapy

 

Treatment of services provided by a licensed occupational therapist. Treatment
and services must be authorized by a physician and include services prescribed
by a physician or other licensed practitioner of the healing arts within the
scope of his or her practice under State law and provided to an Enrollee by or
under the direction of a qualified occupational therapist. Necessary supplies
and equipment will be reviewed for medical necessity and follow the criteria of
the R414.12 rule.

 

Non-Traditional Medicaid:  Physical therapy and occupational therapy (in
combination) are limited to 10 visits per calendar year.

 

CO-PAYMENT

 

Non-Traditional Medicaid:
$3.00 co-payment per visit. Limited to one co-payment per date of service per
provider. Counts toward total maximum co-payment and co-insurance of $500.00
per Enrollee per calendar year.

 

4

 

H.                                    Speech
and Hearing Services

 

Services and appliances, including hearing aids and hearing aid
batteries, provided by a licensed medical professional to test and treat speech
defects and hearing loss are Covered Services.

 

Non-Traditional Medicaid Plan:
Full coverage except hearing aids are limited to congenital (birth defect)
hearing losses only.

 

I.                                         Podiatry
Services

 

Services provided by a licensed podiatrist are Covered Services.

 

Traditional Medicaid Plan: Full
coverage is limited to children up to age 21 and pregnant women. Limited
podiatry benefits are covered for adults.

 

Non-Traditional Medicaid Plan:  Limited podiatry benefits are covered.

 

CO-PAYMENT

 

Traditional Medicaid:  Co-pay is $3.00 per visit. Limited to one
co-payment per date of service per provider. Annual calendar year maximum is
$100.00 per Enrollee for any combination of physician, podiatry, outpatient
hospital, freestanding emergency centers, and surgical centers. Co-payment
required for preventive services and immunizations.

 

Non-Traditional Medicaid:
Co-payment is $3.00 per visit. Limited to one co-payment per date of service
per provider. Counts toward total maximum co-payment and co-insurance of
$500.00 per Enrollee per calendar year.

 

J.                                        End
Stage Renal Disease - Dialysis

 

Treatment of end stage renal dialysis for kidney failure is a Covered
Service. Dialysis is to be rendered by a Medicare-certified Dialysis facility.

 

K.                                    Home
Health Services

 

Home health services are defined as intermittent nursing care provided
by certified nursing professionals (registered nurses, licensed practical
nurses, and home health aides) in the client’s home when the client is
homebound or semi-homebound are Covered Services. Home health care must be
rendered by a Medicare-certified Home Health Agency. The CONTRACTOR agrees to
comply with all federal regulations regarding surety bonds. The CONTRACTOR
agrees to contract with only Medicare-certified Home Health Agencies who carry
a surety bond if federal regulations regarding this requirement are reinstated.
The DEPARTMENT agrees to notify the CONTRACTOR if such federal regulations are
reinstated.

 

5

 

Personal care services as defined in the DEPARTMENT’s Medicaid Personal
Care Provider Manual are included in this Contract. Personal care services may
be provided by a State licensed home health agency.

 

L.                                      Hospice
Services

 

Services delivered to terminally ill patients (six months life
expectancy) who elect palliative versus aggressive care are Covered Services. Hospice
care must be rendered by a Medicare-certified hospice. When an Enrollee is
receiving hospice in a nursing facility, ICF/MR or freestanding hospice facility,
the CONTRACTOR is responsible for up to 30 days of hospice care.

 

M.                                  Private
Duty Nursing

 

Services provided by licensed nurses for ventilator-dependent children
and technology-dependent adults in their home in lieu of hospitalization if
Medically Necessary, feasible, and safe to be provided in the patient’s home
are Covered Services. Requests for continuous care will be evaluated on a case
by case basis and must be approved by the CONTRACTOR.

 

Non-Traditional Medicaid Plan:  Private Duty Nursing is not a covered
service.

 

N.                                    Medical
Supplies and Medical Equipment

 

This Covered Service includes any necessary supplies and equipment used
to assist the Enrollee’s medical recovery, including both durable and
non-durable medical supplies and equipment, and prosthetic devices. The
objective of the medical supplies program is to provide supplies for maximum
reduction of physical disability and restore the Enrollee to his or her best
functional level. Medical supplies may include any necessary supplies and equipment
recommended by a physical or occupational therapist, but should be ordered by a
physician. Durable medical equipment (DME) includes, but is not limited to,
prosthetic devices and specialized wheelchairs. Durable medical equipment and
supplies must be provided by a DME supplier that has a surety bond. Necessary
supplies and equipment will be reviewed for medical necessity and follow the
criteria of the R414.12 of the Utah Administrative Code, with the exception of
criteria concerning long term care since long term care services are not
covered under the Contract.

 

Non-Traditional Medicaid Plan
excludes blood pressure monitors, and replacement of lost, damaged, or stolen
durable medical equipment or prosthesis.

 

O.                                   Abortions
and Sterilizations

 

These Covered Services are provided to the extent permitted by Federal
and State law and must meet the documentation requirement of 42 CFR 441,
Subparts E and F. These requirements must be met regardless of whether Medicaid
is primary or secondary payer.

 

6

 

P.                                      Treatment
for Substance Abuse and Dependency

 

Treatment will cover medical detoxification for alcohol or substance
abuse conditions is a Covered Service. Medical services including hospital
services will be provided for the medical non-psychiatric aspects of the
conditions of alcohol/drug abuse.

 

Q.                                    Organ
Transplants

 

The following transplantations are Covered Services for all Enrollees:
kidney, liver, cornea, bone marrow, stem cell, heart, intestine, lung, pancreas,
small bowel, combination heart/lung, combination intestine/liver, combination
kidney/pancreas, combination liver/kidney, multi visceral, and combination
liver/small bowel unless amended under the provisions of Attachment B, Article
IV (Benefits), Section C, Subsection 2 of this Contract.

 

Non-Traditional Medicaid Plan
is limited to kidney, liver, cornea, bone marrow, stem cell, heart, and lung
transplantations.

 

R.                                    Other
Outside Medical Services

 

The CONTRACTOR, at its discretion and without compromising quality of
care, may choose to provide services in Freestanding Emergency Centers,
Surgical Centers and Birthing Centers.

 

CO-PAYMENT

 

Traditional Medicaid:
$2.00 co-payment per visit. Limited to one co-payment per date of service per
provider. Annual calendar year maximum is $100.00 per Enrollee for any
combination of physician, podiatry, outpatient hospital, freestanding emergency
centers, and surgical centers. (Co-payment does not apply to birthing centers.)

 

Non-Traditional Medicaid:
$3.00 co-payment per visit. Limited to one co-payment per date of service per
provider. Counts toward total maximum co-payment and co-insurance of $500.00
per Enrollee per calendar year.

 

S.                                     Long
Term Care

 

The CONTRACTOR may provide long term care for Enrollees in skilled
nursing facilities requiring such care as a continuum of a medical plan when
the plan includes a prognosis of recovery and discharge within thirty (30) days
or less. When the prognosis of an Enrollee indicates that long term care (over
30 days) will be required, the CONTRACTOR will notify the DEPARTMENT and the
skilled nursing facility of the prognosis determination and will initiate
disenrollment. Skilled nursing care is to be rendered in a skilled nursing
facility which meets federal regulations of participation.

 

7

 

T.                                     Services
to CHEC Enrollees

 

1.                                      CHEC
Services

 

The CONTRACTOR will provide to CHEC Enrollees preventive screening
services and other necessary medical care, diagnostic services, treatment, and
other measures necessary to correct or ameliorate defects and physical and
mental illnesses and conditions discovered by the screening services, whether
or not such services are covered under the State Medicaid Plan. The CONTRACTOR
is not responsible for home and community-based services available through Utah’s
Home and Community-Based waiver programs.

 

The CONTRACTOR will provide the full early and periodic screening,
diagnosis, and treatment services to all eligible children and young adults up
to age 21 in accordance with the periodicity schedule as described in the Utah
CHEC Provider Manual. All children between six months and 72 months must be
screened for blood lead levels.

 

Non-Traditional Medicaid : CHEC
services are not covered. Enrollees who are 19 or 20 years of age receive the
adult scope of services.

 

2.                                      CHEC
Policies and Procedures

 

The CONTRACTOR agrees to have written policies and procedures for
conducting tracking, follow-up, and outreach to ensure compliance with the CHEC
periodicity schedules. These policies and procedures will emphasize outreach
and compliance monitoring for children and young adults, taking into account
the multi-lingual, multi-cultural nature as well as other unique
characteristics of the CHEC Enrollees.

 

U.                                     Family
Planning Services

 

These Covered Services includes disseminating information, counseling,
and treatments relating to family planning services. All services must be
provided by or authorized by a physician, certified nurse midwife, or nurse
practitioner. All services must be provided in concert with Utah law.

 

Birth control services include information and instructions related to
the following:

 

1.                                       Birth
control pills;

2.                                       Norplant
(removal only);

3.                                       Depo
Provera;

4.                                       IUDs;

5.                                       Barrier
methods including diaphragms, male and female condoms, and cervical caps;

 

8

 

6.                                       Vasectomy
or tubal ligations;

7.                                       Nuvaring;
and

8.                                       Office
calls, examinations or counseling related to contraceptive devices.

 

Non-Traditional Medicaid:  Norplant is not a covered service.

 

V.                                    High-Risk
Prenatal Services

 

1.                                      In
General - Ensure Services are Appropriate and Coordinated

 

The CONTRACTOR must ensure that high risk pregnant Enrollees receive an
appropriate level of quality perinatal care that is coordinated, comprehensive,
preventive, and continuous either by direct service or referral to an
appropriate provider or facility. In the determination of the provider and
facility to which a high risk prenatal Enrollee will be referred, care must be
taken to ensure that the provider and facility both have the appropriate
training, expertise and capability to deliver the care needed by the Enrollee
and her fetus/infant. Although many complications in perinatal health cannot be
anticipated, most can be identified early in pregnancy. Ideally,
preconceptional counseling and planned pregnancy are the best ways to assure
successful pregnancy outcome, but this is often not possible. Provision of
routine preconceptional counseling must be made available to those women who
have conditions identified as impacting pregnancy outcome, i.e., diabetes
mellitus, medications which may result in fetal anomalies or poor pregnancy
outcome, or previous severe anomalous fetus/infant, among others.

 

2.                                      Risk
Assessment

 

a.                                       General

 

Enrollees who are pregnant should be risk assessed at their first
prenatal visit, preferably in the first trimester, and later in pregnancy as
low, moderate or high risk for medical and psychosocial conditions which may
contribute to poor birth outcomes. Women found to not be moderate or high risk
should be evaluated for change in risk status throughout their pregnancy.

 

b.                                       Assessment
tools

 

The CONTRACTOR must have a mechanism to assure that prenatal care
providers conduct risk assessments on all pregnant Enrollees on entry into
prenatal care and, as needed, on an ongoing basis to re-assess risk status
throughout pregnancy. Assessment tools used by prenatal care providers should
be consistent with standards of practice and linked to the CONTRACTOR’s care
coordination/case management programs for those Enrollees who have a moderate
or high risk status. All prenatal health care

 

9

 

providers should be able to identify the full range of medical and
psychosocial risk factors and either provide appropriate care or initiate
referrals to the appropriate level of care/consultation throughout pregnancy.

 

The CONTRACTOR’s healthy pregnancy programs must also include
assessment of risk for all pregnant Enrollees as soon as a pregnancy is
identified and as needed, on an ongoing basis. The CONTRACTOR shall refer to
and coordinate care with the prenatal care providers concerning the treatment
plan and risk factors. The CONTRACTOR’s risk assessments shall be overseen by
the CONTRACTOR’s Medical Director.

 

Assessment tools used by prenatal care providers and the CONTRACTOR
should include a means of identifying prenatal risk factors based on medical
and psychosocial conditions that may contribute to poor birth outcomes and that
will assist the CONTRACTOR and prenatal care providers in determining the level
and intensity of care coordination/case management required to ensure the
appropriate level of perinatal care.

 

The DEPARTMENT recommends “Guidelines for Perinatal Care by American
Academy of Pediatrics, and American College of Obstetricians and Gynecologists”
as a resource for evaluating and classification of risk, the level of care and
consultation recommended based on risk status, and the level of care
coordination required. The DEPARTMENT recommends that Enrollees be identified
with a status of no risk, low risk, moderate risk, or high risk and that at a
minimum, Enrollees who are classified as moderate or high risk should receive
care coordination/case management services.

 

c.                                       Recommended
Prenatal Screening

 

(1)                                 Hepatitis
B surface antigen

 

The DEPARTMENT recommends routine prenatal screening of every woman for
hepatitis B surface antigen (HBsAg) early in prenatal care to identify all
those at high risk for transmitting the virus to their newborns and later in
pregnancy for women who tested negative for HbsAg during early pregnancy but
who are at high risk based on:

 

(a)                                  evidence
of clinical hepatitis during pregnancy;

(b)                                 injection
drug use;

(c)                                  occurrence
during pregnancy or a history of STDs; or

(d)                                 judgement
of the health care provider.

 

When a woman is found to be HBsAg-positive, the CONTRACTOR will provide
HBIG and HB vaccine at birth. Initial treatments should be given during the
first 12 hours of life. The CONTRACTOR will comply with all other requirements
as specified in Utah Law R386-702-9.

 

10

 

(2)                                 Sexually
Transmitted Diseases (STDs)

 

The DEPARTMENT recommends prenatal screening including sexually
transmitted diseases such as gonorrhea, chlamydia, and standard serological
testing for syphilis as required by Utah Law 26-6-20. Testing for STDs should
be repeated in the 3rd trimester for Enrollees at high risk for
exposure.

 

(3)                                 HIV
testing

 

The DEPARTMENT also recommends testing of all pregnant Enrollees for
HIV and testing and treatment at labor and delivery for women who have not
received testing during pregnancy. The CONTRACTOR should encourage providers to
develop policies that are consistent with the American College of Obstetricians
and Gynecologists, including but not limited to:

 

(a)                                  universal testing
with an opt-out approach (testing of all pregnant women and not just those who appear
to be at high risk for HIV;

(b)                                 flexibility
in the consent process; and

(c)                                  prevention
and referral through education during prenatal care.

 

Prenatal care providers should have a mechanism to document in medical
records when pregnant Enrollees are offered HIV tests and when tests are
refused. Pregnant Enrollees who refuse HIV testing earlier in pregnancy should
be offered HIV testing again later in pregnancy. Pregnant Enrollees who test
positive should receive treatment throughout their pregnancy and labor and
delivery to reduce the risk of HIV transmission to their newborns.

 

3.                                      Prenatal
Initiative Program

 

Prenatal services provided directly or through agreements with
appropriate providers include those services covered under Medicaid’s Prenatal
Initiative Program which includes the following enhanced services for pregnant
women:

 

a.                                       perinatal care
coordination

b.                                      prenatal and
postnatal home visits

c.                                       group prenatal
and postnatal education

d.                                      nutritional
assessment and counseling

e.                                       prenatal and
postnatal psychosocial counseling

 

Psychosocial counseling is a service designed to benefit the pregnant
client by helping her cope with the stress that may accompany her pregnancy. Enabling
her to manage this stress improves the likelihood that she will have a healthy
pregnancy. This counseling is intended to be short term and directly related to
the pregnancy. However, pregnant women who are also suffering from a serious
emotional or mental illness should be referred to an appropriate mental health
care

 

11

 

provider.

 

W.                                Services
for Children with Special Needs

 

1.                                      In
General

 

In addition to primary care, children with chronic illnesses and
disabilities need specialized care provided by trained experienced
professionals. Since early diagnosis and intervention will prevent costly
complications later on, the specialized care must be provided in a timely
manner. The specialized care must comprehensively address all areas of need to
be most effective and must be coordinated with primary care and other services
to be most efficient. The children’s families must be involved in the planning
and delivery of the care for it to be acceptable and successful.

 

2.                                      Services
Requiring Timely Access

 

All children with special health care needs must have timely access to
the following services:

 

a.                                       Comprehensive evaluation
for the condition.

b.                                      Pediatric
subspecialty consultation and care appropriate to the condition.

c.                                       Rehabilitative
services provided by professionals with pediatric training in areas such as
physical therapy, occupational therapy and speech therapy.

d.                                      Durable medical
equipment appropriate for the condition.

e.                                       Care
coordination for linkage to early intervention, special education and family
support services and for tracking progress.

 

In addition, children with the conditions marked by * below must have
timely access to coordinated multispecialty clinics, when Medically Necessary,
for their disorder.

 

12

 

3.                                      Definition
of Children with Special Health Care Needs

 

The definition of children with special health needs includes, but is
not limited to, the following conditions:

 

	
  a.

  	
   

  	
  Nervous System Defects such as

  
	
   

  	
   

  	
  Spina Bifida*

  
	
   

  	
   

  	
  Sacral Agenesis*

  
	
   

  	
   

  	
  Hydrocephalus

  
	
   

  	
   

  	
   

  
	
  b.

  	
   

  	
  Craniofacial Defects such as

  
	
   

  	
   

  	
  Cleft Lip and Palate*

  
	
   

  	
   

  	
  Treacher - Collins Syndrome

  
	
   

  	
   

  	
   

  
	
  c.

  	
   

  	
  Complex Skeletal Defects such as

  
	
   

  	
   

  	
  Arthrogryposis*

  
	
   

  	
   

  	
  Osteogenesis Imperfecta*

  
	
   

  	
   

  	
  Phocomelia*

  
	
   

  	
   

  	
   

  
	
  d.

  	
   

  	
  Inborn Metabolic Disorders such as

  
	
   

  	
   

  	
  Phenylketonuria*

  
	
   

  	
   

  	
  Galactosemia*

  
	
   

  	
   

  	
   

  
	
  e.

  	
   

  	
  Neuromotor Disabilities such as

  
	
   

  	
   

  	
  Cerebral palsy*

  
	
   

  	
   

  	
  Muscular Dystrophy*

  
	
   

  	
   

  	
  Complex Seizure Disorders

  
	
   

  	
   

  	
   

  
	
  f.

  	
   

  	
  Congenital Heart Defects

  
	
   

  	
   

  	
   

  
	
  g.

  	
   

  	
  Genetic Disorders such as

  
	
   

  	
   

  	
  Chromosome Disorders

  
	
   

  	
   

  	
  Genetic Disorders

  
	
   

  	
   

  	
   

  
	
  h.

  	
   

  	
  Chronic Illnesses such as

  
	
   

  	
   

  	
  Cystic Fibrosis

  
	
   

  	
   

  	
  Hemophilia

  
	
   

  	
   

  	
  Rheumatoid Arthritis

  
	
   

  	
   

  	
  Bronchopulmonary Dysplasia

  
	
   

  	
   

  	
  Cancer

  
	
   

  	
   

  	
  Diabetes

  
	
   

  	
   

  	
  Nephritis

  
	
   

  	
   

  	
  Immune Disorders

  

 

13

 

i.                                          Developmental
Disabilities with multiple or global delays in development such as Down
Syndrome or other conditions associated with mental retardation.

 

The CONTRACTOR agrees to cover all Medically Necessary services for
children with special health care needs such as the ones listed above. The
CONTRACTOR further agrees to cooperate with the DEPARTMENT’s quality assurance
monitoring for this population by providing requested information.

 

X.                                    Medical
and Surgical Services of a Dentist

 

1.                                      Who
May Provide Services

 

Under Utah law, medical and surgical services of a dentist may be
provided by either a physician or a doctor of dental medicine or dental
surgery.

 

2.                                      Universe
of Covered Services

 

Medical and surgical services that under Utah law may be provided by a
physician or a doctor of dental medicine or dental surgery, are covered under
the Contract.

 

3.                                       Services
Specifically Covered

 

The CONTRACTOR is responsible for palliative care and pain relief for
severe mouth or tooth pain in an emergency room. If the emergency room
physician determines that it is not an emergency and the client requires
services at a lesser level, the provider should refer the client to a dentist
for treatment. If the dental-related problem is serious enough for the client
to be admitted to the hospital, the CONTRACTOR is responsible for coverage of
the inpatient hospital stay. The CONTRACTOR is responsible for
authorized/approved medical services provided by oral surgeons consistent with
injury, accident, or disease (excluding dental decay and periodontal disease)
including, but not limited to, removal of tumors in the mouth, setting and
wiring a fractured jaw. Also covered are injuries to sound natural teeth and
associated bone and tissue resulting from accidents including services by
dentists performed in facilities other than the emergency room or hospital.

 

4.                                       Dental Services Not Covered

 

The CONTRACTOR is not responsible for routine dental services such as
fillings, extractions, treatment of abscess or infection, orthodontics, and
pain relief when provided by a dentist in the office or in an outpatient
setting such as a surgical center or scheduled same day surgery in a hospital
including the surgical facilities charges.

 

Y.                                     Diabetes
Education

 

The CONTRACTOR shall provide diabetes self-management education from a
Utah certified or American Diabetes Association recognized program when an
Enrollee:

 

14

 

1.                                       has
recently been diagnosed with diabetes, or

 

2.                                       is
determined by the health care professional to have experienced a significant
change in symptoms, progression of the disease or health condition that warrants
changes in the Enrollee’s self-management plan, or

 

3.                                       is
determined by the health care professional to require re-education or refresher
training.

 

Z.                                     HIV
Prevention

 

The CONTRACTOR shall have in place the following:

 

1.                                      General
Program

 

The CONTRACTOR must have educational methods for promoting HIV
prevention to Enrollees. HIV prevention information, both primary (targeted to
uninfected Enrollees), as well as secondary (targeted to those Enrollees with
HIV) should must be culturally and linguistically appropriate. All Enrollees
should be informed of the availability of both in-plan HIV counseling and
testing services, as well as those available from Utah State-operated programs.

 

2.                                      Focused
Program for Women

 

Special attention should be paid identifying HIV+ women and engaging
them in routine care in order to promote treatment including, but not limited
to, antiretroviral therapy during pregnancy.

 

15

 

SUMMARY OF CO-PAYMENT AND

CO-INSURANCE REQUIREMENTS

 

Pregnant women and children
under age 18 are exempt from all co-payment and co-insurance requirements. Services
related to family planning are excluded from all co-payment and co-insurance
requirements.

 

Traditional Medicaid Plan

 

•                                          Inpatient hospital: Each Enrollee must pay
a $220.00 co-insurance for non-emergency inpatient hospital admissions. The
maximum co-payment per Enrollee per calendar year is $220.00 for non-emergency
inpatient hospital admissions.

 

•                                          Emergency Department: Each enrollee must
pay a $6.00 co-payment for non-emergency use of the emergency room.

 

•                                          Physician, osteopath, podiatrist, outpatient hospital,
freestanding emergency centers, and surgical centers: Each Enrollee
must pay a $3.00 co-payment per provider per day. The maximum co-payment per
Enrollee per calendar year is $100.00 for any combination of the services
provided by the above providers.

 

•                                          Prescription
Drugs: Each Enrollee must pay a co-payment of $3.00 per prescription. The
maximum co-payment is $15.00 per Enrollee per month.*

 

There is no overall out-of-pocket maximum for
the above services.

 

Non-Traditional Medicaid Plan

 

•                                          Inpatient hospital:  Each Enrollee must pay a $220.00 co-insurance
for each non-emergency inpatient hospital admissions.

 

•                                          Emergency Department: Each enrollee must
pay a $6.00 co-payment for non-emergency use of the emergency room.

 

•                                          Physician, osteopath, podiatrist, physical therapist,
occupational therapist, chiropractor*, freestanding emergency centers, surgical
centers: Each Enrollee must pay a $3.00 co-payment per provider per
day.

 

•                                          Prescription Drugs: Each Enrollee must pay
a co-payment of $2.00 per prescription.*

 

The out-of-pocket maximum for each Enrollee
is $500.00 for any combination of the above co-payments and co-insurance.

 

*Pharmacy services and chiropractic services are not the responsibility
of the CONTRACTOR.

 

16

 

Utah’s Quality Assessment and Performance Improvement
Plan

(Utah “QAPIP”)

 

For Contracted Medicaid Health Plans

 

Attachment D: Program Description

 

 

State of Utah

Department of Health

Division of Health Care Financing

Bureau of Managed Health Care

 

August 13, 2003

 

 

 

 

Table of
Contents

 

	
   

  	
   

  	
  Page

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  I. Utah Quality Assessment and Performance Improvement Plan
  (UQAPIP), Executive Summary

  	
   

  	
  3

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  II. Utah Quality Assessment and Performance Improvement
  Plan (UQAPIP), Program Description

  	
   

  	
  4

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  A. Overview

  	
   

  	
  4

  	
   

  
	
  B. Purpose

  	
   

  	
  4

  	
   

  
	
  C. Objectives

  	
   

  	
  4

  	
   

  
	
  D. Quality Assessment and
  Performance Improvement (QAPI) Strategy

  	
   

  	
  5

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   1. Health Plan Compliance
  Reviews

  	
   

  	
  5

  	
   

  
	
  a. CMS
  Reporting

  	
   

  	
  7

  	
   

  
	
  b. Documentation Requirements and Time Lines

  	
   

  	
  7

  	
   

  
	
  c.
  Deeming

  	
   

  	
  7

  	
   

  
	
  d.
  Corrective Actions and Sanctions

  	
   

  	
  8

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   2. Internal Surveillance
  and Tracking (analysis of internal MMCS and Data Warehouse data)

  	
   

  	
  8

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   3. External Quality Reviews
  (EQR’s)

  	
   

  	
  8

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  a. Mandatory EQR activities
  include

  	
   

  	
  8

  	
   

  
	
  b. Optional activities include

  	
   

  	
  9

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   4. Annual Program Evaluation Page

  	
   

  	
  9

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  III.
  Table of Appendices

  	
   

  	
  10

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  IV.
  References

  	
   

  	
  11

  	
   

  

 

2

 

I. Utah Quality Assessment and Performance
Improvement Monitoring Plan (QAPIP) Executive Summary:

 

The Utah Department of Health (DOH), Division
of Health Care Financing (DHCF), Bureau of Managed Health Care (BMHC) by
authority of 42 CFR, Part 438, Subparts C, D, E, F, H (438.602, 438.608,
438.610), and Subpart I (438.700) has oversight responsibility of contracted
Medicaid health plans to ensure the delivery of quality health care and
compliance with state and federal regulations.

 

The BMHC oversight methodology consists of activities to collect and
analyze data from on-site reviews,
required reports, and other internal and external data sources. This
information is used to determine compliance with state Medicaid requirements;
federal regulations pertaining to managed care entities; to identify
opportunities for improvement and areas of non-compliance. When BMHC identifies
non-compliance and areas where improvement is needed, BMHC makes
recommendations and requires corrective action plans (CAP’s). Health plans are
required to submit CAP’s according to specified timeframes; BMHC reviews what
is submitted and either accepts or requests a revised CAP. Health plans can
request extensions to the required CAP timeframes or appeal the BMHC’s findings.
Once the health plan submits an acceptable action plan, the BMHC provides
adequate opportunity for the plan to implement corrections and improvements. Follow
up activities are conducted thereafter to assess progress toward compliance and
address areas for continuous improvement.

 

The BMHC uses information from quality monitoring activities to assess
the effectiveness of its monitoring program, implement improvements to its
oversight processes, update health plan compliance requirements and develop
work plans for subsequent years. The BMHC reports to Centers for Medicare and
Medicaid Services (CMS) as required concerning results of quality monitoring
activities and program evaluations.

 

3

 

II. Utah Quality Assessment and Performance
Improvement Monitoring Plan (QAPIP) Program Description

 

A. Overview:

 

The Utah Department of Health (DOH), Division of
Health Care Financing (DHCF), Bureau of Managed Health Care (BMHC) by authority
of 42 CFR, Part 438, Subparts C, D, E, F, H (438.602, 438.608, 438.610), and
Subpart I (438.700) has oversight responsibility of contracted Medicaid health
plans to ensure the delivery of quality health care and compliance with state
and federal regulations.

 

The UTAH QAPIP encompasses oversight of
regulations pertaining to Managed Care Organizations (MCOs), Prepaid Inpatient
Health Plans (PIHPs) and Primary Care Case Management (PCCM) entities.

 

B. Purpose:

 

The purpose of the Utah Quality Assessment and
Performance Improvement Plan is to ensure that the Medicaid health plans
provide quality health care to Medicaid enrollees, to provide a mechanism to
ensure continuous improvement in the care and services provided and assess
compliance to state and federal regulations required for managed care entities.

 

C. Objectives:

 

•                  To establish a
monitoring plan that uses experts outside of the BMHC to promote interagency
cooperation and support other state DOH programs.

•                  To establish a
monitoring plan which includes deeming provisions, in order to minimize
duplication and redundancy of comparable monitoring content for organizations
that have received accreditation by a nationally recognized accreditation body.

•                  To assess the
quality, availability and access to, coordination of, and appropriateness of
care and services provided to Medicaid enrollees (including those with special
health care needs) under MCO, PIHP and PCCM contracts.

•                  To assure care and
services are provided in a culturally competent manner, which respects the
rights of enrollees, including those with disabilities.

•                  To assess
compliance through regular monitoring in a way that promotes collaboration and
continuous quality improvement.

•                  To ensure adherence
to contract requirements, state and federal regulations applicable to the types
of health plans contracted with Medicaid.

•                  To assure
appropriate adherence to privacy and confidentiality rules in the provision of
care and services.

•                  To assure the
organizations structure, operations and information systems support adherence
to the Utah QAPIP, program oversight needs and meet federal and state
regulations.

•                  To assure that data
and documentation necessary for quality oversight is accurate and complete.

 

4

 

D. Quality Assessment and Performance Improvement
(QAPI) Strategy:

 

The BMHC’s methods of oversight of contracted
Medicaid health plans involve an integrated approach using information derived
from the following four activities. These include:

 

1. Health Plan Compliance Reviews

2.              Internal Surveillance and
Tracking (analysis of internal data)

3.              External Quality Review
(EQR)

4.              Annual Program Review

 

1. Health Plan Compliance Reviews

 

The BMHC conducts periodic reviews of contracted MCOs, PIHPs and PCCMs
to monitor contract compliance and compliance to state and federal regulations
applicable to these types of health plan entities. Reviews are done using the
Utah Quality Assessment and Performance Improvement Plan (QAPIP), which is a
comprehensive set of compliance Standards based on quality improvement,
contract monitoring, and regulatory oversight needs. Most of the compliance
Standards in the QAPIP is applicable to MCO and PIHP health plan entities. Oversight
of PCCM contracts and compliance with state and federal regulations is also
accomplished through the UTAH QAPIP; although, much fewer of the compliance
Standards are applicable to PCCM entities.

 

The BMHC’s conducts periodic comprehensive quality monitoring reviews
(CQMRs) using the UTAH QAPIP compliance Standards. Frequency of CQMRs is
determined by the level of compliance demonstrated during the on-reviews,
internal surveillance and monitoring (number 2, described below), the amount of
structural or operational changes made following reviews or based on other
oversight needs. For all MCO or PIHP entities CQMR’s will occur at least every
threes years and more frequently when necessary. Annually, follow-up reviews
will be done to assess progress toward recommended improvements and CAPs. The
BMHC may also conduct a focused review of a particular area(s); these are
Follow-up/ Focused Quality Monitoring Review’s (FQMR’s).

 

CQMRs consist of review of all UTAH QAPIP pertaining to the type of
entity being reviewed and all applicable data sources for each area. The UTAH
QAPIP delineates compliance areas that require detailed program narratives, any
mandatory data sources needed to assess compliance, authority for particular
areas of compliance, applicability of deeming status for entities who have
received national accreditation, and DOH staff resources that may be used to
assess each compliance area. Documentation requirements for annual monitoring
will be tailored to the level of compliance from the most recent CQMR, analysis
from internal surveillance, and other monitoring needed relating to quality,
access to care and appropriateness of care and services, etc.

 

CQMRs for MCOs or PIHPs will occur “on-site” at the organization’s
local office(s). On-site reviews will consist of reviewing documentation,
interviewing staff and conducting an exit conferencing, which outlines the
organization’s strengths and weaknesses. The BMHC may use on-site review,
in-person meetings or teleconferencing to conduct

 

5

 

FQMRs. For PCCMs, an assessment of compliance to applicable regulations
may be conducted less formally (telephone conference following review of
applicable documentation) and therefore not require an on-site review. The BMHC’s
Quality Monitoring Unit staff and other DOH consultants will participate in
review activities. The BMHC uses consultants from the Division of Community and
Family Health Services, the Office of Health Care Statistics and other DHCF
staff to conduct reviews.

 

Following each review, the BMHC will compile a report addressing the
level of compliance to applicable Utah QAPIP Standards for the type of entity
being reviewed. This report will detail findings, recommendations for
improvements and general comments. Written corrective action plans (CAPs) for
any areas of non-compliance will be required as necessary. The BMHC will
conduct follow-up reviews annually that will assess the plan’s progress toward
CAPs, other recommended improvements and monitoring related to reviews and any
reports required by the contract relating to quality, access to care and
appropriateness of care and services since the last review. Depending on the
level of compliance, BMHC may elect to repeat CQMR as often as necessary or
conduct a partial/focused review annually until the required level of
compliance is achieved. Quarterly progress reports (verbal or written) may be
required depending on the level of non-compliance determined from CQMR or
FQMRs.

 

The BMHC will regularly monitor areas requiring annual oversight (see
compliance Standards for “crosswalk” of annual monitoring areas). Attestation
statements may be permitted to satisfy part(s) of the QAPIP compliance areas
after a sufficient level of performance is demonstrated through CQMR’s. Attestation
statements are permitted only for areas that have not changed or have changed
minimally since the last review. The BMHC will determine if the attestations
are acceptable on a case-by-case basis. These will permit the health plan to
not have to provide full program narratives for areas that have not changed
since the last review or have changed minimally. The BMHC will determine if
attestations are acceptable on a case-by-case basis.

 

Annually, Medicaid MCOs and PIHPs are required to produce a Work Plan
(WP) each new calendar year detailing all quality assessment and performance
improvement (QAPI) activities; including activities related to recommended
improvements from reviews/CAPs, the organization’s clinical and non clinical
performance improvement projects/studies, specific program activities, projects
related to priority population groups, federal or state requirements, etc. Additionally,
on completion of each calendar year the health plans are required to conduct a
comprehensive program evaluation, called a Work Plan Evaluation (WPE), to
determine the effectiveness of interventions in each area of the WP. The WPE is
expected to be part of the process used to develop the WP for each new year and
update the organizations overall Quality Improvement Program Description
(QIPD), if necessary.

 

The BMHC on an ongoing basis will provide input on WP, WPE and annually
updated QIPD’s as part of annual monitoring activities or reviews for MCOs and
PIHPs. PCCMs are not required to submit these documents since they are outside
the scope of their regulations; however, may be required to submit other annual
reports related to applicable regulations or compliance areas.

 

6

 

a. Center for Medicare and Medicaid
Services (CMS) Reporting:

 

In
accordance with 42 CFR, part 438, 438.202, the BMHC will submit to CMS any
required repots relating to BMHC’s UAPIP/quality improvement (QI) strategy,
reports on the implementation and effectiveness of the QAPIP/QI strategy and of
updates whenever substantial changes to the UAPIP/QI strategy are made. Additionally,
CMS may require the BMHC to submit reports of findings from compliance reviews
and EQR’s.

 

b. Documentation Requirements and Timelines:

 

Each health plan will be required to submit documentation that specifically
addresses all compliance Standards in the QAPIP prior to a CQMR and FQMR. This
documentation is required to be organized and categorized in accordance with
the sequencing of each domain and Standard within the Utah QAPIP. Process
narratives (a description of the compliance area and how compliance is
achieved) are mandatory for specific areas in which exhibits alone are
insufficient to determine how the plan operates in the given area (see “crosswalk”
section of compliance Standards).

 

Prior to an audit, the health plan may be required to submit pre-review
documentation as early as 60 days before a CQMR or FQMR. All documentation is
required to be available during the entire time of an on-site review. Organization’s
being reviewed are required to provide suitable, private workspace; i.e.,
private conference room with a phone, for the number of staff participating and
make appropriate plan staff available to assist in finding necessary
information during documentation review sessions or for answering questions. Prior
to a CQMR or FQMR an agenda will be developed including time frames for
reviewing documentation, interviews, post interview team consultation and an
exit conference.

 

Following a CQMR or FQMR the BMHC will complete a compliance report
within 60 calendar days of the date of the exit conference. The health plans,
if necessary, will be required to submit a written plan of correction within 45
calendar days of the receipt of the compliance report or submit an appeal of
the BMHC’s findings. If an extension is required the organization may request,
in writing, an extension to the due date for the CAP and the timeframes will be
adjusted as appropriate. The BMHC will provide written approval as to the
acceptance of the CAP within 30 calendar days of BMHC’s receipt of the CAP. Within
30 calendar days of the receipt of the CAP the BMHC will provide written
approval or request revisions, if not accepted.

 

c. Deeming:

 

The BMHC has incorporated deeming provisions in the
UTAH QAPIP for areas applicable to MCOs and PIHPs. Accreditation by a nationally recognized
accreditation agency that is also recognized by the State will be accepted to
fulfill some compliance requirements. Examples of nationally recognized
accreditation agencies include National Committee for Quality Assurance (NCQA),
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and
Utilization Review and Accreditation Commission (URAC), also known as American
Accreditation HealthCare Commission. The organization must provide written verification
of accreditation in areas where deeming may be applicable. The BMHC will
determine areas applicable for deeming based on comparability and level of
accreditation achieved.

 

7

 

d. Corrective Actions and
Sanctions:

 

Corrective actions may be required to be
submitted relating to quality monitoring activities if the BMHC determines the
contracted Medicaid organization has not provided services in accordance with
the contract or within expected professional standards. The BMHC will request
in writing that the health plan correct deficiencies or identified problems
through a corrective action plan (CAP). The contracted Medicaid health plan
agrees with all applicable procedures and time frames set forth in the contract
regarding compliance with CAP’s. However, CAP’s which are the result of non
compliance findings with the Utah QAPIP, following reviews, longer time frames
are granted for submitting initial CAP’s and subsequent requests for revision
to CAP’s, until final acceptance. Additionally, longer time frames may be
granted prior to implementing sanctions. Areas of non compliance related to
contract requirements or the UQAMP, which are deemed more critical or urgent,
may be subject to time frames associated with requests for CAP’s as set forth
in the contract. The BMHC will follow do-process procedures as outlined in the
contract with regard to requests for CAP’s, requests for extensions of CAP’s,
allowing opportunity to appeal findings, considering explanations of
disagreement and in issuing hearing rights.

 

2.                  Internal Surveillance and
Tracking (analysis of internal MMCS and Data Warehouse data)

 

Additionally,
as a mechanism of quality oversight the BMHC will monitor and analyze other
available internal data. These include internal MMCS data; information
available through the state’s Data Warehouse or reported encounter data. When
possible and appropriate this information will be integrated into compliance
reviews in order to address areas where further study or improvement may be
needed or when additional information is needed.

 

3.                  External Quality Reviews
(EQR’s):

 

The BMHC uses an External Quality Review Organization (EQRO) to conduct
an annual, external assessment of outcomes related to quality, access to and
timeliness of care for services covered in MCO and PIHPs contracts (42 CFR Part
438, Subpart E, 438.320). External review includes mandatory and optional
activities.

 

Mandatory EQR activities include using information from the following
activities:

 

1.               Validation of performance improvement
projects as noted in 438.240(b)(1), validation of performance measures required
by the state in accordance with 438.240(b)(2), and

2.               To conduct a review within the previous 3
year period to determine MCO’s or PIHP’s compliance with standards related to access to care, structure and operations,
and quality measurement [(438.204(g)].

 

8

 

Optional activities include using information derived from the previous
12 months from the following activities:

 

1.               Validation
of encounter data reported by an MCO or PIHP,

2.               Administration
or validation of consumer or provider surveys of quality of care,

3.               Calculation
of performance measures in addition to those reported by an MCO or PIHP and
validation

4.               Conducting
performance improvement projects in addition to those conducted by an MCO or
PIHP.

 

The BMHC assures that EQROs meet the qualifications to perform external
quality reviews (EQRs) as set forth in 42 CFR, Part 438, Subpart E, 438.354
(competence and independence). The state, its agent or the EQRO may perform the
mandatory and optional EQR-related activities [42 CFR, Part 438, Subpart E,
438.358(a)].

 

The BMHC will assure that the date collection methods and tools used by
the EQRO are consistent with the Medicaid managed care provisions of the
Balanced Budget Act (BBA) and the compliance requirements outlined in the Utah
QAPIP, which were developed to assess compliance in accordance with the BBA.

 

The EQRO will submit reports in accordance with requirements in 438.364.
The BMHC will make available upon request information obtained from the
technical report supplied by the EQRO to interested parties, such as
participating health care providers, enrollees and potential enrollees of the
MCO or PIHP, recipient advocacy groups and general public. This information
will be supplied in alternative formats for persons with sensory impairments,
when requested.

 

The EQRO contract may be amended as necessary in order to accommodate
review activities. Study subjects will be determined collaboratively by DHCF,
BMHC, EQRO and health plan staff.

 

4. Annual Program Evaluation

 

Annually, the BMHC will develop a Work Plan,
which outlines the planned review activity (CQMR or follow up reviews), EQR
activity and activities related to available systems data (MMCS/DW,
grievance/appeals, hearings, exemptions, reporting, etc.,). At the end of each
calendar a Work Plan Evaluation will be completed. The Work Plan Evaluation
will be used to develop the Work Plan for each new year and schedule monitoring
reviews. At least every 3 years the BMHC will perform a more comprehensive
evaluation, which will be used to make program improvements. The BMHC will
submit to CMS any required reports relating to the states quality improvement
program.

 

9

 

III. Table
of Appendices

 

	
  Tab Heading

  	
   

  	
  Content

  
	
   

  	
   

  	
   

  
	
  Utah’s
  QAPIP

  	
   

  	
  Utah’s
  Quality Assessment and Performance Improvement Monitoring Plan (Program
  Description Document)

  
	
   

  	
   

  	
   

  
	
  Table
  of Appendices

  	
   

  	
  Listing of all appendices to Attachment G, Utah’s
  QAPIP

  
	
   

  	
   

  	
   

  
	
  Appendix
  A

  Flow Chart

  	
   

  	
  Utah
  QAPIP Flow Chart

  
	
   

  	
   

  	
   

  
	
  Appendix
  B

  Crosswalk

  	
   

  	
  (B1)
  Utah’s QAPIP Compliance Standards Crosswalk (DRAFT)

  (B2) Federal Register

  
	
   

  	
   

  	
   

  
	
  Appendix
  C

  Definitions

  	
   

  	
  Definitions

  
	
   

  	
   

  	
   

  
	
  Appendix
  D

  Scoring

  	
   

  	
  Weighting
  and Scoring (to be developed)

  
	
   

  	
   

  	
   

  
	
  Appendix
  E

  Attestation

  	
   

  	
  Attestation
  Template (to be developed)

  
	
   

  	
   

  	
   

  
	
  Appendix
  F

  Data Collection

  	
   

  	
  Review
  Data Collection Tools

  
	
   

  	
   

  	
   

  
	
  Appendix
  G

  WP Format

  	
   

  	
  Work
  Plan Format (required)

  
	
   

  	
   

  	
   

  
	
  Appendix
  H

  WPE Format

  	
   

  	
  Work
  Plan Format (required)

  
	
   

  	
   

  	
   

  
	
  Appendix
  I

  PI Topics

  	
   

  	
  (I1)
  Example Clinical and Non-Clinical Areas for Study

  (I2) Example Performance
  Improvement (PI) Project Description

  
	
   

  	
   

  	
   

  
	
  Appendix
  J

  CM Report

  	
   

  	
  Example
  Case Management Report

  
	
   

  	
   

  	
   

  
	
  Appendix
  K

  ACOG Record

  	
   

  	
  Example Risk Assessment Information: ACOG
  Antepartum Record© (by permission of Donna Weber, ACOG Marketing,  Inventory and
  Distribution Manager, July 1, 2003)

  
	
   

  	
   

  	
   

  
	
  Appendix
  L

  	
   

  	
  Example
  CHEC Audit Report

  
	
   

  	
   

  	
   

  
	
  Appendix
  M

  	
   

  	
  (M1) Example Grievance, Appeal, Action and Notice
  of Action Requirements

  (M2)
  Example Grievance Tracking
(M3) Flow
  Charts for Grievances, Appeals, Actions, Notices of Action, Continuation of
  Benefits and State Fair          Hearing
  Procedures

  
	
   

  	
   

  	
   

  
	
  Appendix
  N

  	
   

  	
  Example Newsletter Topic Tracking Grid

  
	
   

  	
   

  	
   

  
	
  Appendix
  O

  	
   

  	
  Priority Matrix

  
	
   

  	
   

  	
   

  
	
  Appendix
  P

  	
   

  	
  Member Handbook Checklist (DRAFT)

  

 

10

 

IV.
References

 

	
  1.

  	
   

  	
  Federal
  Register, Volume 67, No. 115, Friday, June 14, 2002, 42 CFR, Part 438,
  Managed Care.

  
	
  2.

  	
   

  	
  Utah
  Quality Assessment and Performance Improvement Plan (QAPIP) (Attachment G of
  contracts).

  
	
  3.

  	
   

  	
  Quality
  Improvement System for Managed Care (QISMC), www.cms.hhs.gov/cop/2d.asp

  
	
  4.

  	
   

  	
  Case
  Management Society of America (CMSA) Standards of Practice, (2003).

  
	
  5.

  	
   

  	
  Aspen
  Publications, Inc. 1185 Avenue of the Americas, New York, NY 10036 (medical
  case management, forms, checklists, & guidelines), (1997),
  www.aspenpublishers.com

  
	
  6.

  	
   

  	
  United
  States Department of Human Services, National Standards for Culturally and
  Linguistically Appropriate Standards (CLAS),
  Http://www.omhrc.gov/omh/programs/2pgprograms/finalreport.pdf

  
	
  7.

  	
   

  	
  Siefker,
  Garrett, Van Genderen, Weis: Guidelines for Practicing Case Managers;
  Fundamentals of Case Management (1998).

  
	
  8.

  	
   

  	
  Powell,
  Suzanne K., A Practical Guide to Success in Managed Care, Case Management
  (2000).

  
	
  9.

  	
   

  	
  Case Management Inc.,10530 Paces Ave. Suite 1511Matthews, NC
  28105-2714Tel. 704.847.1195 management@casemanagement.com

  
	
  10.

  	
   

  	
  Melamed,
  Dennis, Brittin, Alexander, URAC, The HIPAA Handbook: What You Organization
  Should Know About The Federal Privacy Standards (2001).

  
	
  11.

  	
   

  	
  Melamed,
  Dennis, Brittin, Alexander, URAC, The HIPAA Handbook: What You Organization
  Should Know About The Federal Electronic Transaction Standards (2002).

  
	
  12.

  	
   

  	
  Melamed,
  Dennis, Brittin, Alexander, URAC, The HIPAA Handbook: What You Organization
  Should Know About The Federal Security Standards (2002).

  
	
  13.

  	
   

  	
  National
  Association for Healthcare Quality, Guide to Quality Management, Eighth
  Edition (1998).

  
	
  14.

  	
   

  	
  American
  Accreditation Healthcare Commission/URAC, Health Plan Standards, Version 3.2
  (2003).

  
	
  15.

  	
   

  	
  American
  Accreditation Healthcare Commission/URAC, Health Network Standards &
  Interpretive Guide, version 3.2 (2003).

  
	
  16.

  	
   

  	
  National
  Committee for Quality Assurance (NCQA), Standards and Guidelines for the
  Accreditation of MCOs (2003).

  
	
  17.

  	
   

  	
  National
  Committee for Quality Assurance (NCQA), Data Collection Tools (2003).

  
	
  18.

  	
   

  	
  Joint
  Commission on Accreditation of Healthcare Organizations, 2003-2004
  Comprehensive Accreditation Manual for Health Care Networks (2003)

  
	
  19.

  	
   

  	
  The
  Team Handbook, How to Use Teams to Improve Quality, Peter R. Scholtes,
  (1988).

  
	
  20.

  	
   

  	
  United
  Health Care, The Language of Managed Health Care, the Managed Health Care
  Resource (1994).

  
	
  21.

  	
   

  	
  Houghton
  Mifflin Company, Webster’s II, New College Dictionary, (1995).

  
	
  22.

  	
   

  	
  AMSO.com,
  American Medical Specialty Organization, Inc. Definition of Terms, 2003.

  
	
  23.

  	
   

  	
  The
  Managed Care Group, Managed Care Resources, Inc., MCR Canada, Managed Care
  Options, LLC, Managed Care Terms and Definitions,
  http://www.managedcaregroup.com/mcrdef.htm (2003).

  
	
  24.

  	
   

  	
  Center
  for Health Services Research and Policy, The George Washington University2021
  K Street, W, Suite 800Washington, DC 20006, http://www.gwu.edu/~chsrp .

  
	
  25.

  	
   

  	
  The
  U.S. Department of Health and Human Services, 200 Independence Avenue, S. W.
  Washington, D.C. 20201, http://www.hhs.gov/ContactUs.html.

  
	
  26.

  	
   

  	
  http://www.nlm.nih.gov/,
  U.S. National Library of Medicine, 8600 Rockville Pike, Bethesda, MD 20894.

  
	
  27.

  	
   

  	
  http://www.access.gpo.gov/aboutgpo/index.,
  Keepinfg America Informed, United States Government Printing Office.

  
	
  28.

  	
   

  	
  http://www.chcs.org/contact/contact.html,
  Center For Health Care Strategies.

  

 

11

 

Attachment E

Healthy U

 

MEDICAL
SERVICES REVENUE AND COST DEFINITIONS FOR TABLE 2

 

REVENUES (Report all revenues received or receivable
at the end-of-period date on the form)

 

1.                                       Premiums

 

Report premium payments
received or receivable from the DEPARTMENT.

 

2.                                       Delivery Fees

 

Report the delivery fee
received or receivable from the DEPARTMENT.

 

3.                                       Reinsurance

 

Report the reinsurance
payments received or receivable from a reinsurance carrier other than the
DEPARTMENT.

 

4.                                       Stop Loss

 

Report stop loss payments
received or receivable from the DEPARTMENT.

 

5.                                       TPL Collections - Medicare

 

Report all third party
collections received from Medicare.

 

6.                                       TPL Collections - Other

 

Report all third party
collections received other than Medicare collections. (Report TPL savings
because of cost avoidance as a memo amount on line 48).

 

7.                                       Other (specify)

 

8.                                       Other (specify)

 

For lines seven and
eight:  Report all other revenue not
included in lines one through six. (There may not be any amount to report;
however, this line can be used to report revenue from total Utah operations
that do not fit lines one through six.)

 

9.                                       TOTAL REVENUES

 

Total lines one through
eight.

 

NOTE: Duplicate premiums are not considered a
cost or revenue as they are collected by the CONTRACTOR and paid to the
DEPARTMENT. Therefore, the payment to the DEPARTMENT would reduce or offset the
revenue recorded when the duplicate premium was received. However, line 49 has
been established for reporting duplicate premiums as a memo amount.

 

4

 

MEDICAL
COSTS:  Report all costs accrued as of the ending
date on the form. In the first data column (column 3), report all costs for
Utah operations per the general ledger. In the 15 Medicaid data columns
(columns 4 through 18), report only costs for Medicaid Enrollees.

 

10.                                 Inpatient Hospital Services

 

Costs incurred in providing
inpatient hospital services to Enrollees confined to a hospital.

 

11.                                 Outpatient Hospital Services

 

Costs incurred in providing
outpatient hospital services to Enrollees, not including services provided in
the emergency department.

 

12.                                 Emergency Department Services

 

Costs incurred in providing
outpatient hospital emergency room services to Enrollees.

 

13.                                 Primary Care Physician Services (Including
EPSDT Services, Prenatal Care, and Family Planning Services)

 

All costs incurred for
Enrollees as a result of providing primary care physician, osteopath, physician
assistant, nurse practitioner, and nurse midwife services, including payroll
expenses, any capitation and/or contract payments, fee-for-service payments,
fringe benefits, travel and office supplies.

 

14.                                 Specialty Care Physician Services (Including
EPSDT Services, Prenatal Care, and Family Planning Services)

 

All costs incurred as a
result of providing specialty care physician, osteopath, physician assistant,
nurse practitioner, and nurse midwife services to Enrollees, including payroll
expenses, any capitation and/or contract payments, fee-for-service payments,
fringe benefits, travel and office supplies.

 

15.                                 Adult Screening Services

 

Expenses associated with
providing screening services to Enrollees.

 

16.                                 Vision Care - Optometric Services

 

Included are payroll costs,
any capitation and/or contract payments, and fee-for-service payments for
services and procedures performed by an optometrist and other non-payroll
expenses directly related to providing optometric services for Enrollees.

 

17.                                 Vision Care - Optical Services

 

Included are payroll costs,
any capitation and/or contract payments and fee-for-service payments for
services and procedures performed by an optician and other supportive staff,
cost of eyeglass frames and lenses and other non-payroll expenses directly
related to providing optical services for Enrollees.

 

18.                                 Laboratory (Pathology) Services

 

Costs incurred as a result
of providing pathological tests or services to Enrollees including payroll
expenses, any capitation and/or contract payments, fee-for-service payments and
other expenses directly related to in-house laboratory services. Excluded are
costs associated with a hospital visit.

 

5

 

19.                                 Radiology Services

 

Cost incurred in providing
x-ray services to Enrollees, including x-ray payroll expenses, any capitation
and/or contract payments, fee-for-service payments, and occupancy overhead
costs. Excluded are costs associated with a hospital visit.

 

20.                                 Physical and Occupational Therapy

 

Included are payroll costs,
any capitation and/or contract payments, fee-for-service costs, and other
non-payroll expenditures directly related to providing physical and
occupational therapy services.

 

21.                                 Speech and Hearing Services

 

Payroll costs, any
capitation and/or contract payments, fee-for-service payments, and non-payroll
costs directly related to providing speech and hearing services for Enrollees.

 

22.                                 Podiatry Services

 

Salary expenses or outside
claims, capitation and/or contract payments, fee-for-service payments, and
non-payroll costs directly related to providing services rendered by a
podiatrist to Enrollees.

 

23.                                 End Stage Renal Disease (ESRD) Services -
Dialysis

 

Costs incurred in providing
renal dialysis (ESRD) services to Enrollees.

 

24.                                 Home Health Services

 

Included are payroll costs,
any capitation and/or contract payments, fee-for-service payments, and other
non-payroll expenses directly related to providing home health services for
Enrollees.

 

25.                                 Hospice Services

 

Expenses related to hospice
care for Enrollees including home care, general inpatient care for Enrollees
suffering terminal illness and inpatient respite care for caregivers of
Enrollees suffering terminal illness.

 

26.                                 Private Duty Nursing

 

Expenses associated with
private duty nursing for Enrollees.

 

27.                                 Medical Supplies and Medical Equipment

 

This cost center contains
fee-for-service cost for outside acquisition of medical requisites, special
appliances as prescribed by the CONTRACTOR to Enrollees.

 

28.                                 Abortions

 

Medical and hospital costs
incurred in providing abortions for Enrollees.

 

29.                                 Sterilizations

 

Medical and hospital costs
incurred in providing sterilizations for Enrollees.

 

6

 

30.                                 Detoxification

 

Medical and hospital costs
incurred in providing treatment for substance abuse and dependency
(detoxification) for Enrollees.

 

31.                                 Organ Transplants

 

Medical and hospital costs
incurred in providing transplants for Enrollees.

 

32.                                 Other Outside Medical Services

 

The costs for specialized
testing and outpatient surgical centers for Enrollees ordered by the
CONTRACTOR.

 

33.                                 Long Term Care

 

Costs incurred in providing
long-term care for Enrollees required under Attachment C.

 

34.                                 Transportation Services

 

Costs incurred in providing
ambulance (ground and air) services for Enrollees.

 

35.                                 Accrued Costs

 

Costs Incurred for services
rendered to Enrollees but not yet billed.

 

36/37                    Other

 

Report costs not otherwise
reported.

 

38.                                 TOTAL MEDICAL COSTS

 

Total lines10 through 37.

 

ADMINISTRATIVE
COSTS

 

Report payroll costs, any capitation and/or
contract payments, non-payroll costs and occupancy overhead costs for
accounting services, claims processing services, health plan services, data
processing services, purchasing, personnel, Medicaid marketing and regional
administration.

 

Report the administration cost under four
categories - advertising, home office indirect cost allocation, utilization and
all other administrative costs. If there are no advertising costs or indirect home
office cost allocations, report a zero amount in the applicable lines.

 

39.                                 Administration - Advertising

 

40.                                 Home Office Indirect Cost Allocations

 

41.                                 Utilization

 

Payroll cost and any
capitation and/or contract payments for utilization staff and other non-payroll
costs directly associated with controlling and monitoring outside physician
referral and hospital admission and discharges of Enrollees.

 

7

 

42.                                 Administration - Other

 

43.                                 TOTAL ADMINISTRATIVE COSTS

 

Total lines 39 through 42.

 

44.                                 TOTAL COSTS (Medical and
Administrative)

 

Total lines 38 and 43.

 

45.                                 NET INCOME (Gain or Loss)

 

Line 9 minus line 44.

 

46.                                 ENROLLEE MONTHS

 

Total Enrollee months for
period of time being reported.

 

47.                                 MEDICAL COSTS PER ENROLLEE
MONTH

 

Line 38 divided by line 46.

 

48.                                 ADMINISTRATIVE COSTS PER
ENROLLEE MONTH

 

Line 43 divided by line 46.

 

49.                                 TOTAL COSTS PER ENROLLEE
MONTH

 

Line 44 divided by line 46.

 

OTHER DATA

 

50.                                 TPL Savings - Cost Avoidance

 

51.                                 Duplicate Premiums

 

Include all premiums
received for Enrollees from all sources other than Medicaid.

 

52.                                 Number of Deliveries

 

Total number of Enrollee
deliveries when the delivery occurred at 24 weeks or later.

 

53.                                 Family Planning Services

 

Include costs associated with
family planning services as defined in Attachment C (Covered Services, Section
V, Family Planning Services).

 

54.                                 Reinsurance Premiums Received

 

Include the reinsurance
premiums received or receivable that are not counted as revenue.

 

8

 

55.                                 Reinsurance Premiums Paid

 

Include reinsurance premiums
paid to a reinsurance carrier other than the DEPARTMENT.

 

56.                                 Administrative Revenue Retained by the
CONTRACTOR 

 

Include the administrative
revenue retained by the CONTRACTOR from the reinsurance premiums received or
receivable.

 

9

 

MEDICAL SERVICES UTILIZATION DEFINITIONS FOR TABLE 3

 

MEDICAL
SERVICES

 

1.                                       Hospital
Services - General Days

 

Record total
number of inpatient hospital days associated with inpatient medical care.

 

2.                                       Hospital
Services - Discharges

 

Record total
number of inpatient hospital discharges.

 

3.                                       Hospital
Services - Outpatient Visits

 

Record total
number of outpatient visits.

 

4.                                       Emergency
Department Visits

 

Record total
number of emergency room visits.

 

5.                                       Primary
Care Physician Services

 

Number of
services and procedures defined by CPT-4 codes provided by primary care
physicians or licensed physician extenders or assistants under direct
supervision of a physician inclusive of all services except radiology,
laboratory and injections/ immunizations which should be reported in their
appropriate section. The reporting of data under this category includes both
outpatient and inpatient services.

 

6.                                       Specialty
Care Physician Services

 

Number of ser
services and procedures defined by CPT-4 codes provided by specialty care
physicians or licensed physician extenders or assistants under direct
supervision of a physician inclusive of all services except radiology,
laboratory and injections/ immunizations which should be reported in their
appropriate section. The reporting of data under this category includes both
outpatient and inpatient services.

 

7.                                       Adult
Screening Services

 

Number of
adult screenings performed.

 

8.                                       Vision
Care - Optometric Services

 

Number of
optometric services and procedures performed by an optometrist.

 

11

 

9.                                       Vision
Care - Optical Services

 

Number of eye
glasses and contact lenses dispensed.

 

10.                                 Laboratory
(Pathology) Procedures

 

Number of
procedures defined by CPT-4 Codes under the Pathology and Laboratory section.
Excluded are services performed in conjunction with a hospital outpatient or
emergency department visit.

 

11.                                 Radiology
Procedures

 

Number of
procedures defined by CPT-4 Codes under the Radiology section. Excluded are
services performed in conjunction with a hospital outpatient or emergency
department visit.

 

12.                                 Physical
and Occupational Therapy Services

 

Physical
therapy refers to physical and occupational therapy services and procedures
performed by a physician or physical therapist.

 

13.                                 Speech
and Hearing Services

 

Number of
services and procedures.

 

14.                                 Podiatry
Services

 

Number of
services and procedures.

 

15.                                 End
Stage Renal Disease (ESRD) Services - Dialysis

 

Number of ESRD
procedures provided upon referral.

 

16.                                 Home
Health Services

 

Number of home
health visits, such as skilled nursing, home health aide, and personal care
aide visits.

 

17.                                 Hospice
Days

 

Number of days
hospice care is provided, including respite care.

 

18.                                 Private
Duty Nursing Services

 

Hours of
skilled care delivered.

 

12

 

19.                                 Medical
Supplies and Medical Equipment

 

Durable
medical equipment such as wheelchairs, hearing aids, etc., and nondurable
supplies such as oxygen etc.

 

20.                                 Abortion
Procedures

 

Number of
procedures performed.

 

21.                                 Sterilization
Procedures

 

Number of
procedures performed.

 

22.                                 Detoxification
Days

 

Days of
inpatient detoxification.

 

23.                                 Organ
Transplants

 

Number of
transplants.

 

24.                                 Other
Outside Medical Services

 

Specialized
testing and outpatient surgical services ordered by IHC.

 

25.                                 Long
Term Care Facility Days

 

Total days
associated with long-term care.

 

26.                                 Transportation
Trips

 

Number of
ambulance trips.

 

27.                                 Other
(specify)

 

13

 

Attachment F

Molina Healthcare of Utah

January 1, 2006

 

MOLINA

Attachment F:  Payment
Methodology

 

This Contract is classified as
non-risk. Under a non-risk contract, the DEPARTMENT’s total payments to Molina
for medical services provided under this Contract net of third party payments
may not exceed the Payment Limit. The Payment Limit is the total amount
Medicaid would have paid for the same services on a fee-for-service (FFS) basis
net of third party payments. In calculating payments, the DEPARTMENT will use
its reimbursement schedule for each claim and subtract any third party payment
reported on each claim to determine the amount the DEPARTMENT pays on each
claim.

 

Molina may reimburse individual
providers at rates different from the Medicaid fee schedule. However, the
DEPARTMENT’s aggregate payments to Molina for medical services provided to its
Enrollees must not exceed what Medicaid would have paid in aggregate for the
same services on  a FFS basis.

 

Based on direction from the
Centers for Medicare and Medicaid Services (CMS), the 9% add-on amount that the
DEPARTMENT reimburses Molina that includes administration, case management
services, profit earned, etc., and any incentive payments (CHEC screenings and
immunizations) will not be included when determining the total payments the
DEPARTMENT paid Molina when ascertaining compliance with the Payment Limit for
a non-risk contract. The amount for administration, case management services,
and profit that the DEPARTMENT reimburses Molina will be included when
calculating the savings sharing payments. If CMS requires in writing that this
method of calculating the Payment Limit be revised, this Contract will be
amended in accordance with, and only to the extent necessary to comply with,
the specific requirements of CMS.

 

For Molina clients enrolled in
Molina’s Medicare product, Molina will reimburse its providers at no less than
the Medicare fee schedule.

 

A.                                   Molina Cost Plus 9% Payment Provisions Based
on Molina’s Encounter Records

 

1.                                       Molina
will submit encounter records to the DEPARTMENT following the Electronic Data
Interchange (EDI) standards defined in the Encounter
Records 837 Institutional Companion Guide and Encounter Records 837 Professional Companion Guide.
Molina will not submit any encounter record in the same month in which the
service to which the encounter record relates was provided. In the event Molina
inadvertently does so, the DEPARTMENT will not pay for any encounter record in
the same month in which the service was provided.

 

2.                                       The
DEPARTMENT will process Molina’s encounter records and reimburse Molina for
encounter records that pass the Medicaid Managed Care System (MMCS) encounter
records’ edits within 30 calendar days

 

1

 

after the
DEPARTMENT has received the encounter records. However, it is the intent of the
DEPARTMENT to pay Molina within 15 calendar days after the DEPARTMENT has
received the encounter records. The 
DEPARTMENT will reimburse Molina the amount Molina paid its providers as
reflected in each encounter record’s “paid amount” field, net of third party
payments, for those encounters that pass the MMCS edits. In addition, the DEPARTMENT
will pay to Molina an additional amount equal to 9% of the total amount of paid
encounter records, net of third party payments. The 9% does not apply to the
Medicaid payment on encounters for Molina’s Medicaid enrollees who are also
enrolled in Molina’s Medicare plan.

 

3.                                       The
9% is based on the reasonable expenses of managed care plans organizations for
all administrative functions, case management services, profit earned, etc.
necessary to operate as an efficient and effective Medicaid managed care plan
and including federal managed care requirements as described in 42 CFR Part
438–Managed Care. The DEPARTMENT will verify Molina’s costs incurred for
administration, case management services, profit earned, etc. using the
quarterly reports submitted by Molina as defined in Section F., Quarterly
Report of Costs Incurred for Administration, Case Management Services, Etc., of
this

 

Attachment F.

 

4.                                       Rejected
encounter records that are corrected and resubmitted and that clear the MMCS
edits will be paid to Molina in the next regular payment cycle.

 

B.                                    Savings
Sharing Provision for FY2005 and FY2006

 

1.                                       Summary of Savings Sharing Methodology

 

For State
fiscal years 2005 and 2006, the DEPARTMENT will calculate the amount due to
Molina, if any, under this Savings Sharing Provision, utilizing both a
“risk-adjuster” methodology and a “fee-for-service methodology.”  The DEPARTMENT will first apply the
risk-adjuster methodology. The DEPARTMENT will next apply the “fee-for-service”
methodology to determine the Payment Limit. Molina will be entitled to the
greater of the two savings amounts from the two calculation methods as a
savings incentive payment. Under no circumstances will the DEPARTMENT pay
Molina for both savings sharing calculations and in no event shall the savings
sharing payment exceed 95% of the Payment Limit.

 

a.                                       If
one or both of the PMPM urban and rural member calculations show that Molina’s
risk adjusted aggregate PMPM cost for FY2005

 

2

 

and/or FY2006
are less than that of the IHC Access enrollees and/or FFS rural enrollees
respectively, then the DEPARTMENT will pay to Molina either ninety-five percent
(95%) of the aggregate savings amount up to 95% of the Payment Limit or 75% of
the savings calculated in Section B.2.c., whichever is greater.

 

b.                                      If
the PMPM urban and rural calculation show that Molina’s risk adjusted aggregate
PMPM costs for State FY2005 or FY2006 are greater than that of IHC Access urban
enrollees or FFS rural for the same period, then the DEPARTMENT will pay Molina
either nothing or 75% of the savings calculated in Section B.2.c (subject to
Section B.1.a. above regarding the greater of 95% of the Payment Limit and 75%
of the risk adjusted amount).

 

2.                                      Risk-Adjuster
Methodology

 

The same
calculations described below for Molina’s urban enrollees will be used for
Molina’s rural enrollees. The same calculations described below for IHC Access
urban enrollees will be used for fee-for-service rural clients except where
noted.

 

The DEPARTMENT
will calculate Molina’s risk adjusted, aggregate per member per month (PMPM)
cost for State fiscal years 2005 and 2006 for Molina’s urban  members and compare the PMPM cost against
IHC Access urban enrollees for the same time periods. The PMPM amount paid to
Molina’s urban enrollees  is the cost of
claims plus a 9% add-on fee for administration, case management services,
profit earned, etc. The PMPM amount the DEPARTMENT would have paid for IHC’s
urban enrollees is the Medicaid fee schedule plus a 2% administration fee plus
the IHC network access and continuum care case management fees.

 

The PMPM
amount paid to Molina’s rural enrollees is the cost of claims plus a 9% add-on
fee for administration, case management services, profit earned, etc. The PMPM
amount the DEPARTMENT would have paid is the Medicaid fee schedule for rural
fee-for-service Medicaid clients plus a 2% administration fee.

 

In performing
the PMPM calculation, the DEPARTMENT will share with Molina, subject to
appropriate confidentiality agreements, all data, methodologies, and
assumptions used in the PMPM calculations, and shall afford Molina a reasonable
opportunity to review and comment regarding such data, methodologies,
assumptions and report, and to confer with and ask questions of the actuary who
performed the calculations and prepared the report.

 

3

 

The DEPARTMENT
will use an independent actuary to measure cost effectiveness for determining
any savings sharing as follows:

 

a.                                       The
actuary will select a comparable fee-for-service Medicaid population to compare
with the Molina’s managed care population. IHC Access (IHC) urban enrollees
will be the comparable plan for Molina’s urban enrollees. Fee-for-service rural
clients will be the comparable population for Molina’s rural enrollees.

 

b.                                      The
actuary will compare expenditures for Molina urban enrollees with IHC Access
urban enrollees by dates of service and eligibility for the same year as the
Contract year.

 

c.                                       The
items to be compared are as follows:

 

(1)                                  Claims
Expenditures Without Third Party
Payment

 

These
expenditures represent the total dollars that the DEPARTMENT paid to health
plans. For Molina the expenditures are the amount pursuant to Section A. less
expenditures the DEPARTMENT paid to Molina for Enrollees who are “dual
eligible” (have both Medicare and Medicaid). For IHC, the expenditures include
those claims the DEPARTMENT paid for IHC enrollees under Medicaid’s fee-for
service system less 1) expenditures the DEPARTMENT paid for IHC dual eligibles,
and 2) any amounts the DEPARTMENT paid for IHC enrollees with dates of service
during any period when an IHC enrollees was retroactively eligible for
Medicaid. The actuary will summarize the total dollar amounts by rate cell for
Molina and IHC.

 

(2)                                  Claims
Expenditures With Third Party
Payment

 

These
expenditures represent the total dollars which would have been allowed under
the Medicaid fee schedule to health plans and the dollar figure used to
calculate the per member per month expenditure. For Molina, the expenditures
are the amount pursuant to Section A. less expenditures the DEPARTMENT paid to
Molina for Enrollees who are “dual eligible” (have both Medicare and Medicaid).
For IHC, the expenditures include those claims the Department paid for IHC
enrollees under Medicaid’s fee-for service system less 1) expenditures the
DEPARTMENT paid for IHC dual eligibles, and 2) any amounts the

 

4

 

DEPARTMENT
paid for IHC enrollees with dates of service during any period when an IHC
enrollee was retroactively eligible for Medicaid. The actuary will summarize
the total dollar amounts by rate cell for Molina and IHC.

 

5

 

(3)                                  Eligibles

 

For Molina and
IHC, the actuary determines the total number of eligibles by rate cell
(excluding retroactive eligibles and dual eligibles) for each month of the
Contract year for Molina and for IHC. Total member months by rate cell are
calculated for Molina and for IHC by adding all months by rate cell.

 

(4)                                  Raw
Per Member Per Month (PMPM) Calculation

 

The actuary
calculates a  raw PMPM rate by dividing
the “claims expenditures with third party payment” by the number of member
months. This is done for each rate cell as well as total expenditures and total
member months. The calculation includes an eligibility group mix factor that
normalizes the raw calculation for eligibility group mix.

 

(5)                                  Risk
Adjuster

 

The actuary
calculates a risk adjuster from the diagnosis data used in the expenditure
totals. These diagnosis data are applied to a risk adjuster methodology that is
accepted and used nationally. The resulting risk adjuster shows the relative
complexity of each health plan’s cases to each other. The risk adjuster
excludes lab and x-ray and uses a population-normalized risk adjustment factor.
The resulting numbers are a separate risk adjuster by rate cell for each of the
plans compared. The composite risk adjustment scores are calculated using all
plans enrollment distribution and PMPM costs relativity.

 

(6)                                  Per
Member Per Month calculation (risk and eligibility mix adjusted)

 

This
calculation is made by dividing the raw PMPM calculation by the risk adjuster.

 

(7)                                  Administrative
Cost /Adjustment

 

This
adjustment is a PMPM amount by rate cell to account for administrative costs.
Molina’s adjustment is the 9% for administration, case management services, and
profit that is an  add-on to the cost of
claims expenditure (“Claims Expenditures Without
Third Party Payment”) that Molina

 

6

 

receives as
part of its contract. IHC’s adjustment is the administrative add-on includes
the network access and continuum care case management fees; plus the 2%
administration fee. The rural fee-for-service’s adjustment is the 2%
administration fee.

 

(8)                                  Other
Adjustments

 

These rate
cell amounts are the amount added or subtracted to account for items outside
claims processing such as Synagis or other special drugs.

 

(9)                                  Total
Adjustments

 

Administrative
Cost and Other Adjustments added together and then calculated on a PMPM
adjustment value.

 

(10)                            Combined
PMPM Risk Adjusted Claims Expenditure and Adjustment

 

This final
number adds the “PMPM Calculation (Risk and Eligibility Mix Adjusted)” and the
“Total Adjustments” PMPM to give a final comparison number.

 

d.                                      If
Molina’s “Combined Urban PMPM Risk Adjusted Claims Expenditure and
Adjustment” pursuant to Section B.2.c.(10) amount is greater than IHC’s
“Combined Urban PMPM Risk Adjusted Claims Expenditure and Adjustment” pursuant
to Section B.2.c.(10), then a cost savings has not occurred and Molina is not
eligible for a savings sharing payment for urban claims under this
risk-adjuster methodology.

 

If Molina’s
“Combined Rural PMPM Risk Adjusted Claims Expenditure and Adjustment”
pursuant to Section B.2.c.(10) amount is greater than the
fee-for-service “Combined Rural PMPM Risk Adjusted Claims Expenditure and
Adjustment” pursuant to Section B.2.c.(10), then a cost savings has not
occurred and Molina is not eligible for a savings sharing payment for rural
claims under this risk-adjuster methodology.

 

e.                                       If
Molina’s “Combined Urban PMPM Risk Adjusted Claims Expenditure and
Adjustment” amount is less than IHC’s “Combined Urban PMPM Risk Adjusted
Claims Expenditure and Adjustment” pursuant to Section B.2.c.(10), then a cost
savings has occurred and Molina is eligible for a savings sharing payment for
urban

 

7

 

claims under
this risk-adjuster methodology .

 

8

 

If Molina’s
“Combined Rural PMPM Risk Adjusted Claims Expenditure and Adjustment”
amount is less than the fee-for-service rural “Combined Rural PMPM Risk
Adjusted Claims Expenditure and Adjustment” pursuant to Section B.2.c.(10),
then a cost savings has occurred and Molina is eligible for a savings sharing
payment under this risk-adjuster methodology.

 

3.                                      Payment
Limit Methodology

 

a.                                       Determination
of Covered Encounters

 

All encounter
records not rejected in the process under Section A. above will go through a
final cleansing by running said encounters through the DEPARTMENT’s
fee-for-service process. Encounters for which the DEPARTMENT paid the
CONTRACTOR under Section A. but that are not covered encounters based on the criteria
in B.3.b. will be excluded from the Payment Limit calculation.

 

The DEPARTMENT
will provide documentary support for its calculation to Molina and afford
Molina a reasonable opportunity to review and comment.

 

b.                                      Covered
Services Criteria

 

For purposes
of this Attachment F, a covered encounter record is an encounter record that is
covered under this Contract, not rejected by the rejection edits in the
DEPARTMENT’s Encounter Records Companion Guides and:

 

(1)                                  the
procedure codes are either covered by Medicaid as indicated on Medicaid’s
Reference File, or

 

(2)                                  the
Enrollee who received the service was a CHEC eligible, or

 

(3)                                  the
DEPARTMENT approves the payment for services described in Attachment B (Special
Provisions), under Article VI (Authorization of Services and Notices of
Action), A.2. (Process for the CONTRACTOR to Request Payment Authorization of
Services); or

 

(4)                                  the
services provided are in lieu of services covered in the Utah Medicaid State
Plan because they are cost-effective and of equal or higher quality.

 

9

 

c.                                       Determination
of Payments Subject to the Payment Limit

 

For purposes
of determining whether the DEPARTMENT paid Molina more or less than the Payment
Limit, the total amount the DEPARTMENT paid Molina is calculated as follows:

 

(1)                                  the
total amount as determined in Section A. (net of third party payments)
excluding the 9% add-on fee that includes administration, case management
services, profit earned, etc; plus

 

(2)                                  other
covered services not submitted as encounter records (such as Synagis) using the
DEPARTMENT’s Medicaid fee schedule.

 

d.                                       Determination
of Payment Limit

 

The DEPARTMENT
will determine the Payment Limit by pricing, net of third party payments, and
totaling all covered encounter records under B.3.b. plus other covered services
not submitted as encounter records (such as Synagis) using the DEPARTMENT’s
Medicaid fee schedule.

 

For services
that do not have a reimbursement amount in the DEPARTMENT’s Reference File or
the Reference File indicates that the service is manually priced, the amount
the CONTRACTOR paid its provider will be the amount used in determining the
Payment Limit.

 

The DEPARTMENT
will provide documentary support for its calculation to Molina and afford
Molina a reasonable opportunity to review and comment.

 

e.                                       Reconciliation

 

The DEPARTMENT
will then compare the difference between the amounts resulting from the
calculations as provided in Section B.3.c. and Section B.3.d.

 

(1)                                  If
the amount the DEPARTMENT paid to Molina under Section B.3.c. is less
than the amount the

 

10

 

DEPARTMENT
would have paid on a fee-for-service basis under B.3.d., the DEPARTMENT will
pay to Molina as an incentive payment either 75% of the resulting amount as
savings sharing or 95% of the savings under the risk adjuster methodology,
whichever is greater.

 

(2)                                  If
the amount the DEPARTMENT paid Molina under Section B.3.c. is more
than the amount the DEPARTMENT would have paid on a fee-for-service basis under
B.3.d., the DEPARTMENT will recoup the difference from Molina so that all
payments to Molina equal the Payment Limit.

 

3.                                      Examples
of Savings Sharing Calculations

 

a.                                       The
risk-adjuster methodology shows aggregate savings of $3 million. Molina would
be entitled to receive 95% of that amount ($2.85 million), but only up to 95%
of the Payment Limit. Application of the Payment Limit methodology shows that
on a fee-for-service basis, costs would have been only $2 million more than the
amount the DEPARTMENT paid to Molina. Molina is entitled to the greater of 95%
of the savings under the risk adjustor methodology ($2.85 million), but only up
to 95% of the Payment Limit ($1.9 million), or 75% of the difference between
the Payment Limit and the amount the DEPARTMENT paid Molina ($1.5 million).
Therefore, Molina would be entitled to receive $1.9 million.

 

11

 

b.                                      The
risk-adjuster methodology shows aggregate savings of $3 million. Molina would
be entitled to receive 95% of that amount ($2.85 million) but only up to 95% of
the Payment Limit. Application of the Payment Limit methodology shows that on a
fee-for-service basis, costs would have been $4 million more than the amount
the DEPARTMENT paid to Molina. Molina is entitled to the greater of 95% of the
savings under the risk adjuster methodology ($2.85 million), but only up to 95%
of the Payment Limit ($3.8 million) or 75% of the difference between the
Payment Limit and the amount the DEPARTMENT paid Molina ($3 million). Therefore
Molina would be entitled to receive $3 million.

 

c.                                       The
risk-adjuster methodology shows no savings. Application of the Payment Limit
methodology shows the amount the DEPARTMENT paid to Molina is $4 million less
than the Payment Limit. The total amount the DEPARTMENT will pay Molina is 75%
of $4 million or $3 million.

 

C.                                    Payment
Limit for the Contract Period from July 1, 2002 through June 30, 2004

 

Because it was
not previously feasible to process encounter records through the MMCS edits for
State fiscal years 2003 and 2004 to confirm compliance with the Payment Limit,
the CONTRACTOR will submit encounters for these years. The encounter records
will follow the Electronic Data Interchange (EDI) standards defined in the Encounter Records 837 Institutional Companion Guide and
Encounter Records 837 Professional Companion
Guide.

 

12

 

1.                                      Validation
of Compliance with Payment Limit

 

As soon as
practicable, and using in all relevant respects the methodology described in
Section B.3 above regarding the calculation of the Payment Limit and the
comparison of the amounts paid to Molina with the Payment Limit, the DEPARTMENT
will process Molina’s encounter records for each fiscal year 2003 and fiscal year
2004. Each year will be processed and analyzed separately. Such claims
processing is being done solely for the purpose of confirming compliance with
the Payment Limit and no action will be taken by either party with respect to
any previously paid or unpaid claim or particular group of claims.

 

2.                                      Reconciliation

 

a.                                       If
the amount the DEPARTMENT paid to Molina for fiscal year 2003 or fiscal year
2004 is more than the amount of the Payment Limit for each year, the
DEPARTMENT will recoup the difference from Molina. For purposes of such
comparison for fiscal year 2004, the $1.5 million savings sharing payment made
to Molina by the DEPARTMENT will be included in the calculation of the amounts
paid to Molina for such year.

 

b.                                      If
the amount the DEPARTMENT paid to Molina for fiscal year 2003 or fiscal year
2004 is less than the amount of the Payment Limit for each year, the
DEPARTMENT will pay Molina nothing. For purposes of such comparison for fiscal
year 2004, the $1.5 million savings sharing payment made to Molina by the
DEPARTMENT will be included in the calculation of the amounts paid to Molina
for such year.

 

D.                                    CHEC
Screening Incentive Clause

 

1.                                       CHEC Screening Goal

 

Molina will ensure that
Medicaid children have access to appropriate well-child visits. Molina will
follow the Utah EPSDT (CHEC) guidelines for the periodicity schedule for
well-child protocol. The Centers for Medicare and Medicaid Services (CMS),
mandates that all states have 80% of all children screened. The DEPARTMENT and
Molina will work toward that goal.

 

2.                                      Calculation of CHEC
Incentive Payment

 

The DEPARTMENT will
calculate Molina’s annual participation rate based on information supplied by
Molina under the CMS-416 EPSDT (CHEC) reporting requirements. Based

 

13

 

on the CMS-416 data,
Molina’s well-child participation rate was 64% for Federal Fiscal Year (FFY)
2004 (October 1, 2003 through  September
30, 2004). The incentive payment for the Contract year ending June 30, 2005 will
be based on Molina’s FFY 2005 (October 1, 2004 through September 30, 2005)
CMS-416 participation rate. The DEPARTMENT will pay Molina $10,000 if a rate of
80% or higher is attained during FFY 2005.

 

The participation rate will
be calculated no later than April 15, 2006; Molina will be notified of the
incentive payment, if applicable, no later than April 30, 2006.

 

3.                                      MOLINA’s Use of Incentive
Payment

 

The CONTRACTOR agrees to use
this incentive payment to rewardMolina’s employees responsible for improving
the EPSDT (CHEC)   participation rate.

 

E.                                      Immunization Incentive
Clause

 

The CONTRACTOR will ensure
that Enrollees have access to recommended immunizations. Molina will follow the
Advisory Committee on Immunization Practices’ recommendations for immunizations
for children.

 

1.                                       Immunizations for two-year-olds

 

The National Immunization
Survey reported that in 2003 Utah had a statewide immunization level of 78.8%
for two-year-olds. Molina’s 2003 HEDIS rate was 62.1% for the Combination 1
immunization measure for two-year olds. Based on Molina’s 2004 HEDIS result for
the Combination 1 immunization measure, the DEPARTMENT will pay Molina $300 for
each full percentage point above 62.1%.

 

The CONTRACTOR agrees to use
this incentive payment to reward Molina’s employees responsible for improving
the HEDIS immunization rate for two-year olds.

 

2.                                       Immunizations for adolescents

 

The DEPARTMENT realizes it
is important that adolescents are vaccinated according to the schedule
recommended by the Advisory Committee on Immunization Practices and other
professional groups. Molina’s 2003 HEDIS rate was 22.5% for the Combination 1
immunization measure for adolescents. Based on Molina’s 2004 HEDIS measure for
adolescent immunizations, the DEPARTMENT will pay Molina $300 for each full
percentage point above 22.5.8% up to 72.5%.

 

The CONTRACTOR agrees to use
this incentive payment to reward Molina’s employees responsible for improving
the HEDIS immunization rate for adolescents.

 

3.                                       Immunizations for adults

 

The DEPARTMENT will provide
an incentive to Molina using an influenza measure developed by the DEPARTMENT
and the Office of Health Care Statistics. The measurement is the percentage of
Enrollees age 50 and older who receive an influenza immunization during the
previous year’s flu season (September 1 of the previous year through May 31 of
the measurement year). The baseline year is September 1, 2002 through August
31, 2003. Based on Molina’s percentage for the flu season ending in 2005, the
DEPARTMENT will pay Molina $300 for each full percentage point above Molina’s
percentage in the baseline year up to 50 percentage points above the baseline
year.

 

14

 

The CONTRACTOR agrees to use
this incentive payment to reward Molina’s employees responsible for improving
the influenza immunization rate for adults.

 

F.                                      Quarterly
Report of Costs Incurred for Administration, Case Management Services,  Etc.

 

1.                                       On
a quarterly basis, the DEPARTMENT is required to report costs incurred for
administration, case management services, etc., from non-risk managed care
contracts with Federal Financial Participation (FFP). This reporting is
required 30 days after the quarters ending March 31, June 30, September 30, and
December 31. In order to meet this requirement, Molina must submit the cost
data to the DEPARTMENT by the 25th of each month following each
quarter’s end.

 

2.                                       The
CONTRACTOR will report to the DEPARTMENT its costs incurred for
administration,  case management
services,  profit earned, etc. in an
Excel spreadsheet. Molina will develop a cost reporting plan that documents
methods used for reporting including direct assignment and/or allocation
process. The purpose of the plan methods is to facilitate any reviews that the
DEPARTMENT conducts.

 

The CONTRACTOR
will itemize its costs incurred into at least the following cost categories:

 

	
  a.

  	
   

  	
  Family
  Planning

  
	
  b.

  	
   

  	
  Claims
  Processing

  
	
  c.

  	
   

  	
  Provider
  Enrollment

  
	
  d.

  	
   

  	
  Prior
  Authorization

  
	
  e.

  	
   

  	
  Case
  Management Services/Care Coordination

  
	
  f.

  	
   

  	
  Disease
  Management Programs

  
	
  g.

  	
   

  	
  Perinatal
  Care Programs

  
	
  h.

  	
   

  	
  Educational
  Newsletters and other Outreach

  
	
  i.

  	
   

  	
  Provider
  Credentialing and Re-credentialing

  
	
  j.

  	
   

  	
  HEDIS
  Reporting

  
	
  k.

  	
   

  	
  Encounter
  Data Submitted to the DEPARTMENT

  
	
  l.

  	
   

  	
  Grievance
  and Appeals Processes

  
	
  m.

  	
   

  	
  Work related
  to the DEPARTMENT’s External Quality Review Organization

  
	
  n.

  	
   

  	
  Quality
  Improvement Programs

  
	
  o.

  	
   

  	
  Quality
  Committees

  
	
  p.

  	
   

  	
  Performance
  Improvement Projects

  
	
  q.

  	
   

  	
  Health Needs
  Assessments

  
	
  r.

  	
   

  	
  Utilization
  Management other than prior authorization

  
	
  s.

  	
   

  	
  Other
  General Administrative Costs (in detail)

  
	
  t.

  	
   

  	
  Profit from
  Operations Before Taxes

  
	
  u.

  	
   

  	
  Taxes from
  Operations

  

 

15

 

For each of
the cost categories that have a personnel component, Molina will break out the
costs by skilled Medical Professional; i.e, doctors, registered nurses,
pharmacists, social workers, etc.

 

G.                                    Other
Payment-Related References

 

Attachment A,
Article III, #4, #5, and #6 - (unauthorized changes to contract)

Attachment B,
Article XI - Other Requirements (Fraud & Abuse)

Article XII - Payments (Third Party Liability)

Article XIII - Records and Reporting Requirements (Accuracy of Data)

Article XIV - Compliance/Monitoring (Right to Audit)

Article XV - Termination of Contract

 

16Exhibit 10.2

 

DEPARTMENT
OF SOCIAL AND HEALTH SERVICES

 

 

2006
– 2007 CONTRACT

 

 

FOR

 

HEALTHY
OPTIONS

 

AND

 

 

STATE
CHILDREN’S HEALTH

INSURANCE
PLAN

 

APPROVED
AS TO FORM BY THE ATTORNEY GENERAL’S OFFICE

 

 

1.             DEFINITIONS

 

The following definitions
shall apply to this Contract:

 

1.1           Action means the denial or limited authorization of
a requested service, including the type or level of service; the reduction,
suspension, or termination of a previously authorized service; the denial, in
whole or in part, of payment of a service; or the failure to provide services
or act in a timely manner as required herein (42 CFR 438.400(b)).

 

1.2           Advance Directive means a written instruction, such as a
living will or durable power of attorney for health care, recognized under the
laws of the State of Washington, relating to the provision of health care when
an individual is incapacitated (WAC 388-501-0125, 42 CFR 438.6, 42 CFR 438.10,
42 CFR 422.128, and 42 CFR 489 Subpart I).

 

1.3           Ancillary Services means health services ordered by a provider
including, but not limited to, laboratory services, radiology services, and
physical therapy.

 

1.4           Appeal means a request for review of an action (42
CFR 438.400(b)).

 

1.5           Appeal Process means the Contractor’s procedures for
reviewing an action.

 

1.6           Children with Special Health
Care Needs means children
identified by DSHS to the Contractor as children served under the provisions of
Title V of the Social Security Act and children identified by the Contractor as
having special health care needs.

 

1.7           Cold Call Marketing means any unsolicited personal contact by
the Contractor or its designee, with a potential enrollee or an enrollee with
another HO/SCHIP contracted managed care organization for the purposes of
marketing (42 CFR 438.104(a)).

 

1.8           Comparable Coverage means an enrollee has other insurance that
DSHS has determined provides a full scope of health care benefits.

 

1.9           Consumer Assessment of
Health Plans Survey (CAHPS®) means a commercial and Medicaid
standardized survey instrument used to measure client experience of health
care.

 

1.10         Continuity of Care means the
provision of continuous care for chronic or acute medical conditions through
enrollee transitions in providers or service areas, between HO/SCHIP
contractors and between Medicaid fee-for-service and HO/SCHIP in a manner that
does not interrupt medically necessary care or jeopardize the enrollee’s
health.

 

1.11         Coordination of Care means the Contractor’s mechanisms to assure
that the enrollee and providers have access to and take into consideration, all
required

 

1

 

information on the
enrollee’s conditions and treatments to ensure that the enrollee receives
appropriate health care services (42 CFR 438.208).

 

1.12         Covered Services means medically necessary services, as set
forth in Section 11, Benefits, covered under the terms of this Contract.

 

1.13         Duplicate coverage means an enrollee is privately enrolled on
any basis with the Contractor and simultaneously enrolled with the Contractor
under Healthy Options/SCHIP.

 

1.14         EPSDT (Early, Periodic Screening, Diagnosis and
Treatment) means a package of services in a preventive (well child) exam
covered by Medicaid as defined in the Social Security Act (SSA) Section 1905(r)
and the DSHS EPSDT program policy and billing instructions (See Exhibit A for
website link). Services covered by Medicaid include a complete health history
and developmental assessment, an unclothed physical exam, immunizations,
laboratory tests, health education and anticipatory guidance, and screenings
for: vision, dental, substance abuse, mental health and hearing, as well as any
medically necessary services found to be necessary during the EPSDT exam. EPSDT
services covered by the Contractor are described in Section 11, Benefits.

 

1.15         Eligible Clients means Medicaid recipients certified eligible
by DSHS, living in the service area, and eligible to enroll for health care
services under the terms of this Contract, as described in Section 2.2.

 

1.16         Emergency Medical Condition means a medical condition manifesting itself
by acute symptoms of 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 attention to result
in: (a) placing the health of the individual (or, with respect to a pregnant
woman, the health of the woman or her unborn child) in serious jeopardy; (b)
serious impairment to bodily functions; or (c) serious dysfunction of any
bodily organ or part (42 CFR 438.114(a)).

 

1.17         Emergency Services means covered inpatient and outpatient
services that are furnished by a provider that is qualified to furnish the
services and are needed to evaluate or stabilize an emergency medical condition
(42 CFR 438.114(a)).

 

1.18         Enrollee means an Medicaid recipient eligible for any
medical program who is enrolled in Healthy Options/SCHIP managed care through a
health care plan having a Contract with DSHS (42 CFR 438.10(a)).

 

1.19         Enrollee with Special Health
Care Needs means a Medicaid
recipient who has chronic and disabling conditions as defined in WAC
388-538-050.

 

1.20         External Quality Review
(EQR) means the analysis and
evaluation by an EQRO of aggregated information on quality, timeliness and
access to the health care services that the Contractor or its subcontractors
furnish to Medicaid recipients (42 CFR 438.320).

 

2

 

1.21         External Quality Review
Organization (EQRO) means an
organization that meets the competence and independence requirements set forth
in 42 CFR 438.354, and performs external quality review, other EQR-related
activities as set forth in 42 CFR 438.358, or both (42 CFR 438.320). DSHS must
contract with one EQRO to conduct either EQR alone or EQR-related activities
and may contract with additional EQROs to conduct EQR-related activities as set
forth in 42 CFR 438.358.

 

1.22         External Quality Review
Protocols means a series of
nine (9) procedures or guidelines for validating performance. Two of the nine
protocols must be used by state Medicaid agencies. These are:  1) Determining Contractor compliance with
federal Medicaid managed care regulations; and 2) Validation of performance
improvement projects undertaken by the Contractor. The current Centers for
Medicare and Medicaid Services (CMS) Protocols (See Exhibit A for website
link).

 

1.23         External Quality Review
Report - (EQRR) means a
technical report that describes the manner in which the data from all EQR
activities are aggregated and analyzed, and conclusions drawn as to the
quality, timeliness, and access to the care furnished by the Contractor. DSHS
will provide a copy of the EQRR to the Contractor, through print or electronic
media and to interested parties such as participating health care providers,
enrollees and potential enrollees of the Contractor, recipient advocacy groups,
and members of the general public. DSHS must make this information available in
alternative formats for persons with sensory impairments, when requested.

 

1.24         Grievance means an expression of dissatisfaction about
any matter other than an action. Possible subjects for grievances include, but
are not limited to, the quality of care or services provided, and aspects of
interpersonal relationships such as rudeness of a provider or employee, or
failure to respect the enrollee’s rights (42 CFR 438.400(b)).

 

1.25         Grievance Process means the procedure for addressing enrollees’
grievances.

 

1.26         Grievance System means the overall system that includes
grievances and appeals handled by the Contractor and access to the fair hearing
system (42 CFR 438.400).

 

1.27         Health Care Professional means a physician or any of the following
acting within their scope of practice; a podiatrist, optometrist, chiropractor,
psychologist, dentist, physician assistant, physical or occupational therapist,
therapist assistant, speech language pathologist, audiologist, registered or
practical nurse (including nurse practitioner, clinical nurse specialist,
certified registered nurse anesthetist, and certified nurse midwife), licensed
certified social worker, registered respiratory therapist, pharmacist and
certified respiratory therapy technician (42 CFR 438.2).

 

1.28         Health Employer Data and
Information Set - (HEDIS®) means a set of standardized performance
measures designed to ensure that healthcare

 

3

 

purchasers and consumers
have the information they need to reliably compare the performance of managed
health care plans. The performance measures in HEDIS® are related to many
significant public health issues such as immunizations, smoking, asthma, and
diabetes. HEDIS® also includes a standardized survey of consumers’ experiences
that evaluates plan performance in areas such as customer service, access to
care and claims processing. HEDIS® is sponsored, supported, and maintained by National Committee for
Quality Assurance (NCQA).

 

1.29         Health Employer Data and
Information Set (HEDIS®) Compliance Audit  Program means a set of standards and audit
methods used by an NCQA certified auditor to evaluate information systems
capabilities assessment (IS standards) and a Contractor’s ability to comply
with HEDIS® specifications (HD standards).

 

1.30         Managed Care means a prepaid, comprehensive system of
medical and health care delivery, including preventive, primary, specialty and
ancillary health services.

 

1.31         Managed Care Organization
(MCO) means an organization
having a certificate of authority or certificate of registration from the
Office of Insurance Commissioner that contracts with DSHS under a comprehensive
risk contract to provide prepaid health care services to eligible DSHS clients
under the department’s managed care programs (WAC 388-538-050).

 

1.32         Marketing means any communication from the Contractor
to a potential enrollee or enrollee with another DSHS contracted MCO that can
be reasonably interpreted as intended to influence them to enroll with the
Contractor or either to not enroll in, or to disenroll from, another DSHS
contracted MCO (CFR 438.104(a)).

 

1.33         Marketing Materials means materials that are produced in any
medium, by or on behalf of the Contractor that can be reasonably interpreted as
intended as marketing. (42 CFR 438.104(a)).

 

1.34         Medically Necessary Services means services that meet the definition in
WAC 388-500-0005. In addition, medically necessary services shall include
services related to the enrollee’s ability to achieve age-appropriate growth
and development.

 

1.35         National CAHPS® Benchmarking
Database - (NCBD) means a
national repository for data from the Consumer Assessment of Health Plans
Survey (CAHPS).  The database facilitates
comparisons of CAHPS® survey results by survey sponsors.  Data is compiled
into a single national database, which enables NCBD participants to compare
their own results to relevant benchmarks (i.e., reference points such as
national and regional averages). The NCBD also offers an important source of
primary data for specialized research related to consumer assessments of
quality as measured by CAHPS®.

 

4

 

1.36         National Committee for
Quality Assurance - (NCQA)
means an organization responsible for developing and managing health care
measures that assess the quality of care and services that commercial and
Medicaid managed care clients receive.

 

1.37         Participating Provider means a person, health care provider,
practitioner, or entity, acting within their scope of practice, with a written
agreement with the Contractor to provide services to enrollees under the terms
of this Contract.

 

1.38         Peer-Reviewed Medical
Literature means medical
literature published in professional journals that submit articles for review
by experts who are not part of the editorial staff. It does not include
publications or supplements to publications primarily intended as marketing
material for pharmaceutical, medical supplies, medical devices, health service
providers, or insurance carriers.

 

1.39         Physician Group means a partnership, association,
corporation, individual practice association, or other group that distributes
income from the practice among its members. An individual practice association
is a physician group only if it is composed of individual physicians and has no
subcontracts with physician groups.

 

1.40         Physician Incentive Plan means any compensation arrangement between
the Contractor and a physician or physician group that may directly or
indirectly have the effect of reducing or limiting services to enrollees under
the terms of this Contract.

 

1.41         Post-stabilization Services means covered services, related to an
emergency medical condition that are provided after an enrollee is stabilized
in order to maintain the stabilized condition or to improve or resolve the
enrollee’s condition (42 CFR 438.114 and 42 CFR 422.113).

 

1.42         Potential Enrollee means any Medicaid recipient eligible for
enrollment in Healthy Options/SCHIP who is not enrolled with a health care plan
having a contract with DSHS (42 CFR 438.10(a)).

 

1.43         Primary Care Provider (PCP) means a participating provider who has the
responsibility for supervising, coordinating, and providing primary health care
to enrollees, initiating referrals for specialist care, and maintaining the
continuity of enrollee care. PCPs include, but are not limited to Pediatricians,
Family Practitioners, General Practitioners, Internists, Physician Assistants
(under the supervision of a physician), or Advanced Registered Nurse
Practitioners (ARNP), as designated by the Contractor. The definition of
primary care provider is inclusive of the definition of primary care physician
in 42 CFR 400.203 and all Federal requirements for primary care physicians will
be applicable to primary care providers as the term is used in this Contract.

 

1.44         Quality as it pertains to external quality review
means the degree to which a Contractor increases the likelihood of desired
health outcomes of its enrollees through its structural and operational
characteristics and through the provision of

 

5

 

health services that are
consistent with current professional knowledge (42 CFR 438.320).

 

1.45         Risk means the possibility that a loss may be
incurred because the cost of providing services may exceed the payments made
for services. When applied to subcontractors, loss includes the loss of
potential payments made as part of a physician incentive plan, as defined
herein.

 

1.46         Service Areas means the geographic areas covered by this
Contract as described in Section 2.1.

 

1.47         State Children’s Health
Insurance Program (SCHIP) means
a state-funded program to provide
access to medical care for children whose family income exceeds the limit for
Medicaid eligibility, but is not greater than two hundred fifty percent of the
federal poverty level (FPL). SCHIP is authorized by Title XXI of the Social
Security Act and by RCW 74.09.450 (WAC 388-542).

 

1.48         Subcontract means a written agreement between the
Contractor and a subcontractor, or between a subcontractor and another
subcontractor, to perform all or a portion of the duties and obligations the
Contractor is obligated to perform pursuant to this Contract.

 

1.49         Validation means the review of information, data, and
procedures to determine the extent to which they are accurate, reliable, and
free from bias and in accord with standards for data collection and analysis
(42 CFR 438.320).

 

2.             ENROLLMENT

 

2.1           Service Areas:

 

2.1.1                The Contractor’s service areas are described
in Exhibit B, Premiums, Service Areas, and Capacity. DSHS shall update Exhibit
B, Premiums, Service Areas, and Capacity for service area changes as describe
herein.

 

2.1.2                Clients in the eligibility groups described
in Section 2.2 are eligible to enroll with the Contractor if they reside in the
Contractor’s service areas.

 

2.1.3                Service Area Changes:

 

2.1.3.1             With the written approval of DSHS, the
Contractor may expand into additional service areas at any time by giving
written notice to DSHS, along with evidence, as DSHS may require, demonstrating
the Contractor’s ability to support the expansion. DSHS may withhold approval
of a requested expansion, if, in DSHS’ sole judgment, the requested expansion
is not in the best interest of DSHS.

 

2.1.3.2             The Contractor may decrease service areas by
giving DSHS ninety (90) calendar days written notice. The decrease shall not be
effective until

 

6

 

the first day of the month
that falls after the ninety (90) calendar days has elapsed.

 

2.1.3.3             The Contractor shall notify enrollees
affected by any service area decrease sixty (60) calendar days prior to the
effective date. Notices shall have prior approval of DSHS. If the Contractor
fails to notify affected enrollees of a service area decrease sixty (60)
calendar days prior to the effective date, the decrease shall not be effective
until the first day of the month which falls sixty (60) calendar days from the
date the Contractor notifies enrollees.

 

2.1.4                If the U.S. Postal Service alters the zip
code numbers or zip code boundaries within the Contractor’s service areas, DSHS
shall alter the service area zip code numbers or the boundaries of the service
areas with input from the affected contractors.

 

2.1.5                DSHS shall determine, in its sole judgment,
which zip codes fall within each service area. No zip code will be split
between service areas.

 

2.1.6                DSHS will determine whether an enrollee
resides within a service area.

 

2.2           Eligible Client Groups: DSHS shall determine eligibility for
enrollment under this Contract. Clients in the following eligibility groups at
the time of enrollment are eligible for enrollment under this Contract, and
must enroll in Healthy Options/SCHIP unless the enrollee has duplicate coverage
as defined herein, has comparable coverage as defined herein, or is exempted
pursuant to Section 2.4.

 

2.2.1                Clients receiving Medicaid under Social
Security Act (SSA) provisions for coverage of families receiving Temporary
Assistance for Needy Families and clients who are not eligible for cash
assistance who remain eligible for Medicaid.

 

2.2.2                Children, from birth through eighteen years
of age, eligible for Medicaid under expanded pediatric coverage provisions of
the Social Security Act (“H” Children).

 

2.2.3                Pregnant Women, eligible for Medicaid under
expanded maternity coverage provisions of the Social Security Act (“S” women).

 

2.2.4                Children eligible for SCHIP (See Exhibit A
for website link).

 

2.3           Client Notification: DSHS shall notify eligible clients of their
rights and responsibilities as Healthy Options/SCHIP enrollees at the time of
initial eligibility determination and at least annually. The Contractor shall
provide enrollees with additional information as described in this Contract.

 

2.4           Exemption from Enrollment: A client may request exemption from
enrollment. Each request for exemption will be reviewed by DSHS pursuant to WAC
388-

 

7

 

538 or WAC 388-542. When the
client is already enrolled with the Contractor and wishes to be exempted, the
exemption request will be treated as a disenrollment request consistent with
the provisions of Section 2.9.

 

2.5           Enrollment Period: Subject to the provisions of Section 2.7,
enrollment is continuously open. Enrollees shall have the right to change
enrollment prospectively, from one Healthy Options/SCHIP plan to another
without cause, each month.

 

2.6           Enrollment Process: To enroll with the Contractor, the client,
their representative or their responsible parent or guardian must complete and
submit a DSHS enrollment form to DSHS, or call the DSHS, Division of Client
Support toll-free enrollment number. If the client does not exercise their
right to choose a Healthy Options/SCHIP plan, DSHS will assign the client, and
all eligible family members, to a Healthy Options/SCHIP plan in accord with
Section 5.12 of this Contract.

 

DSHS will make every effort
to enroll all family members with the same Healthy Options/SCHIP plan. If a
family member is covered by the Basic Health, DSHS will make every effort to
enroll the remainder of the family with the same managed care plan if the plan
contracts with DSHS to provide Healthy Options/SCHIP. If the plan does not
contract with DSHS, the remaining family members will be enrolled with a
single, but different Healthy Options/SCHIP plan of the client’s choice, or the
client will be assigned as described above if they do not choose.

 

2.7           Effective Date of
Enrollment:

 

2.7.1                Except for newborns whose mother is enrolled
in a Healthy Options/SCHIP plan, enrollment with the Contractor shall be
effective on the later of the following dates:

 

2.7.1.1             If the enrollment is processed on or before
the DSHS cut-off date for enrollment, enrollment shall be effective the first
day of the month following the month in which the enrollment is processed; or

 

2.7.1.2             If the enrollment is processed after the DSHS
cut-off date for enrollment, enrollment shall be effective the first day of the
second month following the month in which the enrollment is processed.

 

2.7.2                Newborns whose mothers are enrollees shall be
deemed enrollees and enrolled beginning from the newborn’s date of birth or the
mother’s date of enrollment, whichever is later. If the mother is disenrolled
before the newborn receives a separate client identifier from DSHS, the newborn’s
coverage shall end when the mother’s coverage ends, except as provided in Section
11.12, Enrollee Hospitalized at Disenrollment. If the newborn does not receive
a separate client identifier by the sixtieth (60th) day of life, supplemental
premiums and coverage shall only be available through the end of the month in
which the sixtieth (60th) day of life falls in accord with

 

8

 

Healthy Options Licensed
Health Carrier Billing Instructions, published by DSHS (See Exhibit A for
website link).

 

2.7.3                Adopted children shall be covered consistent
with the provisions of Title 48 RCW.

 

2.7.4                No retroactive coverage is provided under
this Contract, except as described in this Section.

 

2.8           Enrollment Listing and
Requirements for Contractor’s Response:

 

2.8.1                Before the end of each month DSHS will provide
the Contractor with an electronic file listing the Contractor’s enrollees whose
enrollment is terminated by the end of that month, and the Contractor’s
enrollees for the following month. The electronic file will be provided via a
Health Insurance Portability and Accountability Act (HIPAA) compliant secure
web-based transfer system in the 834 benefit enrollment and maintenance format.

 

2.8.2                The Contractor shall have ten (10) calendar
days from the receipt of the enrollment listing to notify DSHS in writing of
the refusal of an application for enrollment or any discrepancy regarding DSHS’
proposed enrollment effective date. Written notice shall include the reason for
refusal and must be agreed to by DSHS. The effective date of enrollment
specified by DSHS shall be considered accepted by the Contractor and shall be
binding if the notice is not timely or DSHS does not agree with the reasons
stated in the notice. Subject to DSHS approval, the Contractor may refuse to
accept an enrollee for the following reasons:

 

2.8.2.1             DSHS has enrolled the enrollee with the
Contractor in a service area the Contractor is not contracted for.

 

2.8.2.2             The enrollee is not eligible for enrollment
under the terms of this Contract.

 

2.9           Termination of Enrollment:

 

2.9.1                Voluntary Termination: Enrollees may request
termination of enrollment by submitting a written request to terminate
enrollment to DSHS or by calling the Medical Assistance Customer Service Center
(MACSC) toll-free enrollment number. Requests for termination of enrollment may
be made to enroll with another Healthy Options plan, or to disenroll from
Healthy Options as provided in WAC 388-538 or WAC 388-542. Except as provided
in WAC 388-538 or WAC 388-542, enrollees whose enrollment is terminated will be
prospectively disenrolled. DSHS shall notify the Contractor of enrollee
terminations pursuant to Section 2.8. The Contractor may not request voluntary
disenrollment on behalf of an enrollee.

 

9

 

2.9.2                Involuntary Termination Initiated by DSHS for
Ineligibility: The enrollment of any enrollee under this Contract shall be
terminated if the enrollee becomes ineligible for enrollment due to a change in
eligibility status.

 

2.9.2.1             When an enrollee’s enrollment is terminated
for ineligibility, the termination shall be effective:

 

2.9.2.1.1                  The first day of the month following the
month in which the termination is processed by DSHS if the termination is
processed on or before the DSHS cut-off date for enrollment or the Contractor
is informed by DSHS of the termination prior to the first day of the month
following the month in which the termination is processed by DSHS.

 

2.9.2.1.2                  Effective the first day of the second month
following the month in which the termination is processed if the termination is
processed after the DSHS cut-off date for enrollment and the Contractor is not
informed by DSHS of the termination prior to the first day of the month
following the month in which the termination is processed by DSHS.

 

2.9.2.2             Enrollees Eligible for Social Security Income
(SSI):

 

2.9.2.2.1                  Newborn enrollees with a date-of-birth after
calendar year 2003 who are determined by the Social Security Administration
(SSA) to have an SSI eligibility effective date within the first sixty-days of
life, not counting the birth date, shall be ineligible for services under the
terms of this Contract when DSHS receives the SSI eligibility information from
the SSA through the State Data Exchange (SDX). Such newborn enrollees will be
disenrolled retroactively effective the date-of-birth. DSHS shall recoup
premiums paid in accord with Section 4.5.5.

 

2.9.2.2.2                  Except as provided in Section 2.9.2.2.1,
enrollees determined by the SSA to be eligible for SSI shall be ineligible for
services under the terms of this Contract when DSHS receives the SSI
eligibility information from the SSA through the electronic SDX. Such enrollees
will be disenrolled prospectively as described in Section 2.9.2.1. DSHS shall
not recoup any premiums for enrollees determined SSI eligible and the
Contractor shall be responsible for providing services under the terms of this
Contract until the effective date of disenrollment.

 

2.9.2.2.3                  If the Contractor believes an enrollee has
been determined by SSA to be eligible for SSI, the Contractor shall present
documentation of such eligibility to DSHS, DSHS will attempt to verify the
eligibility and, if the enrollee is SSI eligible, DSHS will act upon SSI
eligibility in accord with this Section.

 

10

 

2.9.3                Involuntary Termination Initiated by DSHS for
Comparable Coverage or Duplicate Coverage:

 

2.9.3.1             The Contractor shall notify DSHS as set forth
below when an enrollee has health care insurance coverage with the Contractor
or any other carrier:

 

2.9.3.1.1                  Within fifteen (15) working days when an
enrollee is verified as having duplicate coverage, as defined herein.

 

2.9.3.1.2                  Within sixty (60) calendar days of the date
when the Contractor becomes aware that an enrollee has any health care insurance
coverage with any other insurance carrier. The Contractor is not responsible
for the determination of comparable coverage, as defined herein.

 

2.9.3.2             DSHS will involuntarily terminate the
enrollment of any enrollee with duplicate coverage or comparable coverage as
follows:

 

2.9.3.2.1                  When the enrollee has duplicate coverage that
has been verified by DSHS, DSHS shall terminate enrollment retroactively to the
beginning of the month of duplicate coverage and recoup premiums as describe in
Section 4.5, Recoupments.

 

2.9.3.2.2                  When the enrollee has comparable coverage
which has been verified by DSHS, DSHS shall terminate enrollment effective the
first day of the second month following the month in which the termination is
processed if the termination is processed on or before the DSHS cut-off date
for enrollment or, effective the first day of the third month following the
month in which the termination is processed if the termination is processed
after the DSHS cut-off date for enrollment.

 

2.9.4                Involuntary Termination Initiated by the
Contractor: To request involuntary termination of an enrollee, the Contractor
shall send written notice to DSHS as described in Section 12.26, Notices. Involuntary
termination will occur only with written DSHS approval. DSHS shall review each
request on a case by case basis, and approve or disapprove the request for
termination within thirty (30) working days of receipt of such notice and the
documentation required to substantiate the request. For the termination to be
effective, DSHS must approve the termination request, notify the Contractor,
and disenroll the enrollee. The Contractor shall continue to provide services
to the enrollee until they are disenrolled. DSHS will not disenroll an enrollee
solely due to a request based on an adverse change in the enrollee’s health
status, the cost of meeting the enrollee’s health care needs, because of the
enrollee’s utilization of medical services, uncooperative or disruptive
behavior resulting from his or her special needs or diminished mental capacity
(WAC 388-538-130). DSHS shall

 

11

 

involuntarily terminate the
enrollee when the Contractor has substantiated in writing all of the following:

 

2.9.4.1             The enrollee’s behavior is inconsistent with
the Contractor’s rules and regulations, such as intentional misconduct;

 

2.9.4.2             The Contractor has provided a clinically
appropriate evaluation to determine whether there is a treatable condition
contributing to the enrollee’s behavior and such evaluation either finds no
treatable condition to be contributing, or, after evaluation and treatment, the
enrollee’s behavior continues to prevent the provider from safely or prudently
providing medical care to the enrollee; and

 

2.9.4.3             The enrollee received written notice from the
Contractor of its intent to request the enrollee’s disenrollment, unless the
requirement for notification has been waived by DSHS because the enrollee’s
conduct presents the threat of imminent harm to others. The Contractor’s notice
to the enrollee shall include the enrollee’s right to use the Contractor’s
grievance process to review the request to end the enrollee’s enrollment.

 

2.9.5                An enrollee whose enrollment is terminated
for any reason, other than incarceration, at any time during the month is
entitled to receive covered services, as described in Section 11.1, Scope of
Services, at the Contractor’s expense, through the end of that month.

 

In no event will an enrollee
be entitled to receive services and benefits under this Contract after the last
day of the month in which his or her enrollment is terminated, unless the
enrollee is hospitalized at disenrollment; in accord with Section 11.12,
Enrollee Hospitalized at Disenrollment.

 

2.10         Enrollment Not
Discriminatory:

 

2.10.1              The Contractor will not discriminate against
enrollees or potential enrollees on the basis of health status or need for
health care services (42 CFR 438.6(d)(3)).

 

2.10.2              The Contractor will not discriminate against
enrollees or potential enrollees on the basis of race, color, or national
origin, and will not use any policy or practice that has the effect of
discriminating on the basis of race, color, or national origin (42 CFR
438.6(d)(4)).

 

3.         MARKETING AND INFORMATION
REQUIREMENTS

 

3.1           Marketing:  The
Contractor, and any subcontractors, shall comply with the following
requirements regarding marketing (42 CFR 438.104):

 

12

 

3.1.1                All marketing materials must be reviewed by
and have the prior written approval of DSHS.

 

3.1.2                Marketing materials shall not contain
misrepresentations, or false, inaccurate or misleading information.

 

3.1.3                Marketing materials must be distributed in
all service areas the Contractor serves.

 

3.1.4                Marketing materials must be in compliance
with Section 3.3, Equal Access for Enrollees and Potential Enrollees with
Communication Barriers.

 

3.1.4.1             Marketing materials in English must give
directions in the Medicaid eligible population’s primary languages for
obtaining understandable materials.

 

3.1.4.2             DSHS may determine, in its sole judgment, if
materials that are primarily visual meet the requirements of this Contract.

 

3.1.5                The Contractor shall not offer anything of
value as an inducement to enrollment.

 

3.1.6                The Contractor shall not offer the sale of
other insurance to attempt to influence enrollment.

 

3.1.7                The Contractor shall not directly or
indirectly conduct door-to-door, telephonic or other cold-call marketing of
enrollment.

 

3.2           Information Requirements for
Enrollees and Potential Enrollees:

 

3.2.1                The Contractor shall provide sufficient,
accurate oral and written information to potential enrollees to assist them in
making an informed decision about enrollment (SSA 1932(d)(2) and 42 CFR
438.10).

 

3.2.2                The Contractor shall provide to potential
enrollees upon request and to each enrollee, within fifteen (15) working days
of enrollment, at any time upon request, and at least once a year, the
information needed to understand benefit coverage and obtain care.

 

3.2.3                All enrollee information shall have the prior
written approval of DSHS.

 

3.2.4                Changes to State or Federal law shall be
reflected in information to enrollees no more than ninety (90) calendar days
after the effective date of the change and enrollees shall be notified at least
thirty (30) calendar days prior to the effective date if, in the sole judgment
of DSHS, the change is significant in regard to the enrollees’ quality of or
access to care. DSHS shall notify the Contractor of any significant change in
writing.

 

13

 

3.2.5                The Contractor’s written information to
enrollees and potential enrollees shall include:

 

3.2.5.1             How to choose a PCP, including general
information on available PCPs and how to obtain specific information including
a list of PCPs that includes their identity, location, languages spoken,
qualifications, practice restrictions, and availability.

 

3.2.5.2             How to change a PCP.

 

3.2.5.3             How to access services outside the Contractor’s
service area.

 

3.2.5.4             How to access Emergency Services.

 

3.2.5.5             General information about accessing hospital
care and how to get a list of hospitals that are available to enrollees.

 

3.2.5.6             General information regarding specialists
available to enrollees and how to obtain specific information including a list
of specialists that includes their identity, location, languages spoken,
qualifications, practice restrictions, and availability.

 

3.2.5.7             How to obtain information regarding any
limitations to the availability of or referral to specialists to assist the
enrollee in selecting a PCP.

 

3.2.5.8             How to obtain information regarding Physician
Incentive Plans (42 CFR 422.208 and 422.210), and information on the Contractor’s
structure and operations.

 

3.2.5.9             Informed consent guidelines.

 

3.2.5.10           Information regarding conversion rights under
RCW 48.46.450 or RCW 48.44.370.

 

3.2.5.11           How to request a disenrollment.

 

3.2.5.12           The following information regarding advance
directives:

 

3.2.5.12.1                A statement about an enrollee’s right to make
decisions concerning an enrollee’s medical care, accept or refuse surgical or
medical treatment, execute an advance directive, and revoke an advance
directive at any time.

 

3.2.5.12.2                The written policies and procedures of the
Contractor concerning advance directives, including any policy that would
preclude the Contractor or subcontractor from honoring an enrollee’s advance
directive.

 

3.2.5.12.3                An enrollee’s rights under state law.

 

14

 

3.2.5.13           How to recommend changes in the Contractor’s
policies and procedures.

 

3.2.5.14           Health promotion, health education and
preventive health services available.

 

3.2.5.15           Information on the Contractor’s Grievance
System including:

 

3.2.5.15.1                How to obtain assistance from the Contractor
in using the grievance, appeal and independent review processes (must assure
enrollees that information will be kept confidential except as needed to
process the grievance, appeal or independent review.

 

3.2.5.15.2                How to initiate a grievance or file an
appeal, in accord with the Contractor’s DSHS approved policies and procedures
regarding grievances and appeals.

 

3.2.5.15.3                How to request a fair hearing after the
Contractor’s appeal process is exhausted, how to request a fair hearing and the
rules that govern representation at the fair hearing.

 

3.2.5.15.4                How to request an independent review in
accord with RCW 48.43.535 and WAC 246-305 after the fair hearing process is
exhausted and how to request an independent review.

 

3.2.5.15.5                The enrollees’ right to appeal an independent
review decision to the Board of Appeals and how to request such an appeal.

 

3.2.5.15.6                The requirements and timelines for
grievances, appeals, fair hearings, independent review and Board of Appeals.

 

3.2.5.15.7                The enrollees’ rights and responsibilities,
including potential payment liability, regarding the continuation of services
that are the subject of appeal or fair hearing.

 

3.2.5.15.8                The availability of toll-free numbers for
information about grievances and appeals and to file a grievance or appeal.

 

3.2.5.16           The enrollee’s rights and responsibilities
with respect to receiving covered services.

 

3.2.5.17           Information about covered benefits and how to
contact DSHS regarding services that may be covered by DSHS, but are not
covered benefits under this Contract.

 

3.2.5.18           Specific information about EPSDT.

 

15

 

3.2.5.19           Information regarding the availability of and
how to access or obtain interpretation services and translation of written
information at no cost to the enrollee.

 

3.2.5.20           How to obtain information in alternative
formats.

 

3.2.5.21           The enrollee’s right to and procedure for
obtaining a second opinion.

 

3.2.5.22           The prohibition on charging enrollees for
covered services and circumstances under which an enrollee might be charge for
services.

 

3.3           Equal Access for Enrollees
and Potential Enrollees with Communication Barriers:  The
Contractor shall assure equal access for all enrollees and potential enrollees
when oral or written language creates a barrier to such access for enrollees
and potential enrollees with communication barriers (42 CFR 438.10).

 

3.3.1                Oral Information:

 

3.3.1.1            The Contractor shall assure that interpreter
services are provided for enrollees and potential enrollees with a primary
language other than English for all interactions between the enrollee or
potential enrollee and the Contractor or any of its providers including, but
not limited to, customer services, all appointments with any provider for any
covered service, emergency services, and all steps necessary to file grievances
and appeals.

 

3.3.1.2            The Contractor is responsible for payment for
interpreter services for Contractor administrative matters including, but not
limited to handling enrollee grievances and appeals.

 

3.3.1.3            DSHS is responsible for payment for
interpreter services provided by interpreter agencies contracted with the state
for outpatient medical visits and fair hearings.

 

3.3.1.4            Hospitals are responsible for payment for interpreter
services during inpatient stays.

 

3.3.1.5            Public entities, such as Public Health
Departments, are responsible for payment for interpreter services provided at
their facilities or affiliated sites.

 

3.3.1.6            Interpreter services include the provision of
interpreters for enrollees and potential enrollees who are deaf or hearing
impaired at no cost to the enrollee or potential enrollee.(42 CFR
438.10(c)(4)).

 

16

 

3.3.2                Written Information:

 

3.3.2.1             The Contractor shall provide all generally
available and client specific written materials in a form which may be
understood by each individual enrollee and potential enrollee.

 

3.3.2.2             If 5% or more of the Contractor’s enrollees
speak a specific language other than English, generally available materials
will be translated into that language.

 

3.3.2.3             For enrollees whose primary language is not
translated as required by Section 3.3.2.2, the Contractor may meet the
requirement of this Section by doing any one of the following:

 

3.3.2.3.1                 Translating the material into the enrollee’s
or potential enrollee’s primary reading language.

 

3.3.2.3.2                 Providing the material on tape in the
enrollee’s or potential enrollee’s primary language.

 

3.3.2.3.3                 Having an interpreter read the material to
the enrollee or potential enrollee in the enrollee’s primary language.

 

3.3.2.3.4                 Providing the material in another alternative
medium or format acceptable to the enrollee or potential enrollee. The
Contractor shall document the enrollee’s or potential enrollee’s acceptance of
the material in an alternative medium or format (42 CFR 438.10(d)(1)(ii)).

 

3.3.2.3.5                 Providing the material in English, if the
Contractor documents the enrollee’s or potential enrollee’s preference for
receiving material in English.

 

3.3.2.4             The Contractor shall ensure that all written
information provided to enrollees or potential enrollees is accurate, is not
misleading, is comprehensible to its intended audience, designed to provide the
greatest degree of understanding, and is written at the sixth grade reading
level and fulfils other requirements of the Contract as may be applicable to
the materials (42 CFR 438.10(b)(1) and SMD letter 02/20/98). This shall not be
interpreted to include Disease Management materials, preventative services or
other education materials used by the Contractor for health promotion efforts. DSHS
may make exceptions to the sixth grade reading level when, in the sole judgment
of DSHS, the nature of the materials do not allow for a sixth grade reading
level or the enrollees’ needs are better served by allowing a higher reading
level. DSHS approval of exceptions to the sixth grade reading level must be in
writing.

 

3.3.2.5             All written materials must have the written
approval of DSHS prior to use. For client specific written materials, the
Contractor may use templates that have been pre-approved in writing by DSHS. The

 

17

 

Contractor must provide DSHS
with a copy of all approved materials in final form.

 

4.             PAYMENT

 

4.1           Rates/Premiums:

 

4.1.1                Subject to the provisions of Section 12.32,
Sanctions, DSHS shall pay a monthly premium for each enrollee in full
consideration of the work to be performed by the Contractor under this Contract.
DSHS shall pay the Contractor, on or before the tenth (10th) working day of the
month based on the DSHS list of enrollees whose enrollment is ongoing or
effective on the first day of said calendar month. Such payment will be denied
for new enrollees when, and for so long as, payment for those enrollees is
denied by the Centers for Medicare and Medicaid Services (CMS) under 42 CFR
438.726(b) and 42 CFR 438.730(e).

 

4.1.2                The Contractor shall reconcile the electronic
benefit enrollment listing with the premium payment information and submit a
claim to DSHS for any amount due the Contractor within three hundred sixty five
(365) calendar days of the month of service. When DSHS’ records confirm the
Contractor’s claim, DSHS shall remit payment within thirty (30) calendar days
of the receipt of the claim.

 

4.1.3                The statewide Base Rate, Geographical
Adjustment Factors, Risk Adjustment Factors and Age/Sex Factors are in Exhibit
B, Premiums, Service Areas, and Capacity.

 

4.1.4                The monthly premium payment will be
calculated as follows:

 

Premium Payment = Base Rate
x Age/Sex Factor x Risk Adjustment Factor x Geographical Adjustment Factor (X
Quality Adjustment Factor as described herein).

 

4.1.5                Within sixty (60) calendar days following the
end of the annual legislative session, DSHS will publish the Base Rate for the
following calendar year. If the Contractor will not continue to provide
HO/SCHIP services in the following calendar year, the Contractor shall so
notify DSHS no later than September 2, of the current year under the provisions
of Section 12.26 Notices. If the Contractor so notifies DSHS, this Contract
shall terminate, without penalty to either party, effective midnight, December
31, of the current year. The termination will be considered a termination for
convenience under the provisions of Section 12.37, Termination for Convenience,
but neither party shall have the right to assert a claim for costs.

 

4.1.6                The Geographical Adjustment Factors will be
adjusted by DSHS for the period January 1, through December 31, of the following
year for changes in utilization and to provide for the payment of Critical
Access Hospitals 

 

18

 

(CAH) as required in Section
3.13., Payments to CAH. Geographical Adjustment Factors may be prospectively
updated by DSHS if, in DSHS’ judgment, there are material changes in rates or
utilization related to CAH.

 

4.1.7                The Risk Adjustment Factor will be
recalculated for premiums paid beginning in May for each year based on
enrollment with the Contractor on March 1st of that year, using the
most currently available 12 months of reported encounter data. Risk Adjustment
Factors may also be recalculated by DSHS if, in DSHS’ sole judgment, changes in
contractor participation in HO/SCHIP require rebalancing of the Risk Adjustment
Factors.

 

4.1.8                Each year DSHS will develop a Quality
Incentive based on HEDIS® measures for childhood immunizations and well child
visits. If the Contractor will receive a Quality Incentive, the amount will be
stated in Exhibit B, Premiums, Service Areas, and Capacity and will be paid in
the first quarter of the year.

 

4.1.9                DSHS will update Exhibit B, Premiums, Service
Areas, and Capacity to add the Base Rate and any changes in service areas,
capacity, Geographical Adjustment Factors, and Risk Adjustment Factors as
needed without amending this Contract. DSHS will provide such updates to the
Contractor in writing.

 

4.1.10              DSHS shall automatically generate newborn
premiums whenever possible. For newborns whose premiums DSHS is not able to
automatically generate the Contractor shall submit a supplemental premium
payment request to DSHS within 365 calendar days of the month of service. The
Contractor shall be responsible for reviewing monthly listings provided by DSHS
of the newborn premiums DSHS cannot generate automatically, as well as premium
payment notices, to determine whether a supplemental premium request needs to
be submitted. DSHS shall pay supplemental premiums through the end of the month
in which the sixtieth (60th) day of life occurs.

 

4.1.11              DSHS shall make a full monthly payment to the
Contractor for the month in which an enrollee’s enrollment is terminated except
as otherwise provided herein.

 

4.1.12              The Contractor shall be responsible for
covered medical services provided to the enrollee in any month for which DSHS
paid the Contractor for the enrollee’s care under the terms of this Contract.

 

4.2           Delivery Case Rate Payment:  A
one-time payment of $4,320.50 shall be made to the Contractor for labor and
delivery expenses for enrollees enrolled with the Contractor during the month
of delivery. The Delivery Case Rate shall only be paid to the Contractor if it
has incurred expenses for and paid for labor and delivery. Delivery includes
both live and stillbirths, but does not include miscarriage, induced abortion,
or other fetal demise not requiring labor and

 

19

 

delivery to terminate the
pregnancy. The Contractor shall submit a supplemental premium request for
payment to DSHS after the enrollee delivers.

 

4.3           Renegotiation of Rates: The base rate set forth herein shall be
subject to renegotiation during the Contract period only if DSHS, in its sole
judgment, determines that it is necessary due to a change in federal or state
law or other material changes, beyond the Contractor’s control, which would
justify such a renegotiation.

 

4.4           Reinsurance/Risk Protection: The Contractor may obtain reinsurance for
coverage of enrollees only to the extent that it obtains such reinsurance for
other groups enrolled by the Contractor, provided that the Contractor remains
ultimately liable to DSHS for the services rendered.

 

4.5           Recoupments: Unless mutually agreed to by the parties,
DSHS shall only recoup premium payments for individual enrollees who are:

 

4.5.1                Covered by the Contractor with duplicate
coverage.

 

4.5.2                Deceased prior to the month of enrollment. Premium
payments shall be recouped effective the first day of the month following the
enrollee’s date of death.

 

4.5.3                Retroactively disenrolled as a result of the
enrollee’s placement in foster care.

 

4.5.4                Retroactively disenrolled consistent with the
provisions of Section 2.9.1.

 

4.5.5                Newborns determined to have an SSI
eligibility effective date within the first sixty (60) days of life in accord
with Section 2.9.2.2.1. DSHS shall recoup all premiums paid for the enrollee,
but not the birth mother, back to the month of birth.

 

4.5.6                Found ineligible for enrollment with the
Contractor and DSHS so notifies the Contractor before the first day of the month
for which the premium is paid.

 

4.5.7                The Contractor may recoup payments made to
providers for services provided to enrollees during the period for which DSHS
recoups premiums for those enrollees. If the Contractor recoups said payments,
providers may submit appropriate claims for payment to DSHS through its FFS
program.

 

4.5.8                When DSHS retroactively disenrolls an
individual, DSHS will not disenroll any other family member, except for
newborns whose mother is disenrolled for duplicate coverage.

 

20

 

4.6.          Rate Setting Methodology: DSHS sets actuarially sound Managed care
rates that:

 

4.6.1.               Have been developed in accord with generally
accepted actuarial principles and practices;

 

4.6.2.               Are appropriate for the populations to be
covered, and the services to be furnished under the contract; and

 

4.6.3.               Have been certified, as meeting the
requirements of 42 CFR 438.6(c), by actuaries who meet the qualification
standards established by the American Academy of Actuaries and follow the
practice standards established by the Actuarial Standards Board.

 

4.7.          Copayments:  The
Contractor may impose copayments for services to enrollees for the same
services, populations and amounts that DSHS implements in its fee-for-service
program.

 

4.8.          Information for Rate
Setting:  For rate setting only, the Contractor shall
annually provide information regarding its cost experience related to the
provision of the services required under this Contract. The experience
information shall be provided directly to an actuary designated by DSHS. The
designated actuary will determine the timing, content, format and medium for
such information.

 

4.9.          Payments to Critical Access
Hospitals (CAH):  For services provided by CAH to enrollees, the
Contractor shall pay the CAH the prospective Inpatient and Outpatient
Departmental Weighted Cost-to-Charge rates published by DSHS.

 

4.10.        Encounter Data:  The Contractor shall comply with the required format provided in the
Encounter Data Transaction Guide published by DSHS (See Exhibit A for website
link). Encounter data includes claims paid by the Contractor for services
delivered to enrollees through the Contractor during a specified reporting
period. DSHS collects and uses this data for many reasons such as:  federal reporting; rate setting and risk
adjustment; service verification, managed care quality improvement program,
utilization patterns and access to care; DSHS hospital rate setting; and
research studies.

 

DSHS may change the
Encounter Data Transaction Guide with one hundred and fifty (150) calendar days
written notice to the Contractor. The Encounter Data Transaction Guide may be
changed with less than one hundred and fifty (150) calendar days notice by
mutual agreement of the Contractor and DSHS. The Contractor shall, upon receipt
of such notice from DSHS, provide notice of changes to subcontractors.

 

5.             ACCESS AND CAPACITY

 

5.1.          Network Capacity:

 

21

 

5.1.1.               The Contractor agrees to maintain and monitor
the support services and a provider network sufficient to serve the enrollee
capacity stated in Exhibit B, Premiums, Service Areas, and Capacity, consistent
with the requirements of this Contract.

 

5.1.2.               The Contractor agrees to provide medical services
required by this Contract through non-participating providers, at a cost to the
enrollee that is no greater than if the services were provided by participating
providers, if its network of participating providers is insufficient to meet
the medical needs of enrollees in a manner consistent with this Contract. The
Contractor shall adequately and timely cover these services out of network for
as long as the Contractor’s network is inadequate to provide them (42 CFR
438.206(b)(1)(4)). This provision shall not be construed to require the
Contractor to cover such services without authorization except as required for
emergency services.

 

5.1.3.               The Contractor must submit documentation
regarding its maintenance and monitoring of the network and adequate capacity
and services, as specified by DSHS, at any time upon DSHS request or when there
has been a change in the Contractor’s network or operations that, in the sole
judgment of DSHS, would adversely affect adequate capacity and/or the
Contractor’s ability to provide services.

 

5.1.4.               With the written approval of DSHS, the
Contractor may increase capacity or set its capacity to unlimited at any time
by giving written notice to DSHS. The Contractor shall provide evidence, as
DSHS may require, demonstrating the Contractor’s ability to support the
capacity increase. DSHS may withhold approval of a requested capacity increase,
if, in DSHS’ sole judgment, the requested increase is not in the best interest
of DSHS. The Contractor may decrease capacity by giving DSHS ninety (90)
calendar days written notice. The decrease shall not be effective until the
first day of the month which falls after the ninety (90) calendar days has
elapsed. Exhibit B, Premiums, Service Areas, and Capacity will be updated by
DSHS for increases and decreases in capacity.

 

5.2.          Service Delivery
Network:  In the maintenance and monitoring of its
network, the Contractor must consider the following (42 CFR 438.206(b)):

 

5.2.1.               The stated capacity in Exhibit B of this
Contract

 

5.2.2.               Adequate access to all services covered under
this Contract

 

5.2.3.               The expected utilization of services, taking
into consideration the characteristics and health care needs of the Medicaid
population represented by the Contractor’s enrollees;

 

5.2.4.               The number and types (in terms of training,
experience and specialization) of providers required to furnish the contracted
services;

 

22

 

5.2.5.               The number of network providers who are not
accepting new Medicaid enrollees;

 

5.2.6.               The geographic location of providers and
enrollees, considering distance, travel time, the means of transportation
ordinarily used by potential enrollees, and whether the location provides
physical access for the Contractor’s enrollees with disabilities.

 

5.2.7.               The cultural, ethnic, race and language needs
of enrollees.

 

5.3.          Timely Access to Care:  The
Contractor shall have contracts in place with all subcontractors that meet
state standards for access, taking into account the urgency of the need for
services. The Contractor shall ensure that:

 

5.3.1.               Network providers offer access comparable to
that offered to commercial enrollees or comparable to Medicaid fee-for-service,
if the Contractor serves only Medicaid enrollees. (42 CFR 438.206(b)(1) &
(c)(1));

 

5.3.2.               Mechanisms are established to ensure
compliance by providers;

 

5.3.3.               Providers are monitored regularly to
determine compliance; and

 

5.3.4.               Corrective action is initiated and documented
if there is a failure to comply.

 

5.4.          Hours of Operation for
Network Providers:  The Contractor must require that network
providers offer hours of operation for enrollees that are no less than the
hours of operation offered to any other patient (42 CFR 438.206(c)(1)).

 

5.5.          24/7 Availability: The Contractor shall have the following
services available on a 24-hour-a-day, seven-day-a-week basis by telephone. These
services may be provided directly by the Contractor or may be delegated to
subcontractors (42 CFR 438.206(c)(1)(iii)).

 

5.5.1.               Medical advice for enrollees from licensed
health care professionals concerning the emergent, urgent or routine nature of
medical condition.

 

5.5.2.               Authorization of services.

 

5.6.          Appointment Standards: The Contractor shall comply with appointment
standards that are no longer than the following (42 CFR 438.206(c)(1)(i)):

 

5.6.1.               Non-symptomatic (i.e. preventive care) office
visits shall be available from the enrollee’s PCP or another provider within
thirty (30) calendar days. A non-symptomatic office visit may include, but is not
limited to, well/preventive care such as physical examinations, annual
gynecological examinations, or child and adult immunizations.

 

5.6.2.               Non-urgent, symptomatic (i.e., routine care)
office visits shall be available from the enrollee’s PCP or another provider
within ten (10) calendar days.

 

23

 

A non-urgent, symptomatic
office visit is associated with the presentation of medical signs not requiring
immediate attention.

 

5.6.3.               Urgent, symptomatic office visits shall be
available from the enrollee’s PCP or another provider within forty-eight (48)
hours. An urgent, symptomatic visit is associated with the presentation of
medical signs that require immediate attention, but are not life threatening.

 

5.6.4.               Emergency medical care shall be available
twenty-four (24) hours per day, seven (7) days per week.

 

5.7.          Integrated Provider Network
Database (IPND):  The Contractor shall report their complete
provider network, to include all current contracted providers, monthly to DSHS
through the designated data management contact in accord with the Provider
Network Reporting Requirements published by DSHS (See Exhibit A for website
link).

 

5.8.          Provider Network - Distance
Standards:

 

5.8.1.               The Contractor network of providers shall
meet the distance standards below in every service area. The designation of a
zip code in a service area as rural or urban is in Exhibit B, Premiums, Service
Areas, and Capacity.

 

5.8.1.1.            PCP

 

Urban:  2 within 10 miles for 90% of Healthy Options
enrollees in the Contractor’s service area.

 

Rural:  1 within 25 miles for 90% of Healthy Options
enrollees in the Contractor’s service area.

 

5.8.1.2.            Obstetrics

 

Urban:  2 within 10 miles for 90% of Healthy Options
enrollees in the Contractor’s service area.

 

Rural:  1 within 25 miles for 90% of Healthy Options
enrollees in the Contractor’s service area.

 

5.8.1.3.            Pediatrician or Family Practice Physician
Qualified to Provide Pediatric Services

 

Urban:  2 within 10 miles for 90% of Healthy Options
enrollees in the Contractor’s service area.

 

Rural:  1 within 25 miles for 90% of Healthy Options
enrollees in the Contractor’s service area.

 

24

 

5.8.1.4.            Hospital

 

Urban/Rural: 1 within 25
miles for 90% of Healthy Options enrollees in the Contractor’s service area.

 

5.8.1.5.            Pharmacy

 

Urban:  1 within 10 miles for 90% of Healthy Options
enrollees in the Contractor’s service area.

 

Rural:  1 within 25 miles for 90% of Healthy Options
enrollees in the Contractor’s service area.

 

5.8.2.               DSHS may, at its sole discretion, grant
exceptions to the distance standards. DSHS’ approval of an exception shall be
in writing. The Contractor shall request an exception in writing and shall
provide evidence as DSHS may require to support the request. If the closest
qualified provider is beyond the distance standard applicable to the zip code,
the distance standard defaults to the distance to that provider. The closest
qualified provider may be a provider not participating with the Contractor.

 

5.9.          Standards for Specialty and
Primary Care Providers:  The Contractor defines providers that serve
as PCPs and high volume specialty care providers (SCPs) and establishes
measurable standards for the number of both PCPs and SCPs. The Contractor shall
analyze performance against standards at minimum, annually.

 

5.10.        Access to Specialty Care:

 

5.10.1.             The Contractor shall provide all medically
necessary specialty care for enrollees in a service area. If an enrollee needs
specialty care from a specialist who is not available within the Contractor’s
provider network, the Contractor shall provide the necessary services with a
qualified specialist outside the Contractor’s provider network.

 

5.10.2.             The Contractor shall maintain, and make
readily available to providers, up-to-date information on the Contractor
available network of specialty providers and shall provide any required
assistance to providers in obtaining timely referral to specialty care.

 

5.11.        Capacity Limits and Order of
Acceptance: The Contractor
shall provide care to enrollees up to the capacity limits in Exhibit B,
Premiums, Service Areas, and Capacity. The Contractor shall accept enrollees up
to the total capacity limit in each service area, and enrollees will be
accepted in the order in which they apply. DSHS shall enroll all eligible
clients with the contractor of their choice if the Contractor has not reached
the capacity limit unless DSHS determines, in its sole judgment, that it is in
DSHS’ best interest to withhold or limit enrollment with the Contractor. The
Contractor shall accept clients who are assigned by DSHS in accord with this
Contract, WAC 388-538, and WAC 388-542, except as specifically provided in
Section 2.8.

 

25

 

No
eligible client shall be refused enrollment or re-enrollment, have their
enrollment terminated, or be discriminated against in any way because of their
health status, the existence of a pre-existing physical or mental condition,
including pregnancy and/or hospitalization, or the expectation of the need for
frequent or high cost care (42 CFR 438.6(d)(1&3)).

 

5.12.        Assignment of Enrollees:

 

5.12.1.             Enrollees who do not select a plan in a
service area shall be assigned to a plan in the following manner:

 

5.12.1.1.          DSHS shall determine the total capacity of all contractors receiving
assignments in each service area.

 

5.12.1.2.          The Contractor’s capacity in each service area, as stated in
Exhibit B, Premiums, Service Areas, and Capacity, modified by increases and
decreases in capacity made in accord with this Contract, shall be divided by
the total capacity of all contractors receiving assignment in each service area.
In any area where the Contractor’s capacity is unlimited, DSHS will set the
Contractor’s capacity, for this calculation, at the total number of HO/SCHIP
eligibles in the service area.

 

5.12.1.3.          The result of the calculation in Section 4.10.1.2. will be multiplied
by the total of the households to be assigned.

 

5.12.1.4.          DSHS shall assign the number of households determined in Section
4.10.1.3. to the Contractor.

 

5.12.2.             At DSHS’ sole discretion, DSHS may not make
assignments of enrollees to the Contractor in a service area if the Contractor’s
enrollment, when DSHS calculates assignments, is ninety percent (90%) or more
of its capacity in that service area.

 

5.12.3.             The Contractor may choose not to receive
assignments or limit assignments in any service area by so notifying DSHS in
writing at least sixty (60) calendar days before the first of the month it is
requesting not to receive assignment of enrollees.

 

5.12.4.             DSHS reserves the right to make no
assignments, or to withhold or limit assignments to the Contractor, when, in
its sole judgment, it is in the best interest of DSHS.

 

5.12.5.             If either the Contractor or DSHS limits
assignments as described herein, the Contractor’s capacity, only for the
purposes of the calculation in Section 4.10.1.2., shall be that limit.

 

26

 

5.13.        Provider Network Changes:

 

5.13.1.             The Contractor shall give DSHS a minimum of
ninety (90) calendar days prior written notice, in accord with Section 12.26,
Notices, of the loss of a material provider. A material provider is one whose
loss would impair the Contractor’s ability to provide continuity of and access
to care for the Contractor’s current enrollees and/or the number of enrollees
the Contractor has agreed to serve in a service area.

 

5.13.2.             The Contractor shall make a good faith effort
to provide written notification to enrollees affected by any provider
termination within fifteen (15) calendar days after receiving or issuing a
provider termination notice (42 CFR 438.10(f)(5)). Enrollee notices shall have
prior approval of DSHS. If the Contractor fails to notify affected enrollees of
a provider termination at least sixty (60) calendar days prior to the effective
date of termination, the Contractor shall allow affected enrollees to continue
to receive services from the terminating provider, at the enrollees’ option, and
administer benefits for the lesser of a period ending the last day of the month
in which sixty (60) calendar days elapses from the date the Contractor notifies
enrollees or the enrollee’s effective date of enrollment with another plan.

 

6.             QUALITY OF CARE

 

6.1.          Quality Assessment and
Performance Improvement (QAPI) Program

 

6.1.1.               The Contractor shall have and maintain a
quality assessment and performance improvement (QAPI) program for the services
it furnishes to its enrollees that meets the provisions of 42 CFR 438, Subpart
D, Medicaid Managed Care Protocols (See Exhibit A for website link).

 

6.1.1.1.            The Contractor shall define its QAPI program
structure and processes and assign responsibility to appropriate individuals.

 

6.1.1.2.            The QAPI program structure shall include the
following elements:

 

6.1.1.2.1.                 A written description of the QAPI program
including identification of designated physician and behavioral health
practitioners. The QAPI program description shall include:

 

6.1.1.2.1.1.              A listing of all quality-related
committee(s),

 

6.1.1.2.1.2.              Descriptions of committee responsibilities,

 

6.1.1.2.1.3.              Contractor staff and practicing provider
committee participant titles,

 

6.1.1.2.1.4.              Meeting frequency, and

 

6.1.1.2.1.5.              Maintenance of meeting minutes reflecting
decisions made by each committee, as appropriate.

 

27

 

6.1.1.2.2.                 A Quality Improvement Committee that oversees
the quality functions of the Contractor. The Quality Improvement Committee:

 

6.1.1.2.2.1.              Recommends policy decisions,

 

6.1.1.2.2.2.              Analyzes and evaluates the results of QI
activities,

 

6.1.1.2.2.3.              Institutes actions, and

 

6.1.1.2.2.4.              Ensures appropriate follow-up.

 

6.1.1.2.3.                 An annual work plan.

 

6.1.1.2.4.                 An annual evaluation of the QAPI program to
include an evaluation of performance improvement projects, trending of
performance measures and evaluation of the overall effectiveness of the QI
program.

 

6.1.2.               The Contractor shall make available the QAPI
program description, and information on the Contractor’s progress towards
meeting its goals to providers and enrollees upon request.

 

6.1.3.               The Contractor shall provide evidence of
oversight of delegated entities responsible for quality improvement. Oversight
activities shall include evidence of:

 

6.1.3.1.            A delegation agreement with each delegated
entity describing the responsibilities of the Contractor and delegated entity;

 

6.1.3.2.            Evaluation of the delegated organization
prior to delegation;

 

6.1.3.3.            An annual evaluation of the delegated entity;

 

6.1.3.4.            Evaluation of regular delegated entity
reports; and

 

6.1.3.5.            Follow-up on issues out of compliance with
delegated agreement or DSHS contract specifications.

 

6.2.          Performance Improvement
Projects:

 

6.2.1.               The Contractor shall have an ongoing program
of performance improvement projects that focus on clinical and non-clinical
areas. The Contractor shall conduct at least five (5) Performance Improvement
Projects (PIPs) of which at least three (3) are clinical and at least two (2) are
non-clinical as described in 42 CFR 438.240 and as specified in the CMS
protocol (See Exhibit A for website link).

 

6.2.2.               The projects must be designed to achieve,
through ongoing measurements and intervention, significant improvement,
sustained over time, in clinical and non-clinical areas that are expected to
have a favorable effect on

 

28

 

health
outcomes and enrollee satisfaction. Annually, through implementation of
performance improvement projects the Contractor shall:

 

6.2.2.1.            Measure performance using objective, quality
indicators.

 

6.2.2.2.            Implement system interventions to achieve
improvement in quality.

 

6.2.2.3.            Evaluate the effectiveness of the
interventions.

 

6.2.2.4.            Plan and initiate activities for increasing
or sustaining improvement.

 

6.2.2.5.            Report the status and results of each project
to DSHS.

 

6.2.2.6.            Complete projects in a reasonable time period
as to allow aggregate information on the success of the projects to produce new
information on the quality of care every year (CFR 42 438.240).

 

6.2.3.               Annually, the Contractor shall submit to DSHS
three (3) clinical and two (2) non-clinical performance improvement projects
which, in the judgment of the Contractor, best meet the requirements of a
performance improvement project. Each project will be documented on a
performance improvement project worksheet found in the Conducting Performance
Improvement Projects (See Exhibit A for website link).

 

6.2.4.               If any of the Contractor’s Health Plan Employer
Data and Information Set (HEDIS®) rates on Well Child Visits in the first 15
months (six (6) or more well child visits measure), Well Child Visits in the 3rd,
4th, 5th and 6th years of life, or Adolescent
Well Care Visits are below 60% in 2006 or 2007, the Contractor shall implement
a clinical PIP designed to increase the rates. The Contractor may, at their
option, count the required project toward meeting the requirement for at least
three (3) clinical PIPs in Section 5.2.1.

 

6.2.5.               If any of the Contractor’s HEDIS® Combination
2, Childhood Immunization rates are below 70% in 2006 or below 75% in 2007, the
Contractor shall implement a performance improvement project designed to
increase the rates. The Contractor may, at their option, count the required
project toward meeting the requirement for at least three (3) clinical PIPs in
Section 5.2.1.

 

6.2.6.               The Contractor shall continue the CAHPS®
non-clinical performance improvement project(s) required in the 2004-2005
Healthy Options/SCHIP contract and communicated by DSHS to the Contractor in
February 2005 unless directed otherwise in writing by DSHS.

 

6.2.7.               In addition to the PIPs required under
Sections 6.2.1 through 6.2.6. and upon request of DSHS, the Contractor shall
participate in a yearly statewide performance measure reporting project,
performance improvement project or research project designed by DSHS. The study
shall be designed to maximize resources and reduce cost to contractors. The
Contractor will receive copies of aggregate data and reports produced from
these projects.

 

29

 

6.3.          Performance Measures using
Health Employer Data and Information Set (HEDIS®):

 

6.3.1.               In accord with Section 12.26, Notices, the
Contractor shall report to DSHS HEDIS® measures using the current HEDIS®
Technical Specifications and official corrections published by NCQA, unless
directed otherwise in writing by DSHS. For the 2006 and 2007 HEDIS® measures
listed below, the Contractor shall use the administrative or hybrid data
collection methods, specified in the current HEDIS® Technical Specifications,
unless directed otherwise by DSHS.

 

6.3.2.               No later than June 15th of each year, HEDIS®
measures shall be submitted electronically to DSHS using the NCQA data
submission tool (DST) or other NCQA-approved method.

 

6.3.3.               The following HEDIS® measures shall be
submitted to DSHS in 2006:

 

6.3.3.1.            Childhood Immunization

 

6.3.3.2.            Chlamydia Screening in Women

 

6.3.3.3.            Prenatal and Postpartum Care

 

6.3.3.4.            Well Child Visits in the First 15 Months of
Life

 

6.3.3.5.            Well Child Visits in the Third, Fourth, Fifth
and Sixth Years of Life

 

6.3.3.6.            Adolescent Well Child Visits

 

6.3.3.7.            Use of Appropriate Medications for People
with Asthma

 

6.3.3.8.            Children and Adolescents’ Access to Primary
Care Practitioners

 

6.3.3.9.            Practitioner Turnover (for Primary Care
Practitioners and OB/GYN and other Prenatal Care Practitioners only)

 

6.3.3.10.          Inpatient Utilization-General Hospital/Acute Care

 

6.3.3.11.          Ambulatory Care

 

6.3.3.12.          Birth and Average Length of Stay, Newborns

 

6.3.4.               The following HEDIS® measures shall be
submitted to DSHS in 2007:

 

6.3.4.1.            Childhood Immunization

 

6.3.4.2.            Chlamydia Screening in Women

 

6.3.4.3.            Prenatal and Postpartum Care

 

6.3.4.4.            Well Child Visits in the First 15 Months of
Life

 

30

 

6.3.4.5.            Well Child Visits in the Third, Fourth, Fifth
and Sixth Years of Life

 

6.3.4.6.            Adolescent Well Child Visits

 

6.3.4.7.            Use of Appropriate Medications for People
with Asthma

 

6.3.4.8.            Comprehensive Diabetes Care

 

6.3.4.9.            Children and Adolescents’ Access to Primary
Care Practitioners

 

6.3.4.10.          Practitioner Turnover (for Primary Care Practitioners and OB/GYN and
other Prenatal Care Practitioners only)

 

6.3.4.11.          Inpatient Utilization-General Hospital/Acute Care

 

6.3.4.12.          Ambulatory Care

 

6.3.4.13.          Birth and Average Length of Stay, Newborns

 

6.3.5.               The Contractor shall submit raw HEDIS® data
for three measures:  Childhood
Immunization, Use of Appropriate Medication for People with Asthma, and
Children and Adolescents’ Access to Primary Care Practitioners, no later than
June 30th of each year. The Contractor shall submit the raw HEDIS®
data to DSHS electronically, according to specifications communicated by DSHS
to the Contractor no later than February of each year.

 

6.3.6.               All measures shall be audited, by a National
CAHPS® Benchmarking Database (NCBD) licensed organization in accord with
methods described in the current HEDIS® Compliance AuditTM Standards, Policies
and Procedures. DSHS will fund and the DSHS designated EQRO will conduct the
audit.

 

6.3.7.               The Contractor shall cooperate with DSHS’
designated EQRO to validate the Contractor’s Health Employer Data and
Information Set (HEDIS®) performance measures and CAHPS® sample frame.

 

6.3.7.1.            If the Contractor does not have NCQA
accreditation for Healthy Options managed care from the National Committee for
Quality Assurance (NCQA), the Contractor shall receive a partial audit.

 

6.3.7.2.            If the Contractor has NCQA accreditation for
Healthy Options managed care or is seeking accreditation with a scheduled NCQA
visit in 2006 or 2007, the Contractor shall receive a full audit.

 

6.3.7.3.            Data collected and the methods employed for
HEDIS® validation may be supplemented by indicators and/or processes published
in the Centers for Medicare and Medicaid (CMS) Validating Performance Measures
protocol identified by the DSHS designated EQRO.

 

31

 

6.3.8.               The Contractor shall provide evidence of trending
of measures to assess performance in quality and safety of clinical care and
quality of non-clinical or service-related care.

 

6.3.9.               The Contractor shall collect and maintain
data on ethnicity, race and language markers as established by DSHS on all enrollees
by January 1, 2007. The Contractor shall record and maintain enrollee
self-identified data as established by the Contractor.

 

6.3.10.             The Contractor shall rotate HEDIS® measures
only with the advance written permission of DSHS. The Contractor may request
permission to rotate measures by making a written request to the DSHS contact
named in the Notices section of this agreement. Childhood Immunization and
well-child measures shall not be rotated.

 

6.4.          Consumer Assessment of
Health Plans Survey (CAHPS®):

 

6.4.1.               In 2006, A DSHS designated EQRO shall conduct
the CAHPS® Children and Children with Chronic Conditions survey based upon 2006
HEDIS® Specifications for Survey Measures.

 

6.4.1.1.            The Contractor shall create the sampling
frame file.

 

6.4.1.1.1.                 The Contractor shall receive file
specifications and instructions specifying the format and other required
information for the sample files from DSHS, or the DSHS designated EQRO, by
November 30, 2005.

 

6.4.1.1.2.                 The Contractor shall submit the eligible
sample frames to the DSHS designated EQRO by January 5, 2006.

 

6.4.1.1.3.                 The Contractor’s eligible sample frame
file(s) will be certified by the DSHS EQRO, a Certified HEDIS® Auditor.

 

6.4.1.1.4.                 The Contractor shall receive written notice
of the sample frame file(s) compliance audit certification from the DSHS
designated EQRO by January 30, 2006.

 

6.4.1.2.            The Contractor will be allowed up to eight
Contractor–determined supplemental questions and DSHS will also be allowed up
to eight supplemental questions. The Contractor will be notified of DSHS
selected eight supplemental questions.

 

6.4.1.2.1.                 The Contractor shall submit the questions to
DSHS for written approval for the amount, content, and survey placement prior
to December 15, 2005.

 

6.4.1.2.2.                 The Contractor shall receive a copy of the
approved DSHS questionnaire for informational purposes by January 30, 2006. DSHS
EQRO shall determine the questionnaire format, questions 

 

32

 

and
question placement, using the most recent HEDIS® version of the Children and
Children with Chronic Conditions questionnaire, plus approved supplemental
and/or custom questions as determined by DSHS.

 

6.4.1.3.            The Contractor shall provide National CAHPS®
Benchmarking Database (NCBD) submission information as determined by DSHS.

 

6.4.1.3.1.                 The Contractor shall submit the information
to the DSHS designated EQRO by April 14, 2006. The DSHS designated EQRO shall
submit the data to the NCBD.

 

6.4.2.               In 2007, the Contractor shall conduct the
CAHPS® of adult Medicaid members enrolled in Healthy Options.

 

6.4.2.1.            The Contractor shall contract with an NCQA
certified HEDIS® survey vendor qualified to administer the CAHPS® survey and
conduct the survey according to NCQA protocol. The Contractor shall submit the
following information to the DSHS designated EQRO:

 

6.4.2.1.1.                 Contractor CAHPS® survey staff member
contact, CAHPS® vendor name and CAHPS® primary vendor contact by January 5,
2007.

 

6.4.2.1.2.                 Timeline for implementation of vendor tasks
by February 15, 2007.

 

6.4.2.2.            The Contractor shall ensure the survey sample
frame consists of all non-Medicare and non-commercial adult plan members (not
just subscribers) 18 (eighteen) years and older with Washington State addresses.
The Contractor shall submit the survey sample frame to DSHS by January 5, 2007.
In administering the CAHPS® the Contractor shall:

 

6.4.2.2.1.                 Be allowed up to eight Contractor-determined
supplemental questions.

 

6.4.2.2.2.                 Allow DSHS up to eight supplemental questions.

 

6.4.2.2.3.                 Be notified of DSHS’ selected eight
supplemental questions on or before November 1, 2005.

 

6.4.2.2.4.                 Submit their questions to DSHS for written
approval prior to December 15, 2006.

 

6.4.2.2.5.                 Submit the eligible sample frame file(s) for
certification by the DSHS designated EQRO, a Certified HEDIS® Auditor by
January 5, 2007.

 

33

 

6.4.2.2.6.                 Receive written notice of the sample frame
file(s) compliance audit certification from the DSHS designated EQRO by January
31, 2007.

 

6.4.2.2.7.                 Receive the approved DSHS questionnaire by
January 31, 2007. DSHS EQRO shall determine the questionnaire format, questions
and question placement, using the most recent HEDIS® version of the Medicaid
adult questionnaire (currently 3.0H), plus approved supplemental and/or custom
questions as determined by DSHS.

 

6.4.2.2.8.                 Conduct the mixed methodology (mail and phone
surveys) for CAHPS® survey administration.

 

6.4.2.2.9.                 Submit the final disposition report by June
1, 2007.

 

6.4.2.2.10.               Submit a copy of the Washington State adult
Medicaid response data set according to 2007 NCQA/CAHPS® standards to the DSHS
designated EQRO by June 1, 2007.

 

6.4.2.3.            The Contractor shall provide NCBD data
submission information as determined by DSHS.

 

6.4.2.3.1.                 The Contractor shall submit the information
to the DSHS designated EQRO by April 14, 2007.

 

6.4.2.3.2.                 The DSHS designated EQRO shall submit the
data to the NCBD.

 

6.4.2.4.            The Contractor is required to include
performance guarantee language in their vendor subcontracts that require a
vendor to achieve at least a 35% response rate.

 

6.4.3.               If a Contractor cannot conduct the required
annual CAHPS® surveys (Children, Children with Chronic Conditions, or Adult)
because of limited total enrollment and/or sample size, the Contractor shall
notify DSHS in writing whether they have a physician or physician group at
substantial financial risk in accord with the physician incentive plan
requirements under Section 8.8.

 

6.5.          External Quality Review:

 

6.5.1.               The Contractor’s quality program shall be
examined using a series of required validation procedures. At DSHS’ sole
option, the examination shall be implemented and conducted by DSHS, its agent,
or an EQRO. The following required activities will be validated:

 

6.5.1.1.            Performance improvement projects;

 

6.5.1.2.            Performance measures, and

 

34

 

6.5.1.3.            A monitoring review of standards established
by DSHS and included in this Contract to comply with 42 CFR 438.204 (g) and a
comprehensive review conducted within the previous 3-year period (42 CFR
438.358(b)(1)(2)(3)).

 

6.5.2.               The following optional activity will be
validated annually:

 

6.5.2.1.            Administration and/or validation of consumer
or provider surveys of quality of care, i.e., the CAHPS® survey.

 

6.5.3.               DSHS reserves the right to include additional
optional activities described in 42 CFR 438.358 if additional funding becomes
available and as mutually negotiated between DSHS and the Contractor. These
additional, optional validation activities may include:

 

6.5.3.1.            Validation of encounter data;

 

6.5.3.2.            Calculation of performance measures in
addition to those reported by the Contractor and validated by DSHS’ EQRO;

 

6.5.3.3.            Conduct of performance improvement projects
in addition to those conducted by the Contractor and validated by DSHS or its
designated EQRO; and

 

6.5.3.4.            Conduct of studies on quality that focus on a
particular aspect of clinical or non-clinical services at a point in time.

 

6.5.4.               The Contractor shall submit to an annual DSHS
TeaMonitor and/or EQRO monitoring review. The monitoring review process uses
standard methods and data collection tools and methods found in the CMS
External Quality Review Protocols and assesses the Contractor’s compliance with
regulatory requirements and standards of the quality outcomes and timeliness
of, and access to, services provided by Medicaid MCOs.

 

6.5.4.1.            The Contractor shall, during an annual
monitoring review of the Contractor’s compliance with contract standards or
upon request by DSHS or its External Quality Review Organization (EQRO)
contractor(s), provide evidence of how external quality review findings, agency
audits and contract monitoring activities, enrollee grievances, HEDIS® and CAHPS®
results are used to identify and correct problems and to improve care and
services to enrollees.

 

6.5.4.2.            The Contractor will provide data requested by
the EQRO for purposes of completing the External Quality Review Report (EQRR). The
EQRR is a detailed technical report that describes the manner in which the data
from all activities described in Sections 6.4.1 through 6.4.3 and conducted in
accord with CFR 42 438.358 were aggregated and analyzed and conclusions drawn
as to the quality, timeliness and access to the care furnished by the MCO.

 

35

 

6.5.4.3.            DSHS will provide a copy of the EQRR to the
Contractor, through print or electronic media and to interested parties such as
participating health care providers, enrollees and potential enrollees of the
Contractor, recipient advocacy groups, and members of the general public. DSHS
must make this information available in alternative formats for persons with
sensory impairments, when requested.

 

6.5.4.4.            If the Contractor has had an accreditation
review or visit by NCQA or another accrediting body, the Contractor shall
provide the complete report from that organization to DSHS. If permitted by the
accrediting body, the Contractor shall allow a state representative to
accompany any accreditation review team during the site visit in an official
observer status. The state representative shall be allowed to share information
with DSHS, Department of Health (DOH), and Health Care Authority (HCA) as
needed to reduce duplicated work for both the Contractor and the state.

 

6.6.          Enrollee Mortality: The Contractor shall maintain a record of
known enrollee deaths, including the enrollee’s name, date of birth, age at
death, location of death, and cause(s) of death. This information shall be
available to DSHS upon request. The Contractor shall assist DSHS in efforts to
evaluate and improve the availability and utility of selected mortality
information for quality improvement purposes.

 

6.7.          Practice Guidelines:  The Contractor shall adopt practice guidelines. The Contractor may
develop or adopt guidelines developed by organizations such as the American
Diabetes Association or the American Lung Association. Practice guidelines
shall meet the following requirements (42 CFR 438.236):

 

6.7.1.               Are based on valid and reliable clinical
evidence or a consensus of health care professionals in the particular field.

 

6.7.2.               Consider the needs of enrollees and support
client and family involvement in care plans;

 

6.7.3.               Are adopted in consultation with contracting
health care professionals;

 

6.7.4.               Are reviewed and updated at least every two
years and as appropriate;

 

6.7.5.               Are disseminated to all affected providers
and, upon request, to DSHS, enrollees and potential enrollees; and

 

6.7.6.               Are the basis for and are consistent with
decisions for utilization management, enrollee education, coverage of services,
and other areas to which the guidelines apply.

 

6.8.          Drug Formulary Review and
Approval: The Contractor
shall submit its drug formulary, for use with enrollees covered under the terms
of this Contract, to DSHS for review and approval by January 31st of
each year of this Contract. The formulary shall be submitted to:

 

36

 

Siri
Childs, Pharm D, Pharmacy Policy Manager (or her successor)

Department
of Social and Health Services

Division of Medical Management

P.O.
Box 45506

Olympia,
WA  98504-5506

 

childsa@dshs.wa.gov

 

7.             SUBCONTRACTS

 

7.1.          Contractor Remains Legally
Responsible: Subcontracts, as
defined herein, may be used by the Contractor for the provision of any service
under this Contract. However, no subcontract shall terminate the Contractor’s
legal responsibility to DSHS for any work performed under this Contract (42 CFR
434.6 (c)).

 

7.2.          Solvency Requirements for
Subcontractors: For any
subcontractor at financial risk, as described in Section 8.8.3. Substantial
Financial Risk, or Section 1.17. Risk, the Contractor shall establish, enforce
and monitor solvency requirements that provide assurance of the subcontractor’s
ability to meet its obligations.

 

7.3.          Provider Nondiscrimination:

 

7.3.1.               The Contractor shall not discriminate, with
respect to participation, reimbursement, or indemnification, against providers
practicing within their licensed scope of practice solely on the basis of the
type of license or certification they hold.

 

7.3.2.               If the Contractor declines to include
individual or groups of providers in its network, it shall give the affected
providers written notice of the reason for its decision.

 

7.3.3.               The Contractor’s provider selection policies
and procedures shall not discriminate against particular providers that serve
high-risk populations or specialize in conditions that require costly treatment
(42CFR 438.214(c)).

 

7.3.4.               Consistent with the Contractors
responsibilities to the enrollees, this Section may not be construed to require
the Contractor to Contract with providers beyond the number necessary to meet
the needs of its enrollees; preclude the Contractor from using different
reimbursement amounts for different specialties or for different providers in
the same specialty; or preclude the Contractor from establishing measures that
are designed to maintain quality of services and control costs.

 

7.4.          Required Provisions: Subcontracts shall be in writing, consistent
with the provisions of 42 CFR 434.6. All subcontracts shall contain the
following provisions:

 

37

 

7.4.1.               Identification of the parties of the
subcontract and their legal basis for operation in the State of Washington.

 

7.4.2.               Procedures and specific criteria for
terminating the subcontract.

 

7.4.3.               Identification of the services to be
performed by the subcontractor and which of those services may be subcontracted
by the subcontractor.

 

7.4.4.               Reimbursement rates and procedures for
services provided under the subcontract.

 

7.4.5.               Release to the Contractor of any information
necessary to perform any of its obligations under this Contract.

 

7.4.6.               Reasonable access to facilities and financial
and medical records for duly authorized representatives of DSHS or DHHS for
audit purposes, and immediate access for Medicaid fraud investigators.

 

7.4.7.               The requirement to completely and accurately
report encounter data to the Contractor. Contractor shall ensure that all
subcontractors required to report encounter data have the capacity to comply
with the Encounter Data Transaction Guide published by DSHS.

 

7.4.8.               The requirement to comply with the Contractor’s
DSHS approved fraud and abuse policies and procedures.

 

7.4.9.               No assignment of the subcontract shall take
effect without the DSHS’ written agreement.

 

7.4.10.             The subcontractor shall comply with the
applicable state and federal rules and regulations as set forth in this Contract,
including the applicable requirements of 42 CFR 438.6(1).

 

7.4.11.             Subcontracts shall set forth and require the
subcontractor to comply with any term or condition of this Contract that is
applicable to the services to be performed under the subcontract.

 

7.4.12.             The Contractor shall provide the following
information regarding the grievance system to all subcontractors (42 CFR
438.414 and 42 CFR 438.10(g)(1)):

 

7.4.12.1.          The toll-free numbers to file oral grievances and appeals.

 

7.4.12.2.          The availability of assistance in filing.

 

7.4.12.3.          The enrollee’s right to request continuation of benefits during an
appeal or fair hearing and, if the Contractor’s action is upheld, the enrollee’s
responsibility to pay for the continued benefits.

 

38

 

7.4.12.4.          The enrollee’s right to file grievances and appeals and their
requirements and timeframes for filing.

 

7.4.12.5.          The enrollee’s right to a fair hearing, how to obtain a hearing, and
representation rules at a hearing.

 

7.5.          Health Care Provider
Subcontracts, including
those for facilities and pharmacy benefit management, shall also contain the
following provisions:

 

7.5.1.               A quality improvement system tailored to the
nature and type of services subcontracted, which affords quality control for
the health care provided, including but not limited to the accessibility of
medically necessary health care, and which provides for a free exchange of
information with the Contractor to assist the Contractor in complying with the
requirements of this Contract.

 

7.5.2.               A statement that primary care and specialty
care provider subcontractors shall cooperate with QI activities.

 

7.5.3.               A means to keep records necessary to
adequately document services provided to enrollees for all delegated activities
including Quality Improvement, Utilization Management, Member Rights and
Responsibilities, and Credentialing and Recredentialing.

 

7.5.3.1.            Delegated activities are documented and
agreed upon between Contractor and subcontractor. The document must include:

 

7.5.3.1.1.                 Assigned responsibilities;

 

7.5.3.1.2.                 Delegated activities;

 

7.5.3.1.3.                 A mechanism for evaluation

 

7.5.3.1.4.                 Corrective action policy and procedure.

 

7.5.4.               Information about enrollees, including their
medical records, shall be kept confidential in a manner consistent with state
and federal laws and regulations.

 

7.5.5.               The subcontractor accepts payment from the
Contractor as payment in full and shall not request payment from DSHS or any
enrollee for covered services performed under the subcontract.

 

7.5.6.               The subcontractor agrees to hold harmless
DSHS and its employees, and all enrollees served under the terms of this
Contract in the event of non-payment by the Contractor. The subcontractor
further agrees to indemnify and hold harmless DSHS and its employees against
all injuries, deaths, losses, damages, claims, suits, liabilities, judgments,
costs and expenses

 

39

 

which
may in any manner accrue against DSHS or its employees through the intentional
misconduct, negligence, or omission of the subcontractor, its agents, officers,
employees or contractors.

 

7.5.7.               If the subcontract includes physician
services, provisions for compliance with the PCP requirements stated in this
Contract.

 

7.5.8.               A ninety (90) day termination notice
provision.

 

7.5.9.               A specific termination provision for
termination with short notice when a provider is excluded from participation in
the Medicaid program.

 

7.5.10.             The subcontractor agrees to comply with the
appointment wait time standards of this Contract. The subcontract must provide
for regular monitoring of timely access and corrective action if the
subcontractor fails to comply with the appointment wait time standards (42 CFR
438.206(c)(1)).

 

7.5.11.             A provision for ongoing monitoring and
periodic formal review that is consistent with industry standards and OIC
regulations. Formal review must be completed no less than once every three
years and must identify deficiencies or areas for improvement and provide for
corrective action (42 CFR 438.230(b)).

 

7.6.          Health Care Provider
Subcontracts Delegating Administrative Functions: 
Subcontracts that delegate administrative functions under the terms of
this Contract shall include the following additional provisions:

 

7.6.1.               For those subcontractors at financial risk,
that the subcontractor shall maintain the Contractor’s solvency requirements
throughout the term of the Contract.

 

7.6.2.               Clear descriptions of any administrative
functions delegated by the Contractor in the subcontract, including but not
limited to utilization/ medical management, claims processing, enrollee
grievances and appeals, and the provision of data or information necessary to
fulfill any of the Contractor’s obligations under this Contract.

 

7.6.3.               How frequently and by what means the
Contractor will monitor compliance with solvency requirements and requirements
related to any administrative function delegated in the subcontract.

 

7.6.4.               Provisions for revoking delegation or
imposing sanctions if the subcontractor’s performance is inadequate.

 

7.6.5.               Whether referrals for enrollees will be
restricted to providers affiliated with the group and, if so, a description of
those restrictions.

 

7.7.          Excluded Providers:

 

40

 

7.7.1.               Pursuant to Section 1128 of the Social
Security Act, the Contractor may not subcontract with an individual
practitioner or provider, or an entity with an officer, director, agent, or
manager, or an individual who owns or has a controlling interest in the entity,
who has been: convicted of crimes as specified in Section 1128 of the Social
Security Act, excluded from participation in the Medicare and Medicaid program,
assessed a civil penalty under the provisions of Section 1128, has a
contractual relationship with an entity convicted of a crime specified in
Section 1128, or is a person described in Section 7.26 of this Contract,
Excluded Persons. The Contractor shall terminate subcontracts of excluded
providers immediately with the Contractor becomes aware of such exclusion or
when the Contractor receives notice from DSHS, whichever is earlier.

 

7.7.2.               In addition, if DSHS terminates a
subcontractor from participation any DSHS program, the Contractor shall exclude
the subcontractor from participation in Healthy Options/SCHIP. The Contractor
shall terminate subcontracts of excluded providers immediately when the
Contractor becomes aware of such exclusion or when the Contractor receives
notice from DSHS, whichever is earlier. Suspension of a subcontractor shall
continue until DSHS notifies the Contractor that the subcontractor is no longer
suspended or the subcontractor is to be terminated (WAC 388-502-0030).

 

7.7.3.               If the Contractor terminates a subcontractor
for cause, the Contractor shall notify DSHS, in writing, as provided in the
Notices Section and explain the circumstances regarding the termination.

 

7.8.          Home Health Providers: If the pending Medicaid home health agency
surety bond requirement (Section 4708(d) of the Balanced Budget Act of 1997)
becomes effective before or during the term of this Contract, beginning on the
effective date of the requirement the Contractor may not subcontract with a
home health agency unless the state has obtained a surety bond from the home
health agency in the amount required by federal law. DSHS will provide a
current list of bonded home health agencies upon request to the Contractor.

 

7.9.          Physician Incentive Plans: Physician incentive plans, as defined
herein, are subject to the conditions set forth in this Section in accord with
federal regulations (42 CFR 438.6(h), 42 CFR 422.208 and 42 CFR 422.210).

 

7.9.1.               Prohibited Payments:  The Contractor shall make no payment to a
physician or physician group, directly or indirectly, under a physician
incentive plan as an inducement to reduce or limit medically necessary services
provided to an individual enrollee.

 

7.9.2.               Disclosure Requirements:  Risk sharing arrangements in subcontracts
with physicians or physician groups are subject to review and approval by DSHS.
The Contractor shall provide the following information about its 

 

41

 

physician
incentive plan, and the physician incentive plans of all its subcontractors in
any tier, to the Department annually upon request:

 

7.9.2.1.            Whether the incentive plan includes referral
services.

 

7.9.2.2.            If the incentive plan includes referral
services:

 

7.9.2.2.1.                 The type of incentive plan (e.g. withhold,
bonus, capitation)

 

7.9.2.2.2.                 For incentive plans involving withholds or
bonuses, the percent that is withheld or paid as a bonus.

 

7.9.2.2.3.                 Proof that stop-loss protection meets the
requirements of Section 8.8.4.1., including the amount and type of stop-loss
protection.

 

7.9.2.2.4.                 The panel size and, if commercial members and
enrollees are pooled, a description of the groups pooled and the risk terms of
each group. Medicaid, Medicare, and commercial members in a physician’s or
physician group’s panel may be pooled provided the terms of risk for the pooled
enrollees and commercial members are comparable, and the incentive payments are
not calculated separately for pooled enrollees. Commercial members include
military and Basic Health members.

 

7.9.3.               Substantial Financial Risk:  A physician, or physician group as defined
herein, is at substantial financial risk when more than 25% of the total
maximum potential payments to the physician or physician group depend on the
use of referral services. When the panel size is fewer than 25,000 members
arrangements that cause substantial financial risk include, but are not limited
to, the following:

 

7.9.3.1.            Withholds greater than 25% of total potential
payments

 

7.9.3.2.            Withholds less than 25% of total potential
payments but the physician or physician group is potentially liable for more
than 25% of total potential payments.

 

7.9.3.3.            Bonuses greater than 33% of total potential
payments, less the bonus.

 

7.9.3.4.            Withholds plus bonuses if the withholds plus
bonuses equal more than 25% of total potential payments.

 

7.9.3.5.            Capitation arrangements if the difference
between the minimum and maximum possible payments is more than 25% of the
maximum possible payments, or the minimum and maximum possible payments are not
clearly explained in the Contract.

 

7.9.4.               Requirements if a Physician or Physician
Group is at Substantial Financial Risk: 
If the Contractor, or any subcontractor (e.g. IPA, PHO), places a

 

42

 

physician
or physician group at substantial financial risk, the Contractor shall assure
that all physicians and physician groups have either aggregate or per member
stop-loss protection for services not directly provided by the physician or
physician group.

 

7.9.4.1.            If aggregate stop-loss protection is
provided, it must cover 90% of the costs of referral services that exceed 25%
of maximum potential payments under the subcontract.

 

7.9.4.2.            If stop-loss protection is based on a
per-member limit, it must cover 90% of the cost of referral services that
exceed the limit as indicated below based on panel size, and whether stop-loss
is provided separately for professional and institutional services or is
combined for the two.

 

7.9.4.2.1.                 1,000 members or fewer, the threshold is
$3,000 for professional services and $10,000 for institutional services, or
$6,000 for combined services.

 

7.9.4.2.2.                 1,001 - 5,000 members, the threshold is
$10,000 for professional services and $40,000 for institutional services, or
$30,000 for combined services.

 

7.9.4.2.3.                 5,001 - 8,000 members, the threshold is
$15,000 for professional services and $60,000 for institutional services, or
$40,000 for combined services.

 

7.9.4.2.4.                 8,001 - 10,000 members, the threshold is
$20,000 for professional services and $100,000 for institutional services, or
$75,000 for combined services.

 

7.9.4.2.5.                 10,001 - 25,000, the threshold is $25,000 for
professional services and $200,000 for institutional services, or $150,000 for
combined services.

 

7.9.4.2.6.                 25,001 members or more, there is no risk
threshold.

 

7.9.4.3.            For a physician or physician group at
substantial financial risk, the Contractor shall periodically conduct surveys
of enrollee satisfaction with the physician or physician group. DSHS shall
require such surveys annually. DSHS may, at its sole option, conduct enrollee
satisfaction surveys that satisfy this requirement and waive the requirement
for the Contractor to conduct such surveys. DSHS shall notify the Contractor in
writing if the requirement is waived. If DSHS does not waive the requirement,
the Contractor shall provide the survey results to DSHS annually upon request. The
surveys shall:

 

7.9.4.3.1.                 Include current enrollees, and enrollees who
have disenrolled within 12 months of the survey for reasons other than loss of

 

43

 

Medicaid eligibility or
moving outside the Contractor’s service area.

 

7.9.4.3.2.                 Be conducted according to commonly accepted
principles of survey design and statistical analysis.

 

7.9.4.3.3.                 Address enrollees satisfaction with the
physician or physician group’s:

 

7.9.4.3.3.1.              Quality of services provided.

 

7.9.4.3.3.2.              Degree of access to services.

 

7.9.5.               Sanctions and Penalties: DSHS or CMS may
impose intermediate sanctions, as described in Section 12.32, Sanctions, of
this Contract, for failure to comply with the rules in this Section.

 

7.10.        Payment to FQHCs/RHCs: The Contractor shall not pay a federally
qualified health center or a rural health clinic less than the Contractor would
pay non-FQHC/RHC providers for the same services (42 USC 1396(m)(2)(A)(ix)).

 

7.11.        Provider Education:  The Contractor will maintain
records of the number and type of providers and support staff participating in
provider education, including evidence of assessment of participant
satisfaction with the training process.

 

The
Contractor shall maintain a system for keeping participating practitioners and
providers informed about:

 

7.11.1.             Covered services for enrollees served under
this Contract;

 

7.11.2.             Coordination of care requirements;

 

7.11.3.             DSHS policies as related to this Contract;

 

7.11.4.             Interpretation of data from the quality
improvement program;

 

7.11.5.             Practice guidelines (see Section 5.9).

 

7.12.        Claims Payment Standards: The Contractor shall meet the timeliness of
payment standards specified for Medicaid fee-for-service in Section
1902(a)(37)(A) of the Social Security Act and specified for health carriers in
WAC 284-43-321. To be compliant with both payment standards the Contractor
shall pay or deny, and shall require subcontractors to pay or deny, 95% of
clean claims within thirty (30) calendar days of receipt, 95% of all claims
within sixty (60) of receipt and 99% of clean claims within ninety (90)
calendar days of receipt. The Contractor and its providers may agree to a
different payment requirement in writing on an individual claim.

 

44

 

7.12.1.             A claim is a bill for services, a line item
of service or all services for one enrollee within a bill.

 

7.12.2.             A clean claim is a claim that can be
processed without obtaining additional information from the provider of the
service or from a third party.

 

7.12.3.             The date of receipt is the date the
Contractor receives the claim from the provider.

 

7.12.4.             The date of payment is the date of the check
or other form of payment.

 

7.13.        FQHC/RHC Report: The Contractor shall provide DSHS with information related to
subcontracted federally-qualified health centers (FQHC) and rural health
clinics (RHC), as required by the DSHS Healthy Options Licensed Health Carrier
Billing Instructions, published by DSHS (See Exhibit A for website link).

 

7.14.        Provider Credentialing:  The
Contractor must have written policies and procedures for credentialing and
recredentialing providers who have signed contracts or participation agreements
with the Contractor.

 

7.14.1.             The Contractor’s medical director or other
designated physician’s shall have direct responsibility and participation in
the credentialing process.

 

7.14.2.             The Contractor shall have a designated
Credentialing Committee to oversee the credentialing process.

 

7.14.3.             Credentialing policies and procedures must
specify at a minimum:

 

7.14.3.1.          Type of providers that are credentialed and recredentialed;

 

7.14.3.2.          Verification sources used to make credentialing decisions, including
any evidence of provider sanctions; and

 

7.14.3.3.          Prohibition against employment or contracting with providers excluded
from participation in Federal health care programs under federal law, the
Contractor’s Medical Director and participating providers.

 

7.14.4.             The Contractor shall have criteria used to
credential and recredential providers shall include:

 

7.14.4.1.          Evidence of a current; valid license to practice

 

7.14.4.2.          A valid DEA or CDS certificate if applicable

 

7.14.4.3.          Evidence of education and training

 

7.14.4.4.          Board certification if applicable

 

7.14.4.5.          Work history

 

45

 

7.14.4.6.          A history of liability claims resulting in settlements or judgments
paid on or on behalf of the provider

 

7.14.5.             The Contractor shall have a process for
making determinations shall include a signed, dated attestation statement from
the provider that addresses:

 

7.14.5.1.          Lack of present illegal drug use;

 

7.14.5.2.          History of loss of license and felony convictions;

 

7.14.5.3.          History of loss or limitation of privileges or disciplinary activity;

 

7.14.5.4.          Current malpractice coverage; and

 

7.14.5.5.          Accuracy and completeness of the application.

 

7.14.6.             The Contractor shall have methods for managing
credentialing files;

 

7.14.7.             The Contractor shall have a process for
delegation of credentialing or recredentialing;

 

7.14.8.             The Contractor shall have provider selection
policies and procedures that are consistent with 42 CFR 438.12, and must not
discriminate against particular providers that serve high-risk populations or
specialize in conditions that require costly treatment, and any other methods
for assuring nondiscrimination;

 

7.14.9.             The Contractor shall have a process for
communicating findings that differ from the provider’s submitted materials,
including:

 

7.14.9.1.          Communication of the providers right to review materials

 

7.14.9.2.          Correct incorrect or erroneous information

 

7.14.9.3.          Be informed of their credentialing status

 

7.14.9.4.          The ability to appeal an adverse determination by the Contractor

 

7.14.10.           The Contractor shall have a process for notifying providers within
sixty (60) days of the credentialing committee’s decision;

 

7.14.11.           The Contractor shall have a process to ensure confidentiality;

 

7.14.12.           The Contractor shall have a process to ensure listing in provider
directories for enrollees are consistent with credentialing file content,
including education, training, certification and specialty designation.

 

46

 

7.14.13.           The Contractor shall have a process for recredentialing providers at
minimum every thirty-six (36) months through information verified from primary
sources, unless otherwise indicated.

 

7.14.14.           The Contractor shall have a process to ensure that offices of all
primary care providers, obstetricians/gynecologists and high volume providers
meet office site standards established by the Contractor.

 

7.14.15.           A system for monitoring sanctions or limitations on licensure,, complaints
and quality issues or information from identified adverse events and provides
evidence of action, as appropriate based on defined methods or criteria.

 

8.             Enrollee Rights and
Protections:

 

8.1.          General Requirements:  The
Contractor shall have written policies and procedures regarding all enrollee
rights (42 CFR 438.100(a)(1)).

 

8.1.1.               The Contractor shall comply with any
applicable Federal and State laws that pertain to enrollee rights and ensure
that its staff and affiliated providers take those rights into account when
furnishing services to enrollees (42 CFR 438.100(a)(2)).

 

8.1.2.               The Contractor shall guarantee each enrollee
the following rights (42 CFR 438.100(b)(2)):

 

8.1.2.1.            To be treated with respect and with
consideration for their dignity and privacy.

 

8.1.2.2.            To receive information on available treatment
options and alternatives, presented in a manner appropriate to the enrollee’s
ability to understand.

 

8.1.2.3.            To participate in decisions regarding their
health care, including the right to refuse treatment.

 

8.1.2.4.            To be free from any form of restraint or
seclusion used as a means of coercion, discipline, convenience, or retaliation.

 

8.1.2.5.            To request and receive a copy of their
medical records, and to request that they be amended or corrected, as specified
in 45 CFR 164.

 

8.1.2.6.            Each enrollee must be free to exercise their
rights, and exercise of those rights must not adversely affect the way the
Contractor or its subcontractors treat the enrollee (42 CFR 438.100(c)).

 

8.2.          Cultural Considerations:  The
Contractor shall participate in and cooperate with DSHS’ efforts to promote the
delivery of services in a culturally competent manner to all enrollees,
including those with limited English proficiency and

 

47

 

diverse
cultural and ethnic backgrounds (42 CFR 438.206(c)(2)).

 

8.3.          Advance Directives:

 

8.3.1.               The Contractor shall maintain written
policies and procedures for advance directives that meet the requirements of
WAC 388-501-0125, 42 CFR 438.6, 42 CFR 438.10, 42 CFR 422.128, and 42 CFR 489
Subpart I. The Contractor’s advance directive policies and procedure shall be
disseminated to all affected providers, enrollees, DSHS, and, upon request,
potential enrollees.

 

8.3.2.               The Contractor’s written policies respecting
the implementation of advance directive rights shall include a clear and
precise statement of limitation if the Contractor cannot implement an advance
directive as a matter of conscience. At a minimum, this statement must do the
following:

 

8.3.3.               Clarify any differences between Contractor
conscientious objections and those that may be raised by individual physicians.

 

8.3.4.               Identify the state legal authority permitting
such objection.

 

8.3.5.               Describe the range of medical conditions or
procedures affected by the conscience objection.

 

8.3.6.               If an enrollee is incapacitated at the time
of initial enrollment and is unable to receive information (due to the
incapacitating condition or a mental disorder) or articulate whether or not he
or she has executed an advance directive, the Contractor may give advance
directive information to the enrollee’s family or surrogate in the same manner
that it issues other materials about policies and procedures to the family of
the incapacitated enrollee or to a surrogate or other concerned persons in
accord with State law. The Contractor is not relieved of its obligation to
provide this information to the enrollee once he or she is no longer
incapacitated or unable to receive such information. Follow-up procedures must
be in place to ensure that the information is given to the individual directly
at the appropriate time.

 

8.3.7.               The Contractor’s policies and procedures must
require, and the Contractor must ensure, that the enrollee’s medical record
documents, in a prominent part, whether or not the individual has executed an
advance directive.

 

8.3.8.               The Contractor shall not condition the
provision of care or otherwise discriminate against an enrollee based on
whether or not the enrollee has executed an advance directive.

 

8.3.9.               The Contractor shall ensure compliance with
requirements of State and Federal law (whether statutory or recognized by the
courts of the State) regarding advance directives.

 

48

 

8.3.10.             The Contractor shall provide for education of
staff concerning its policies and procedures on advance directives.

 

8.3.11.             The Contractor shall provide for community
education regarding advance directives that may include material required herein,
either directly or in concert with other providers or entities. Separate
community education materials may be developed and used, at the discretion of
the Contractor. The same written materials are not required for all settings,
but the material should define what constitutes an advance directive,
emphasizing that an advance directive is designed to enhance an incapacitated
individual’s control over medical treatment, and describe applicable State and
Federal law concerning advance directives. The Contractor shall document its
community education efforts.

 

8.3.12.             The Contractor is not required to provide
care that conflicts with an advance directive; and is not required to implement
an advance directive if, as a matter of conscience, the Contractor cannot
implement an advance directive and State law allows the Contractor or any
subcontractor providing services under this Contract to conscientiously object.

 

8.3.13.             The Contractor shall inform enrollees that
they may file a grievance with the Contractor if the enrollee is dissatisfied
with the Contractor’s advance directive policy and procedure or the Contractor’s
administration of those policies and procedures. The Contractor shall also
inform enrollees that they may file a grievance with DSHS if they believe the
Contractor is non-compliant with advance directive requirements.

 

8.4.          Enrollee Choice of PCP:

 

8.4.1.               The Contractor shall allow, to the extent
possible and appropriate, each new enrollee to choose a participating PCP.

 

8.4.2.               In the case of newborns, the parent shall
choose the newborn’s PCP.

 

8.4.3.               If the enrollee does not make a choice at the
time of enrollment, the Contractor shall assign the enrollee to a PCP or
clinic, within reasonable proximity to the enrollee’s home, no later than fifteen
(15) working days after coverage begins.

 

8.4.4.               The Contractor shall allow an enrollee to
change PCP or clinic at anytime with the change becoming effective no later
than the beginning of the month following the enrollees request for the change
(WAC 388-538-060 and WAC 284-43-251(1)).

 

8.5.          Direct Access for Enrollees
with Special Health Care Needs:  The Contractor shall allow children with
special health care needs who utilize a specialist frequently to retain the
specialist as a PCP, or alternatively, be allowed direct access to specialists
for needed care. The Contractor shall also allow enrollees with special health
care needs as defined in WAC 388-538-050 to retain a

 

49

 

specialist
as a PCP or be allowed direct access to a specialist if the assessment required
under the provisions of this Contract demonstrates a need for a course of
treatment or regular monitoring by such specialist (42 CFR 438.208 and
438.6(m)).

 

8.6.          Prohibition on Enrollee
Charges for Covered Services:
Under no circumstances shall the Contractor, or any providers used to deliver
services covered under the terms of this Contract, charge enrollees for covered
services in excess of the copayments DSHS implements in its fee-for-service
program as referenced in Section 3.11 (SSA 1932(b)(6), SSA 1128B(d)(1)) and WAC
388-502-0160).

 

8.7.          Provider/Enrollee
Communication: The
Contractor may not prohibit, or otherwise restrict, a health care professional
acting within their lawful scope of practice, from advising or advocating on
behalf of an enrollee who is his or her patient, for the following (42 CFR
438.102(a)(1)):

 

8.7.1.               The enrollee’s health status, medical care,
or treatment options, including any alternative treatment that may be self-administered.

 

8.7.2.               Any information the enrollee needs in order
to decide among all relevant treatment options.

 

8.7.3.               The risks, benefits, and consequences of
treatment or non-treatment.

 

8.7.4.               The enrollee’s right to participate in
decisions regarding his or her health care, including the right to refuse
treatment, and to express preferences about future treatment decisions.

 

8.8.          Enrollee Self-Determination: The Contractor shall ensure that all
providers: obtain informed consent prior to treatment from enrollees, or
persons authorized to consent on behalf of an enrollee as described in RCW
7.70.065; comply with the provisions of the Natural Death Act (RCW 70.122) and
state and federal Medicaid rules concerning advance directives (WAC
388-501-0125 and 42 CFR 438.6(m)); and, when appropriate, inform enrollees of
their right to make anatomical gifts (RCW 68.50.540).

 

9.             Utilization Management Program
and Authorization of Services

 

9.1.          Utilization Management Program:

 

9.1.1.               The Contractor shall have and maintain a
Utilization Management Program (UMP) for the services it furnishes its
enrollees.

 

9.1.2.               The Contractor defines its UMP structure and
assigns responsibility to appropriate individuals.

 

9.1.3.               A written description of the UMP that
includes identification of designated physician and behavioral health
practitioner’s and evidence of the physician

 

50

 

and
behavioral health practitioner’s involvement in program development and
implementation The UMP program description shall include:

 

9.1.3.1.            A written description of all UM-related
committee(s);

 

9.1.3.2.            Descriptions of committee responsibilities;

 

9.1.3.3.            Contractor staff and practicing provider
committee participant title(s);

 

9.1.3.4.            Meeting frequency;

 

9.1.3.5.            Maintenance of meeting minutes reflecting
decisions made by each committee, as appropriate.

 

9.1.4.               UMP behavioral health and non-behavioral
health policies and procedures at minimum, shall include the following content:

 

9.1.4.1.            Documentation of use and periodic review of
written clinical decision-making criteria based on clinical evidence, including
policies and procedures for appropriate application of the criteria.

 

9.1.4.2.            Mechanisms for providers and enrollees on how
they can obtain the UM decision-making criteria upon request, including UM
action or denial determination letter template language reflecting same.

 

9.1.4.3.            Mechanisms for assessment of inter-rater
reliability of all clinical professionals and as appropriate, non-clinical
staff responsible for UM decisions.

 

9.1.4.4.            Written job descriptions with qualification
for providers who review denials of care based on medical necessity that
requires education, training or professional experience in medical or clinical
practice and current non-restricted license.

 

9.1.4.5.            To detect both underutilization and over
utilization of services and produce a yearly report which identifies and
reports findings on utilization measures and includes completed or planned
interventions to address under or over-utilization patterns of care.

 

9.1.4.5.1.         Specify the type of personnel responsible for each level of UM
decision-making.

 

9.1.4.5.2.         A physician or behavioral health practitioner or pharmacist as
appropriate reviews any behavioral health denial of care based on medical
necessity.

 

9.1.4.5.3.         Use of board certified consultants to assist in making medical
necessity determinations.

 

51

 

9.1.4.5.4.             Appeals
of adverse determinations evaluated by a health care providers who were not
involved in the initial decision and who have appropriate expertise in the
field of medicine that encompasses the covered person’s condition or disease
(PBOR 284-43-620(4)).

 

9.1.4.6.            Documentation of
timelines for appeals in accord with Section 10.1.11.9.1. and 10.1.11.11.2.

 

9.1.5.               Annually evaluate
and update the UM program.

 

9.1.6.               The Contractor
shall not structure compensation to individuals or entities that conduct
utilization management activities so as to provide incentives for the
individual or entity to deny, limit, or discontinue medically necessary
services to any enrollee.

 

9.1.7.               The Contractor
shall not penalize or threaten a provider or facility with a reduction in
future payment or termination of participating provider or participating
facility status because the provider or facility disputes the Contractor’s
determination with respect to coverage or payment for health care service (PBOR
284-43-210(6)).

 

9.2.          Authorization of Services:  The Contractor shall have in place policies
and procedures for the authorization of services that comply with 42 CFR
438.210, WAC 388-538 and the provisions of this Contract and require
subcontractors with delegated authority for authorization to comply with such
policies and procedures.

 

9.2.1.               The Contractor
shall have in effect mechanisms to ensure consistent application of review
criteria for authorization decisions.

 

9.2.2.               The Contractor
shall consult with the requesting provider when appropriate.

 

9.2.3.               The Contractor
shall require that any decision to deny a service authorization request or to
authorize a service in an amount, duration, or scope that is less than
requested, be made by a health care professional who has appropriate clinical
expertise in treating the enrollee’s condition or disease.

 

9.2.4.               The Contractor
shall notify the requesting provider, and give the enrollee written notice of
any decision by the Contractor to deny a service authorization request, or to
authorize a service in an amount, duration, or scope that is less than
requested.  The notice shall meet the
following requirements, except that the notice to the provider need not be in
writing (42 CFR 438.404):

 

52

 

9.2.4.1.            The notice to the
enrollee shall be in writing and shall meet the requirements of Section 4.7 of
this Contract to ensure ease of understanding.

 

9.2.4.2.            The notice shall
explain the following:

 

9.2.4.2.1.             The
action the Contractor has taken or intends to take.

 

9.2.4.2.2.             The
reasons for the action, in easily understood language.

 

9.2.4.2.3.             The
enrollee’s right to file an appeal.

 

9.2.4.2.4.             The
procedures for exercising the enrollee’s rights.

 

9.2.4.2.5.             The
circumstances under which expedited resolution is available and how to request
it.

 

9.2.4.2.6.             The
enrollee’s right to have benefits continue pending resolution of the appeal,
how to request that benefits be continued, and the circumstances under which
the enrollee may be required to pay for these services.

 

9.2.5.               The Contractor
shall provide for the following timeframes for authorization decisions and
notices:

 

9.2.5.1.            For denial of payment
that may result in payment liability for the enrollee, at the time of any
action affecting the claim.

 

9.2.5.2.            For termination,
suspension, or reduction of previously authorized services, ten (10) calendar
days prior to such termination, suspension, or reduction, except if the
criteria stated in 42 CFR 431.213 and 431.214 are met.  The notice shall be mailed within this ten
(10) calendar day period by a method that certifies receipt and assures
delivery within three (3) calendar days.

 

9.2.5.3.            For standard
authorization decisions, a determination must be made within two business days
of the receipt of necessary information and notification of the decision shall
be made to the attending physician, ordering provider, facility, and enrollee
within two days, (PBOR 284-43-410) but timeframes may not exceed 14 calendar
days following receipt of the request for service, with a possible extension of
up to 14 additional calendar days under the following circumstances (42 CFR
438.210):

 

9.2.5.3.1.                 The
enrollee, or the provider, requests extension; or

 

9.2.5.3.2.                 The
Contractor justifies and documents a need for additional information and how
the extension is in the enrollee’s interest.

 

9.2.5.3.3.                 If
the Contractor extends that timeframe, it shall:

 

53

 

9.2.5.3.3.1.              Give
the enrollee written notice of the reason for the decision to extend the
timeframe and inform the enrollee of the right to file a grievance if he or she
disagrees with that decision; and

 

9.2.5.3.3.2.              Issue
and carry out its determination as expeditiously as the enrollee’s health
condition requires and no later than the date the extension expires.

 

9.2.5.4.            For cases in which a
provider indicates, or the Contractor determines, that following the timeframe
for standard authorization decisions could seriously jeopardize the enrollee’s
life or health or ability to attain, maintain, or regain maximum function, the
Contractor shall make an expedited authorization decision and provide notice as
expeditiously as the enrollee’s health condition requires and no later than
three (3) working days after receipt of the request for service.  The Contractor may extend the three (3)
working days by up to 14 calendar days under the following circumstances:

 

9.2.5.4.1.                 The
enrollee, or the provider, requests extension; or

 

9.2.6.               The Contractor justifies
and documents a need for additional information and how the extension is in the
enrollee’s interest.

 

10.      Grievance System

 

10.1.        General Requirements: 
The Contractor shall have a grievance system which complies with the
requirements of 42 CFR 438 Subpart F and WACs 388-538 and 284-43, insofar as it
is not in conflict with 42 CFR 438 Subpart F. 
The grievance system shall include a grievance process, an appeal
process, and access to the fair hearing process.  NOTE: 
Provider claim disputes initiated by the provider are not subject to
this Section.

 

10.1.1.             The Contractor shall
have policies and procedures addressing the grievance system, which comply with
the requirements of this Contract. DSHS must approve, in writing, all policies
and procedures and related notices to enrollees regarding the grievance
system.  DSHS must also approve in
writing any changes to policies and procedures.

 

10.1.2.             The Contractor shall give enrollees any
assistance necessary in completing forms and other procedural steps for
grievances and appeals (WAC 284-43-615(2)(e)).

 

10.1.3.             The Contractor shall acknowledge receipt of each grievance, either orally or in writing, and appeal, in writing, within five (5) working
days.

 

10.1.4.             The Contractor shall ensure that decision makers
on grievances and appeals were not involved in previous levels of review or
decision-making.

 

54

 

10.1.5.             Decisions regarding grievances and appeals shall be made by health care
professionals with clinical expertise in treating the enrollee’s condition or
disease if any of the following apply:

 

10.1.5.1.          If the enrollee is appealing an action concerning medical necessity.

 

10.1.5.2.          If an enrollee grievance concerns a denial of expedited resolution of an appeal.

 

10.1.5.3.          If the grievance or appeal involves any clinical
issues.

 

10.2.        Grievance Process:  The
following requirements are specific to the grievance process:

 

10.2.1.             Only an enrollee may
file a grievance with the Contractor; a provider may not file a grievance on
behalf of an enrollee.

 

10.2.2.             The Contractor shall accept grievances forwarded by DSHS.

 

10.2.3.             The Contractor shall
cooperate with any representative authorized in writing by the covered enrollee
(WAC 284-43-615).

 

10.2.4.             The Contractor shall
consider all information submitted by the covered person or representative (WAC
284-43-615).

 

10.2.5.             The Contractor shall
investigate and resolve all grievances (WAC 284-43-615).

 

10.2.6.             The Contractor shall
complete the disposition of a grievance and notice to the affected parties
within ninety (90) calendar days of receiving the grievance.

 

10.2.7.             The Contractor may
notify enrollees of the disposition of grievances orally or in writing for
grievances not involving clinical issues. 
Notices of disposition for clinical issues must be in writing.

 

10.2.8.             Enrollees do not have
the right to a fair hearing in regard to the disposition of a grievance.

 

10.3.        Appeal Process:  The
following requirements are specific to the appeal process:

 

10.3.1.             An enrollee, or a
provider acting on behalf of the enrollee and with the enrollee’s written
consent, may appeal a Contractor action.

 

10.3.2.             If DSHS receives a
request to appeal an action of the Contractor, DSHS will forward relevant
information to the Contractor and the Contractor will contact the enrollee.

 

55

 

10.3.3.             For appeals of
standard service authorization decisions, an enrollee must file an appeal,
either orally or in writing, within ninety (90) calendar days of the date on
the Contractor’s notice of action. This also applies to an enrollee’s request
for an expedited appeal.

 

10.3.4.             For appeals for
termination, suspension, or reduction of previously authorized services when
the enrollee requests continuation of such services, an enrollee must file an
appeal within ten (10) calendar days of the date of the Contractor’s mailing of
the notice of action.  If the enrollee is
notified in a timely manner and the enrollee’s request for continuation of
services is not timely, the Contractor is not obligated to continue services
and the timeframes for appeals of standard resolution apply (42 CFR 438.408).

 

10.3.5.             Oral inquiries
seeking to appeal an action shall be treated as appeals and be confirmed in
writing, unless the enrollee or provider requests an expedited resolution.

 

10.3.6.             The appeal process
shall provide the enrollee a reasonable opportunity to present evidence, and
allegations of fact or law, in person as well as in writing.  The Contractor shall inform the enrollee of
the limited time available for this in the case of expedited resolution.

 

10.3.7.             The appeal process
shall provide the enrollee and the enrollee’s representative opportunity,
before and during the appeals process, to examine the enrollee’s case file,
including medical records, and any other documents and records considered
during the appeal process.

 

10.3.8.             The appeal process
shall include as parties to the appeal, the enrollee and the enrollee’s
representative, or the legal representative of the deceased enrollee’s estate.

 

10.3.9.             The Contractor shall
resolve each appeal and provide notice, as expeditiously as the enrollee’s
health condition requires, within the following timeframes:

 

10.3.9.1.          For standard resolution of appeals and for
appeals for termination, suspension, or reduction of previously authorized
services a decision must be made within fourteen (14) days after receipt of the
appeal, unless the Contractor notifies the enrollee that an extension is
necessary to complete the appeal; however the extension cannot delay the
decision beyond thirty (30) days of the request for appeal, without the
informed written consent of the enrollee. 
In all circumstances the appeal determination must not be extended
beyond forty-five (45) calendar days from the day the Contractor receives the
appeal request.

 

10.3.9.2.          For expedited resolution of appeals, including
notice to the affected parties, no longer than three (3) calendar days after
the Contractor receives the appeal.  This
timeframe may not be extended.

 

56

 

10.3.10.           The notice of the
resolution of the appeal shall:

 

10.3.10.1.        Be in writing. 
For notice of an expedited resolution, the Contractor shall also make
reasonable efforts to provide oral notice.

 

10.3.10.2.        Include the reasons for the determination in easily
understood language and the date completed.

 

10.3.10.3.        A written statement of the clinical rationale for the
decision, including how the requesting provider or enrollee may obtain the
Utilization Management clinical review or decision-making criteria.

 

10.3.10.4.        For appeals
not resolved wholly in favor of the enrollee:

 

10.3.10.4.1.             Include
information on the enrollee’s right to request a fair hearing and how to do so.

 

10.3.10.4.2.             Include
information on the enrollee’s right to receive services while the hearing is
pending and how to make the request.

 

10.3.10.4.3.             Inform
the enrollee that the enrollee may be held liable for the amount the Contractor
pays for services received while the hearing is pending, if the hearing
decision upholds the Contractor’s action.

 

10.4.        Expedited Appeal Process:

 

10.4.1.             The Contractor shall
establish and maintain an expedited appeal review process for appeals when the
Contractor determines, for a request from the enrollee, or the provider
indicates, in making the request on the enrollee’s behalf or supporting the
enrollee’s request, that taking the time for a standard resolution could
seriously jeopardize the enrollee’s life or health or ability to attain,
maintain, or regain maximum function.

 

10.4.2.             The Contractor shall
make a decision on the enrollee’s request for expedited appeal and provide
notice, as expeditiously as the enrollee’s health condition requires, within
three (3) calendar days after the Contractor receives the appeal.  The Contractor shall also make reasonable
efforts to provide oral notice.

 

10.4.3.             The Contractor shall
ensure that punitive action is neither taken against a provider who requests an
expedited resolution or supports an enrollee’s appeal.

 

10.4.4.             If the Contractor
denies a request for expedited resolution of an appeal, it shall transfer the
appeal to the timeframe for standard resolution and make reasonable efforts to
give the enrollee prompt oral notice of the denial, and follow up within two
(2) calendar days with a written notice.

 

57

 

10.5.        Fair Hearing:

 

10.5.1.             A provider may not
request a fair hearing on behalf of an enrollee.

 

10.5.2.             If an enrollee does
not agree with the Contractor’s resolution of the appeal, the enrollee may file
a request for a fair hearing within the following time frames (see WAC
388-538-112 for the fair hearing process for enrollees):

 

10.5.2.1.          For fair hearings
regarding a standard service, within ninety (90) calendar days of the date on
the Contractor’s mailing of the notice of the resolution of the appeal.

 

10.5.2.2.          For fair hearings
regarding termination, suspension, or reduction of a previously authorized
service, if the enrollee requests continuation of services, within ten (10)
calendar days of the date on the Contractor’s mailing of the notice of the
resolution of the appeal.  If the
enrollee is notified in a timely manner and the enrollee’s request for
continuation of services is not timely, the Contractor is not obligated to
continue services and the timeframes for fair hearing regarding a standard
service apply.

 

10.5.3.             If the enrollee
requests a fair hearing, the Contractor shall provide to DSHS upon request and
within three (3) working days, all Contractor-held documentation related to the
appeal, including but not limited to, any transcript(s), records, or written
decision(s) from participating providers or delegated entities.

 

10.5.4.             The Contractor is an
independent party and is responsible for its own representation in any fair
hearing, independent review, Board of Appeals and subsequent judicial
proceedings.

 

10.5.5.             The Contractor’s
medical director or designee shall review all cases where a fair hearing is
requested and any related appeals, when medical necessity is an issue.

 

10.5.6.             The enrollee must
exhaust all levels of resolution and appeal within the Contractor’s grievance
system prior to filing a request for a fair hearing with DSHS.

 

10.5.7.             DSHS will notify the
Contractor of fair hearing determinations. The Contractor will be bound by the
fair hearing determination, whether or not the fair hearing determination
upholds the Contractor’s decision.  Implementation of such fair hearing
decision shall not be the basis for disenrollment of the enrollee by the
Contractor.

 

10.5.8.             If the fair hearing
decision is not within the purview of this Contract, then DSHS will be
responsible for the implementation of the fair hearing decision.

 

58

 

10.6.        Independent Review:  After
exhausting both the Contractor’s appeal process and the fair hearing process an
enrollee has a right to independent review in accord with RCW 48.43.535 and WAC
284-43-630.

 

10.7.        Board of Appeals:  An enrollee
who is aggrieved by the final decision of an independent review may appeal the
decision to the DSHS Board of Appeals in accord with WAC ###-##-####
through ###-##-####.  Notice of this
right will be included in the written determination from the Contractor or
Independent Review Organization.

 

10.8.        Continuation of Services:

 

10.8.1.             The Contractor shall
continue the enrollee’s services if all of the following apply:

 

10.8.1.1.          An appeal, fair hearing
or independent review is requested on or before the later of the following:

 

10.8.1.1.1.               Within
ten (10) calendar days of the Contractor mailing the notice of action, which
for actions involving services previously authorized, shall be delivered by a
method that certifies receipt and assures delivery within three (3) calendar
days.

 

10.8.1.1.2.               The
intended effective date of the Contractor’s proposed action.

 

10.8.1.2.          The appeal involves the
termination, suspension, or reduction of a previously authorized course of
treatment.

 

10.8.1.3.          The services were ordered
by an authorized provider.

 

10.8.1.4.          The original period
covered by the original authorization has not expired.

 

10.8.1.5.          The enrollee requests an
extension of services.

 

10.8.2.             If, at the enrollee’s
request, the Contractor continues or reinstates the enrollee’s services while
the appeal, fair hearing, independent review or DSHS Board of Appeals is
pending, the services shall be continued until one of the following occurs:

 

10.8.2.1.          The enrollee withdraws
the appeal, fair hearing or independent review request.

 

10.8.2.2.          Ten (10) calendar days
pass after the Contractor mails the notice of the resolution of the appeal and
the enrollee has not requested a fair hearing (with continuation of services
until the fair hearing decision is reached) within the ten (10) calendar days.

 

59

 

10.8.2.3.          Ten (10) calendar days
pass after DSHS mails the notice of resolution of the fair hearing and the
enrollee has not requested an independent review (with continuation of services
until the independent review decision is reached) within the ten (10) calendar
days.

 

10.8.2.4.          Ten (10) calendar days
pass after the Contractor mails the notice of the resolution of the independent
review and the enrollees has not requested a DSHS Board of Appeals (with
continuation of services until the DSHS Board of Appeals decision is reached)
within ten (10) calendar days.

 

10.8.2.5.          The time period or
service limits of a previously authorized service has been met.

 

10.8.3.             If the final resolution
of the appeal upholds the Contractor’s action, the Contractor may recover the
amount paid for the services provided to the enrollee while the appeal was
pending, to the extent that they were provided solely because of the
requirement for continuation of services.

 

10.9.        Effect of Reversed Resolutions
of Appeals and Fair Hearings:

 

10.9.1.             If the Contractor,
DSHS Office of Administrative Hearings (OAH), independent review organization
(IRO) or DSHS Board of Appeals reverses a decision to deny, limit, or delay
services that were not provided while the appeal was pending, the Contractor
shall authorize or provide the disputed services promptly, and as expeditiously
as the enrollee’s health condition requires.

 

10.9.2.             If the Contractor,
OAH, IRO or DSHS Board of Appeals reverses a decision to deny authorization of
services, and the enrollee received the disputed services while the appeal was
pending, the Contractor shall pay for those services.

 

10.10.      Actions, Grievances, Appeals and Independent Reviews: The
Contractor shall maintain records of all actions, grievances, appeals and
independent reviews of adverse appeal decisions by an independent review
organization.

 

10.10.1.           The records shall
include actions, grievances and appeals handled by delegated entities.

 

10.10.2.           The Contractor shall
provide a report of complete actions, grievances, appeals and independent
reviews to DSHS biannually for the prior six months.

 

10.10.2.1.            The
report for the six months ending March 31st is due no later than
June 1st.

 

10.10.2.2.            The
report for the six months ending September 30th is due no later than
November 1st.

 

60

 

10.10.3.           The Contractor is
responsible for maintenance of records for and reporting of any grievance,
actions and appeals handled by delegated entities.

 

10.10.4.           Delegated actions,
grievances and appeals are to be integrated into the Contractor’s report.

 

10.10.5.           Data shall be reported
in the DSHS and Contractor agreed upon format.

 

10.10.6.           The report medium shall
be specified by DSHS.

 

10.10.7.           Reporting of actions
shall include all denials or limited authorization of a requested service,
including the type or level of service, and the reduction, suspension, or
termination of a previously authorized service but will not include denials of
payment to providers unless the enrollee may be liable for payment.

 

10.10.8.           The Contractor shall
provide information to DSHS regarding denial of payment to providers upon
request.

 

10.10.9.           Reporting of grievances
shall include all expressions of enrollee dissatisfaction not related to an
action.

 

10.10.10.         The records shall
include, at a minimum:

 

10.10.10.1.              Plan
Name

 

10.10.10.2.              Name of
the delegated entity, if any

 

10.10.10.3.              Quarter
of occurrence

 

10.10.10.4.              Name of
Program: HO, SCHIP, or BH+

 

10.10.10.5.              Enrollee
Identifier - Patient Identification Code (PIC)

 

10.10.10.5.1.               Enrollee
Last Name

 

10.10.10.5.2.               Enrollee
First Name

 

10.10.10.5.3.               Enrollee
Middle Initial

 

10.10.10.5.4.               Enrollee
Birthday

 

10.10.10.6.              Provider
Last Name

 

10.10.10.7.              Provider
First Name

 

10.10.10.8.              Provider
Middle Initial

 

61

 

10.10.10.9.              Provider
Category (Optional)

 

10.10.10.10.            Provider
Category Code (Optional)

 

10.10.10.11.            Type/Level:

 

10.10.10.11.1.                  Type
1 Grievance

 

10.10.10.11.2.                  Type
3 Action

 

10.10.10.11.3.                  Type
4 Appeal - First Level

 

10.10.10.11.4.                  Type
5 Appeal - Second Level

 

10.10.10.11.5.                  Type
6 IRO

 

10.10.10.12.            Expedited:
Yes or No

 

10.10.10.13.            Grievance,
Appeal or Requested Service Denied Category

 

10.10.10.14.            Grievance
or Requested Service Denied Category Code

 

10.10.10.15.            Grievance
or Action Reason Type

 

10.10.10.16.            Grievance
or Action Reason Type Code

 

10.10.10.17.            Resolution
of Grievance, Appeal or IRO

 

10.10.10.18.            Date
Received

 

10.10.10.19.            Date of
Resolution

 

10.10.10.20.            Resolution
Code

 

10.10.10.21.            Date
written notification of Action or Grievance, Appeal or IRO outcome sent to
enrollee and provider

 

11.      BENEFITS

 

11.1.        Scope of Services:

 

11.1.1.             The Contractor is
responsible for covering medically necessary services relating to:

 

11.1.1.1.          The prevention,
diagnosis, and treatment of health impairments.

 

11.1.1.2.          The achievement
age-appropriate growth and development.

 

11.1.1.3.          The attainment,
maintenance, or regaining of functional capacity.

 

62

 

11.1.2.             If a specific
procedure or element of a covered service is covered by DSHS under its
fee-for-service program, as described in DSHS’ billing instructions, (See
Exhibit A for website link) the Contractor shall cover the service subject to
the specific exclusions and limitations as described in this Contract.

 

11.1.3.             Except as otherwise
specifically provided in this Contract, the Contractor shall provide covered
services in the amount, duration and scope described in the Medicaid State
Plan.

 

11.1.4.             The amount and
duration of covered services that are medically necessary depends on the
enrollee’s condition.

 

11.1.5.             The Contractor shall
not arbitrarily deny or reduce the amount, duration or scope of required
services solely because of the enrollee’s diagnosis, type of illness or
condition.

 

11.1.6.             Except as
specifically provided in Section 10.18, Authorization of Services, this shall
not be construed to prevent the Contractor from establishing utilization
control measures as it deems necessary to assure that services are
appropriately utilized, provided that utilization control measures do not deny
medically necessary covered services to enrollees.  The Contractor’s utilization control measures
are not required to be the same as those in the Medicaid fee for service
program.

 

11.1.7.             For specific covered
services, this shall also not be construed as requiring the Contractor to cover
the specific items covered by DSHS under its fee-for-service program, but shall
rather be construed to require the Contractor to cover the same scope of
services.

 

11.1.8.             Nothing in this
Contract shall be construed to require or prevent the Contractor from covering
services outside of the scope of services covered under this Contract.

 

11.1.9.             The Contractor may
limit coverage of services to participating providers except as specifically
provided in Section 4, Access and Capacity; Section 11, Benefits, for emergency
services; as necessary to provide medically necessary services as described in
Section 10.1.2. Out of Service Area; and as necessary to coordinate benefits
under the requirements of Section 3.8. Third Party Liability when an enrollee
has other medical coverage.

 

11.1.10.           Within the Service
Areas: Within the Contractor’s service areas, as defined in Section 2.1, the
Contractor shall cover enrollees for all medically necessary services included
in the scope of services covered by this Contract.

 

11.1.11.           Outside the Service
Areas:  For the enrollees still enrolled
with the Contractor who are temporarily outside of the service areas or who
have

 

63

 

moved to a service area not served by the Contractor, the Contractor
shall cover the following services:

 

11.1.11.1.                Emergency
and post-stabilization services.

 

11.1.11.2.                Urgent
care services associated with the presentation of medical signs that require
immediate attention, but are not life threatening.  The Contractor may require pre-authorization
for urgent care services as long as the wait times specified in Section 4.4,
Appointment Standards, are not exceeded.

 

11.1.11.3.                Services
that are neither emergent nor urgent, but are medically necessary and cannot
reasonably wait until enrollee’s return to the service area.  The Contractor is not required to cover
non-symptomatic (i.e. preventive care) out of the service area.  The Contractor may require pre-authorization
for such services as long as the wait times specified in Section 4.4, Appointment
Standards, are not exceeded.

 

11.1.11.4.                The
Contractor’s obligation for services outside the service area is limited to
ninety (90) calendar days beginning with the first of the month following the
month in which the enrollee leaves the service area or changes residence.

 

11.1.11.5.                The
Contractor is not responsible for coverage of any services when an enrollee is
outside the United States of America and its territories and possessions.

 

11.2.        Medical Necessity Determination: The Contractor shall
determine which services are medically necessary, according to utilization
management requirements and the definition of Medically Necessary Services in
this Contract.  The Contractor’s
determination of medical necessity in specific instances shall be final except
as specifically provided in this Contract regarding appeals, fair hearings and
independent review.

 

11.3.        Enrollee Self-Referral:

 

11.3.1.             Enrollees have the
right to self-refer for certain services to local health departments and family
planning clinics paid through separate arrangements with the State of
Washington.

 

11.3.2.             The Contractor is not
responsible for the coverage of the services provided through such separate
arrangements.

 

11.3.3.             The enrollees also
may choose to receive such services from the Contractor.  The Contractor shall assure that enrollees
are informed, whenever appropriate, of all options in such a way as not to
prejudice or direct the enrollee’s choice of where to receive the
services.  If the

 

64

 

Contractor in any manner deprives enrollees of their free choice to
receive services through the Contractor.

 

11.3.4.             If the Contractor
subcontracts with local health departments or family planning clinics as
participating providers or refers enrollees to them to receive services, the
Contractor shall pay the local health department or family planning facility
for services provided to enrollees up to the limits described herein.

 

11.3.5.             The services to which
an enrollee may self-refer are:

 

11.3.5.1.                  Family planning services and sexually-transmitted disease
screening and treatment services provided at family planning facilities, such
as Planned Parenthood.

 

11.3.5.2.                  Immunizations,
sexually-transmitted disease screening and follow-up, immunodeficiency virus
(HIV) screening, tuberculosis screening and follow-up, and family planning
services through the local health department.

 

11.4.        Women’s Health Care Services: The Contractor must provide
female enrollees with direct access to a women’s health specialist within the
Contractors network for covered care necessary to provide women’s routine and
preventive health care services in accord with the provisions of WAC 284-43-250
and 42 CFR 438.206(b)(2).

 

11.5.        Maternity Newborn Length of Stay: The Contractor shall ensure
that hospital delivery maternity care is provided in accord with RCW 48.43.115.

 

11.6.        Continuity of Care:  The
Contract shall ensure the Continuity of Care, as defined herein, for enrollees
in an active course of treatment for a chronic or acute medical condition.  The Contractor shall ensure that medically
necessary care for enrollees is not interrupted (42 CFR 438.208).

 

11.6.1.             For changes in the
Contractor’s provider network or service areas, the Contractor shall comply with
the provisions of Sections 2.1.3.3 and 4.11.2.

 

11.6.2.             If possible and
reasonable, the Contractor shall preserve enrollee provider relationships
through transitions.

 

11.6.3.             Where preservation of
provider relationships is not possible and reasonable, the Contractor shall
provide transition to a provider who will provide equivalent, uninterrupted
care as expeditiously as the enrollee’s medical condition requires.

 

11.6.4.             The Contractor shall
allow new enrollees with the Contractor to fill prescriptions written prior to
enrollment until the first of the following occurs:

 

11.6.4.1.                  The thirtieth
(30th) calendar day after enrollment with the Contractor.

 

65

 

11.6.4.2.                  The enrollee’s
prescription expires.

 

11.6.4.3.                  A participating
provider examines the enrollee to evaluate the continued need for the
prescription.

 

11.7.        Coordination of Care: 
The Contractor shall ensure that health care services are coordinated
for enrollees as follows (42 CFR 438.208):

 

11.7.1.             The Contractor shall
ensure that PCPs are responsible for the provision, coordination, and
supervision of health care to meet the needs of each enrollee, including
initiation and coordination of referrals for medically necessary specialty
care.

 

11.7.2.             The Contractor shall
also provide or shall ensure PCPs provide ongoing coordination of
community-based services required by enrollees, including but not limited to:

 

11.7.2.1.                  First Steps
Maternity Services and Maternity Case Management,

 

11.7.2.2.                  Transportation
services,

 

11.7.2.3.                  Regional Support
Networks for mental health services,

 

11.7.2.4.                  Developmental
Disability services, including the Infant Toddler Early Intervention Program
(ITEIP),

 

11.7.2.5.                  Health
Department services, including Title V services for children with special
health care needs,

 

11.7.2.6.                  Home and
Community Services for older and physically disabled individuals,

 

11.7.2.7.                  Alcohol and
Substance Abuse services

 

11.7.3.             The Contractor shall
provide support services to assist PCPs in providing coordination if it is not
provided directly by the Contractor.

 

11.7.4.             The Contractor shall
ensure that enrollee health information is shared between providers in a manner
that facilitates coordination of care while protecting confidentiality and
enrollee rights.

 

11.7.5.             The Contractor shall
identify or shall ensure that providers identify enrollees with special health
care needs as defined in WAC 388-538-050. 
The Contractor’s obligation for identification of enrollees with special
health care needs is limited to identification in the course of any health care
visit initiated by the enrollee.

 

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11.7.6.             The Contractor shall
ensure that PCPs, in consultation with other appropriate health care professionals,
assess and develop individualized treatment plans for children with special
health care needs and enrollees with special health care needs as defined
herein, which ensure integration of clinical and non-clinical disciplines and
services in the overall plan of care.

 

11.7.6.1.                  Documentation
regarding the assessment and treatment plan shall be in the enrollee’s case
file, including enrollee participation in the development of the treatment
plan.

 

11.7.6.2.                  If the
Contractor requires approval of the treatment plan, approval must be provided
in a timely manner appropriate to the enrollee’s health condition.

 

11.8.        Second Opinions:

 

11.8.1.             The Contractor must
authorize a second opinion regarding the enrollee’s health care from a
qualified health care professional within the Contractor’s network, or
authorize for the enrollee to obtain a second opinion outside the Contractor’s
network, if the Contractor’s network is unable to provide for a qualified
health care professional, at no cost to the enrollee.

 

11.8.2.             This Section shall
not be construed to require the Contractor to cover unlimited second opinions,
nor to require the Contractor to cover any services other than the professional
services of the second opinion provider (42 CFR 438.206(b)(3)).

 

11.9.        Sterilizations and Hysterectomies: The Contractor shall assure
that all sterilizations and hysterectomies performed under this Contract are in
compliance with 42 CFR 441 Subpart F, and that the DSHS Sterilization Consent
Form (DSHS 13-364(x)) or its equivalent is used.

 

11.10.      Experimental and Investigational Services:

 

11.10.1.           If the Contractor
excludes or limits benefits for any services for one or more medical conditions
or illnesses because such services are deemed to be experimental or investigational,
the Contractor shall develop and follow policies and procedures for such
exclusions and limitations.  The policies
and procedures shall identify the persons responsible for such decisions.  The policies and procedures and any criteria
for making decisions shall be made available to DSHS upon request (WAC’s
284-44-043, 284-46-507 and 284-96-015).

 

11.10.2.           In making the
determination, whether a service is experimental and investigational and,
therefore, not a covered service, the Contractor shall consider the following:

 

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11.10.2.1.                Evidence
in peer-reviewed, medical literature, as defined herein, and pre-clinical and
clinical data reported to the National Institute of Health and/or the National
Cancer Institute, concerning the probability of the service maintaining or
significantly improving the enrollee’s length or quality of life, or ability to
function, and whether the benefits of the service or treatment are outweighed
by the risks of death or serious complications.

 

11.10.2.2.                Whether
evidence indicates the service or treatment is likely to be as beneficial as
existing conventional treatment alternatives.

 

11.10.2.3.                Any
relevant, specific aspects of the condition.

 

11.10.2.4.                Whether
the service or treatment is generally used for the condition in the State of
Washington.

 

11.10.2.5.                Whether
the service or treatment is under continuing scientific testing and research.

 

11.10.2.6.                Whether
the service or treatment shows a demonstrable benefit for the condition.

 

11.10.2.7.                Whether
the service or treatment is safe and efficacious.

 

11.10.2.8.                Whether
the service or treatment will result in greater benefits for the condition than
another generally available service.

 

11.10.2.9.                If
approval is required by a regulating agency, such as the Food and Drug
Administration, whether such approval has been given before the date of
service.

 

11.10.3.           Criteria to determine
whether a service is experimental or investigational shall be no more stringent
for Medicaid enrollees than that applied to any other members.

 

11.10.4.           A service or treatment
that is not experimental for one enrollee with a particular medical condition
cannot be determined to be experimental for another enrollee with the same
medical condition and similar health status.

 

11.10.5.           A service or treatment
may not be determined to be experimental and investigational solely because it
is under clinical investigation when there is sufficient evidence in
peer-reviewed medical literature to draw conclusions, and the evidence
indicates the service or treatment will probably be of significant benefit to
enrollees.

 

11.10.6.           An adverse
determination made by the Contractor shall be subject to appeal through the
Contractor’s appeal process, including independent review, through the fair
hearing process and independent review.

 

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11.11.      Enrollee Hospitalized at Enrollment:

 

11.11.1.           If an enrollee is
enrolled in Healthy Options/SCHIP on the day the enrollee was admitted to an
acute care hospital, then the plan the enrollee is enrolled with on the date of
admission shall be responsible for payment of all inpatient facility and
professional services provided from the date of admission until the date the
enrollee is no longer confined to an acute care hospital.

 

11.11.2.           Except as provided in
Section 3.6.4., for newborns born while their mother is hospitalized, the party
responsible for the payment for the mother’s hospitalization shall be
responsible for payment of all inpatient facility and professional services
provided to the newborn from the date of admission until the date the newborn
is no longer confined to an acute care hospital.

 

11.11.3.           For newborns who are
disenrolled retroactive to the date of birth and whose premiums are recouped as
provided herein, DSHS shall be responsible for payment of all inpatient
facility and professional services provided to and associated with the
newborn.  The provisions of 3.6.1. or
3.6.2. shall apply for services provided to and associated with the mother.

 

11.11.4.           If DSHS is responsible
for payment of all inpatient facility and professional services provided to a
mother, DSHS shall not pay the Contractor a Delivery Case Rate under the
provisions of Section 3.2.

 

11.12.      Enrollee Hospitalized at Disenrollment: If an enrollee is in
an acute care hospital at the time of disenrollment and the enrollee was
enrolled with the Contractor on the date of admission, the Contractor shall be
responsible for payment of all covered inpatient facility and professional
services from the date of admission to the date the enrollee is no longer
confined to an acute care hospital.

 

11.13.      General Description of Covered Services:  This Section is a general description of
services covered under this Contract and is not intended to be exhaustive.

 

11.13.1.           Medical services
provided to enrollees who have a diagnosis of alcohol and/or chemical
dependency or mental health diagnosis are covered when those services are
otherwise covered services.

 

11.13.2.           Inpatient Services:
Provided by acute care hospitals (licensed under RCW 70.41), or nursing
facilities (licensed under RCW 18-51) when nursing facility services are not
covered by the Department’s Aging and Disability Services Administration and
the Contractor determines that nursing facility care is more appropriate than
acute hospital care.  Inpatient physical
rehabilitation services are included.

 

11.13.3.           Outpatient Hospital
Services: Provided by acute care hospitals (licensed under RCW 70.41).

 

69

 

11.13.4.           Emergency Services and
Post-stabilization Services:

 

11.13.4.1.                Emergency
Services:  Emergency services are defined
herein.

 

11.13.4.1.1.             The
Contractor will provide all inpatient and outpatient emergency services in
accord with the requirements of 42 CFR 438.114.

 

11.13.4.1.2.             The
Contractor shall cover all emergency services provided by a provider who is
qualified to furnish Medicaid services, without regard to whether the provider
is a participating or non-participating provider.

 

11.13.4.1.3.             Emergency
services shall be provided without requiring prior authorization.

 

11.13.4.1.4.             What
constitutes an emergency medical condition may not be limited on the basis of
lists of diagnoses or symptoms (42 CFR 438.114 (d)(i)).

 

11.13.4.1.5.             The
Contractor shall cover treatment obtained under the following circumstances:

 

11.13.4.1.5.1.              An
enrollee had an emergency medical condition, including cases in which the
absence of immediate medical attention would not have had the outcomes
specified in the definition of an emergency medical condition.

 

11.13.4.1.5.2.              A
participating provider or other Contractor representative instructs the
enrollee to seek emergency services.

 

11.13.4.1.6.             If there
is a disagreement between a hospital and the Contractor concerning whether the
patient is stable enough for discharge or transfer, or whether the medical
benefits of an unstabilized transfer outweigh the risks, the judgment of the
attending physician(s) actually caring for the enrollee at the treating
facility prevails and is binding on the Contractor.

 

11.13.4.2.                Post-stabilization
Services:  Post-stabilization services
are defined herein.

 

11.13.4.2.1.             The
Contractor will provide all inpatient and outpatient post-stabilization services
in accord with the requirements of 42 CFR 438.114 and 42 CFR 422.113(c).

 

11.13.4.2.2.             The
Contractor shall cover all post-stabilization services provided by a provider
who is qualified to furnish Medicaid services, without regard to whether the
provider is a participating or non-participating provider.

 

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11.13.4.2.3.             The
Contractor shall cover post-stabilization services under the following
circumstances:

 

11.13.4.2.3.1.              The
services are pre-approved by a participating provider or other Contractor
representative.

 

11.13.4.2.3.2.              The
services are not pre-approved by a participating provider or other Contractor
representative, but are administered to maintain the enrollee’s stabilized
condition within 1 hour of a request to the Contractor for pre-approval of
further post-stabilization care services.

 

11.13.4.2.3.3.              The
services are not pre-approved by a participating provider or other Contractor
representative, but are administered to maintain, improve, or resolve the
enrollee’s stabilized condition and:

 

11.13.4.2.3.3.1.               The
Contractor does not respond to a request for pre-approval within thirty (30)
minutes (RCW 48.43.093(d));

 

11.13.4.2.3.3.2.               The
Contractor cannot be contacted; or

 

11.13.4.2.3.3.3.               The
Contractor representative and the treating physician cannot reach an agreement
concerning the enrollee’s care and a Contractor physician is not available for
consultation.  In this situation, the
Contractor shall give the treating physician the opportunity to consult with a
Contractor physician and the treating physician may continue with care of the
enrollee until a Contractor physician is reached or one of the criteria in
Section 11.1.6.2.4. is met.

 

11.13.4.2.4.             The
Contractor’s responsibility for post-stabilization services it has not
pre-approved ends when:

 

11.13.4.2.4.1.              A
participating provider with privileges at the treating hospital assumes
responsibility for the enrollee’s care;

 

11.13.4.2.4.2.              A
participating provider assumes responsibility for the enrollee’s care through
transfer;

 

11.13.4.2.4.3.              A
Contractor representative and the treating physician reach an agreement
concerning the enrollee’s care; or

 

11.13.4.2.4.4.              The
enrollee is discharged.

 

71

 

11.13.5.           Ambulatory Surgery
Center: Services provided at ambulatory surgery centers.

 

11.13.6.           Provider Services:
Services provided in an inpatient or outpatient (e.g., office, clinic,
emergency room or home) setting by licensed professionals including, but not
limited to, physicians, physician assistants, advanced registered nurse
practitioners, midwives, podiatrists, audiologists, registered nurses, and
certified dietitians.  Provider Services
include, but are not limited to:

 

11.13.6.1.                Medical
examinations, including wellness exams for adults and EPSDT for children

 

11.13.6.2.                Immunizations

 

11.13.6.3.                Maternity
care

 

11.13.6.4.                Family
planning services provided or referred by a participating provider or
practitioner

 

11.13.6.5.                Performing
and/or reading diagnostic tests

 

11.13.6.6.                Private
duty nursing

 

11.13.6.7.                Surgical
services

 

11.13.6.8.                Services
to correct defects from birth, illness, or trauma, or for mastectomy
reconstruction

 

11.13.6.9.                Anesthesia

 

11.13.6.10.              Administering
pharmaceutical products

 

11.13.6.11.              Fitting
prosthetic and orthotic devices

 

11.13.6.12.              Rehabilitation
services

 

11.13.6.13.              Enrollee
health education

 

11.13.6.14.              Nutritional
counseling for specific conditions such as diabetes, high blood pressure, and
anemia.

 

11.13.7.           Tissue and Organ
Transplants: Heart, kidney, liver, bone marrow, lung, heart-lung, pancreas,
kidney-pancreas, cornea, and peripheral blood stem cell.

 

11.13.8.           Laboratory, Radiology,
and Other Medical Imaging Services: Screening and diagnostic services and
radiation therapy.

 

72

 

11.13.9.           Vision Care: Eye
examinations for visual acuity and refraction once every twenty-four (24)
months for adults and once every twelve (12) months for children under age
twenty-one (21).  These limitations do
not apply to additional services needed for medical conditions.  The Contractor may restrict non-emergent care
to participating providers.  Enrollees
may self-refer to participating providers for these services.

 

11.13.10.         Outpatient Mental Health:

 

11.13.10.1.              Psychiatric
and psychological testing, evaluation and diagnosis:

 

11.13.10.1.1.               Once
every twelve (12) months for adults twenty-one (21) and over

 

11.13.10.1.2.               Unlimited
for children under age twenty-one (21) when identified in an EPSDT visit

 

11.13.10.2.              Unlimited
medication management:

 

11.13.10.2.1.               Provided
by the PCP or by PCP referral

 

11.13.10.2.2.               Provided
in conjunction with mental health treatment covered by the Contractor

 

11.13.10.3.              Twelve
hours per calendar year for treatment for enrollees who do not meet the RSN’s
access standards for receiving treatment.

 

11.13.10.4.              Transition
to the RSN, as appropriate to the enrollee’s condition to assure continuity of
care.

 

11.13.10.5.              The
Contractor may subcontract with RSN’s to provide the outpatient mental health
services that are the responsibility of the Contractor.  Such contracts shall not be written or
construed in a manner that provides less than the services otherwise described
in this Section as the Contractor’s responsibility for outpatient mental health
services.

 

11.13.10.6.              The
DSHS Mental Health Division (MHD) and the Division of Program Support (DPS)
shall each appoint a Mental Health Care Coordinator (MHCC).  The MHCC’s shall be empowered to decide all
Contractor and RSN issues regarding outpatient mental health coverage that
cannot be otherwise resolved between the Contractor and the RSN.  The MHCC’s will also undertake training and
technical assistance activities that further coordination of care between DPS,
MHD, Healthy Options contractors, and RSN’s. 
The Contractor shall cooperate with the activities of the MHCC’s.

 

11.13.11.         Neurodevelopmental
Services, Occupational Therapy, Speech Therapy, and Physical Therapy: Services
for the restoration or maintenance of a

 

73

 

function affected by an enrollee’s illness, disability, condition or
injury, or for the amelioration of the effects of a developmental disability
when provided by a facility that is not a DSHS recognized neurodevelopmental
center.  The Contractor may refer
children to a DSHS recognized neurodevelopmental center for the services as
long as appointment wait time standards and access to care standards of this
Contract are met (See Exhibit A for website link).

 

11.13.12.         Pharmaceutical Products:
Prescription drug products according to a Department approved formulary, which
includes both legend and over-the-counter (OTC) products.  The Contractor’s formulary shall include all
therapeutic classes in DSHS’ fee-for-service drug file and a sufficient variety
of drugs in each therapeutic class to meet enrollees’ medically necessary
health care needs.  The Contractor shall
provide participating pharmacies and participating providers with its formulary
and information about how to request non-formulary drugs.  The Contractor shall have policies and
procedures for the administration of the pharmacy benefit including formulary
exceptions.  The Contractor shall approve
or deny all requests for non-formulary drugs by the business day following the
day of request.  Covered drug products
shall include:

 

11.13.12.1.              Oral,
enteral and parenteral nutritional supplements and supplies, including
prescribed infant formulas;

 

11.13.12.2.              All
Food and Drug Administration (FDA) approved contraceptive drugs, devices, and
supplies; including but not limited to Depo-Provera, Norplant, and OTC
products;

 

11.13.12.3.              Antigens
and allergens; and

 

11.13.12.4.              Therapeutic
vitamins and iron prescribed for prenatal and postnatal care.

 

11.13.13.         Home Health Services:
Home health services through state-licensed agencies.

 

11.13.14.         Durable Medical Equipment
(DME) and Supplies: Including, but not limited to: DME; surgical appliances;
orthopedic appliances and braces; prosthetic and orthotic devices; breast
pumps; incontinence supplies for enrollees over three (3) years of age; and
medical supplies.  Incontinence supplies
shall not include non-disposable diapers unless the enrollee agrees.

 

11.13.15.         Oxygen and Respiratory
Services: Oxygen, and respiratory therapy equipment and supplies.

 

11.13.16.         Hospice Services: When
the enrollee elects hospice care. Includes facility services.

 

74

 

11.13.17.         Blood, Blood Components
and Human Blood Products: Administration of whole blood and blood components as
well as human blood products.  In areas
where there is a charge for blood and/or blood products, the Contractor shall
cover the cost of the blood or blood products.

 

11.13.18.         Treatment for Renal
Failure: Hemodialysis, or other appropriate procedures to treat renal failure,
including equipment needed in the course of treatment.

 

11.13.19.         Ambulance Transportation:
The Contractor shall cover ground and air ambulance transportation for
emergency medical conditions, as defined herein, including, but not limited to,
Basic and Advanced Life Support Services, and other required transportation
costs, such as tolls and fares.  In
addition, the Contractor shall cover ambulance services under two circumstances
for non-emergencies:

 

11.13.19.1.              When
it is necessary to transport an enrollee between facilities to receive a
covered services; and,

 

11.13.19.2.              When
it is necessary to transport an enrollee, who must be carried on a stretcher,
or who may require medical attention en route (RCW 18.73.180) to receive a
covered service.

 

11.13.20.         Smoking Cessation
Services: For pregnant women through sixty (60) calendar days post pregnancy.

 

11.13.21.         Newborn Screenings:  The Contractor shall cover all newborn
screenings required by the Department of Health as of January 1, 2006.

 

11.13.22.         EPSDT:

 

11.13.22.1.              The
Contractor shall meet all requirements under the DSHS EPSDT program policy and
billing instructions (See Exhibit A for website link).

 

11.13.22.2.              The
following services are cover when referred as a result of an EPSDT exam:

 

11.13.22.2.1.               Chiropractic
services;

 

11.13.22.2.2.               Nutritional
counseling; and

 

11.13.22.2.3.               Unlimited
psychiatric and psychological testing evaluation and diagnosis.

 

11.14.      Exclusions:  The
following services and supplies are excluded from coverage under this
agreement.  Unless otherwise required by
this agreement, ancillary services resulting from excluded services are also
excluded.  Complications resulting from
an excluded service are also excluded for a period of one hundred

 

75

 

and eighty (180) calendar days following the occurrence of the excluded
service not counting the date of service, except for complication resulting
from surgery for weight loss or reduction, which are excluded for a period of
three hundred and sixty-five (365) calendar days following the occurrence of
the excluded service not counting the date of service.  Thereafter, complications resulting from an
excluded service are a covered service when they would otherwise be a covered
service under the provisions of this agreement.

 

11.14.1.           Services Covered By
DSHS Fee-For-Service Or Through Other Contracts:

 

11.14.1.1.                School
Medical Services for Special Students as described in the DSHS billing
instructions for School Medical Services.

 

11.14.1.2.                Eyeglass
Frames, Lenses, and Fabrication Services covered under DSHS’ selective contract
for these services, and associated fitting and dispensing services.

 

11.14.1.3.                Voluntary
Termination of Pregnancy.

 

11.14.1.4.                Transportation
Services other than Ambulance: including but not limited to Taxi, cabulance,
voluntary transportation, public transportation and common carriers.

 

11.14.1.5.                Dental
Care, Prostheses, Orthodontics and Oral Surgery, including physical exams
required prior to hospital admissions for oral surgery and anesthesia for
dental care.

 

11.14.1.6.                Hearing
Aid Devices, including fitting, follow-up care and repair.

 

11.14.1.7.                First
Steps Maternity Case Management and Maternity Support Services.

 

11.14.1.8.                Sterilizations
for enrollees under age 21, or those that do not meet other federal
requirements (42 CFR 441 Subpart F) (See Exhibit A for website link).

 

11.14.1.9.                Health
care services provided by a neurodevelopmental center recognized by DSHS.

 

11.14.1.10.              Services
provided by a health department or family planning clinic when a client
self-refers for care.

 

11.14.1.11.              Inpatient
psychiatric professional services.

 

11.14.1.12.              Emergency
mental health services.

 

11.14.1.13.              Pharmaceutical
products prescribed by any provider related to services provided under a
separate Contract with DSHS or related to services not covered by the
Contractor.

 

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11.14.1.14.              Laboratory
services required for medication management of drugs prescribed by community
mental health providers whose services are purchased by the Mental Health
Division.

 

11.14.1.15.              Protease
Inhibitors.

 

11.14.1.16.              Services
ordered as a result of an EPSDT exam that are not otherwise covered services.

 

11.14.1.17.              Surgical
procedures for weight loss or reduction, when approved by DSHS in accord with
WAC 388-531-0200.  The Contractor has no
obligation to cover surgical procedures for weight loss or reduction.

 

11.14.1.18.              Prenatal
Diagnosis Genetic Counseling provided to enrollees to allow enrollees and their
PCPs to make informed decisions regarding current genetic practices and
testing.  Genetic services beyond
Prenatal Diagnosis Genetic Counseling are covered only for pregnant women as
maternity care when medically necessary, see Section 11.1.8.3.

 

11.14.2.           Services Covered By
Other Divisions In The Department Of Social And Health Services:

 

11.14.2.1.                Substance
abuse treatment services covered through the Division of Alcohol and Substance
Abuse (DASA).

 

11.14.2.2.                Community-based
services (e.g. COPES and Personal Care Services) covered through the Aging and
Disability Services Administration.

 

11.14.2.3.                Nursing
facilities covered through the Aging and Disability Services Administration.

 

11.14.2.4.                Mental
health services separately purchased for all Medicaid clients by the Mental
Health Division, including 24-hour crisis intervention, outpatient mental
health treatment services, Club House, respite care, Supported Employment and
inpatient psychiatric services.

 

11.14.2.5.                Health
care services covered through the Division of Developmental Disabilities for
institutionalized clients.

 

11.14.2.6.                Infant
formula for oral feeding provided by the Women, Infants and Children (WIC)
program in the Department of Health. 
Medically necessary nutritional supplements for infants are covered
under the pharmacy benefit.

 

11.14.3.           Services Not Covered by
Either DSHS or the Contractor:

 

11.14.3.1.                Medical
examinations for Social Security Disability.

 

77

 

11.14.3.2.                Services
for which plastic surgery or other services are indicated primarily for
cosmetic reasons.

 

11.14.3.3.                Physical
examinations required for obtaining continuing employment, insurance or
governmental licensing.

 

11.14.3.4.                Sports
physicals.

 

11.14.3.5.                Experimental
and Investigational Treatment or Services, determined in accord with Section
10.16, Experimental and Investigational Services, and services associated with
experimental or investigational treatment or services.

 

11.14.3.6.                Reversal
of voluntary induced sterilization.

 

11.14.3.7.                Personal
Comfort Items, including but not limited to guest trays, television and
telephone charges.

 

11.14.3.8.                Biofeedback
Therapy.

 

11.14.3.9.                Massage
Therapy.

 

11.14.3.10.              Acupuncture.

 

11.14.3.11.              TMJ
for Adults.

 

11.14.3.12.              Diagnosis
and treatment of infertility, impotence, and sexual dysfunction.

 

11.14.3.13.              Orthoptic
(eye training) care for eye conditions.

 

11.14.3.14.              Naturopathy.

 

11.14.3.15.              Tissue
or organ transplants that are not specifically listed as covered.

 

11.14.3.16.              Immunizations
required for international travel purposes only.

 

11.14.3.17.              Court-ordered
services.

 

11.14.3.18.              Any
service provided to an incarcerated enrollee, beginning when a law enforcement
officer takes the enrollee into legal custody and ending when the enrollee is
no longer in legal custody.

 

11.14.3.19.              Any
service, product, or supply paid for by DSHS under its fee-for-service program
only on an exception to policy basis.

 

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11.14.3.20.              Any
other service, product, or supply not covered by DSHS under its fee-for-service
program.

 

11.15.      Coordination of Benefits and Subrogation of Rights of
Third Party Liability:

 

11.15.1.           Coordination
of Benefits:

 

11.15.1.1.                Until
such time as DSHS shall terminate the enrollment of an enrollee who has
comparable coverage as described in Section 2.9.3., the services and benefits
available under this Contract shall be secondary to any other medical coverage.

 

11.15.1.2.                Nothing
in this Section negates any of the Contractor’s responsibilities under this
Contract including, but not limited to, the requirement of Section 10.13.,
Prohibition on Enrollee Charges for Covered Services. The Contractor shall:

 

11.15.1.2.1.                 Not
refuse or reduce services provided under this Contract solely due to the
existence of similar benefits provided under any other health care contracts
(RCW 48.21.200), except in accord with applicable coordination of benefits
rules in WAC 284-51.

 

11.15.1.2.2.                 Attempt
to recover any third-party resources available to enrollees (42 CFR 433 Subpart
D) and shall make all records pertaining to coordination of benefits
collections for enrollees available for audit and review.

 

11.15.1.2.3.                 Pay
claims for prenatal care and preventive pediatric care and then seek
reimbursement from third parties (42 CFR 433.139(b)(3)).

 

11.15.1.2.4.                 Pay
claims for covered services when probable third party liability has not been
established or the third party benefits are not available to pay a claim at the
time it is filed (42 CFR 433.139(c)).

 

11.15.1.2.5.                 Communicate
the requirements of this Section to subcontractors that provide services under
the terms of this Contract, and assure compliance with them.

 

11.15.2.           Subrogation
Rights of Third-Party Liability:

 

11.15.2.1.                Injured
person means an enrollee covered by this Contract who sustains bodily injury.

 

11.15.2.2.                Contractor’s
medical expense means the expense incurred by the Contractor for the care or
treatment of the injury sustained computed in accord with the Contractor’s
fee-for-service schedule.

 

79

 

11.15.2.3.                If
an enrollee requires medical services from the Contractor as a result of an
alleged act or omission by a third-party giving rise to a claim of legal
liability against the third-party, the Contractor shall have the right to
obtain recovery of its cost of providing benefits to the injured person from
the third-party.

 

11.15.2.4.                DSHS
specifically assigns to the Contractor the DSHS’ rights to such third party
payments for medical care provided to an enrollee on behalf of DSHS, which the
enrollee assigned to DSHS as provided in WAC 388-505-0540.

 

11.15.2.5.                DSHS
also assigns to the Contractor its statutory lien under RCW 43.20B.060. The
Contractor shall be subrogated to the DSHS’ rights and remedies under RCW
74.09.180 and RCW 43.20B.040 through RCW 43.20B.070 with respect to medical
benefits provided to enrollees on behalf of DSHS under RCW 74.09.

 

11.15.2.6.                The
Contractor may obtain a signed agreement from the enrollee in which the
enrollee agrees to fully cooperate in effecting collection from persons causing
the injury. The agreement may provide that if an injured party settles a claim
without protecting the Contractor’s interest, the injured party shall be liable
to the Contractor for the full cost of medical services provided by the
Contractor.

 

11.15.2.7.                The
Contractor shall notify DSHS of the name, address, and other identifying
information of any enrollee and the enrollee’s attorney who settles a claim
without protecting the Contractor’s interest in contravention of RCW
43.20B.050.

 

12.       GENERAL TERMS AND CONDITIONS

 

12.1.        Amendment: 
This Contract, or any term or condition, may be modified or extended by
a written amendment signed by both parties. Only personnel authorized to bind
each of the parties may sign an amendment.

 

12.2.        Assignment of this Contract:  The Contractor shall not assign this
Contract, including the rights, benefits and duties hereunder, without
obtaining the express written consent of DSHS. DSHS shall not recognize any
assignment made without such prior written consent. In the event that consent
is given and this Contract is assigned, all terms and conditions of this
Contract shall be binding upon the Contractor’s successors and assignees.

 

12.3.        Access to Facilities and Records:  The Contractor and its subcontractors shall
cooperate with audits performed by duly authorized representatives of the State
of Washington, the federal Department of Health and Human Services, auditors
from the federal Government Accountability Office, federal Office of the
Inspector General and federal Office of Management and Budget. With reasonable
notice, generally thirty (30) calendar days, the Contractor and its
subcontractors shall

 

80

 

provide access to its facilities and the records pertinent to this
Contract to monitor and evaluate performance under this Contract, including,
but not limited to, the quality, cost, use and timeliness of services (42 CFR
434.52), and assessment of the Contractor’s capacity to bear the potential
financial losses (42 CFR 434.58). The Contractor and its subcontractors shall
provide immediate access to facilities and records pertinent to this Contract
for Medicaid fraud investigators.

 

12.4.        Compliance with All Applicable Laws and Regulations:  In the provision of services under this
Contract, the Contractor and its subcontractors shall comply with all
applicable federal, state and local laws and regulations, and all amendments
thereto, that are in effect when the Contract is signed or that come into
effect during the term of this Contract (42 CFR 438.100(d)). This includes, but
is not limited to:

 

12.4.1.             Title
XIX and Title XXI of the Social Security Act;

 

12.4.2.             Title
VI of the Civil Rights Act of 1964;

 

12.4.3.             Title
IX of the Education Amendments of 1972, regarding any education programs and
activities;

 

12.4.4.             The
Age Discrimination Act of 1975;

 

12.4.5.             The
Rehabilitation Act of 1973;

 

12.4.6.             All
federal and state professional and facility licensing and accreditation
requirements/standards that apply to services performed under the terms of this
Contract, including but not limited to:

 

12.4.6.1.              All
applicable standards, orders, or requirements issued under Section 306 of the
Clean Water Act (33 US 1368), Executive Order 11738, and Environmental
Protection Agency (EPA) regulations (40 CFR Part 15), which prohibit the use of
facilities included on the EPA List of Violating Facilities. Any violations
shall be reported to DSHS, DHHS, and the EPA.

 

12.4.6.2.              Any
applicable mandatory standards and policies relating to energy efficiency that
are contained in the State Energy Conservation Plan, issued in compliance with
the Federal Energy Policy and Conservation Act.

 

12.4.6.3.              Those
specified for laboratory services in the Clinical Laboratory Improvement
Amendments (CLIA).

 

12.4.6.4.              Those
specified in Title 18 RCW for professional licensing.

 

12.4.6.5.              Industrial
Insurance – Title 51 RCW.

 

81

 

12.4.6.6.              Reporting
of abuse as required by RCW 26.44.030.

 

12.4.6.7.              Federal
Drug and Alcohol Confidentiality Laws in 42 CFR Part 2.

 

12.4.6.8.              EEO
Provisions

 

12.4.6.9.              Copeland
Anti-Kickback Act.

 

12.4.6.10.            Davis-Bacon
Act.

 

12.4.6.11.            Byrd
Anti-Lobbying Amendment.

 

12.4.6.12.            All
federal and state nondiscrimination laws and regulations.

 

12.4.6.13.            Americans
with Disabilities Act:  The Contractor
shall make reasonable accommodation for enrollees with disabilities, in accord
with the Americans with Disabilities Act, for all covered services and shall
assure physical and communication barriers shall not inhibit enrollees with
disabilities from obtaining covered services.

 

12.4.6.14.            Any
other requirements associated with the receipt of federal funds.

 

12.5.        Complete Contract:  This Contract incorporates Exhibits to this
Contract and the DSHS billing instructions applicable to the Contractor. All
terms and conditions of this Contract are stated in this Contract and its
incorporations. No other agreements, oral or written, are binding.

 

12.6.        Confidentiality:  The Contractor may use Personal Information
and other information gained by reason of this Contract only for the purpose of
this Contract. The Contractor shall not disclose, transfer or sell any such
information to any party, including but not limited to medical records, except
as provided by law or, in the case or Personal Information, with the prior
written consent of the person to whom the Personal Information pertains or
their legal guardian. The Contractor shall maintain and protect the
confidentiality of all Personal Information and other information gained by
reason of this Contract. Upon written request by DSHS, the Contractor shall
either return or destroy and certify destruction of all Personal Information.

 

12.6.1.             The
Contractor and DSHS agree to share information regarding enrollees in a manner
that complies with applicable state and federal law protecting confidentiality
of such information (including but not limited to the Health Insurance
Portability and Accountability Act (HIPAA) of 1996, codified at 42 USC 1320(d)
et.seq. and 45 CFR parts 160, 162, and 164., the HIPAA regulations, 42 CFR 431
Subpart F, RCW 5.60.060(4), and RCW 70.02). The Contractor and the Contractor’s
subcontractors shall fully cooperate with DSHS efforts to implement HIPAA
requirements.

 

12.6.2.             Retained
client data shared by DSHS with the Contractor, due to the confidentiality of
the information, must be maintained throughout the life

 

82

 

cycle of the data, to include any record retention cycle, or archival
period, in a manner that will retain its confidential nature regardless of the
age or media format of the data.

 

12.7.        Contractor Certification Regarding Ethics:  The Contractor certifies that the Contractor
is now, and shall remain, in compliance with Chapter 42.52 RCW, Ethics in
Public Services, throughout the term of this Contract.

 

12.8.        Covenant Against Contingent Fees:  The Contractor promises that no person or
agency has been employed or retained on a contingent fee for the purpose of
seeking or obtaining this Contract. This does not apply to legitimate employees
or an established commercial or selling agency maintained by the Contractor for
the purpose of securing business. In the event of breach of this clause by the
Contractor, DSHS may, at its discretion: 
a) annul the Contract without any liability; or b) deduct from the
Contract price or consideration or otherwise recover the full amount of any
such contingent fee.

 

12.9.        Data Certification Requirements:  Any information and/or data required by this
Contract and submitted to DSHS after April 1, 2005 shall be certified by the
Contractor as follows (42 CFR 438.600 through 42 CFR 438.606):

 

12.9.1.             Source
of certification:  The information and/or
data shall be certified by one of the following:

 

12.9.1.1.              The
Contractor’s Chief Executive Officer

 

12.9.1.2.              The
Contractor’s Chief Financial Officer

 

12.9.1.3.              An
individual who has delegated authority to sign for, and who reports directly
to, the Contractor’s Chief Executive Officer or Chief Financial Officer

 

12.9.2.             Content
of certification: The Contractor’s certification shall attest, based on best
knowledge, information, and belief, to the accuracy, completeness and
truthfulness of the information and/or data.

 

12.9.3.             Timing
of certification: The Contractor shall submit the certification concurrently
with the certified information and/or data.

 

12.9.4.             Data
that must be certified include documents specified by DSHS and include
enrollment information, encounter data and other information contained in
contracts or proposals, as required by DSHS.

 

12.10.      Disputes: 
When a dispute arises over an issue that pertains in any way to this
Contract, the parties agree to the following process to address the dispute:

 

12.10.1.           The
Contractor and DSHS shall attempt to resolve the dispute through informal means
between the Contractor and the Office Chief of the DSHS, Division of Program
Support, Office of Managed Care.

 

83

 

12.10.2.           If
the Contractor is not satisfied with the outcome of the resolution with the
Office Chief, the Contractor may submit the disputed issue, in writing, for
review, within ten (10) working days of the outcome, to:

 

MaryAnne
Lindeblad, Director (or her successor)

Department of
Social and Health Services

Division of
Program Support

P.O. Box 45530

Olympia,
WA  98504-5530

 

The Director
may request additional information from the Office Chief and/or the Contractor.
The Director shall issue a written review decision to the Contractor within
thirty (30) calendar days of receipt of all information relevant to the issue. The
review decision will be provided to the Contractor according to Section 7.       .

 

12.10.3.           When
the Contractor disagrees with the review decision of the Director, the
Contractor may request independent mediation of the dispute. The request for
mediation must be submitted to the Director, in writing, within ten (10)
working days of the contractor’s receipt of the Director’s review decision. The
Contractor and DSHS shall mutually agree on the selection of the independent
mediator and shall bear all costs associated with mediation equally. The
results of mediation shall not be binding on either party.

 

12.10.4.           Both
parties agree to make their best efforts to resolve disputes arising from this
Contract and agree that the dispute resolution process described herein shall
precede any court action. This dispute resolution process is the sole
administrative remedy available under this Contract.

 

12.10.5.           DSHS
Not Guarantor:  The Contractor
acknowledges and certifies that neither DSHS nor the State of Washington are
guarantors of any obligations or debts of the Contractor.

 

12.11.      Excluded Persons:

 

12.11.1.           The
Contractor may not knowingly have a director, officer, partner, or person with
a beneficial ownership of more than 5% of the Contractor’s equity, or have an
employee, consultant or contractor who is significant or material to the
provision of services under this Contract, who has been, or is affiliated with
someone who has been debarred, suspended, or otherwise excluded by any federal
agency (SSA 1932(d)(1)). A list of excluded parties in available on the
following Internet website: www.arnet.gov/epls.

 

12.11.2.           By
entering into this Contract, the Contractor certifies that it does not
knowingly have anyone who is an excluded person, or is affiliated with an
excluded person, as a director, officer, partner, employee, contractor, or
person with a beneficial ownership of more than 5% of its equity. The 

 

84

 

Contractor is required to notify DSHS when circumstances change that
affect such certification.

 

12.11.3.           The
Contractor is not required to consult the excluded parties list, but may
instead rely on certification from directors, officers, partners, employees,
contractors, or persons with beneficial ownership of more than 5% of the
Contractor’s equity, that they are not debarred or excluded from a federal
program.

 

12.12.      Five Percent Equity: The Contractor shall
provide to DSHS, according to Section 7.     ,
Notices, a list of persons with a beneficial ownership of more than 5% of the
Contractor’s equity no later than February 28th of each year of this Contract.

 

12.13.      Force Majeure:  If the Contractor is prevented from
performing any of its obligations hereunder in whole or in part as a result of
a major epidemic, act of God, war, civil disturbance, court order or any other
cause beyond its control, such nonperformance shall not be a ground for
termination for default. Immediately upon the occurrence of any such event, the
Contractor shall commence to use its best efforts to provide, directly or
indirectly, alternative and, to the extent practicable, comparable performance.
Nothing in this Section shall be construed to prevent DSHS from terminating
this Contract for reasons other than for default during the period of events
set forth above, or for default, if such default occurred prior to such event.

 

12.14.      Fraud and Abuse Requirements – Policies and
Procedures:

 

12.14.1.           The
Contractor shall have administrative and management arrangements or procedures,
and a mandatory compliance plan, that are designed to guard against fraud and
abuse (42 CFR 438.608(a)).

 

12.14.2.           The
Contractor’s arrangements or procedures shall include the following (42 CFR
438.608(b)(1)):

 

12.14.2.1.            Written
policies, procedures, and standards of conduct that articulates the Contractor’s
commitment to comply with all applicable federal and state standards.

 

12.14.2.2.            The
designation of a compliance officer and a compliance committee that is
accountable to senior management.

 

12.14.2.3.            Effective
training for the compliance officer and the Contractor’s employees.

 

12.14.2.4.            Effective
lines of communication between the compliance officer and the Contractor’s
staff.

 

12.14.2.5.            Enforcement
of standards through well-publicized disciplinary guidelines.

 

85

 

12.14.2.6.            Provision
for internal monitoring and auditing.

 

12.14.2.7.            Provision
for prompt response to detected offenses, and for development of corrective
action initiatives.

 

12.14.3.           The
Contractor shall submit a written copy of its administrative and management
arrangement or procedures and mandatory compliance plan regarding fraud and
abuse to DSHS for approval, according to Section
7.     , Notices, by March 31st each year of this
Contract. DSHS shall respond with approval or denial with required
modifications within thirty (30) calendar days of receipt. The Contractor shall
have thirty (30) calendar days to resubmit the policies and procedures. If the
administrative and management arrangements or procedures and mandatory
compliance plan regarding fraud and abuse have been approved by DSHS for the
previous year and they are unchanged, the Contractor shall not be required to
resubmit them but instead shall certify in writing to DSHS that they are
unchanged, in accord with Section 7.0, Notices.

 

12.14.4.           The
Contractor may request a copy of the guidelines that DSHS will use in
evaluating the Contractor’s written administrative and management arrangements
or procedures and mandatory compliance plan regarding fraud and abuse, and may
request technical assistance in preparing the written administrative and
management arrangements or procedures and mandatory compliance plan regarding
fraud and abuse, by contacting the DSHS, Office of Managed Care e-mail box at
healthyoptions@dshs.wa.gov.

 

12.15.      Fraud and Abuse Reporting:  The Contractor shall report in writing all
verified cases of fraud and abuse, including fraud and abuse by the Contractor’s
employees and subcontractors, within seven (7) calendar days to DSHS according
to Section 7.4, Notices. The report shall include the following information:

 

12.15.1.           Subject(s)
of complaint by name and either provider/subcontractor type or employee
position.

 

12.15.2.           Source
of complaint by name and provider/subcontractor type or employee position, if
applicable.

 

12.15.3.           Nature
of complaint.

 

12.15.4.           Estimate
of the amount of funds involved.

 

12.15.5.           Legal
and administrative disposition of case.

 

12.16.      Governing Law and Venue:  This Contract shall be governed by the laws
of the State of Washington. In the event of any action brought hereunder, venue
shall be proper only in Thurston County, Washington. By execution of this
Contract,

 

86

 

the Contractor acknowledges the jurisdiction of the courts of the State
of Washington regarding this matter.

 

12.17.      Headings not Controlling:  The headings and the index used herein are
for reference and convenience only, and shall not enter into the interpretation
thereof, or describe the scope or intent of any provisions or sections of this
Contract.

 

12.18.      Health and Safety:  The Contractor shall perform any and all of
its obligations under this Contract in a manner that does not compromise the
health and safety of any DSHS client with whom the Contractor has contact.

 

12.19.      Health Information Systems:  The Contractor shall maintain and shall
require subcontractors to maintain a health information system that complies
with the requirements of 42 CFR 438.242 and provides the information necessary
to meet the Contractor’s obligations under this Contract. The Contractor shall
have in place mechanisms to verify the health information received from
subcontractors. The health information system must:

 

12.19.1.           Collect,
analyze, integrate, and report data. The system must provide information on
areas including but not limited to, utilization, grievance and appeals, and
disenrollments for other than loss of Medicaid eligibility.

 

12.19.2.           Ensure
data received from providers is accurate and complete by:

 

12.19.2.1.            Verifying
the accuracy and timeliness of reported data;

 

12.19.2.2.            Screening
the data for completeness, logic, and consistency; and

 

12.19.2.3.            Collecting
service information on standardized formats to the extent feasible and
appropriate.

 

12.19.3.           The
Contractor shall make all collected data available to DSHS and the Center for
Medicare and Medicaid Services (CMS) upon request.

 

12.20.      Independent Contractor:  The Contractor acknowledges that the Contractor
is an independent Contractor, and certifies that none of its directors,
officers, partners, employees, or agents are officers, employees, or agents of
DSHS or the State of Washington. Neither the Contractor nor any of its
directors, officers, partners, employees, or agents shall hold themselves out
as, or claim to be, an officer, employee, or agent of DSHS or the State of
Washington by reason of this Contract. Neither the Contractor nor any of its
directors, officers, partners, employees, or agents shall claim any rights,
privileges, or benefits that would accrue to a civil service employee under RCW
41.06.

 

12.20.1.           Contractor
shall be responsible for the payment of its internal administrative costs,
including but not limited to federal, state and social security tax
payments.  The Contractor shall indemnify and hold DSHS harmless from all
obligations to pay or withhold federal or state taxes or contributions on

 

87

 

behalf of the Contractor or the Contractor’s employees.

 

12.21.      Information on Outstanding Claims at Termination:  In the event this agreement is terminated,
the Contractor shall provide DSHS, within three hundred and sixty-five (365)
calendar days, all available information reasonably necessary for the
reimbursement of any outstanding claims for services to enrollees (42 CFR
434.6(a)(6)). Information and reimbursement of such claims is subject to the
provisions of Section 3, Payment.

 

12.22.      Insolvency:

 

12.22.1.           If
the Contractor becomes insolvent during the term of this Contract:

 

12.22.1.1.            The
State of Washington and enrollees shall not be in any manner liable for the
debts and obligations of the Contractor;

 

12.22.1.2.            In
accord with Section        , Prohibition on
Enrollee Charges for Covered Services, under no circumstances shall the
Contractor, or any providers used to deliver services covered under the terms
of this Contract, charge enrollees for covered services.

 

12.22.1.3.            The
Contractor shall, in accord with RCW 48.44.055, or RCW 48.46.425, provide for
the continuity of care for enrollees.

 

12.23.      Insurance: 
The Contractor shall at all times comply with the following insurance
requirements:

 

12.23.1.           Commercial
General Liability Insurance (CGL):  The
Contractor shall maintain CGL insurance, including coverage for bodily injury,
property damage, and contractual liability, with the following minimum
limits:  Each Occurrence - $1,000,000;
General Aggregate - $2,000,000. The policy shall include liability arising out
of premises, operations, independent contractors, products-completed
operations, personal injury, advertising injury, and liability assumed under an
insured contract. The State of Washington, DSHS, its elected and appointed
officials, agents, and employees shall be named as additional insureds
expressly for, and limited to, Contractor’s services provided under this
Contract.

 

12.23.2.           Professional
Liability Insurance (PL):  The Contractor
shall maintain Professional Liability Insurance, including coverage for losses
caused by errors and omissions, with the following minimum limits: Each
Occurrence - $1,000,000; General Aggregate - $2,000,000.

 

12.23.3.           Worker’s
Compensation:  The Contractor shall comply with all applicable worker’s
compensation, occupational disease, and occupational health and safety laws and
regulations.  The State of Washington and DSHS shall not be held
responsible as an employer for claims filed by the Contractor or its employees
under such laws and regulations.

 

88

 

12.23.4.           Employees
and Volunteers:  Insurance required of the Contractor under the Contract
shall include coverage for the acts and omissions of the Contractor’s employees
and volunteers.

 

12.23.5.           Subcontractors: 
The Contractor shall ensure that all subcontractors have and maintain insurance
appropriate to the services to be performed. The Contractor shall make
available copies of Certificates of Insurance for subcontractors, to DSHS if
requested.

 

12.23.6.           Separation
of Insureds:  All insurance Commercial General Liability policies shall
contain a “separation of insureds” provision.

 

12.23.7.           Insurers: 
The Contractor shall obtain insurance from insurance companies authorized to do
business within the State of Washington, with a “Best’s Reports” rating of A-,
Class VII or better.  Any exception must be approved by the DSHS. 
Exceptions include placement with a “Surplus Lines” insurer or an insurer with
a rating lower than A-, Class VII.

 

12.23.8.           Evidence
of Coverage:  The Contractor shall submit Certificates of Insurance in
accord with the notices section of this Contract, Section
        , for each coverage required
under this Contract upon execution of this Contract. Each Certificate of
Insurance shall be executed by a duly authorized representative of each
insurer.

 

12.23.9.           Material
Changes:  The Contractor shall give DSHS, in accord with the Notices
Section of this Contract, 45 days advance notice of cancellation or non-renewal
of any insurance in the Certificate of Coverage.  If cancellation is due
to non-payment of premium, the Contractor shall give DSHS 10 days advance
notice of cancellation.

 

12.23.10.         General: 
By requiring insurance, the State of Washington and DSHS do not represent that
the coverage and limits specified will be adequate to protect the
Contractor.  Such coverage and limits shall not be construed to relieve
the Contractor from liability in excess of the required coverage and limits and
shall not limit the Contractor’s liability under the indemnities and
reimbursements granted to the State and DSHS in this Contract.  All
insurance provided in compliance with this Contract shall be primary as to any
other insurance or self-insurance programs afforded to or maintained by the
State.

 

Contractor may
waive the requirements contained in Section
          ,
          ,
           and
         if self-insured.  In the
event the Contractor is self insured, the Contractor must send to DSHS by
January 15, 2006, a signed written document, which certifies that the
contractor is self insured, carries coverage adequate to meet the requirements
of Section 7.28, will treat DSHS as an additional insured, expressly for, and
limited to, the Contractor’s services provided under this Contract, and
provides a point of contact for DSHS.

 

89

 

12.24.      Mutual Indemnification and Hold Harmless:  East party shall be responsible for, and
shall indemnify and hold the other party harmless from, all claims and/or
damages to persons and/or property resulting from its own all negligent acts
and omissions. The Contractor shall indemnify and hold harmless DSHS from any
claims by non-participating providers related to the provision to enrollees of
covered services under this Contract.

 

12.24.1.           The
Contractor waives its immunity under Title 51 RCW to the extent it is required
to indemnify, defend, and hold harmless the State and its agencies, officials,
agents, or employees.

 

12.25.      No Federal or State Endorsement:  Award of this Contract does not indicate
endorsement of the Contractor by CMS, the federal or state government or any
similar entity. No federal funds have been used for lobbying purposes in
connection with this Contract or managed care program.

 

12.26.      Notices:

 

12.26.1.           Whenever
one party is required to give notice to the other under this Contract, it shall
be deemed given if mailed by United States Postal Services, registered or
certified mail, return receipt requested, postage prepaid and addressed as
follows:

 

12.26.2.           In
the case of notice to the Contractor, notice will be sent to the point of
contact submitted to DSHS on the Contractor Intake Form.

 

In the case of
notice to DSHS:

 

Peggy Wilson,
Office Chief (or successor)

Department of
Social and Health Services

Division of
Program Support 

Office of Managed Care

P.O. Box 45530

Olympia,
WA  98504-5530

 

Said notice
shall become effective on the date delivered as evidenced by the return receipt
or the date returned to the sender for non-delivery other than for insufficient
postage. Either party may at any time change its address for notification
purposes by mailing a notice in accord with this Section, stating the change
and setting forth the new address, which shall be effective on the tenth day
following the effective date of such notice unless a later date is specified.

 

12.27.      Order of Precedence:  In the interpretation of this Contract and
incorporated documents, the various terms and conditions shall be construed as
much as possible to be complementary. In the event that such interpretation is
not possible the following order of precedence shall apply:

 

90

 

12.27.1.           Title
XIX of the federal Social Security Act of 1935, as amended, and its
implementing regulations, as well as federal statutes and regulations
concerning the operation of Managed Care Organizations;

 

12.27.2.           State
of Washington statues and regulations concerning the operation of the DSHS
programs participating in this Contract, including but not limited to chapters
388-538 (Managed Care), 388-865 (Mental Health) and 388-805 (DASA) WAC.

 

12.27.3.           State
of Washington statutes and regulations concerning the operation of Health
Maintenance Organizations, Health Care Service Contractors, and Life and
Disability Insurance Carriers;

 

12.27.4.           The
terms and conditions of this Contract;

 

12.27.5.           Exhibits,
if any, as indicated on page one of this Contract;

 

12.27.6.           DSHS
solicitation documents associated with this Contract;

 

12.27.7.           Any
other material incorporated herein by reference.

 

12.28.      Pre-termination:

 

12.28.1.           Dispute
Resolution:  If the Contractor disagrees
with a DSHS decision to terminate this Contract, other than a termination
for convenience, the Contractor will have the right to a dispute resolution as
described in Section           
Disputes.

 

12.28.2.           Pre-termination
Hearing and Procedures:  If the dispute
process is not successful, DSHS shall provide the Contractor a pre-termination
hearing prior to termination of the Contract under 42 CFR 438.708. DSHS shall:

 

12.28.2.1.            Give
the Contractor written notice of the intent to terminate, the reason for
termination, and the time and place of the hearing;

 

12.28.2.2.            Give
the Contractor (after the hearing) written notice of the decision affirming or
reversing the proposed termination of this Contract, and for an affirming
decision the effective date of termination; and

 

12.28.2.3.            For
an affirming decision, given enrollees notice of the termination and
information consistent with 42 CFR 438.10 on their options for receiving
Medicaid services following the effective date of termination.

 

12.29.      Program Information:  At the Contractor’s request, DSHS shall
provide the Contractor with pertinent documents including statutes,
regulations, and current versions of billing instructions and other written documents
which describe DSHS policies and guidelines related to service coverage and
reimbursement (See Exhibit A for website link).

 

91

 

12.30.      Proprietary Rights:  DSHS recognizes that nothing in this Contract
shall give DSHS ownership rights to the systems developed or acquired by the
Contractor during the performance of this Contract. The Contractor recognizes
that nothing in this Contract shall give the Contractor ownership rights to the
systems developed or acquired by DSHS during the performance of this Contract.

 

12.31.      Records Maintenance and Retention:

 

12.31.1.           Maintenance:  The Contractor and its subcontractors shall
maintain financial, medical and other records pertinent to this Contract. All
financial records shall follow generally accepted accounting principles. Medical
records and supporting management systems shall include all pertinent
information related to the medical management of each enrollee. Other records
shall be maintained as necessary to clearly reflect all actions taken by the
Contractor related to this Contract.

 

12.31.2.           Retention:  All records and reports relating to this
Contract shall be retained by the Contractor and its subcontractors for a
minimum of six (6) years after final payment is made under this Contract. However,
when an audit, litigation, or other action involving records is initiated prior
to the end of said period, records shall be maintained for a minimum of six (6)
years following resolution of such action.

 

12.31.3.           Review
of Client Information:  DSHS agrees to
provide the Contractor with copies of written client information, which DSHS
intends to distribute to clients.

 

12.32.      Sanctions:

 

12.32.1.           If
the Contractor fails to meet one or more of its obligations under the terms of
this Contract, DSHS may impose sanctions by withholding up to five percent of
its scheduled payments to the Contractor rather than terminating the Contract.

 

DSHS may withhold payment from the end the cure period until the
default is cured or any resulting dispute is resolved in the Contractor’s
favor.

 

12.32.2.           DSHS
will notify the Contractor in writing of the basis and nature of any sanctions,
and if, applicable, provide a reasonable deadline for curing the cause for the
sanction before imposing sanctions. The Contractor may request a dispute
resolution, as described in Section 7.     , if the
Contractor disagrees with DSHS’ position.

 

12.32.3.           DSHS,
CMS or the Office of the Inspector General (OIG) may impose intermediate
sanctions in accord with 42 CFR 438.700, 42 CFR 438.702, 42 CFR 438.704, 45 CFR
92.36(i)(1), 42 CFR 422.208 and 42 CFR 422.210, against the Contractor for:

 

92

 

12.32.3.1.            Failing
to provide medically necessary services that the Contractor is required to
provide, under law or under this Contract, to an enrollee covered under this
Contract.

 

12.32.3.2.            Imposing
on enrollees premiums or charges that are in excess of the premiums or charges
permitted under law or under this Contract;

 

12.32.3.3.            Acting
to discriminate among enrollees on the basis of their health status or need for
health care services. This includes termination of enrollment or refusal to
reenroll an enrollee, except as permitted under law or under this Contract, or
any practice that would reasonably be expected to discourage enrollment by
enrollees whose medical condition or history indicates probable need for
substantial future medical services;

 

12.32.3.4.            Misrepresenting
or falsifying information that it furnishes to CMS or to the DSHS;

 

12.32.3.5.            Failing
to comply with the requirements for physician incentive plans;

 

12.32.3.6.            Distributing
directly or indirectly through any agent or independent contractor, marketing
materials that have not been approved by DSHS or that contain false or
materially misleading information.

 

12.32.3.7.            Violating
any of the other requirements of Sections 1903(m) or 1932 of the Social
Security Act, and any implementing regulations.

 

12.32.3.8.            Intermediate
sanctions may include:

 

12.32.3.8.1.                 Civil
monetary penalties in the following amounts:

 

12.32.3.8.1.1.              A
maximum of $25,000 for each determination of failure to provide services;
misrepresentation or false statements to enrollees, potential enrollees or
healthcare providers; failure to comply with physician incentive plan
requirements; or marketing violations;

 

12.32.3.8.1.2.              A
maximum of $100,000 for each determination of discrimination; or
misrepresentation or false statements to CMS or DSHS;

 

12.32.3.8.1.3.              A
maximum of $15,000 for each potential enrollee DSHS determines was not enrolled
because of a discriminatory practice subject to the $100,000 overall limit;

 

12.32.3.8.1.4.              A
maximum of $25,000 or double the amount of the charges, whichever is greater,
for charges to enrollees that are not allowed under WMIP. DSHS will deduct from
the penalty the amount charged and return it to the enrollee.

 

93

 

12.32.3.8.2.                 Appointment
of temporary management for the Contractor as provided in 42 CFR 438.706. DSHS
will only impose temporary management if it finds that the Contractor has
repeatedly failed to meet substantive requirements in Sections 1903(m) or 1932
of the Social Security Act. Temporary management will be imposed in accord with
RCW 48.44.033.

 

12.32.3.8.3.                 Suspension
of all new enrollments, including default enrollment, after the effective date
of the sanction. DSHS shall notify current enrollees of the sanctions and that
they may terminate enrollment at any time.

 

12.32.3.8.4.                 Suspension
of payment for enrollees enrolled after the effective date of the sanction and
until CMS or DSHS is satisfied that the reason for imposition of the sanction
no longer exists and is not likely to recur.

 

12.33.      Severability:  The terms and conditions of this Contract are
severable. If any term or condition of this Contract is held invalid by any
court, such invalidity shall not affect the validity of the other terms or
conditions of this Contract.

 

12.34.      Solvency:

 

12.34.1.           The
Contractor shall have a Certificate of Registration as a Health Maintenance
Organization (HMO), Health Care Service Contractor (HCSC) or Life and
Disability Insurance Carrier, from the Washington State Office of the Insurance
Commissioner (OIC). The Contractor shall comply with the solvency provisions of
chapter 48.44 or 48.46 RCW, as amended.

 

12.34.2.           The
Contractor agrees that DSHS may at any time access any information related to
the Contractor’s financial condition, or compliance with OIC requirements, from
OIC and consult with OIC concerning such information.

 

12.35.      State Conflict of Interest Safeguards:  The Contractor shall have conflict of
interest safeguards, at least equal to federal safeguards (41 USC 423).

 

12.36.      Survivability:

 

12.36.1.           The
terms and conditions contained in this Contract that shall survive the
expiration or termination of this Contract include but are not limited to:  Confidentiality, Indemnification and Hold
Harmless, Access to Facilities and Records, and Maintenance of Records.

 

12.36.2.           After
termination of this Contract, the Contractor remains obligated to:

 

12.36.2.1.            Cover
hospitalized enrollees until discharge consistent with Section
     .

 

94

 

12.36.2.2.            Submit
reports required in Section       , Reporting;

 

12.36.2.3.            Provide
access to records required in Section 7.     .

 

12.36.2.4.            Provide
the administrative services associated with covered services (e.g. claims
processing, enrollee appeals) provide to enrollees under the terms of this
Contract.

 

12.37.      Termination for Convenience:  Either party may terminate, upon one-hundred
twenty (120) calendar days advance written notice, performance of work under
this Contract in whole or in part, whenever, for any reason, either party
determines that such termination is in its best interest.

 

12.37.1.           In
the event DSHS terminates this Contract for convenience, the Contractor shall
have the right to assert a claim for the Contractor’s direct termination costs.
Such claim must be:

 

12.37.1.1.            Delivered
to DSHS as provided in Section 7.       ,
Notices;

 

12.37.1.2.            Asserted
within ninety (90) calendar days of termination for convenience, or, in the
event the termination was originally issued under the provisions of Section
      , Termination by DSHS for Default, ninety
(90) calendar days from the date the notice of termination was deemed to have
been issued under this Section. DSHS may extend said ninety (90) calendar days
if the Contractor makes a written request to DSHS and DSHS deems the grounds
for the request to be reasonable. DSHS will evaluate the claim for termination
costs and either pay or deny the claim. DSHS shall notify the Contractor of
DSHS’ decision within sixty (60) calendar days of receipt of the claim.

 

12.37.2.           In
the event the Contractor terminates this Contract for convenience, DSHS shall
have the right to assert a claim for DSHS’ direct termination costs. Such claim
must be:

 

12.37.2.1.            Delivered
to the Contractor as provided in Section
7.        Notices;

 

12.37.2.2.            Asserted
within ninety (90) calendar days of the date of termination for convenience. The
Contractor may extend said ninety (90) calendar days if DSHS makes a written
request to the Contractor and the Contractor deems the grounds for the request
to be reasonable.

 

12.37.2.3.            The
Contractor shall evaluate the claim for termination costs and either pay or
deny the claim. The Contractor shall notify DSHS of the Contractor’s decision
within sixty (60) calendar days of receipt of the claim.

 

95

 

12.37.3.           In
the event the Contractor or DSHS disagrees with the decision entered by the
other party pursuant to this Section, the Contractor or DSHS shall have the
right to a dispute resolution as described in Section
7.       Disputes.

 

12.37.4.           In
no event shall the claim from termination costs exceed the average monthly
amount paid to the Contractor for the twelve (12) months immediately prior to
termination.

 

12.37.5.           In
addition to DSHS’ or Contractor’s direct termination costs, the Contractor or
DSHS shall be liable for administrative costs incurred by the other party in
procuring supplies or services similar to and/or replacing those terminated.

 

12.37.6.           Neither
the Contractor nor DSHS shall be liable for any termination costs if it notifies
the other party of its intent not to renew this Contract at least one hundred
twenty (120) calendar days prior to the renewal date.

 

12.37.7.           In
the event this Contract is terminated for the convenience of either party, the
effective date of termination shall be the last day of the month in which the
one hundred twenty (120) day notification period is satisfied, or the last day
of such later month as may be agreed upon by both parties.

 

12.38.      Termination by the Contractor for Default:  The Contractor may terminate this Contract
whenever DSHS defaults in performance of the Contract and fails to cure the
default within a period of one hundred twenty (120) calendar days (or such
longer period as the Contractor may allow) after receipt from the Contractor of
a written notice specifying the default. For purposes of this section, default
means failure to meet one or more material obligations of this Contract. In the
event it is determined that DSHS was not in default, DSHS may claim damages for
wrongful termination through the dispute resolution provisions of this Contract
or by a court of competent jurisdiction. The procedure for determining damages
shall be as stated in Section       .

 

12.39.      Termination by DSHS for Default:  The Contract Administrator may terminate this
Contract whenever the Contractor shall default in performance of this Contract
and fails to cure the default within a period of one hundred twenty (120)
calendar days (or such longer period as the Contractor may allow) after receipt
from the Contractor of a written notice specifying the default. For purposes of
this section, default means failure to meet one or more material obligations of
this Contract. In the event it is determined that DSHS was not in default, DSHS
may claim damages for wrongful termination through the dispute resolution
provisions of this Contract or by a court of competent jurisdiction. The
procedure for determining damages shall be as stated in Section
      .

 

12.40.      Termination for Reduction in Funding: In
the event funding from state, federal, or other sources is withdrawn, reduced
or limited in any way after the effective date of this Contract and prior to
the termination date, DSHS may terminate this Contract under the “Termination
for Convenience” clause.

 

96

 

12.41.      Terminations - Pre-termination Processes:

 

12.41.1.           DSHS
shall give the Contractor written notice of the intent to terminate this
Contract and the reason for termination.

 

12.41.2.           If
the Contractor disagrees with a DSHS decision to terminate this Contract, other
than a termination for convenience, the Contractor will have the right to a
dispute resolution as described in Section       ,
Disputes.

 

12.41.3.           If
the dispute resolution process is not successful, DSHS shall provide the
Contractor a pre-termination hearing prior to termination of the Contract under
42 CFR 438.708. DSHS shall notify the Contractor in writing of the time and
place of the hearing;

 

12.41.4.           Within
thirty (30) calendar days after the hearing DSHS shall give the Contractor
written notification of the decision affirming or reversing the proposed
termination of the Contract, and if the termination is upheld, provide the
effective date of termination.

 

12.41.5.           If
the termination is upheld, DSHS shall give enrollees notice of the termination
and information consistent with 42 CFR 438.10 on their options for receiving
Medicaid services following the effective date of termination.

 

12.41.6.           Pre-termination
Dispute Resolution:  If the Contractor
disagrees with a DSHS decision to terminate this Contract, other than a
termination for convenience, the Contractor will have the right to a dispute
resolution as described in Section         Disputes.

 

12.41.7.           Pre-termination
Hearing and Procedures:  If the dispute
process is not successful, DSHS shall provide the Contractor a pre-termination
hearing prior to termination of the Contract under 42 CFR 438.708. DSHS shall:

 

12.41.7.1.            Give
the Contractor written notice of the intent to terminate, the reason for
termination, and the time and place of the hearing;

 

12.41.7.2.            Give
the Contractor (after the hearing) written notice of the decision affirming or
reversing the proposed termination of this Contract, and for an affirming
decision the effective date of termination; and

 

12.41.7.3.            For
an affirming decision, give enrollees notice of the termination and information
consistent with 42 CFR 438.10 on their options for receiving Medicaid services
following the effective date of termination.

 

12.42.      Washington Public Disclosure Act:  The Contractor acknowledges that DSHS is
subject to the Public Records Act (the Act, which is codified at RCW 42.17.250,
et seq.) This Contract will be a ‘public record’ as defined in RCW
42.17.020.  Any documents submitted to DSHS by the Contractor may also be
construed as ‘public records’ and therefore subject to public disclosure under
the Act.  The Contractor may label documents submitted to DSHS as ‘confidential’
or

 

97

 

‘proprietary’ if it so chooses; however, the Contractor acknowledges
that such labels are not determinative of whether the documents are subject to
disclosure under the Act.  If DSHS receives a public disclosure request
that would encompass any Contractor document that has been labeled by the
Contractor as ‘confidential’ or ‘proprietary’, then DSHS will notify the
Contractor pursuant to RCW 42.17.330.  The Contractor then will have the
option, under RCW 42.17.330, of seeking judicial intervention to prevent the public
disclosure of the affected document(s).

 

12.43.      Waiver: 
The failure of either party to enforce any provision of this Contract
shall not constitute a waiver of that or any other provision, and will not be
construed to be a modification of the terms and conditions of the Contract
unless incorporated into the Contract by an amendment.

 

98

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