Document:

Filed by Automated Filing Services Inc. (604) 609-0244 - Skyflyer Inc. - Exhibit 10.1

LOAN AGREEMENT

THIS AGREEMENT dated as of the 17th day of October,
2007.

BETWEEN:

SKYFLYER INC., of 

  #205 - 1480 Gulf Road

  Point Roberts, WA 98281

(hereinafter called the "Borrower")

OF THE FIRST PART

AND:

BLACK POINTE HOLDINGS INC.
  of 

  Richmond House, P.O.Box 127, 

  Leeward Highway, Providenciales, 

  Turks and Caicos Islands, BWI

(hereinafter called the "Lender")

OF THE SECOND PART

WHEREAS:

A.             The
Borrower has requested that the Lender lend $280,000 (U.S.) to the Borrower;

B.             The
Lender has agreed to lend such sum to the Borrower subject to the terms and upon
the conditions hereinafter set forth.

NOW THEREFORE THIS AGREEMENT WITNESSES THAT in consideration
  of the sum of $1.00 paid by each party to the other (the receipt of which is
  hereby acknowledged) the parties hereto mutually covenant and agree as follows:

1.            INTERPRETATION

1.1            Definitions.
Where used herein or in any amendment hereto each of the following words and
phrases shall have the meanings set forth as follows:

	 	(a) 	
      "Agreement" means this Loan Agreement including the
      Schedules hereto together with any amendments hereof;

	 	 	 
	 	(b) 	
      "Closing Date" means October 17,
2007;

2

	 	(c) 	
      "Event of Default" means any event set forth in paragraph
      6.1;

	 	 	 
	 	(d) 	
      "Loan" means the loan of $280,000 (U.S.) of which,
      $30,000 has been advanced to date, to be made by the Lender to the
      Borrower in accordance with this Agreement;

	 	 	 
	 	(e) 	
      “Maturity” means April 30, 2009; and

	 	 	 
	 	(f) 	
      "Principal Sum" means the sum of $280,000
  (U.S.).

1.2             Number
and Gender. Wherever the singular or the masculine are used herein the same
shall be deemed to include the plural or the feminine or the body politic or
corporate where the context or the parties so require.

1.3             Headings.
The headings to the articles, paragraphs, subparagraphs or clauses of this
Agreement are inserted for convenience only and shall not affect the
construction hereof.

1.4             References.
Unless otherwise stated a reference herein to a numbered or lettered article,
paragraph, subparagraph or clause refers to the article, paragraph, subparagraph
or clause bearing that number or letter in this Agreement. A reference to this
Agreement or herein means this Loan Agreement, including the Schedule hereto,
together with any amendments thereof.

1.5             Currency.
  All dollar amounts expressed herein refer to lawful currency of The United States
  of America.

2.            TERMS
  OF LOAN

2.1             Loan
and Repayment. The Lender hereby agrees to lend to the Borrower the
Principal Sum of $280,000 (U.S.). The Loan shall be made in United States
currency and shall be repaid by the Borrower on or before April 30, 2009.

2.2             Interest.
The Borrower shall pay on the amount of the Principal Sum, interest at a rate of
8% per annum, payable on Maturity. The Borrower shall pay interest at the
aforesaid rate on all overdue interest.

2.3             Advances.
The Principal Sum shall be advanced by the lender as follows:

		a. 	
      $30,000 previously advanced to the Borrower, the receipt
      of which is acknowledged;

	 	 	 
		b. 	
      $170,500 on execution of this Agreement; and

	 	 	 
		c. 	
      the balance of $79,500 on or before October 31,
    2007.

2.4             Pre-Payment.
The Borrower may pre-pay all or any portion of the loan at any time.

3

3.            PROMISSORY
  NOTES, EXTENSIONS & WAIVER

3.1             Loan.
To evidence the Loan, the Borrower agrees to enter into promissory notes in the
forms attached hereto as Schedule “A”.

3.2             Extensions.
The Lender may grant extensions as the Lender may see fit without prejudice to
the liability of the Borrower or to the Lender's rights under this Agreement or
under the Promissory Notes.

3.3             Waiver.
  The Lender may waive any breach by the Borrower of this Agreement or of any
  default by the Borrower in the observance or performance of any covenant or
  condition required to be observed or performed by the Borrower hereunder or
  under the Promissory Notes. No failure or delay on the part of the Lender to
  exercise any right, power or remedy given herein or by statute or at law or
  in equity or otherwise shall operate as a waiver thereof, nor shall any single
  or partial exercise of any right preclude any other exercise thereof or the
  exercise of any other right, power or remedy, nor shall any waiver by the Lender
  be deemed to be a waiver of any subsequent similar or other event.

4.            REPRESENTATIONS
  AND WARRANTIES

4.1             Representations.
The Borrower represents and warrants to the Lender, and acknowledges that the
Lender is relying upon such representations and warranties in entering into this
Agreement, as follows:

(a) the Borrower has the capacity to
enter into this Agreement, and the execution of this Agreement and the
completion of the transactions contemplated hereby shall not be in violation any
agreement to which the Borrower is a party; and

(b) the Promissory Notes have been duly
executed by the Borrower and are enforceable against the Borrower in accordance
with their terms.

5.            CLOSING
  ARRANGEMENTS

5.1             Conditions
  Precedent. The Lender's obligation to advance the Principal Sum to the Borrower
  shall be subject to the satisfaction of the following conditions:

	 	(a) 	
      the representations and warranties of the Borrower shall
      be true as of the date hereof and as of the Closing Date; and

	 	 	 
	 	(b) 	
      the Borrower shall have complied with all of its
      obligations hereunder; and

The foregoing conditions precedent are inserted for the benefit
of the Lender and may be waived in whole or in part by the Lender at any time
prior to closing by delivering to the Borrower written notice to that
effect.

5.2             Time
of Closing. The closing of the Loan shall take place on execution of this
Loan Agreement.

4

5.3             Deliveries
by the Lender. On the Closing Date the Lender shall deliver or cause to be
delivered to the Borrower a certified check, bank draft or wire transfer for the
Principal Sum.

	6. 	
      EVENTS OF DEFAULT AND
  REMEDIES

6.1             Events
of Default. Any one or more of the following events, whether or not any such
event shall be voluntary or involuntary or be effected by operation of law or
pursuant to or in compliance with any judgment, decree or order of any court or
any order, rule or regulation of any administrative or governmental body, shall
constitute an Event of Default:

(a) if the Borrower defaults in the
payment of any monies due hereunder as and when the same is due;

(b) if the Borrower defaults in the
observance or performance of any other provision hereof;

(c) if the Borrower commits an act of
bankruptcy or makes a general assignment for the benefit of its creditors or
otherwise acknowledges its insolvency; or

(d) if the Borrower makes default in
the due payment, performance or observance, in whole or in part, of any debt,
liability or obligation of the Borrower to the Lender, whether secured hereby or
otherwise.

6.2             Remedies
Upon Default. Upon the occurrence of any Event of Default and at any time
thereafter, provided that the Borrower has not by then remedied such Event of
Default, the Lender may, in its discretion, by notice to the Borrower, declare
this Agreement to be in default. At any time thereafter, while the Borrower
shall not have remedied such Event of Default, the Lender, in its discretion,
may:

	 	(a) 	
      declare the Loan and other monies owing by the Borrower
      to the Lender to be immediately due and payable;

	 	 	 
	 	(b) 	
      demand payment from the Borrower and exercise all
      remedies available to the Lender.

	7. 	
      MISCELLANEOUS

7.1             Notices.
Any notice required or permitted to be given under this Agreement or the
Promissory Notes shall be in writing and may be given by delivering same or
mailing same by registered mail or sending same by telegram, telex, telecopier
or other similar form of communication to the following addresses:

5

	The Borrower: 	#205 - 1480 Gulf Road 
	  	Point Roberts, WA 98281 
	  	  
	The Lender: 	Richmond House, P.O.Box 127, 
	  	Leeward Highway, Providenciales, 
	  	Turks and Caicos Islands, BWI

Any notice so given shall:

	 	(a) 	
      if delivered, be deemed to have been given at the time of
      delivery;

	 	 	 
	 	(b) 	
      if mailed by registered mail, be deemed to have been
      given on the fourth business day after and excluding the day on which it
      was so mailed, but should there be, at the time of mailing or between the
      time of mailing and the deemed receipt of the notice, a mail strike,
      slowdown or other labour dispute which might affect the delivery of such
      notice by the mails, then such notice shall be only effective if actually
      delivered; and

	 	 	 
	 	(c) 	
      if sent by telegraph, telex, telecopier or other similar
      form of communication, be deemed to have been given or made on the first
      business day following the day on which it was
sent.

Any party may give written notice of a change of address in the
aforesaid manner, in which event such notice shall thereafter be given to such
party as above provided at such changed address.

7.2             Amendments.
Neither this Agreement nor any provision hereof may be amended, waived,
discharged or terminated orally, but only by an instrument in writing signed by
the party against whom enforcement of the amendment, waiver, discharge or
termination is sought.

7.3             Entire
Agreement. This Agreement embodies the entire agreement and understanding
between the parties hereto and supersedes all prior agreements and undertakings,
whether oral or written, pertaining to the subject matter hereof.

7.4             Action
on Business Day. If the date upon which any act or payment hereunder is
required to be done or made falls on a day which is not a business day, then
such act or payment shall be performed or made on the first business day next
following.

7.5             No
Merger of Judgment. The taking of a judgment on any covenant contained
herein or on any covenant set forth in any other security for payment of any
indebtedness hereunder or performance of the obligations hereby secured shall
not operate as a merger of any such covenant or affect the Lender's right to
interest at the rate and times provided in this Agreement on any money owing to
the Lender under any covenant herein or therein set forth and such judgment
shall provide that interest thereon shall be calculated at the same rate and in
the same manner as herein provided until such judgment is fully paid and
satisfied.

6

7.6             Severability.
If any one or more of the provisions of this Agreement should be invalid,
illegal or unenforceable in any respect in any jurisdiction, the validity,
legality or enforceability of such provision shall not in any way be affected or
impaired thereby in any other jurisdiction and the validity, legality and
enforceability of the remaining provisions contained herein shall not in any way
be affected or impaired thereby.

7.7             Successors
and Assigns. This Agreement shall enure to the benefit of and be binding
upon all parties hereto and their respective heirs, personal representatives,
successors and assigns, as the case may be.

7.8             Governing
Law. This Agreement shall be governed by and be construed in accordance with
the laws of the State of Nevada and the parties hereto agree to submit to the
jurisdiction of the courts of Nevada with respect to any legal proceedings
arising herefrom.

7.9             Independent
Legal Advice. This Agreement has been prepared by O’Neill Law Group PLLC
acting solely on behalf of the Borrower and the Lender acknowledges that it has
been advised to obtain independent legal advice.

7.10           Time.
Time is of the essence of this Agreement.

7.11           Headings.
The headings of the paragraphs of this Agreement are inserted for convenience
only and do not define, limit, enlarge or alter the meanings of any paragraph or
clause herein.

7.12           Counterparts.
This agreement may be executed in one or more counter-parts, each of which so
executed shall constitute an original and all of which together shall constitute
one and the same agreement.

IN WITNESS WHEREOF the parties hereto have caused this
Agreement to be duly executed and delivered as of the day and year first written
above.

THE BORROWER:

SKYFLYER INC.
by its authorized signatory

/s/ John
Boschert
________________________________
John Boschert,
Secretary

THE LENDER:

BLACK POINTE HOLDINGS INC.
by its authorized
signatory:

/s/ Richard W.
Donaldson
________________________________
Richard W.
Donaldson

SCHEDULE “A”

PROMISSORY NOTES

PROMISSORY NOTE

	EXECUTED BY: 	SKYFLYER INC. 
	  	(the "Borrower") 
	 	 
	IN FAVOUR OF: 	Black Pointe Holdings Inc. 
	  	(the "Lender") 
	 	 
	PRINCIPAL AMOUNT: 	$30,000 (U.S.) 
	 	 
	DATE OF EXECUTION: 	September 13, 2007 

FOR VALUE RECEIVED the Borrower hereby promises to pay
to or to the order of the Lender on April 30, 2009, the principal sum of $30,000
(U.S.), together with interest thereon at the rate of 8% per annum, calculated
and compounded annually, both before and after maturity from the date
hereof.

The Borrower waives presentment, demand, notice, protest and
notice of dishonour and all other demands and notices in connection with the
delivery, acceptance, performance, default or enforcement of this Promissory
Note.

The Borrower agrees this Promissory Note may be negotiated,
assigned, discounted, or pledged by the Lender and in every case payment will be
made to the holder of this Promissory Note instead of the Lender upon notice
being given by the holder to the undersigned, and no holder of this Promissory
Note will be affected by the state of accounts between the undersigned and the
Lender or by any equities existing between the undersigned and the Lender and
will be deemed to be a holder in due course and for the value of the Promissory
Note held by him.

DATED this 13th day of September, 2007.

SKYFLYER INC.
by its authorized signatory:

________________________________
John Boschert,
Secretary

PROMISSORY NOTE

	EXECUTED BY: 	SKYFLYER INC. 
	  	(the "Borrower") 
	 	 
	IN FAVOUR OF: 	Black Pointe Holdings Inc. 
	  	(the "Lender") 
	 	 
	PRINCIPAL AMOUNT: 	$170,500 (U.S.) 
	 	 
	DATE OF EXECUTION: 	October 17, 2007 

FOR VALUE RECEIVED the Borrower hereby promises to pay
to or to the order of the Lender on April 30, 2009, the principal sum of
$170,500 (U.S.), together with interest thereon at the rate of 8% per annum,
calculated and compounded annually, both before and after maturity from the date
hereof.

The Borrower waives presentment, demand, notice, protest and
notice of dishonour and all other demands and notices in connection with the
delivery, acceptance, performance, default or enforcement of this Promissory
Note.

The Borrower agrees this Promissory Note may be negotiated,
assigned, discounted, or pledged by the Lender and in every case payment will be
made to the holder of this Promissory Note instead of the Lender upon notice
being given by the holder to the undersigned, and no holder of this Promissory
Note will be affected by the state of accounts between the undersigned and the
Lender or by any equities existing between the undersigned and the Lender and
will be deemed to be a holder in due course and for the value of the Promissory
Note held by him.

DATED this 13th day of October, 2007.

SKYFLYER INC.
by its authorized signatory:

________________________________
John Boschert,
Secretary

PROMISSORY NOTE

	EXECUTED BY: 	SKYFLYER INC. 
	  	(the "Borrower") 
	 	 
	IN FAVOUR OF: 	Black Pointe Holdings Inc. 
	  	(the "Lender") 
	 	 
	PRINCIPAL AMOUNT: 	$79,500 (U.S.) 
	 	 
	DATE OF EXECUTION: 	October 31, 2007 

FOR VALUE RECEIVED the Borrower hereby promises to pay
to or to the order of the Lender on April 30, 2009, the principal sum of $79,500
(U.S.), together with interest thereon at the rate of 8% per annum, calculated
and compounded annually, both before and after maturity from the date
hereof.

The Borrower waives presentment, demand, notice, protest and
notice of dishonour and all other demands and notices in connection with the
delivery, acceptance, performance, default or enforcement of this Promissory
Note.

The Borrower agrees this Promissory Note may be negotiated,
assigned, discounted, or pledged by the Lender and in every case payment will be
made to the holder of this Promissory Note instead of the Lender upon notice
being given by the holder to the undersigned, and no holder of this Promissory
Note will be affected by the state of accounts between the undersigned and the
Lender or by any equities existing between the undersigned and the Lender and
will be deemed to be a holder in due course and for the value of the Promissory
Note held by him.

DATED this 13th day of October, 2007.

SKYFLYER INC.
by its authorized signatory:

________________________________
John Boschert,
Secretaryexhibit101.htm

    Exhibit
      10.1

    
       

      

      
        	
              
	
                Part
                  1: Parties to the Contract:

              

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

                 

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

                 

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

              
	
                Part
                  2: Effective Date of Amendment:

              	
                Part
                  3: Contract Expiration Date

              	
                Part
                  4: Operational Start Date:

              
	
                September
                  1, 2007

              	
                August
                  31, 2008

              	
                STAR
                  and CHIP HMOs:  September 1, 2006 STAR+PLUS
                  HMOs:  February 1, 2007 CHIP Perinatal HMOs:  January
                  1, 2007

              
	
                Part
                  5: Project Managers:

              
	
                HHSC:
                  Cindy Jorgensen Director of Medicaid/CHIP Health Plan Operations
                  11209
                  Metric Boulevard, Building H Austin, Texas 78758 Phone: 512-491-1302
                  Fax:
                  512-491-1966 

                HMO:
                  Stacey Hull Vice President of Regulatory Affairs 2100 South IH-35,
                  Suite
                  202 Austin, Texas 78704 Phone: 512-692-1465 Fax: 512-692-1474 E-mail:
                  shull@centene.com

              
	
                Part
                  6: Deliver Legal Notices to:

              
	
                HHSC:
                  General Counsel 4900 North Lamar Boulevard, 4th Floor Austin,
                  Texas
                  78751 Fax: 512-424-6586 

                HMO:
                  Superior HealthPlan 2100 South IH-35, Suite 202 Austin, Texas 78704
                  Fax:
                  512-692-1435

              

      

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        	
                Part
                  7: HMO Programs and Service
                  Areas:

              

      

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

                

                 x
                  Medicaid STAR HMO
                  Program 

                    Service
                  Areas: 

                    x
                   Bexar                       
                   x
                   Lubbock  

                    o Dallas                         x
                   Nueces

                    x
 El
                  Paso                      oTarrant
                  

                    o
                  Harris                         x
 Travis
                  

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

              
	
                  x
                  Medicaid
                  STAR+PLUS HMO Program 

                    Service
                  Areas: 

                    xBexar               
                  x
                  Nueces

                    oHarris                                oTravis
                  

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

              
	
                 xCHIP
                  HMO Program
                  

                    Core
                  Service Areas: 

                  x
Bexar       x
                  Nueces
                  

                  o      
Dallas      oTarrant   

                  x
El
                  Paso                x  Travis

                   o
                  Harris                        o
                  Webb

                  x
                  Lubbock       
                  

                 

                    Optional
                  Service Areas: 

                  x
                  Bexar                  x  Lubbock   

                  x  
El
                  Paso               xNueces

                  o
                  Harris                  xTravis

                     

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

              

      

    

    
    

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

    
      	
              xCHIP Perinatal
                Program

                  Core
                Service Areas: 

                  xBexar        x
                Nueces
                

                  o
                Dallas        oTarrant   

                  xEl
                Paso                     x  Travis

                  oHarris                        oWebb

                  xLubbock       
                

               

                  Optional
                Service Areas: 

                  xBexar                 x Lubbock   

                  xEl
                Paso               xNueces

                 oHarris                  xTravis

                   

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

            

    

    
    

    
    

    
      	
              Part
                8: Payment

            
	
              Part
                8 of the HHSC Managed Care Contract document, “Payment,” is modified to
                add the capitation rates for Rate Period
                2.

            

    

     

    xMedicaid
      STAR HMO
      PROGRAM

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

    
       

    

    
      	
            	
              Service
                Area: BEXAR

            	 	 
	 	
              Rate
                Cell

            	
               

            	
               
                Rate
                Period 2  Capitation Rates

            
	
              1

            	
              TANF
                Adult

            	 	
              $
                345.82

            
	
              2

            	
              TANF
                Child>12 months

            	 	
              $
                102.97

            
	
              3

            	
              Expansion
                Child>12 months

            	 	
              $
                108.32

            
	
              4

            	
              Newborn
                < 12 months

            	 	
              $
                705.42

            
	
              5

            	
              TANF
                child < 12 months

            	 	
              $
                225.72

            
	
              6

            	
              Expansion
                child < 12 months

            	 	
              $
                236.12

            
	
              7

            	
              Federal
                Mandate child

            	 	
              $
                83.88

            
	
              8

            	
              Pregnant
                Woman

            	 	
              $463.85

            
	
              9

            	
              Delivery
                Supplemental Payment

            	 	
              $3,266.59

            

    

     

    
      	 	
              Service
                Area: EL PASO

            	 	 
	 	
              Rate
                Cell

            	
               

            	
               
                Rate
                Period 2  Capitation Rates

            
	
              1

            	
              TANF
                Adult

            	 	
              $
                270.85

            
	
              2

            	
              TANF
                Child>12 months

            	 	
              $
                88.14

            
	
              3

            	
              Expansion
                Child>12 months

            	 	
              $
                104.55

            
	
              4

            	
              Newborn
                < 12 months

            	 	
              $
                584.53

            
	
              5

            	
              TANF
                child < 12 months

            	 	
              $
                360.60

            
	
              6

            	
              Expansion
                child < 12 months

            	 	
              $
                212.40

            
	
              7

            	
              Federal
                Mandate child

            	 	
              $
                81.89

            
	
              8

            	
              Pregnant
                Woman

            	 	
              $443.70

            
	
              9

            	
              Delivery
                Supplemental Payment

            	 	
              $3,443.04

            

    

    
    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      	 	
              Service
                Area: LUBBOCK

            	 	 
	 	
              Rate
                Cell

            	
               

            	
              Rate
                Period 2 Capitation Rates

            
	
              1

            	
              TANF
                Adult

            	 	
              $
                292.63

            
	
              2

            	
              TANF
                Child>12 months

            	 	
              $
                96.20

            
	
              3

            	
              Expansion
                Child>12 months

            	 	
              $
                99.81

            
	
              4

            	
              Newborn
                < 12 months

            	 	
              $
                437.14

            
	
              5

            	
              TANF
                child < 12 months

            	 	
              $
                183.18

            
	
              6

            	
              Expansion
                child < 12 months

            	 	
              $
                262.61

            
	
              7

            	
              Federal
                Mandate child

            	 	
              $
                89.39

            
	
              8

            	
              Pregnant
                Woman

            	 	
              $
                542.76

            
	
              9

            	
              Delivery
                Supplemental Payment

            	 	
              $3,230.39

            

    

     

    
      	 	
              Service
                Area: NUECES

            	 	 
	 	
              Rate
                Cell

            	
               

            	
              Rate
                Period 2 Capitation Rates

            
	
              1

            	
              TANF
                Adult

            	 	
              $
                321.57

            
	
              2

            	
              TANF
                Child>12 months

            	 	
              $
                123.41

            
	
              3

            	
              Expansion
                Child>12 months

            	 	
              $
                128.78

            
	
              4

            	
              Newborn
                < 12 months

            	 	
              $936.09

            
	
              5

            	
              TANF
                child < 12 months

            	 	
              $
                450.28

            
	
              6

            	
              Expansion
                child < 12 months

            	 	
              $
                450.28

            
	
              7

            	
              Federal
                Mandate child

            	 	
              $
                93.82

            
	
              8

            	
              Pregnant
                Woman

            	 	
              $
                407.48

            
	
              9

            	
              Delivery
                Supplemental Payment

            	 	
              $3,203.82

            

    

     

    
      	 	
              Service
                Area: TRAVIS

            	 	 
	 	
              Rate
                Cell

            	
               

            	
               Rate
                Period 2 Capitation Rates

            
	
              1

            	
              TANF
                Adult

            	 	
              $
                230.91

            
	
              2

            	
              TANF
                Child>12 months

            	 	
              $
                81.64

            
	
              3

            	
              Expansion
                Child>12 months

            	 	
              $
                98.68

            
	
              4

            	
              Newborn
                < 12 months

            	 	
              $
                760.37

            
	
              5

            	
              TANF
                child < 12 months

            	 	
              $
                229.19

            
	
              6

            	
              Expansion
                child < 12 months

            	 	
              $
                290.55

            
	
              7

            	
              Federal
                Mandate child

            	 	
              $
                77.94

            
	
              8

            	
              Pregnant
                Woman

            	 	
              $
                464.58

            
	
              9

            	
              Delivery
                Supplemental Payment

            	 	
              $3,247.49

            

    

    
    

    

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

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    x Medicaid
      STAR+PLUS HMO Program

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

    
    

    

    
      	
              STAR+PLUS
                Service Area:  BEXAR

            	 
	 	
              Rate
                Cell

            	
              Rate
                Period 2  Capitation Rates

            
	
              1.

            	
              Medicaid
                Only Standard Rate

            	
              $
                462.72

            
	
              2.

            	
              Medicaid
                Only 1915(C) Nursing Facility Waiver Rate

            	
              $
                3,138.64

            
	
              3.

            	
              Dual
                Eligible Standard Rate

            	
              $
                270.37

            
	
              4.

            	
              Dual
                Eligible 1915(C) Nursing Facility Waiver Rate

            	
              $
                1,931.47

            
	
              5.

            	
              Nursing
                Facility – Medicaid Only

            	
              $
                462.72

            
	
              6.

            	
              Nursing
                Facility – Dual Eligible

            	
              $
                270.37

            

    

    
    

     

    
      	
              STAR+PLUS
                Service Area:  NUECES

            	 
	 	
              Rate
                Cell

            	
              Rate
                Period 2  Capitation Rates

            
	
              1.

            	
              Medicaid
                Only Standard Rate

            	
              $
                533.57

            
	
              2.

            	
              Medicaid
                Only 1915(C) Nursing Facility Waiver Rate

            	
              $
                3,062.58

            
	
              3.

            	
              Dual
                Eligible Standard Rate

            	
              $
                337.13

            
	
              4.

            	
              Dual
                Eligible 1915(C) Nursing Facility Waiver Rate

            	
              $
                1,887.61

            
	
              5.

            	
              Nursing
                Facility – Medicaid Only

            	
              $
                533.57

            
	
              6.

            	
              Nursing
                Facility – Dual Eligible

            	
              $
                337.13

            

    

    
    

    

     

    x CHIP
      HMO
      PROGRAM

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

    

    
      	 	
              Service
                Area: BEXAR

            	 	 
	 	
              Rate
                Cell

            	
               

            	
               Rate
                Period 2 Capitation Rates

            
	
              1

            	
              <
                Age 1

            	 	
              $
                89.60

            
	
              2

            	
              Ages
                1 through 5

            	 	
              $
                93.96

            
	
              3

            	
              Ages
                6 through 14

            	 	
              $
                60.55

            
	
              4

            	
              Ages
                15 through 18

            	 	
              $
                78.04

            

    

    
    

    

    
      	 	
              Service
                Area: EL PASO

            	 	 
	 	
              Rate
                Cell

            	
               

            	
               Rate
                Period 2 Capitation Rates

            
	
              1

            	
              <
                Age 1

            	 	
              $
                67.70

            
	
              2

            	
              Ages
                1 through 5

            	 	
              $
                67.69

            
	
              3

            	
              Ages
                6 through 14

            	 	
              $
                58.59

            
	
              4

            	
              Ages
                15 through 18

            	 	
              $
                64.24

            

    

    
    

    

    
      	 	
              Service
                Area: LUBBOCK

            	 	 
	 	
              Rate
                Cell

            	
               

            	
               RatePeriod
                2 Capitation Rates

            
	
              1

            	
              <
                Age 1

            	 	
              $
                80.56

            
	
              2

            	
              Ages
                1 through 5

            	 	
              $
                78.16

            
	
              3

            	
              Ages
                6 through 14

            	 	
              $
                62.30

            
	
              4

            	
              Ages
                15 through 18

            	 	
              $
                89.83

            

    

    
    

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
       

      
        	 	
                Service
                  Area: NUECES

              	 	 
	 	
                Rate
                  Cell

              	
                 

              	
                 Rate
                  Period 2 Capitation Rates

              
	
                1

              	
                <
                  Age 1

              	 	
                $
                  62.31

              
	
                2

              	
                Ages
                  1 through 5

              	 	
                $
                  97.40

              
	
                3

              	
                Ages
                  6 through 14

              	 	
                $
                  84.79

              
	
                4

              	
                Ages
                  15 through 18

              	 	
                $
                  116.44

              

      

      
      

       

    

     

    
      	 	
              Service
                Area: TRAVIS

            	 	 
	 	
              Rate
                Cell

            	
               

            	
               Rate
                Period 2 Capitation Rates

            
	
              1

            	
              <
                Age 1

            	 	
              $
                129.53

            
	
              2

            	
              Ages
                1 through 5

            	 	
              $
                99.35

            
	
              3

            	
              Ages
                6 through 14

            	 	
              $
                86.64

            
	
              4

            	
              Ages
                15 through 18

            	 	
              $
                117.02

            

    

    
    

     

    
      Delivery
        Supplemental Payment:  See Attachment A, “HHSC
        Uniform Managed Care Contract Terms and Conditions,” Article 10, for a
        description of the methodology for establishing the Delivery Supplemental
        Payment for the CHIP Program. The CHIP Delivery Supplemental Payment is
        $3,100.00 for all Service Areas.

    

    x CHIP
      Perinatal Program

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

     

    
      	 	
              Service
                Area: BEXAR

            	 	 
	 	
              Rate
                Cell

            	
               

            	
               Rate
                Period 2 Capitation Rates

            
	
              1

            	
               Perinate
                0% - 185%

            	 	
              $
                539.19

            
	
              2

            	
              Perinate
                186% - 200%

            	 	
              $
                175.04

            
	
              3

            	
              Perinate
                Newborn 0% - 185%

            	 	
              $
                394.44

            
	
              4

            	
              Perinate
                Newborn 186% - 200%

            	 	
              $
                741.26

            

    

    
    

     

    
      
        	 	
                Service
                  Area: EL PASO

              	 	 
	 	
                Rate
                  Cell

              	
                 

              	
                 Rate
                  Period 2 Capitation Rates

              
	
                1

              	
                 Perinate
                  0% - 185%

              	 	
                $
                  539.19

              
	
                2

              	
                Perinate
                  186% - 200%

              	 	
                $
                  175.04

              
	
                3

              	
                Perinate
                  Newborn 0% - 185%

              	 	
                $
                  323.76

              
	
                4

              	
                Perinate
                  Newborn 186% - 200%

              	 	
                $
                  608.42

              

      

      
      

       

    

    
      	 	
              Service
                Area: LUBBOCK

            	 	 
	 	
              Rate
                Cell

            	
               

            	
               Rate
                Period 2 Capitation Rates

            
	
              1

            	
               Perinate
                0% - 185%

            	 	
              $
                539.19

            
	
              2

            	
              Perinate
                186% - 200%

            	 	
              $
                175.04

            
	
              3

            	
              Perinate
                Newborn 0% - 185%

            	 	
              $
                244.43

            
	
              4

            	
              Perinate
                Newborn 186% - 200%

            	 	
              $
                459.35

            

    

    
    

    

    
      	 	
              Service
                Area: NUECES

            	 	 
	 	
              Rate
                Cell

            	
               

            	
               Rate
                Period 2 Capitation Rates

            
	
              1

            	
               Perinate
                0% - 185%

            	 	
              $
                539.19

            
	
              2

            	
              Perinate
                186% - 200%

            	 	
              $
                175.04

            
	
              3

            	
              Perinate
                Newborn 0% - 185%

            	 	
              $
                523.42

            
	
              4

            	
              Perinate
                Newborn 186% - 200%

            	 	
              $
                983.65

            

    

    
    

    

    
      	 	
              Service
                Area: TRAVIS

            	 	 
	 	
              Rate
                Cell

            	
               

            	
               Rate
                Period 2 Capitation Rates

            
	
              1

            	
              Perinate
                0% - 185%

            	 	
              $
                539.19

            
	
              2

            	
              Perinate
                186% - 200%

            	 	
              $
                175.04

            
	
              3

            	
              Perinate
                Newborn 0% - 185%

            	 	
              $
                434.23

            
	
              4

            	
              Perinate
                Newborn 186% - 200%

            	 	
              $
                816.04

            

    

    
    

    

    Delivery
      Supplemental Payment:  See Attachment A, “HHSC
      Uniform Managed Care Contract Terms and Conditions,” Article 10, for a
      description of the methodology for establishing the Delivery Supplemental
      Payment for the CHIP Perinatal Program.  The CHIP Perinatal Delivery
      Supplemental Payment is $3,100.00 for Perinates between 186% and 200% of the
      Federal Poverty Level for all Service Areas.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      	
              Part
                9: Contract Attachments:

            
	
               

            

    

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

    A:
      HHSC
      Uniform Managed Care Contract Terms & Conditions - Version 1.7 is
      replaced with Version 1.8

    B:
      Scope
      of Work/Performance Measures – Version 1.7 is replaced with Version 1.8 for
      all attachments, except if noted.

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

        B-2:
      Covered
      Services

            B-2.1
      STAR+PLUS
      Covered Services

            B-2.2
      CHIP Perinatal
      Program Covered Services

        B-3:
      Value-added Services

            B-3.1
      STAR+PLUS Value-added Services

            B-3.2
      CHIP Perinatal Program Value-added Services

        B-4:
      Performance Improvement Goals

            B-4.1
      SFY 2008
      Performance Improvement Goals

        B-5:
      Deliverables/Liquidated Damages Matrix

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

            B-6.1
      STAR+PLUS
      Service Areas

            B-6.2
      CHIP Perinatal
      Program Service Areas

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

    C:
      HMO’s
      Proposal and Related Documents

        C-1:
      HMO’s
      Proposal 

        C-2:
      HMO
      Supplemental Responses 

        C-3:
      Agreed
      Modifications to HMO’s Proposal

    
      
        
        

        
          	
                  Part
                    10: Special Provisions for Nueces Service Area

                
	
                   

                

        

      

       

    

    Attachment
      A, Section 10.04 is amended to include sub-part (b) as
      follows:

    (b)
      In
      addition to the reasons set forth in Section 10.04(a), the Parties expressly
      understand and agree that HHSC may, at any time, unilaterally adjust the Rate
      Period 2 STAR Program Capitation Rates for the Nueces Service
      Area.  HHSC is entitled to unilaterally adjust such rates,
      prospectively and/or retrospectively, if it determines
      that: (1) the cumulative Rate Period 2 Encounter Data for all HMOs in the Nueces
      Service Area does not
      support the Capitation Rates; or (2) economic factors in the Nueces Service
      Area
      significantly and measurably
      impact providers or the delivery of Covered Services to Members.  For
      adjustments made pursuant to this Section 10.04(b), HHSC will provide written
      notice at least ten (10) Business Days before: (1) the effective date of a
      prospective adjustment; (2) offsetting Capitation Payments to recover
      retrospective adjustments.  Any adjustments to the Rate Period 2
      Capitation Rates must meet the actuarial soundness requirements of Attachment
      A,
      Section 10.03, “Certification of Capitation Rates.”

     

    
      	
              Part
                11:  Signatures:

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

               

              Texas
                Health and Human Services Commission 

              /s/
                C. E. Bell, MD

              Charles
                E. Bell, M.D. 

              Deputy
                Executive Commissioner for Health Services 

              Date:
                9/05/07

               

              Superior
                HealthPlan, Inc. 

              /s/
                Christopher D.
                Bowers

              By:  Christopher
                Bowers 

              Title:
                President and CEO 

              Date:
                8/22/07

            

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Responsible
      Office: HHSC Office of General Counsel (OGC)  Subject:
      Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions Version 1.8

     

     

    Texas
      Health & Human Services Commission 

    

    Uniform
      Managed Care Contract Terms & Conditions 

    Version
      1.8

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Responsible
      Office: HHSC Office of General Counsel (OGC)

    Subject:
      Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions Version 1.8

    DOCUMENT
      HISTORY LOG

    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	
              Baseline

            	
              n/a

            	 	
              Initial
                version of the Uniform Managed Care Contract Terms &
                Conditions

            
	
              Revision

            	
              1.1

            	
              June
                30, 2006

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

               

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

               

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

               

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

               

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

            
	
              Revision

            	
              1.2

            	
              September
                1, 2006

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

               

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

               

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

               

              Article
                10 is amended to clarify the following sections: 10.01(d), regarding
                the
                fixed monthly Capitation Rate components; 10.10(c), regarding updating
                the
                state

            

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Responsible
      Office: HHSC Office of General Counsel (OGC)

    Subject:
      Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions Version 1.8

    
      	 	 	 	
              system
                for Members who become eligible for SSI.  Section 10.17 is added
                regarding recoupment for federal disallowance.  

               

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

            
	
              Revision

            	
              1.3

            	
              September
                1, 2006

            	
              Article
                2 is amended to modify and add the following definitions to include
                the
                CHIP Perinatal Program- Appeal, CHIP Perinatal Program, CHIP Perinatal
                HMO, CHIP Perinate, CHIP Perinate Newborn, Covered Services, Complaint,
                Delivery Supplemental Payment, Eligibles, Experience Rebate, HHSC
                Administrative Services Contractor, Major Population Group, Member,
                Optional Service Area, and Service Management. Article 5 is amended
                to add
                the following sections: 5.04.1 CHIP Perinatal eligibility and enrollment;
                5.05(c) CHIP Perinatal HMOs. 

               

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

            
	
              Revision

            	
              1.4

            	
              September,
                1 2006

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

            
	
              Revision

            	
              1.5

            	
              January
                1, 2007

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

               

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

               

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

               

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

               

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

               

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

               

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

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

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

            
	
              Revision

            	
              1.7

            	
              July
                1, 2007

            	
              Article
                2 is modified to correct and align definition for “Clean Claim” with the
                UMCM. 

               

              Section
                4.08(c) is modified to add a cross-reference
                to

            

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Responsible
      Office: HHSC Office of General Counsel (OGC)

    Subject:
      Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions Version 1.8

    
      	 	 	 	
              new
                Attachment B-1, Section 8.1.1.2. 

               

              Section
                5.05(a), Medicaid HMOs, is amended to clarify provisions regarding
                enrollment into Medicaid Managed Care from Medicaid Fee-for-Service
                while
                in the hospital, changing HMOs while in the hospital, and addressing
                which
                HMO is responsible for professional and hospital charges during the
                hospital stay. 

               

              New
                Section 10.05.1 (c) is added to clarify capitation payments (delays
                in
                payment and levels of capitation) for Members certified to receive
                STAR+PLUS Waiver Services. 

               

              Section
                10.06.1 is modified to include the CHIP Perinatal pass through for
                delivery physician services for women under 185% FPL. 

               

              Section
                10.11 is modified to include treatment of the new Incentives and
                Disincentives (within the Experience Rebate
                determination);  additionally, several clarifications are added
                with respect to the continuing accrual of any unpaid interest, etc.
                

               

              Section
                10.11.1 is modified to include treatment of the new Incentives and
                Disincentives (within the Experience Rebate determination); additionally,
                several clarifications are added with respect to the continuing accrual
                of
                any unpaid interest, etc.

            
	
              Revision

            	
              1.8

            	
              September
                1, 2007

            	
              Article
                2 is modified to add definitions for Migrant Farmworker and FWC as
                a
                result of the Frew litigation corrective action plans. 

               

              Article
                2 is modified to reflect legislative changes required by SB 10 to
                the
                definition for Value-added Services. New 

               

              Section
                5.03.1 is added to clarify the enrollment process for infants born
                to
                pregnant women in STAR+PLUS. 

               

              Section
                5.04 is modified to reflect legislative changes required by HB 109.
                

               

              Section
                10.18 is added to clarify the required pass through of physician
                rate
                increases for all programs to comply with HHSC
                directives.

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

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

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

            

    

    
    

    

    Responsible
      Office: HHSC Office of General Counsel (OGC)  Subject:
      Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions Version 1.8

    TABLE
      OF CONTENTS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Section
      3.07
      Publicity.....................................................................................................................................16
      

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

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

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

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

    Section
      3.12 Attorneys’ fees.
      .........................................................................................................................17
      

    Section
      3.13 Preferences under service
      contracts.........................................................................................17
      

    Section
      3.14 Time of the
      essence..................................................................................................................17
      

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

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

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

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

    Section
      4.03 Executive
      Director.....................................................................................................................18
      

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

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

    Section
      4.05 Responsibility for HMO personnel and
      Subcontractors.............................................................19

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

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

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

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

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

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

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

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

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

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

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

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

    Section
      5.07 Special Temporary STAR Default Process
      ...............................................................................24
      

    Section
      5.08 Special Temporary STAR+PLUS Default
      Process....................................................................24

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

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

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

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

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Responsible
      Office: HHSC Office of General Counsel (OGC)

    Subject:
      Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions Version 1.8

     

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

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

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

    Section
      7.06 Environmental protection laws.
      .................................................................................................26
      

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

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

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

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

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

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

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

    Section
      8.06 CMS approval of Medicaid amendments
      ..................................................................................27
      

    Section
      8.07 Required compliance with amendment and modification procedures.
      ......................................27

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

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

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

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

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

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

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

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

    Section
      10.02 Time and Manner of
      Payment.................................................................................................29
      

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

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

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

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

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

    Section
      10.07 HMO input during rate setting
      process....................................................................................31
      

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

    Section
      10.09 Delivery Supplemental Payment for CHIP, CHIP Perinatal and STAR HMOs.
      .......................32 

    Section
      10.10 Administrative Fee for SSI
      Members.......................................................................................32
      

    Section
      10.11 STAR, CHIP, and CHIP Perinatal Experience
      Rebate............................................................33

    Section
      10.11.1 STAR+PLUS Experience
      Rebate.........................................................................................34
      

    Section
      10.12 Payment by Members.
      ............................................................................................................36
      

    Section
      10.13 Restriction on assignment of fees.
      ..........................................................................................36
      

    Section
      10.14 Liability for taxes.
      ....................................................................................................................37
      

    Section
      10.15 Liability for employment-related charges and benefits.
      ...........................................................37 

    Section
      10.16 No additional
      consideration.....................................................................................................37
      

    Section
      10.17 Federal
      Disallowance..............................................................................................................37
      

    Section
      10.18 Required Pass Through of Physician Rate Increases
      .............................................................37

    Article
      11. Disclosure & Confidentiality  of Information
      ...........................................................................37

    Section
      11.01
      Confidentiality..........................................................................................................................38
      

    Section
      11.02 Disclosure of HHSC’s Confidential
      Information.......................................................................38
      

    Section
      11.03 Member
      Records.....................................................................................................................38
      

    Section
      11.04 Requests for public
      information...............................................................................................39
      

    Section
      11.05 Privileged Work
      Product..........................................................................................................39
      

    Section
      11.06 Unauthorized acts.
      ..................................................................................................................39
      

    Section
      11.07 Legal
      action.............................................................................................................................39

    Article
      12. Remedies & Disputes
      ................................................................................................................39

    Section
      12.01 Understanding and
      expectations.............................................................................................39
      

    Section
      12.02 Tailored remedies.
      ..................................................................................................................40
      

    Section
      12.03 Termination by HHSC.
      ............................................................................................................42
      

    Section
      12.04 Termination by
      HMO...............................................................................................................43

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Responsible
      Office: HHSC Office of General Counsel (OGC)

    Subject:
      Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions Version 1.8

     

    Section
      12.05 Termination by mutual
      agreement...........................................................................................44
      

    Section
      12.06 Effective date of
      termination....................................................................................................44
      

    Section
      12.07 Extension of termination effective date.
      ..................................................................................44
      

    Section
      12.08 Payment and other provisions at Contract
      termination............................................................44

    Section
      12.09 Modification of Contract in the event of remedies.
      ..................................................................44

    Section
      12.10 Turnover
      assistance................................................................................................................44
      

    Section
      12.11 Rights upon termination or expiration of Contract.
      ..................................................................44

    Section
      12.12 HMO responsibility for associated costs.
      ................................................................................44
      

    Section
      12.13 Dispute resolution.
      ..................................................................................................................44
      

    Section
      12.14 Liability of
      HMO.......................................................................................................................45

    Article
      13. Assurances & Certifications
      .....................................................................................................45

    Section
      13.01 Proposal certifications.
      ............................................................................................................45
      

    Section
      13.02 Conflicts of
      interest..................................................................................................................45
      

    Section
      13.03 Organizational conflicts of interest.
      .........................................................................................46
      

    Section
      13.04 HHSC personnel recruitment
      prohibition.................................................................................46
      

    Section
      13.05 Anti-kickback
      provision............................................................................................................46
      

    Section
      13.06 Debt or back taxes owed to State of
      Texas.............................................................................46
      

    Section
      13.07 Certification regarding status of license, certificate, or permit.
      ................................................46 

    Section
      13.08 Outstanding debts and
      judgments...........................................................................................47

    Article
      14. Representations &
Warranties..................................................................................................47

    Section
      14.01 Authorization.
      ..........................................................................................................................47
      

    Section
      14.02 Ability to perform.
      ....................................................................................................................47
      

    Section
      14.03 Minimum Net Worth.
      ...............................................................................................................47
      

    Section
      14.04 Insurer
      solvency......................................................................................................................47
      

    Section
      14.05 Workmanship and performance.
      .............................................................................................47
      

    Section
      14.06 Warranty of deliverables.
      ........................................................................................................47
      

    Section
      14.07 Compliance with Contract.
      ......................................................................................................48
      

    Section
      14.08 Technology Access
      .................................................................................................................48

    Article
      15. Intellectual Property
      ..................................................................................................................48

    Section
      15.01 Infringement and
      misappropriation..........................................................................................48
      

    Section
      15.02
      Exceptions...............................................................................................................................48
      

    Section
      15.03 Ownership and
      Licenses.........................................................................................................48

    Article
      16. Liability
      .......................................................................................................................................49

    Section
      16.01 Property
      damage.....................................................................................................................49
      

    Section
      16.02 Risk of
      Loss.............................................................................................................................50
      

    Section
      16.03 Limitation of HHSC’s Liability.
      .................................................................................................50

    Article
      17. Insurance &
Bonding.................................................................................................................50

    Section
      17.01 Insurance
      Coverage................................................................................................................50
      

    Section
      17.02 Performance Bond.
      .................................................................................................................51
      

    Section
      17.03 TDI Fidelity
      Bond.....................................................................................................................51

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Article
      1. Introduction 

    Section
      1.01 Purpose.

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

    Section
      1.02 Risk-based contract.

    This
      is a
      Risk-based contract.

    Section
      1.03 Inducements.

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

    

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

    

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

    

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

    

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

    

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

    

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

     

    Section
      1.04 Construction of the
      Contract.   

    (a)
      Scope of Introductory Article.

     

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

    

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

    

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

     

    (d)
      Survival of terms. Termination or expiration of this Contract for
      any

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

    

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

    

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

     

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

    

    (f)
      Global drafting conventions.

    

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

    

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

    

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

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Section
      1.05 No implied authority.

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

    (1)
      make
      public policy;

    

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

    

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

    

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

    Section
      1.06 Legal Authority.

    

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

    

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

    

    Article
      2. Definitions

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

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

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

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

    Action
      (Medicaid only) means:

    

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

    

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

    

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

    

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

    

    (5)
      the
      failure of an HMO to act within the timeframes set forth in the Contract and
      42

    

    C.F.R.
      §438.408(b); or

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

    An
      Adverse Determination is one type of Action. 

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

    Acute
      Care Hospital means a hospital that

    provides
      acute care services 

    Adjudicate
      means to deny or pay a clean claim. 

    Administrative
      Services see HMO Administrative
      Services. 

    Administrative
      Services Contractor see HHSC Administrative Services Contractor.

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

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

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

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    AAP
      means the American Academy of Pediatrics.

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

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

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

    Auxiliary
      Aids and Services includes:

    

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

    

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

    

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

    

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

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

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

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

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

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

    Capitation
      Rate means a fixed predetermined fee paid by HHSC to the HMO each
      month in accordance with the Contract, for each enrolled

    Member
      in
      a defined Rate Cell, in exchange for the HMO arranging for or providing a
      defined set of Covered Services to such a Member, regardless of the amount
      of
      Covered Services used by the enrolled Member.

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

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

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

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

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

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

    

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

    

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

    

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

    

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

    

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

    

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

    CHIP
      HMOs means HMOs participating in the CHIP HMO Program.

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

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

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

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

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

    Clean
      Claim means a claim submitted by a physician or provider for
      medical care or health care services rendered to a Member, with the data
      necessary for the MCO or subcontracted claims processor to adjudicate and
      accurately report the claim. A Clean Claim must meet all requirements for
      accurate and complete data as defined in the appropriate 837-(claim type)
      encounter guides as follows:

    

    (1)
      837
      Professional Combined Implementation Guide

    

    (2)
      837
      Institutional Combined Implementation Guide

    

    (3)
      837
      Professional Companion Guide

    

    (4)
      837
      Institutional Companion Guide

    

    The
      HMO
      may not require a physician or provider to submit documentation that conflicts
      with the requirements of Texas Administrative Code, Title 28, Part 1, Chapter
      21, Subchapters C and T.

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

    COLA
      means the Cost of Living Adjustment.

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

    Community
      Resource Coordination Groups (CRCGs) means a statewide system of
      local interagency groups, including both public and private

    providers,
      which coordinate services for ”multi-need” children and youth. CRCGs develop
      individual service plans for children and adolescents whose needs can be met
      only through interagency cooperation. CRCGs address Complex Needs in a model
      that promotes local decision-making and ensures that children receive the
      integrated combination of social, medical and other services needed to address
      their individual problems.

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

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

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

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

    Comprehensive
      Care Program: See definition for Texas Health Steps.

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

    

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

    

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

    

    (3)
      All
      Privileged Work Product;

    

    (4)
      All
      information designated by HHSC or any other State agency as confidential, and
      all information designated as confidential under the Texas Public Information
      Act, Texas Government Code, Chapter 552;

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

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

    

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

    

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

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

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

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

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

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

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

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

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

    Covered
      Services means Health Care Services the HMO must arrange to provide
      to Members, including all services required by the Contract and state and
      federal law, and all Value-added Services negotiated by the Parties (see
Attachments B-2, B­2.1, B-2.2 and B-3 of the HHSC
      Managed Care Contract
      relating to “Covered Services” and “Value­added
      Services”).  Covered Services include Behavioral Health
      Services.

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

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

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

    Day
      means a calendar day unless specified otherwise.

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

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

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

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

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

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

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

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

    Disability
      means a physical or mental impairment that substantially limits one or more
      of
      an individual’s major life activities, such as caring for oneself, performing
      manual tasks, walking, seeing,

    hearing,
      speaking, breathing, learning, and/or working.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Disability-related
      Access means that facilities are readily accessible to and usable
      by individuals with disabilities, and that auxiliary aids and services are
      provided to ensure effective communication, in compliance with Title III of
      the
      Americans with Disabilities Act.

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

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

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

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

    EDI
      means electronic data interchange.

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

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

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

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

    

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

    

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

    

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

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

    

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

    

    (2)
      serious impairment to bodily functions;

    

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

    

    (4)
      serious disfigurement; or

    

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

    

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

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

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

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

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

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

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

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

    Expedited
      Appeal means an appeal to the HMO in which the decision is required
      quickly based on the Member's health status, and the amount of time

    necessary
      to participate in a standard appeal could jeopardize the Member's life or health
      or ability to attain, maintain, or regain maximum function.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

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

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

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

    Farmworker
      Child (FWC) means a child under age 21 of a Migrant
      Farmworker.

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

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

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

    FPL
      means the Federal Poverty Level.

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

    applicable
      federal or state law.

    FSR
      means Financial Statistical Report.

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

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

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

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

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

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

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

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

    HHSC.

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

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

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

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

    

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

    

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

    

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

    processing,
      management information systems operation and reporting.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

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

    Home
      and Community Support Services Agency or HCSS means an entity
      licensed to provide home health, hospice, or personal assistance services
      provided to individuals in their own home or independent living environment
      as
      prescribed by a physician or individualized service plan. Each HCSS must provide
      clients with a plan of care that includes specific services the agency agrees
      to
      perform. The agencies are licensed and monitored by DADS or its
      successor.

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

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

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

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

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

    JCAHO
      means Joint Commission on Accreditation of Health Care
      Organizations.

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

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

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

    Local
      Health Department means a local health department established
      pursuant to Health and Safety

    Code,
      Title 2, Local Public Health Reorganization Act §121.031.

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

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

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

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

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

    (1)
      enroll with the HMO; or

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

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

    MCO
      means managed care organization. Medicaid means the
      medical assistance entitlement program authorized and funded pursuant to Title
      XIX, Social Security Act (42 U.S.C. §1396 et seq.) and administered by
      HHSC. Medicaid HMOs means contracted HMOs participating
      in STAR and/or STAR+PLUS. Medical Assistance
      Only  (MAO) means a person that does not receive SSI
      benefits but qualifies financially and functionally for limited Medicaid
      assistance. Medical Home means a PCP or specialty care
      Provider who has accepted the responsibility for providing accessible,
      continuous, comprehensive and coordinated care to Members participating in
      a
      HHSC HMO Program. Medically Necessary
means:

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

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

    

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

    

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

    

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

    

    (d)
      consistent with the diagnoses of the conditions;

    

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

    

    (f)
      are
      not experimental or investigative; and

    

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

    

    (2)
      Behavioral Health Services that are:

    

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

    

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

    

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

    

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

    

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

    

    (f)
      are
      not experimental or investigative; and

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

     

    Member
      means a person who:

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

    in
      the
      STAR or STAR+PLUS Program and the

    HMO’s
      STAR or STAR+PLUS HMO;

    

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

    

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

    

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

    

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

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

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

    

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

    

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

    

    Migrant
      Farmworker means a migratory agricultural worker, generally defined
      as an individual whose principal employment is in agriculture on a seasonal
      basis, who has been so employed within the last twenty-four months, and who
      establishes for the purposes of such employment a temporary abode.

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

    MIS
      means Management Information System.

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

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

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

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

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

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

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

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

    OB/GYN
      means obstetrician-gynecologist.

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

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

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

    Operations
      Phase means the period of time when HMO is responsible for
      providing the Covered Services and all related Contract functions for a Service
      Area.  The Operations Phase begins on the

    Operational
      Start Date, and may vary by HMO Program and Service Area.

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

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

    Parties
      means HHSC and HMO, collectively.

    Party
      means either HHSC or HMO, individually.

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

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

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

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

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

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

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

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

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

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

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

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

    Public
      Information means information that:

    

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

    

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

    

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

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

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

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

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

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

    Real-Time
      Captioning (also known as CART, Communication Access Real-Time
      Translation) means a process by which a trained individual uses a shorthand
      machine, a computer, and real-time translation software to type and
      simultaneously translate spoken language into text on a computer

    screen.
      Real Time Captioning is provided for individuals who are deaf, have hearing
      impairments, or have unintelligible speech. It is usually used to interpret
      spoken English into text English but may be used to translate other spoken
      languages into text.

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

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

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

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

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

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

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

    

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

    

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

    

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

    

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

    

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

    

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

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

    SDX
      means State Data Exchange.

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

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

    Service
      Management is an administrative service in the STAR, CHIP and CHIP
      Perinatal Programs performed by the HMO to facilitate development of a Service
      Plan and coordination of services among a Member’s PCP, specialty providers and
      non-medical providers to ensure Members with Special Health Care Needs and/or
      Members needing high-cost treatment have access to, and appropriately utilize,
      Medically Necessary Covered Services, Non­capitated Services, and other
      services and supports.

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

    (1)
      the
      Member’s history;

    

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

    

    (3)
      short
      and long term needs and goals;

    

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

    

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

    

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

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

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

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

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

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

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

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

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

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

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

    SSA
      means the Social Security Administration.

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

    10.10
      of
      this document.   Stabilize means to
      provide such medical care as to assure within reasonable medical probability
      that no deterioration of the condition is likely to result from, or occur from,
      or occur during discharge, transfer, or admission of the Member.
STAR+PLUS or STAR+PLUS Program means the State of Texas
      Medicaid managed care program in which HHSC contracts with HMOs to provide,
      arrange, and coordinate preventive, primary, acute and long term care Covered
      Services to adult persons with disabilities and elderly persons age 65 and
      over
      who qualify for Medicaid through the SSI program and/or the MAO program.
      Children under age 21, who qualify for Medicaid through the SSI

    program,
      may voluntarily participate in the STAR+PLUS program.

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

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

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

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

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

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

    T.A.C.
      means Texas Administrative Code. TDD means
      telecommunication device for the deaf. It is interchangeable with the term
      Teletype

    machine
      or TTY.

    TDI
      means the Texas Department of Insurance.

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

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

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

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

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

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

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

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

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

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

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

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

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

    

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

    

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

    

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

    

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

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

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

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

    Value-added
      Services means additional services for coverage beyond those
      specified in Attachments B-2, B-2.1, and B-2.2.  Value-added Services
      may be actual Health Care Services,  benefits, or positive incentives
      that HHSC determines will promote healthy lifestyles and improve health outcomes
      among Members.  Value-added Services that promote healthy lifestyles
      should target specific weight loss, smoking cessation, or other programs
      approved by HHSC. Temporary phones, cell phones, additional transportation
      benefits, and extra home health services may be Value-added Services, if
      approved by HHSC.  Best practice approaches to delivering Covered
      Services are not considered Value-added Services.

    Waste
      means practices that are not cost-efficient.

    Article
      3. General Terms & Conditions

    Section
      3.01 Contract elements.

    

    (a)
      Contract documentation. The Contract between the Parties will consist
      of

    

    the
      HHSC
      Managed Care Contract document and all attachments and amendments.

    

    (b)
      Order
      of documents. In the event of any conflict or contradiction between or among
      the
      contract documents, the

    

    documents
      shall control in the following order of precedence:

    

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

    

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

    

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

    

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

    

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

    

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

    

    (7)
      HHSC
      Managed Care Contract

    Attachment
      C-1 – “HMO’s Proposal.”  

    Section
      3.02 Term of the Contract.

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

    Section
      3.03 Funding.

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

    Section
      3.04 Delegation of authority.

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

    Section
      3.05 No waiver of sovereign immunity.

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

    Section
      3.06 Force majeure.

    Neither
      Party will be liable for any failure or delay in performing its obligations
      under the Contract if such failure or delay is due to any cause beyond the
      reasonable control of such Party, including, but not limited to, unusually
      severe weather, strikes, natural disasters, fire, civil disturbance, epidemic,
      war, court order, or acts of God.  The existence of such causes of
      delay or failure will extend the period of

    performance
      in the exercise of reasonable diligence until after the causes of delay or
      failure have been removed.  Each Party must inform the other in
      writing with proof of receipt within five (5) Business Days of the existence
      of
      a force majeure event or otherwise waive this right as a defense.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Section
      3.07 Publicity.

    

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

    

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

    

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

    

    (1)
      proposals or reports submitted to HHSC, an administrative agency of the State
      of
      Texas, or a governmental agency or unit of another state or the federal
      government;

    

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

    

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

    

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

    

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

    

    Section
      3.08 Assignment.

    (a)
      Assignment by HMO. HMO shall not assign all or any portion of its rights under
      or interests in the Contract or delegate any of its duties without prior written
      consent of HHSC. Any written request for assignment or delegation must be
      accompanied by written acceptance of the assignment or delegation by the
      assignee or delegation by the delegate.  Except where otherwise agreed
      in writing by HHSC, assignment or delegation will not release HMO
      from

    its
      obligations pursuant to the Contract. An HHSC-approved Material Subcontract
      will
      not be considered to
      be an
      assignment or delegation for purposes of this section.

    

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

    

    (c)
      Assumption. Each party to whom a transfer is made (an "Assignee") must assume
      all or any part of HMO’S or HHSC's interests in the Contract, the product, and
      any documents executed with respect to the Contract, 

    including,
      without limitation, its obligation for all or any portion of the purchase
      payments, in whole or in part.

     

    Section
      3.09 Cooperation with other vendors and prospective
      vendors.

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

    Section
      3.10 Renegotiation and reprocurement rights.

    

    (a)
      Renegotiation of Contract terms. Notwithstanding anything in the Contract to
      the
      contrary, HHSC may at any time during the term of the Contract exercise the
      option to notify HMO that HHSC has elected to renegotiate certain terms of
      the
      Contract. Upon HMO’s receipt of any notice pursuant to this Section, HMO and
      HHSC will undertake good faith negotiations of the subject terms of the
      Contract,

    

    and
      may
      execute an amendment to the Contract in accordance with Article
      8.

    

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

    

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

    

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

    Section
      3.11 RFP errors and
      omissions.

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Subject:
      Attachment A -- HHSC Uniform Managed Care Contract Terms &
Conditions Version 1.8

     

     

    Section
      3.12 Attorneys’ fees.

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

    Section
      3.13 Preferences under service contracts.

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

    Section
      3.14 Time of the essence.

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

    Section
      3.15 Notice

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

    Article
      4. Contract Administration & Management

     

    Section
      4.01 Qualifications, retention and replacement
      of HMO employees.

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

     

    Section
      4.02 HMO’s Key Personnel.

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

    

    (1)
      Member Services;

    

    (2)
      Management Information Systems;

    

    (3)
      Claims Processing,

     

    (4)
      Provider Network Development and Management;

    

    (5)
      Benefit Administration and Utilization and Care Management;

    

    (6)
      Quality Improvement;

    

    (7)
      Behavioral Health Services;

    

    (8)
      Financial Functions;

    

    (9)
      Reporting;

    

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

    

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

    

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

    

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

    

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Section
      4.03 Executive Director.

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

     

    Section 4.04 Medical
      Director

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

    

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

    

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

    

    Section
      4.04.1 STAR+PLUS Service Coordinator

    

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

    

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

    

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

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Section
      4.05 Responsibility for HMO personnel and
      Subcontractors.

    

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

    

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

    

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

    

    (d)
      HMO
      agrees that any claim on behalf of any person arising out of employment or
      alleged employment by the HMO  (including, but not limited to, claims
      of discrimination against HMO, its officers, or its agents) is the sole
      responsibility of HMO and not the responsibility of HHSC.  HMO will
      indemnify and hold harmless the State from any and all claims asserted against
      the State arising out of such employment or alleged employment by the
      HMO.  HMO understands that any person who alleges a claim arising out
      of employment or alleged employment by HMO will not be entitled to any
      compensation, rights, or benefits from HHSC (including, but not limited to,
      tenure rights, medical and hospital care, sick and annual/vacation leave,
      severance pay, or retirement benefits).

    

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

    

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

    

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

    

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

     

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

     

    Section
      4.06 Cooperation with HHSC and stateadministrative
      agencies.

    

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

    

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

    

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

    

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

    

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

    

    Section
      4.07 Conduct of HMO personnel.

    

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

    

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

    

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

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

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

     

    (1)
      Removing the employee from the project;

    

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

    

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

     

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

    

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

    

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

    

    Section
      4.08 Subcontractors.

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

    

    (b)
      HMO
      must:

    

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

    

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

    

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

     

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

     

    (6)
      a
      Readiness Review is requested by HHSC.
      The
      HMO must submit information required by HHSC for each proposed Material
      Subcontractor as indicated in Attachment B-1, Section 7. Refer
      to Attachment B-1, Sections 8.1.1.2 and

    8.1.18
      for additional information regarding HMO Readiness Reviews during
      the
      Contract Period.

    

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

    

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

    

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

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

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

    

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

    

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

    

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

    

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

    

    Section
      4.09 HHSC’s ability to contract
      withSubcontractors.

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

     

    Section
      4.10 HMO Agreements with Third Parties

    

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

    

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

    

    (c)
      All
      agreements described in subsections (a) and (b) must show the dollar amount,
      the
      percentage

    

    of
      money,
      or the value of any consideration that HMO pays to or receives from the third
      party.

    

    (d)
      HMO
      must submit a copy of each third party agreement described in subsections (a)
      and (b) to HHSC. If the third party agreement is entered into prior to the
      Effective Date of the Contract, HMO must submit a copy no later than thirty
      (30)
      days after the Effective Date of the Contract.  If the third party
      agreement is executed after the Effective Date of the Contract, HMO must submit
      a copy no later than five

    

    (5)
      Business Days after execution. (e) For third party agreements valued under
      $100,000 per State Fiscal Year that are reported as Allowable Expenses, the
      HMO
      must maintain financial records and data sufficient to verify the accuracy
      of
      such expenses in accordance with the requirements of Article
      9.

    

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

    

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

    

    Article
      5. Member Eligibility & Enrollment

     

    Section
      5.01 Eligibility Determination

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

     

    Section
      5.02 Member Enrollment & Disenrollment.

    

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

    

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

    

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

    

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

    Section
      5.03 STAR enrollment for pregnant women and
      infants.

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

     

    (b)
      The
      HHSC Administrative Services Contractor will enroll newborns born to Medicaid
      eligible mothers who are enrolled in a STAR HMO in the same HMO for 90 days
      following the date of birth, unless the mother requests a plan change as a
      special exception.  The Administrative Service Contractor will
      consider such requests on a case-by­case basis. The HHSC Administrative
      Services Contractor will retroactively, to date of birth, enroll newborns in
      the
      applicable STAR HMO.

     

    Section
      5.03.1 Enrollment for infants born to pregnant women in
      STAR+PLUS.

    If
      a
      newborn is born to a Medicaid-eligible mother enrolled in a STAR+PLUS HMO,
      the
      HHSC Administrative Service Contractor will enroll the newborn into that HMO’s
      STAR HMO product, if one exists. All rules related to STAR newborn enrollment
      will apply to the newborn. If the STAR+PLUS HMO does not have a STAR product
      but
      the newborn is eligible for STAR, the newborn will be enrolled in traditional
      Fee-for-Service Medicaid, and given the opportunity to select a STAR
      HMO.

     

    Section
      5.04 CHIP eligibility and enrollment.

    (a)
      Term
      of coverage.  The Administrative Services Contractor determines CHIP
      eligibility on behalf of HHSC. The Administrative Services
      Contractor will enroll and disenroll eligible individuals into and out of
      CHIP.  CHIP Members with an Effective Date of Coverage on or
      after
      September 1, 2007 will have twelve (12) months of coverage.  CHIP
      Members with an Effective Date of Coverage prior to September 1, 2007 will
      be
      required to re-enroll in the CHIP Program at the end of their six month coverage
      period, at which point they will have a new Effective Date of Coverage and
      twelve (12) months of coverage.

    

    (b)
      Pregnant Members and Infants.

    

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

    

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

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
       

      Section
        5.04.1 CHIP Perinatal eligibility, enrollment, and
        disenrollment

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

    

    

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

    

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

    

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

    

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

    

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

    

    Section
      5.05 Span of Coverage

    

    (a)
      Medicaid HMOs.

    

    (1)
      HHSC
      will conduct continuous open enrollment for Medicaid Eligibles and the HMO
      must
      accept all persons who choose to enroll as Members in the HMO or who are
      assigned as Members in the HMO by HHSC, without regard to the Member’s health
      status, inpatient status, or any other factor.

    

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

    

    (3)
      A
      Member cannot change from one Medicaid HMO to another Medicaid HMO during an
      inpatient hospital stay.  Medicaid HMOs are responsible for
      professional charges during every month for which the HMO receives a full
      capitation for a Member.

    

    (4)
      The
      payor responsible for the hospital charges at the start of an Inpatient Stay
      remains responsible for hospital charges until the time of discharge, or until
      such time that there is a loss of Medicaid eligibility.  Medicaid HMOs
      are not responsible for any services after the effective date of loss of
      Medicaid eligibility.

    

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

    

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

    

    Covered
      Services terminates on the Date of Disenrollment.

     

    Section
      5.06 Verification of Member Eligibility.

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Section
      5.07 Special Temporary STAR Default Process

    

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

    

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

    

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

    

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

    

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

     

    Section 5.08 Special Temporary STAR+PLUS
      Default Process

     

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

    

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

    

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

    

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

     

    Article
      6. Service Levels & Performance Measurement

    Section
      6.01 Performance measurement.

     

    Satisfactory
      performance of this Contract will be measured by:

    

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

    

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

    

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

    

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

    

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

    

    Article
      7. Governing Law & Regulations

    Section
      7.01 Governing law and venue.

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

     

    Section
      7.02 HMO responsibility for compliance with
      laws and regulations.

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

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

    

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

    

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

    

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

    

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

    

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

    

    Section
      7.03 TDI licensure/ANHC certification and
      solvency.

    

    (a)
      Licensure HMO must be either licensed by the TDI as an HMO or a certified ANHC
      in all counties for the

    

    Service
      Areas included within the scope of the Contract.

    

    (b)
      Solvency HMO must maintain compliance with the Texas Insurance Code and rules
      promulgated and administered by the TDI requiring a fiscally sound
      operation.  HMO must have a plan and take appropriate measures to
      ensure adequate provision against the risk of insolvency as required by
      TDI.

    

    Such
      provision must be adequate to provide for the following in the event of
      insolvency:

    

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

    

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

    

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

    

    Provision
      against the risk of insolvency must be made by establishing adequate reserves,
      insurance or other guarantees in full compliance with all financial requirements
      of TDI.

     

    Section
      7.04 Immigration Reform and Control Act of
      1986.

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

     

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

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Section
      7.06 Environmental protection laws.

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

    

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

    

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

    

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

    

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

    

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

     

    Section
      7.07 HIPAA.

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

     

    Article
      8. Amendments & Modifications

    Section
      8.01 Mutual agreement.

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

     

    Section
      8.02 Changes in law or contract.

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

     

    Section
      8.03 Modifications as a remedy.

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

     

    Section
      8.04 Modifications upon renewal or extension of
      Contract.

    

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

    

    (b)
      HMO
      must respond to HHSC’s proposed modification within the timeframe specified by
      HHSC, generally within thirty (30) days of receipt.  Upon receipt of
      HMO’s response to the proposed modifications, HHSC may enter into negotiations
      with HMO to arrive at mutually agreeable Contract amendments. In the event
      that
      HHSC determines that the Parties will be unable to reach agreement on mutually
      satisfactory contract modifications, then HHSC will provide written notice
      to
      HMO of its intent not to extend the Contract beyond the Contract Term then
      in
      effect.

    

    Section
      8.05 Modification of HHSC Uniform Managed Care
      Manual.

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

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

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

     

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

     

    Section
      8.06 CMS approval of Medicaid amendments

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

     

    Section
      8.07 Required compliance with amendment and modification
      procedures.

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

     

    Article
      9. Audit & Financial Compliance

    Section
      9.01 Financial record retention and audit.

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

     

    Section
      9.02 Access to records, books, and documents.

    (a)
      Upon
      reasonable notice, HMO must provide, and cause its Subcontractors to provide,
      the officials and entities identified in this Section with prompt, reasonable,
      and adequate access to any records,

    books,
      documents, and papers that are related to the performance of the Scope of
      Work.

    

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

    

    (1)
      Examination;

    

    (2)
      Audit;

    

    (3)
      Investigation;

    

    (4)
      Contract administration; or

    

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

    

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

    

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

    

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

    

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

    

    (4)
      The
      Office of Inspector General;

    

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

    

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

    

    (7)
      A
      State or Federal law enforcement agency;

    

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

    

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

    

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

    

    Section
      9.03 Audits of Services, Deliverables and
      inspections.

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

     

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

     

    (2)
      HMO
      Software and Equipment.

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

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

    

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

    

    (2)
      the
      Services and Deliverables provided;

    

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

    

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

    

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

    

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

    

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

    

    Section
      9.04 SAO Audit

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

     

    Section
      9.05 Response/compliance with audit orinspection
      findings.

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

    

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

    

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

    

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

    

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

    

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

    

    Article
      10. Terms & Conditions of Payment

    Section
      10.01 Calculation of monthly Capitation
      Payment.

    

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

    

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

    

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

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

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

     

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

    

    (2)
      an
      amount for administering the program,

    

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

    

    (4)
      with
      respect to the Medicaid program, pass
      through funds for high-volume providers. Capitation Rates for each HMO Program
      may vary by Service Area and MCO.  HHSC will employ or retain
      qualified actuaries to perform data analysis and calculate the Capitation Rates
      for each Rate Period.

     

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

     

    Section
      10.02 Time and Manner of Payment.

    

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

    

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

    

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

    

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

    

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

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

     

    Section
      10.03 Certification of Capitation
      Rates.

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

     

    Section
      10.04 Modification of Capitation Rates.

    The
      Parties expressly understand and agree that the agreed Capitation Rates are
      subject to modification in accordance with Article 8
(“Amendments and Modifications,”) if changes in state

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

     

    Section
      10.05 STAR Capitation Structure.

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

    

    (1)
      TANF
      adults;

    

    (2)
      TANF
      children over 12 months of age;

     

    (3)
      Expansion children over 12 months of age;

    

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

    

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

    

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

    

    (7)
      Federal mandate children; and

    

    (8)
      Pregnant women.

    

    (b)
      STAR
      Capitation Rate development:

    

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

    

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

    

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

    

    For
      Service Areas where HHSC has not operated the STAR Program prior to
      the

    Effective
      Date of this Contract, HHSC will establish base Capitation Rates for Rate
      Periods 1 and 2 by analyzing Fee-for-Service claims data for the Service
      Area.  This analysis will include a review of historical enrollment
      and claims experience information; any changes to Covered Services and covered
      populations; rate changes specified by the Texas Legislature; and any other
      relevant information.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

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

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

     

    (c)
      Acuity adjustment. HHSC may evaluate and implement an acuity adjustment
      methodology, or alternative reasonable methodology, that appropriately
      reimburses the HMO for acuity and cost differences that deviate from that of
      the
      community average, if HHSC in its sole discretion determines that such a
      methodology is reasonable and appropriate.  The community average is a
      uniform rate for all HMOs in a Service Area, and is determined by combining
      all
      the experience for all HMOs
      in a
      Service Area to get an average rate for the Service Area. Value-added Services
      will not be included in the rate-

    setting
      process.

     

    Section
      10.05.1STAR+PLUS Capitation Structure.

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

    

    (1)
      Medicaid Only Standard Rate

    

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

    

    (3)
      Dual
      Eligible Standard Rate

    

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

    

    (5)
      Nursing Facility – Medicaid only

    

    (6)
      Nursing Facility - Dual Eligible

    

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

    

    (b)
      STAR+PLUS Capitation Rates  For All Service Areas, HHSC will establish
      base Capitation Rates by Service Area based on fee-for­service experience in
      the counties included in the Service Area. For the base Capitation Rate in
      the
      Harris Service Area, the encounter data from existing STAR+PLUS plans in Harris
      County will be blended with the fee-for-service experience from the balance
      of
      counties in the Harris Service Area. HHSC may adjust the base Capitation Rate
      by
      the HMO’s Case Mix Index to yield the final Capitation Rates. HHSC reserves the
      right to trend forward these rates
      until sufficient Encounter Data is available to base Capitation Rates on
      Encounter Data.

    

    (c)
      Delay
      in Increased Capitation Level for Certain Members Receiving Waiver
      Services

    

    Once
      a
      current HMO Member has been certified to receive STAR+PLUS Waiver (SPW)
      services, there is a two-month delay before the HMO will begin receiving the
      higher capitation payment.

    Non-Waiver
      Members who qualify for STAR+PLUS based on eligibility for SPW services and
      Waiver recipients who transfer from another region will not be subject to this
      two-month delay in the increased capitation payment.

    All
      SPW
      recipients will be registered into Service Authorization System Online
      (SASO).  The Premium Payment System (PPS) will process data from the
      SASO system in establishing a Member’s correct capitation payment.

     

    Section
      10.06 CHIP Capitation Rates Structure.

    (a)
      CHIP
      Rate Cells. CHIP Capitation Rates are defined on a per Member per month basis
      by
      the Rate Cells applicable

    to
      a
      Service Area.  CHIP Rate Cells are based on the Member’s age group as
      follows:

    

    (1)
      under
      age one (1);

    

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

    

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

    

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

    

    (b)
      CHIP
      Capitation Rate development:   HHSC will establish base
      Capitation Rates by analyzing Encounter Data and financial data for each Service
      Area.  This analysis will include a review of historical enrollment
      and claims experience information; any changes to Covered Services and covered
      populations; rate changes specified by the Texas Legislature; and any other
      relevant information.  HHSC may modify the Service Area base
      Capitation

    Rate
      using diagnosis based risk adjusters to yield the final Capitation
      Rates.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

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

    

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

     

    Section 10.06.1 CHIP Perinatal Program
      Capitation Structure.

     

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

    

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

    

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

    

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

     

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

    

    (b)
      CHIP
      Perinatal Program Capitation Rate Development

    

    (1)
      Until
      such time as adequate encounter data is available to set rates, CHIP Perinatal
      Program capitation rates will be established based on experience from comparable
      populations in the Medicaid Fee-for-Service and STAR programs.  This
      analysis will include: a review of historical enrollment and claims experience
      information; changes to Covered Services and covered populations; rate changes
      specified by the Texas Legislature; and any other relevant
      information.  HHSC may modify the Service Area based Capitation Rate
      using diagnosis-based risk adjusters to yield the final Capitation
      Rates.

    

    (2)
      Effective 4/1/07, on a prospective basis, the monthly premium rate for Perinatal
      expectant mothers at or below 185% of FPL has been increased. The rate increase
      is to be passed on to all physicians involved in the labor with delivery for
      members at or below 185% FPL. The average increase for the fee schedule for
      the
      procedure codes related to labor with delivery is 26.1%.

    

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

    

    Section
      10.07 HMO input during rate setting process.

    

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

    

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

    

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

    

    Section
      10.08 Adjustments to CapitationPayments.

    

    (a)
      Recoupment. HHSC
      may
      recoup a payment made to the HMO for a Member if:

    

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

    

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

    

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

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

    

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

     

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

    

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

    

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

    

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

    

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

    

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

    

    (f)
      HMO
      must maintain complete claims and adjudication disposition documentation,
      including paid and denied amounts for each delivery. The HMO must submit the
      documentation to HHSC within five

    

    (5)
      Business Days after receiving a request for such information from
      HHSC.

    

    Section
      10.10 Administrative Fee for SSI Members

    

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

    

    STAR
      Program; however, HHSC reserves the right to discontinue such voluntary
      participation.

    

    (b)
      Administrative services and functions.

    

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

    

    (i)
      prior
      authorization of services;

    

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

    

    (iii)
      health education;

    

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

    

    (v)
      quality assessment and performance improvement activities;

    

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

    

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

    

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

    

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
Section
      10.11STAR, CHIP , and CHIP Perinatal Experience
      Rebate

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

    

    (b)
      Graduated Experience Rebate Sharing Method.

    

    
      	
              Experience
                Rebate as a % of Revenues

            	
              HMO
                Share

            	
              HHSC
                Share

            
	
              <
                3%

            	
              100%

            	
              0%

            
	
              >
                3% and < 7%

            	
              75%

            	
              25%

            
	
              >
                7% and < 10%

            	
              50%

            	
              50%

            
	
              >
                10% and < 15%

            	
              25%

            	
              75%

            
	
              >
                15%

            	
              0%

            	
              100%

            

    

    
    

    

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

    

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

    

    (2)
      HHSC
      and the HMO will share that portion of the Net Income before Taxes that is
      over
      3% but less than or equal to 7% of the total Revenues received with 75% to
      the
      HMO and 25% to HHSC.

    

    (3)
      HHSC
      and the HMO will share that portion of the Net Income before Taxes that is
      over
      7% but less than or equal to 10% of the total Revenues received with 50% to
      the
      HMO and 50% to HHSC.

    

    (4)
      HHSC
      and the HMO will share that portion of the Net Income before Taxes that is
      over
      10% but less than or equal to 15% of the total Revenues received with 25% to
      the
      HMO and 75% to HHSC.

    

    (5)
      HHSC
      will be paid the entire portion of the Net Income before Taxes that exceeds
      15%
      of the total Revenues.

     

    (c)
      Net
      income before taxes.

    

    (1)
      The
      HMO must compute the Net Income before Taxes in accordance with the HHSC
      Uniform Managed Care Manual’s “Cost Principles for Administrative Expenses”
and“FSR Instructions for Completion” and applicable
      federal regulations. The Net Income before Taxes will be confirmed by HHSC
      or
      its agent for the Rate Year relating to all revenues and expenses incurred
      pursuant to the Contract. HHSC reserves the right to modify the “Cost
      Principles for Administrative Expenses” and“FSR Instructions
      for Completion” found in HHSC’s Uniform Managed Care
      Manual in accordance with Section 8.05.

    

    (2)
      For
      purposes of calculating Net Income before Taxes, the following items are not
      Allowable Expenses:

    

    (i)
      the
      payment of an Experience Rebate;

    

    (ii)
      any
      interest expense associated with late or underpayment of the Experience
      Rebate;

    

    (iii)
      financial incentives, including without limitation the Quality Challenge Award
      described in Attachment B-1, Section 6.3.2.3; and

    

    (iv)
      financial disincentives, including without limitation: the Performance-based
      Capitation Rate described in Attachment B-1, Section 6.3.2.2; and the liquidated
      damages described in Attachment B-5.

    

    (3)
      Financial incentives are true net bonuses and shall not be reduced by the
      potential increased Experience Rebate payments.  Financial
      disincentives are true net disincentives, and shall not be offset in whole
      or
      part by potential decreases in Experience Rebate payments.

    

    (4)
      For
      FSR reporting purposes, financial incentives incurred shall not be reported
      as
      an increase in Revenues or as an offset to costs, and any award of such will
      not
      increase reported income.  Financial disincentives incurred shall not
      be included as reported expenses, and shall not reduce reported
      income.  The reporting or recording of any of these incurred items
      will be done on a memo basis, which is below the income line, and will be listed
      as separate items.

    

    (d)
      Carry
      forward of prior Rate Year losses. Losses incurred by a STAR, CHIP, or CHIP
      Perinatal HMO for one Rate Year may be carried forward to the next Rate Year,
      and applied as an offset against a STAR, CHIP, or CHIP Perinatal Experience
      Rebate. Prior losses may be carried forward for only one Rate Year for this
      purpose.  If the HMO offsets a loss against another STAR, CHIP, or
      CHIP Perinatal Service Area, only that portion of the loss
      that
      was not used as an offset may be carried forward to the next Rate Year. Losses
      incurred by a STAR,
      CHIP, CHIP Perinatal HMO cannot be offset against the STAR+PLUS
      Program.

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    (e)
      Settlements for payment.

    

    (1)
      There
      will be at least two
      settlements for HMO payment(s) of the State share of the Experience Rebate
      for
      the STAR, CHIP, and CHIP Perinatal Programs. The first scheduled settlement
      shall equal 100% of the State share of the Experience Rebate as derived from
      the
      FSR, and shall be paid on the same day the 90-day FSR Report is submitted to
      HHSC, accompanied by an actuarial opinion certifying the reserve.

    

    (2)
      The
      second scheduled settlement shall be an adjustment to the first settlement
      and
      shall be paid by the HMO to HHSC on the same day that the 334-day FSR Report
      is
      submitted to HHSC if the adjustment is a payment from the HMO to
      HHSC.

    

    (3)
      HHSC
      or its agent may audit or review the FSRs. If HHSC determines that corrections
      to the FSRs are required, based on an HHSC audit/review or other documentation
      acceptable to HHSC, to determine an adjustment to the amount of the second
      settlement, then final adjustment shall be made by HHSC within three years
      from
      the date that the HMO submits the 334-day FSR.  Any settlement payment
      resulting from an audit or final adjustment shall be due from the HMO within
      30
      days of the earlier of:

    

    (i)
      the
      date of the management representation letter resulting from the audit;
      or

    

    (ii)
      the
      date of any invoice issued by HHSC. Payment within the 30-day timeframe will
      not
relieve
      the HMO of any interest payment obligation that may exist under Section
      10.11(f).

    

    (4)
      HHSC
      may offset any Experience Rebates and/or corresponding interest payments owed
      to
      the State from any future Capitation Payments, or collect such sums directly
      from the HMO. HHSC must receive the settlements by their due dates or HHSC
      will
      assess interest on the amounts due at the current prime interest rate as set
      forth below. HHSC may adjust the Experience Rebate if HHSC determines the HMO
      has paid amounts for goods or services that are not reasonable, necessary,
      and
      allowable in accordance with the HHSC Uniform Managed Care Manual’s
“Cost Principles for Administrative Expenses” and“FSR
      Instructions for Completion” and applicable federal regulations. HHSC
      has final authority in auditing and determining the amount of the Experience
      Rebate.

    

    (f)
      Interest on Experience Rebate.

    

    (1)
      Interest on any Experience Rebate owed to HHSC shall be charged beginning thirty
      (30) days after the due date for each settlement, as described in Section
      10.11(e).  In addition, if any adjusted amount is owed to HHSC at the
      final settlement date, then interest will be charged on the adjusted amount
      owed
beginning
      thirty (30) days after the second settlement date to the date of the final
      settlement payment.  HHSC will calculate interest at the Department of
      Treasury’s Median Rate (resulting from the Treasury’s auction of 13-week bills)
      for the week in which the liability is assessed.

    

    (2)
      If an
      audit or adjustment determines a downward revision of income after an interest
      payment has previously been required for the same State Fiscal Year, then HHSC
      will recalculate the interest and, if necessary, issue a full or partial refund
      or credit to the HMO.

    

    (3)
      Any
      interest obligations that are incurred pursuant to Section 10.11 that are not
      timely paid will be subject to accumulation of interest as well, at the same
      rate as applicable to the underlying Experience Rebate.

    

    (4)
      All
      interest assessed pursuant to Section 10.11
      will continue to accrue until such point as a payment is received by HHSC,
      at
      which point interest on the amount received will stop accruing.  If a
      balance remains at that point that is subject to interest, then the balance
      shall continue to accrue interest. If interim payments are made, such as between
      the first and second settlements, then any interest that may be due will only
      be
      charged on amounts for the time period during which they remained
      unpaid.  By way of example only, if $100,000 is subject to interest
      commencing on a given day, and a payment is received for $75,000 35 days after
      the start of interest, then the $75,000 will be subject to 35 days of interest,
      and the $25,000 balance will continue to accrue interest until
      paid.

     

    Section
      10.11.1 STAR+PLUS Experience Rebate

    

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

    

    (b)
      Graduated STAR+PLUS Experience Rebate Sharing Method.

    

    
      	
              Experience
                Rebate as a % of Revenues

            	
              HMO
                Share

            	
              HHSC
                Share

            
	
              <
                3%

            	
              50%

            	
              50%

            
	
              >
                3%

            	
              75%

            	
              25%

            

    

    
    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

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

    

    (1)
      HHSC
      and the STAR+PLUS HMO will share that portion of the Net Income before Taxes
      that is equal to or less than 3% of the total STAR+PLUS Revenues received with
      50% to the HMO and 50% to HHSC.

    

    (2)
      HHSC
      and the STAR+PLUS HMO will share that portion of the Net Income before Taxes
      that is over 3% of the total STAR+PLUS Revenues received with 75% to the HMO
      and
      25% to HHSC.

    

    (c)
      Net
      income before taxes. 1) The HMO must compute the Net Income before Taxes in
      accordance with the HHSC Uniform Managed Care Manual’s “Cost Principles
      for Administrative Expenses” and“FSR Instructions for
      Completion” and applicable federal regulations. The Net Income before
      Taxes will be confirmed by HHSC or its agent for the Rate Year relating to
      all
revenues
      and expenses incurred pursuant to the Contract. HHSC reserves the right to
      modify the “Cost
      Principles for Administrative Expenses” and“FSR Instructions
      for Completion” found in HHSC’s Uniform Managed Care
      Manual in accordance with Section 8.05.

    

    (2)
      For
      purposes of calculating Net Income before Taxes, the following items are not
      Allowable Expenses:

    

    (i)
      the
      payment of an Experience Rebate;

    

    (ii)
      any
      interest expense associated with late or underpayment of the Experience
      Rebate;

    

    (iii)
      financial incentives, including without limitation the Quality Challenge Award
      described in Attachment B-1, Section 6.3.2.3, and the STAR+PLUS Hospital
      Inpatient Incentive Shared Savings Award described in Attachment B-1, Section
      6.3.2.5.2; and

    

    (iv)
      financial disincentives, including without limitation: the Performance-based
      Capitation Rate described in Attachment B-1, Section 6.3.2.2; the STAR+PLUS
      Hospital Inpatient Disincentive Administrative Fee at Risk described in
      Attachment B-1, Section 6.3.2.5.1; and the liquidated damages described in
      Attachment B-5.

    

    (3)
      Financial incentives are true net bonuses and shall not be reduced by the
      potential increased Experience Rebate payments.  Financial
      disincentives are true net disincentives, and shall not be offset in whole
      or
      part by potential decreases in Experience Rebate payments.

    

    (4)
      For
      FSR reporting purposes, financial incentives incurred shall not be reported
      as
      an increase
      in Revenues or as an offset to costs, and any award of such will not increase
      reported income.  Financial disincentives incurred shall not be
      included as reported expenses, and shall not reduce reported
      income.  The reporting or recording of any of these incurred items
      will be done on a memo basis, which is below the income line, and will be listed
      as separate items.

    

    (d)
      Carry
      forward of prior Rate Year losses. Losses incurred by a STAR+PLUS HMO for one
      Rate Year may be carried forward to the next Rate Year, and applied as an offset
      against a STAR+PLUS Experience Rebate.  Prior losses may be carried
      forward for only one Rate Year for this purpose.  If the HMO offsets a
      loss against another STAR+PLUS Service Area, only that portion of the loss
      that
      was not used as an offset may be carried forward to the next Rate
      Year. Losses incurred by a STAR+PLUS HMO cannot be offset against the STAR
      or
      CHIP Programs.

    

    (e)
      Settlements for payment.

    

    (1)
      There
      will be at least two settlements for HMO payment(s) of the State share of the
      Experience Rebate for the STAR, CHIP, and CHIP Perinatal Programs. The first
      scheduled settlement shall equal 100% of the State share of the Experience
      Rebate as derived from the FSR, and shall be paid on the same day the 90-day
      FSR
      Report is submitted to HHSC, accompanied by an actuarial opinion certifying
      the
      reserve.

    

    (2)
      The
      second scheduled settlement shall be an adjustment to the first settlement
      and
      shall be paid by the HMO to HHSC on the same day that the 334-day FSR Report
      is
      submitted to HHSC if the adjustment is a payment from the HMO to
      HHSC.

    

    (3)
      HHSC
      or its agent may audit or review the FSRs. If HHSC determines that corrections
      to the FSRs are required, based on an HHSC audit/review or other documentation
      acceptable to HHSC, to determine an adjustment to the amount of the second
      settlement, then final adjustment shall be made by HHSC within three years
      from
      the date that the HMO submits the 334-day FSR.  Any settlement payment
      resulting from an audit or final adjustment shall be due from the HMO within
      30
      days of the earlier of:

    

    (i)
      the
      date of the management representation letter resulting from the audit;
      or

    

    (ii)
      the
      date of any invoice issued by HHSC. Payment within the 30-day timeframe will
      not
relieve
      the HMO of any interest payment obligation that may exist under Section
      10.11.1(f).

     

    (4)
      HHSC
      may offset any Experience Rebates and/or corresponding interest payments owed
      to
      the State from any future Capitation Payments, or collect such sums directly
      from the HMO.  HHSC must receive settlements by their due dates or
      HHSC will assess interest on the amounts due at the current prime
      interest rate as set forth below. HHSC may adjust the Experience Rebate if
      HHSC
      determines the HMO has paid amounts for goods or services that are not
      reasonable, necessary, and allowable in accordance with the HHSC Uniform
      Managed Care Manual’s “Cost Principles for Administrative Expenses”
and“FSR Instructions for Completion” and applicable
      federal regulations. HHSC has final authority in auditing and determining the
      amount of the Experience Rebate.

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    (f)
      Interest on Experience Rebate.

    

    (1)
      Interest on any Experience Rebate owed to HHSC shall be charged beginning thirty
      (30) days after the due date for each settlement, as described in Section
      10.11.1(e).  In addition, if any adjusted amount is owed to HHSC at
      the final settlement date, then interest will be charged on the adjusted amount
      owed beginning thirty (30) days after the second settlement date to the date
      of
      the final settlement payment.  HHSC will calculate interest at the
      Department of Treasury’s Median Rate (resulting from the Treasury’s auction of
      13-week bills) for the week in which the liability is assessed.

    

    (2)
      If an
      audit or adjustment determines a downward revision of income after an interest
      payment has previously been required for the same State Fiscal Year, then HHSC
      will recalculate the interest and, if necessary, issue a full or partial refund
      or credit to the HMO.

    

    (3)
      Any
      interest obligations that are incurred pursuant to Section 10.11.1 that are
      not
      timely paid will be subject to accumulation of interest as well, at the same
      rate as applicable to the underlying Experience Rebate.

    

    (4)
      All
      interest assessed pursuant to Section 10.11.1
      will continue to accrue until such point as a payment is received by HHSC,
      at
      which point interest on the amount received will stop accruing.  If a
      balance remains at that point that is subject to interest, then the balance
      shall continue to accrue interest. If interim payments are made, such as between
      the first and second settlements, then any interest that may be due will only
      be
      charged on amounts for the time period during which they remained
      unpaid.  By way of example only, if $100,000 is subject to interest
      commencing on a given day, and a payment is received for $75,000 35 days after
      the start of interest, then the $75,000 will be subject to 35 days of interest,
      and the $25,000 balance will continue to accrue interest until
      paid.

     

    Section
      10.12 Payment by Members.

    (a)
      Medicaid HMOs Medicaid HMOs and their Network Providers are prohibited from
      billing or collecting any amount from a Member
      for Health Care Services covered by this Contract. HMO must inform Members
      of
      costs for

    non-covered
      services, and must require its Network Providers to:

    

    (1)
      inform Members of costs for non-covered services prior to rendering such
      services; and

    

    (2)
      obtain a signed Private Pay form from such Members.

     

    (b)
      CHIP
      HMOs.

    

    (1)
      Families that meet the enrollment period cost share limit requirement must
      report it to the HHSC Administrative Services Contractor. The HHSC
      Administrative Service Contractor notifies the HMO that a family’s cost share
      limit has been reached. Upon notification from the HHSC Administrative Services
      Contractor that a family has reached its cost-sharing limit for the term of
      coverage, the HMO will generate and mail to the CHIP Member a new Member ID
      card
      within five days, showing that the CHIP Member’s cost-sharing obligation for
      that term of coverage has been met.  No cost-sharing may be collected
      from these CHIP Members for the balance of their term of coverage.

    

    (2)
      Providers are responsible for collecting all CHIP Member co-payments at the
      time
      of service. Co-payments that families must pay vary according to their income
      level. No co-payments apply, at any income level, to well-child or well-baby
      visits or immunizations. Except for costs associated with unauthorized
      non-emergency services provided to a Member by Out-of-Network providers and
      for
      non-covered services, the co-payments outlined in the CHIP Cost Sharing table
      in
the HHSC Uniform Managed Care Manual are the only amounts that
      a provider may collect from a CHIP-eligible family.

    

    (3)
      Federal law prohibits charging cost-sharing or deductibles to CHIP Members
      of
      Native Americans or Alaskan Natives. The HHSC Administrative Services Contractor
      will notify the HMO of CHIP Members who are not subject to cost-sharing
      requirements.  The HMO is responsible for educating Providers
      regarding the cost-sharing waiver for this population.

    

    (4)
      An
      HMO’s monthly Capitation Payment will not be reduced for a family’s failure to
      make its CHIP premium payment.  There is no relationship between the
      per Member/per month amount owed to the HMO for coverage provided during a
      month
      and the family’s payment of its CHIP premium obligation for that
      month.

    

    (c)
      CHIP
      Perinatal HMOs Cost-sharing does not apply to CHIP Perinatal Program
      Members.  The exemption from cost-sharing applies
      through the end of the original 12-month enrollment period.

     

    Section
      10.13 Restriction on assignment of fees.

    During
      the term of the Contract, HMO may not, directly or indirectly, assign to any
      third party any beneficial or legal interest of the HMO in or to
      any

    payments
      to be made by HHSC pursuant to this Contract. This restriction does not apply
      to
      fees paid to Subcontractors.

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Section
      10.14 Liability for taxes.

    HHSC
      is
      not responsible in any way for the payment of any Federal, state or local taxes
      related to or incurred in connection with the HMO’s performance of this
      Contract. HMO must pay and discharge any and all such taxes, including any
      penalties and interest. In addition, HHSC is exempt from Federal excise taxes,
      and will not pay any personal property taxes or income taxes levied on HMO
      or
      any taxes levied on employee wages.

     

    Section
      10.15 Liability for employment-related charges and
      benefits.

    HMO
      will
      perform work under this Contract as an independent contractor and not as agent
      or representative of HHSC. HMO is solely and exclusively liable for payment
      of
      all employment-related charges incurred in connection with the performance
      of
      this Contract, including but not limited to salaries, benefits, employment
      taxes, workers compensation benefits, unemployment insurance and benefits,
      and
      other insurance or fringe benefits for Staff.

     

    Section
      10.16 No additional consideration.

    

    (a)
      HMO
      will not be entitled to nor receive from HHSC any additional consideration,
      compensation, salary, wages, charges, fees, costs, or any other type of
      remuneration for Services and Deliverables provided under the Contract, except
      by properly authorized and executed Contract amendments.

    

    (b)
      No
      other charges for tasks, functions, or activities that are incidental or
      ancillary to the delivery of the Services and Deliverables will be sought from
      HHSC or any other state agency, nor will the failure of HHSC or any other party
      to pay for such incidental or ancillary services entitle the HMO to withhold
      Services and Deliverables due under the Agreement.

    

    (c)
      HMO
      will not be entitled by virtue of the Contract to consideration in the form
      of
      overtime, health insurance benefits, retirement benefits, disability retirement
      benefits, sick leave, vacation time, paid holidays, or other paid leaves of
      absence of any type or kind whatsoever.

    

    Section
      10.17 Federal Disallowance

    If
      the
      federal government recoups money from the state for expenses and/or costs that
      are deemed unallowable by the federal government, the state has the right to,
      in
      turn, recoup payments made to the HMOs for these same expenses and/or costs,
      even if they had not been previously disallowed by the state and were incurred
      by the HMO, and any such expenses and/or costs would then be deemed unallowable
      by the state.  If the state retroactively recoups money from the HMOs
      due to a federal

    disallowance,
      the state will recoup the entire amount paid to the HMO for the federally
      disallowed expenses and/or costs, not just the federal portion.

     

    Section
      10.18 Required Pass Through of Physician Rate
      Increases

    

    (a)
      Effective September 1, 2007, all HMOs participating in the STAR, STAR+PLUS,
      CHIP
      and CHIP Perinatal Programs are required to adjust their physician fee schedules
      to reflect the physician rate increases funded through Legislative
      Appropriations during the 80th Regular
      Legislative Session.  The HMOs are required to pass on all
      appropriated targeted physician rate increases to physicians serving their
      Members.

    

    (b)
      The
      Medicaid Fee Schedule in effect on September 1, 2007 (the “updated Medicaid Fee
      Schedule”) will include the legislatively-mandated physician rate increases
      based on the age of the Member, under 21 and over 21. The HMO must pay the
      appropriate rate for the age of the Member on the date of service.

    

    (c)
      If,
      under the terms of a Network Provider contract in place prior to September
      1,
      2007, the HMO pays for physician services based on the Medicaid Fee Schedule,
      then the HMO must pay for physician services provided on or after September
      1,
      2007 based on the updated Medicaid Fee Schedule.

    

    (d)
      If,
      under the terms of a Network Provider contract in place prior to September
      1,
      2007, the HMO pays for physician services based on a percentage of the Medicaid
      Fee Schedule, then the HMO must pay for physician services provided on or after
      September 1, 2007 based on the same percentage of the updated Medicaid Fee
      Schedule.  By way of example only, if prior to September 1, 2007, the
      HMO paid for physician services at110% of the Medicaid Fee Schedule, then the
      HMO will pay for physician services provided on or after September 1, 2007
      at
      110% of the updated Medicaid Fee Schedule.

    

    (e)
      If,
      under the terms of a Network Provider contract in place prior to September
      1,
      2007, the HMO uses benchmarks other than the Medicaid Fee Schedule (e.g. rates
      that are a percentage of Medicare) to pay for physician services, then for
      physician services provided on or after September 1, 2007, the HMO must increase
      its rates by 25% for services to Members under 21 and by 10% for Members age
      21
      and over.  The HMO must provide HHSC with a copy of both the prior and
      new Network Provider agreements and demonstrate how the new rates are 125%
      or
      110%, depending on the age of the Member, of the former rates.

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    (f)
      The
      HMO’s Chief Executive Officer will attest that the HMO has appropriately
      increased physician reimbursements as required above.  HHSC will
perform
      sample audits to verify payments to physicians are in accordance with this
      Contract requirement.

     

    Article
      11. Disclosure & Confidentiality of Information

    Section
      11.01 Confidentiality.

    

    (a)
      HMO
      and all Subcontractors, consultants, or agents under the Contract must treat
      all
      information that is obtained through performance of the Services under the
      Contract, including, but not limited to, information relating to applicants
      or
      recipients of HHSC Programs as Confidential Information to the extent that
      confidential treatment is provided under law and regulations.

    

    (b)
      HMO
      is responsible for understanding the degree to which information obtained
      through performance of this Contract is confidential under State and Federal
      law, regulations, or administrative rules.

    

    (c)
      HMO
      and all Subcontractors, consultants, or agents under the Contract may not use
      any information obtained through performance of this Contract in any manner
      except as is necessary for the proper discharge of obligations and securing
      of
      rights under the Contract.

    

    (d)
      HMO
      must have a system in effect to protect all records and all other documents
      deemed confidential under this Contract maintained in connection with the
      activities funded under the Contract. Any disclosure or transfer of Confidential
      Information by HMO, including information required by HHSC, will be in
      accordance with applicable law. If the HMO receives a request for information
      deemed confidential under this Contract, the HMO will immediately notify HHSC
      of
      such request, and will make reasonable efforts to protect the information from
      public disclosure.

    

    (e)
      In
      addition to the requirements expressly stated in this Section, HMO must comply
      with any policy, rule, or reasonable requirement of HHSC that relates to the
      safeguarding or disclosure of information relating to Members, HMO’S operations,
      or HMO’s performance of the Contract.

    

    (f)
      In
      the event of the expiration of the Contract or termination of the Contract
      for
      any reason, all Confidential Information disclosed to and all copies thereof
      made by the HMOI shall be returned to HHSC or, at HHSC’s option, erased or
      destroyed.  HMO shall provide HHSC certificates evidencing such
      destruction.

    

    (g)
      The
      obligations in this Section shall not restrict any disclosure by the HMO
      pursuant to any applicable law, or by order of any court or government agency,
      provided that the HMO shall give prompt notice to HHSC of such
      order.

    

    (h)
      With
      the exception of confidential Member information, Confidential Information
      shall
      not be afforded the protection of the Contract if such data was:

    

    (1)
      Already known to the receiving Party without restrictions at the time of its
      disclosure by the furnishing Party;

    

    (2)
      Independently developed by the receiving Party without reference to the
      furnishing Party’s Confidential Information;

    

    (3)
      Rightfully obtained by the other Party without restriction from a third party
      after its disclosure by the furnishing Party;

    

    (4)
      Publicly available other than through the fault or negligence of the other
      Party; or

    

    (5)
      Lawfully released without restriction to anyone.

     

    Section
      11.02 Disclosure of HHSC’s Confidential
      Information.

    

    (a)
      HMO
      will immediately report to HHSC any and all unauthorized disclosures or uses
      of
      HHSC’s Confidential Information of which it or its Subcontractor(s),
      consultant(s), or agent(s) is aware or has knowledge.  HMO
      acknowledges that any publication or disclosure of HHSC’s Confidential
      Information to others may cause immediate and irreparable harm to HHSC and
      may
      constitute a violation of State or federal laws.  If HMO, its
      Subcontractor(s), consultant(s), or agent(s) should publish or disclose such
      Confidential Information to others without authorization, HHSC will immediately
      be entitled to injunctive relief or any other remedies to which it is entitled
      under law or equity.  HHSC will have the right to recover from HMO all
      damages and liabilities caused by or arising from HMO’s, its Subcontractors’,
      consultants’, or agents’ failure to protect HHSC’s Confidential
      Information.  HMO will defend with counsel approved by HHSC, indemnify
      and hold harmless HHSC from all damages, costs, liabilities, and expenses
      (including without limitation reasonable attorneys’ fees and costs) caused by or
      arising from HMO’s or its Subcontractors’, consultants’ or agents’ failure to
      protect HHSC’s Confidential Information.  HHSC will not unreasonably
      withhold approval of counsel selected by the HMO.

    

    (b)
      HMO
      will require its Subcontractor(s), consultant(s), and agent(s) to comply with
      the terms of this provision.

    

    Section
      11.03 Member Records

    

    (a)
      HMO
      must comply with the requirements of state and federal laws, including the
      HIPAA
      requirements set forth in Section 7.07, regarding the transfer
      of Member Records.

    

    (b)
      If at
      any time during the Contract Term this Contract is terminated, HHSC may require
      the transfer of Member Records, upon written notice to HMO,
      to
      another entity, as consistent with federal and state laws and applicable
      releases.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    (c)
      The
      term “Member Record” for this Section means only those administrative,
      enrollment, case management and other such records maintained by HMO and is
      not
      intended to include patient records maintained by participating Network
      Providers.

     

    Section
      11.04 Requests for public information.

    

    (a)
      HHSC
      agrees that it will promptly notify HMO of a request for disclosure of
      information filed in accordance with the Texas Public Information Act, Chapter
      552 of the Texas Government Code, that consists of the HMO’S confidential
      information, including without limitation, information or data to which HMO
      has
      a proprietary or commercial interest.  HHSC will deliver a copy of the
      request for public information to HMO.

    

    (b)
      With
      respect to any information that is the subject of a request for disclosure,
      HMO
      is required to demonstrate to the Texas Office of Attorney General the specific
      reasons why the requested information is confidential or otherwise excepted
      from
      required public disclosure under law.  HMO will provide HHSC with
      copies of all such communications.

    

    (c)
      To
      the extent authorized under the Texas Public Information Act, HHSC agrees to
      safeguard from disclosure information received from HMO that the HMO believes
      to
      be confidential information.  HMO must clearly mark such information
      as confidential information or provide written notice to HHSC that it considers
      the information confidential.

    

    Section
      11.05 Privileged Work Product.

    

    (a)
      HMO
      acknowledges that HHSC asserts that privileged work product may be prepared
      in
      anticipation of litigation and that HMO is performing the Services with respect
      to privileged work product as an agent of HHSC, and that all matters related
      thereto are protected from disclosure by the Texas Rules of Civil Procedure,
      Texas Rules of Evidence, Federal Rules of Civil Procedure, or Federal Rules
      of
      Evidence.

    

    (b)
      HHSC
      will notify HMO of any privileged work product to which HMO has or may have
      access.  After the HMO is notified or otherwise becomes aware that
      such documents, data, database, or communications are privileged work product,
      only HMO personnel, for whom such access is necessary for the purposes of
      providing the Services, may have access to privileged work product.

    

    (c)
      If
      HMO receives notice of any judicial or other proceeding seeking to obtain access
      to HHSC’s privileged work product, HMO will:

    

    (1)
      Immediately notify HHSC; and

     

    (2)
      Use
      all reasonable efforts to resist providing such access.

    

    (d)
      If
      HMO resists disclosure of HHSC’s privileged work product in accordance with this
      Section, HHSC will, to the extent authorized under Civil Practices and Remedies
      Code or other applicable State law, have the right and duty to:

    

    (1)
      represent HMO in such resistance;

    

    (2)
      to
      retain counsel to represent HMO; or

    

    (3)
      to
      reimburse HMO for reasonable attorneys' fees and expenses incurred in resisting
      such access.

    

    (e)
      If a
      court of competent jurisdiction orders HMO to produce documents, disclose data,
      or otherwise breach the confidentiality obligations imposed in the Contract,
      or
      otherwise with respect to maintaining the confidentiality, proprietary nature,
      and secrecy of privileged work product, HMO will not be liable for breach of
      such obligation.

    

    Section
      11.06 Unauthorized acts.

    Each
      Party agrees to:

    

    (1)
      Notify the other Party promptly of any unauthorized possession, use, or
      knowledge, or attempt thereof, by any person or entity that may become known
      to
      it, of any HHSC Confidential Information or any information identified by the
      HMO as confidential or proprietary;

    

    (2)
      Promptly furnish to the other Party full details of the unauthorized possession,
      use, or knowledge, or attempt thereof, and use reasonable efforts to assist
      the
      other Party in investigating or preventing the reoccurrence of any unauthorized
      possession, use, or knowledge, or attempt thereof, of Confidential
      Information;

    

    (3)
      Cooperate with the other Party in any litigation and investigation against
      third
      Parties deemed necessary by such Party to protect its proprietary rights;
      and

    

    (4)
      Promptly prevent a reoccurrence of any such unauthorized possession, use, or
      knowledge such information.

    

    Section
      11.07 Legal action.

    Neither
      party may commence any legal action or proceeding in respect to any unauthorized
      possession, use, or knowledge, or attempt thereof by any person or entity of
      HHSC’s Confidential Information or information identified by the HMO as
      confidential or proprietary, which action or proceeding identifies the other
      Party such information without such Party’s consent.

     

    Article
      12. Remedies & Disputes

    Section
      12.01 Understanding and expectations.

    The
      remedies described in this Section are directed to HMO’s timely and responsive
      performance of the Services and production of Deliverables, and the creation
      of
      a flexible and responsive relationship

    between
      the Parties.  The HMO is expected to meet or exceed all HHSC
      objectives and standards, as set forth in the Contract.  All areas of
      responsibility and all Contract requirements will be subject to performance
      evaluation by HHSC.  Performance reviews may be conducted at the
      discretion of HHSC at any time and may relate to any responsibility and/or
      requirement.  Any and all responsibilities and/or requirements not
      fulfilled may be subject to remedies set forth in the Contract.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Section
      12.02 Tailored remedies.

    

    (a)
      Understanding of the Parties. HMO agrees and understands that HHSC may pursue
      tailored contractual remedies for noncompliance with the Contract.  At
      any time and at its discretion, HHSC may impose or pursue one or more remedies
      for each item of noncompliance and will determine remedies on a case-by-case
      basis.  HHSC’s pursuit or non-pursuit of a tailored
      remedy

    

    does
      not
      constitute a waiver of any other remedy that HHSC may have at law or
      equity.

    

    (b)
      Notice and opportunity to cure for non-material breach.

    

    (1)
      HHSC
      will notify HMO in writing of specific areas of HMO performance that fail to
      meet performance expectations, standards, or schedules set forth in the
      Contract, but that, in the determination of HHSC, do not result in a material
      deficiency or delay in the implementation or operation of the
      Services.

    

    (2)
      HMO
      will, within five (5) Business Days (or another date approved by HHSC) of
      receipt of written notice of a non-material deficiency, provide the HHSC Project
      Manager a written response that:

    

    (A)
      Explains the reasons for the deficiency, HMO’s plan to address or cure the
      deficiency, and the date and time by which the deficiency will be cured;
      or

    

    (B)
      If
      HMO disagrees with HHSC’s findings, its reasons for disagreeing with HHSC’s
      findings.

    

    (3)
      HMO’s
      proposed cure of a non-material deficiency is subject to the approval of HHSC.
      HMO’s repeated commission of non-material deficiencies or repeated failure to
      resolve any such deficiencies may be regarded by HHSC as a material deficiency
      and entitle HHSC to pursue any other remedy provided in the Contract or any
      other appropriate remedy HHSC may have at law or equity.

    

    (c)
      Corrective action plan.

    

    (1)
      At
      its option, HHSC may require HMO to submit to HHSC a written plan (the
“Corrective Action Plan”) to correct or resolve a material breach of this
      Contract, as determined by HHSC.

    

    (2)
      The
      Corrective Action Plan must provide:

    

    (A)
      A
      detailed explanation of the reasons for the cited deficiency;

    

    (B)
      HMO’s
      assessment or diagnosis of the cause; and

    

    (C)
      A
      specific proposal to cure or resolve the deficiency.

     

    (3)
      The
      Corrective Action Plan must be submitted by the deadline set forth in HHSC’s
      request for a Corrective Action Plan.  The Corrective Action Plan is
      subject to approval by HHSC, which will not unreasonably be
      withheld.

    

    (4)
      HHSC
      will notify HMO in writing of HHSC’s final disposition of HHSC’s
      concerns.  If HHSC accepts HMO’s proposed Corrective Action Plan, HHSC
      may:

    

    (A)
      Condition such approval on completion of tasks in the order or priority that
      HHSC may reasonably prescribe;

    

    (B)
      Disapprove portions of HMO’s proposed Corrective Action Plan; or

    

    (C)
      Require additional or different corrective action(s).

    

    Notwithstanding
      the submission and acceptance of a Corrective Action Plan, HMO remains
      responsible for achieving all written performance criteria.

    

    (5)
      HHSC’s acceptance of a Corrective Action Plan under this Section will
      not:

    

    (A)
      Excuse HMO’s prior substandard performance;

    

    (B)
      Relieve HMO of its duty to comply with performance standards; or

    

    (C)
      Prohibit HHSC from assessing additional tailored remedies or pursuing other
      appropriate remedies for continued substandard performance.

    

    (d)
      Administrative remedies.

    

    (1)
      At
      its discretion, HHSC may impose one or more of the following remedies for each
      item of material noncompliance and will determine the scope and severity of
      the
      remedy on a case-by-case basis:

    

    (A)
      Assess liquidated damages in accordance with Attachment B-5 to
      the HHSC Managed Care Contract, “Liquidated Damages
      Matrix;”

    

    (B)
      Conduct accelerated monitoring of the HMO. Accelerated monitoring includes
      more
      frequent or more extensive monitoring by HHSC or its agent;

    

    (C)
      Require additional, more detailed, financial and/or programmatic reports to
      be
      submitted by HMO;

    

    (D)
      Decline to renew or extend the Contract;

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    (E)
      Appoint temporary management;

    

    (F)
      Initiate disenrollment of a Member or Members;

    

    (G)
      Suspend enrollment of Members;

    

    (H)
      Withhold or recoup payment to HMO;

    

    (I)
      Require forfeiture of all or part of the HMO’s bond; or

    

    (J)
      Terminate the Contract in accordance with Section 12.03,
      (“Termination by HHSC”).

    

    (2)
      For
      purposes of the Contract, an item of material noncompliance means a specific
      action of HMO that:

    

    (A)
      Violates a material provision of the Contract;

    

    (B)
      Fails
      to meet an agreed measure of performance; or

    

    (C)
      Represents a failure of HMO to be reasonably responsive to a reasonable request
      of HHSC relating to the Services for information, assistance, or support within
      the timeframe specified by HHSC.

    

    (3)
      HHSC
      will provide notice to HMO of the imposition of an administrative remedy in
      accordance with this Section, with the exception of accelerated monitoring,
      which may be unannounced.  HHSC may require HMO to file a written
      response in accordance with this Section.

    

    (4)
      The
      Parties agree that a State or Federal statute, rule, regulation, or Federal
      guideline will prevail over the provisions of this Section unless the statute,
      rule, regulation, or guidelines can be read together with this Section to give
      effect to both.

    

    (e)
      Damages.

    

    (1)
      HHSC
      will be entitled to actual and consequential damages resulting from the HMO’S
      failure to comply with any of the terms of the Contract.  In some
      cases, the actual damage to HHSC or State of Texas as a result of HMO’S failure
      to meet any aspect of the responsibilities of the Contract and/or to meet
      specific performance standards set forth in the Contract are difficult or
      impossible to determine with precise accuracy.  Therefore, liquidated
      damages will be assessed in writing against and paid by the HMO in accordance
      with and for failure to meet any aspect of the responsibilities of the Contract
      and/or to meet the specific performance standards identified by the HHSC in
      Attachment B-5 to the HHSC Managed Care Contract,
“Deliverables/Liquidated Damages Matrix.” Liquidated damages will be
      assessed if HHSC determines such failure is the fault of the HMO (including
      the
      HMO’S Subcontractors and/or consultants) and is not materially caused or
      contributed to by HHSC or its agents.  If at any time,

    

    HHSC
      determines the HMO has not met any aspect of the responsibilities of the
      Contract and/or the specific performance standards due to mitigating
      circumstances, HHSC reserves the right to waive all or part of the liquidated
      damages.  All such waivers must be in writing, contain the reasons for
      the waiver, and be signed by the appropriate executive of HHSC.

    

    (2)
      The
      liquidated damages prescribed in this Section are not intended to be in the
      nature of a penalty, but are intended to be reasonable estimates of HHSC’s
      projected financial loss and damage resulting from the HMO’s nonperformance,
      including financial loss as a result of project delays.  Accordingly,
      in the event HMO fails to perform in accordance with the Contract, HHSC may
      assess liquidated damages as provided in this Section.

    

    (3)
      If
      HMO fails to perform any of the Services described in the Contract, HHSC may
      assess liquidated damages for each occurrence of a liquidated damages event,
      to
      the extent consistent with HHSC's tailored approach to remedies and Texas
      law.

    

    (4)
      HHSC
      may elect to collect liquidated damages:

    

    (A)
      Through direct assessment and demand for payment delivered to HMO;
      or

    

    (B)
      By
      deduction of amounts assessed as liquidated damages as set-off against payments
      then due to HMO or that become due at any time after assessment of the
      liquidated damages. HHSC will make deductions until the full amount payable
      by
      the HMO is received by HHSC.

    

    (f)
      Equitable Remedies

    

    (1)
      HMO
      acknowledges that, if HMO breaches (or attempts or threatens to breach) its
      material obligation under this Contract, HHSC may be irreparably
      harmed.  In such a circumstance, HHSC may proceed directly to court to
      pursue equitable remedies.

    

    (2)
      If a
      court of competent jurisdiction finds that HMO breached (or attempted or
      threatened to breach) any such obligations, HMO agrees that without any
      additional findings of irreparable injury or other conditions to injunctive
      relief, it will not oppose the entry of an appropriate order compelling
      performance by HMO and restraining it from any further breaches (or attempted
      or
      threatened breaches).

    

    (g)
      Suspension of Contract

    

    (1)
      HHSC
      may suspend performance of all or any part of the Contract if:

    

    (A)
      HHSC
      determines that HMO has committed a material breach of the
      Contract;

    

    (B)
      HHSC
      has reason to believe that HMO has committed, assisted in the commission of
      Fraud, Abuse, Waste, malfeasance,
      misfeasance, or nonfeasance by any party concerning the Contract;

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    (C)
      HHSC
      determines that the HMO knew, or should have known of, Fraud, Abuse, Waste,
      malfeasance, or nonfeasance by any party concerning the Contract, and the HMO
      failed to take appropriate action; or

    

    (D)
      HHSC
      determines that suspension of the Contract in whole or in part is in the best
      interests of the State of Texas or the HHSC Programs.

    

    (2)
      HHSC
      will notify HMO in writing of its intention to suspend the Contract in whole
      or
      in part.  Such notice will:

     

    (A)
      Be
      delivered in writing to HMO;

    

    (B)
      Include a concise description of the facts or matter leading to HHSC’s decision;
      and

    

    (C)
      Unless HHSC is suspending the contract for convenience, request a Corrective
      Action Plan from HMO or describe actions that HMO may take to avoid the
      contemplated suspension of the Contract.

    

    Section
      12.03 Termination by HHSC.

    This
      Contract will terminate upon the Expiration Date. In addition, prior to
      completion of the Contract Term, all or a part of this Contract may be
      terminated for any of the following reasons:

    

    (a)
      Termination in the best interest of HHSC. HHSC may terminate the Contract
      without cause at any time when, in its sole discretion, HHSC determines that
      termination is in the best interests of the State of Texas.  HHSC will
      provide reasonable advance written notice of the termination, as it deems
      appropriate under the circumstances.  The

    

    termination
      will be effective on the date specified in HHSC’s notice of
      termination.

    

    (b)
      Termination for cause. HHSC reserves the right to terminate this

    

    Contract,
      in whole or in part, upon the following conditions:

    (1)
      Assignment for the benefit of creditors,

    appointment
      of receiver, or inability to pay debts. HHSC may terminate this Contract at
      any time if HMO:

    

    (A)
      Makes
      an assignment for the benefit of its creditors;

    

    (B)
      Admits in writing its inability to pay its debts generally as they become due;
      or

    

    (C)
      Consents to the appointment of a receiver, trustee, or liquidator of HMO or
      of
      all or any part of its property.

    

    (2)
      Failure to adhere to laws, rules, ordinances, or orders.HHSC
      may
      terminate this Contract if a court of competent jurisdiction finds HMO failed
      to
      adhere to any laws, ordinances, rules, regulations or orders of any public
      authority having jurisdiction and such violation prevents or substantially
      impairs performance of HMO’s duties under this Contract.  HHSC will
      provide at least thirty (30) days advance written notice of such
      termination.

     

    (3)
      Breach of confidentiality. HHSC may terminate this Contract at any time
      if HMO breaches confidentiality laws with respect
      to the Services and Deliverables provided under this Contract.

     

    (4)
      Failure to maintain adequate personnel or resources.HHSC
      may
      terminate this Contract if, after providing notice and an opportunity to
      correct, HHSC determines that HMO has failed to supply personnel or resources
      and such failure results in HMO’s inability to fulfill its duties under this
      Contract. HHSC will provide at least thirty (30) days advance written notice
      of
      such termination.

     

    (5)
      Termination for gifts and gratuities.

    

    (A)
      HHSC
      may terminate this Contract at any time following the determination by a
      competent judicial or quasi-judicial authority and HMO’s exhaustion of all legal
      remedies that HMO, its employees, agents or representatives have either offered
      or given any thing of value to an officer or employee of HHSC or the State
      of
      Texas in violation of state law.

    

    (B)
      HMO
      must include a similar provision in each of its Subcontracts and shall enforce
      this provision against a Subcontractor who has offered or given any thing of
      value to any of the persons or entities described in this Section, whether
      or
      not the offer or gift was in HMO’s behalf.

    

    (C)
      Termination of a Subcontract by HMO pursuant to this provision will not be
      a
      cause for termination of the Contract unless:

    

    (1)
      HMO
      fails to replace such terminated Subcontractor within a reasonable time;
      and

    

    (2)
      Such
      failure constitutes cause, as described in this Subsection
      12.03(b).

    

    (D)
      For
      purposes of this Section, a “thing of value” means any item of tangible or
      intangible property that has a monetary value of more than $50.00 and includes,
      but is not limited to, cash, food, lodging, entertainment,
      and charitable contributions.  The term does not include contributions
      to holders of public office or candidates for public office that are paid and
      reported in accordance with State and/or Federal law.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    (6)
      Termination for non-appropriation of funds. Notwithstanding any other
      provision of this Contract, if funds for the continued fulfillment of this
      Contract by HHSC are at any time not forthcoming or are insufficient, through
      failure of any entity to appropriate funds or otherwise, then HHSC will have
      the
      right to terminate this Contract at no additional cost and with no penalty
      whatsoever by giving prior written notice documenting the lack of
      funding.  HHSC will provide at least thirty (30) days advance written
      notice of such termination.  HHSC will use
      reasonable efforts to ensure appropriated funds are available.

    

    (7)
      Judgment and execution.

    

    (A)
      HHSC
      may terminate the Contract at any time if judgment for the payment of money
      in
      excess of $500,000.00 that is not covered by insurance, is rendered by any
      court
      or governmental body against HMO, and HMO does not:

    

    (1)
      Discharge the judgment or provide for its discharge in accordance with the
      terms
      of the judgment;

    

    (2)
      Procure a stay of execution of the judgment within thirty (30) days from the
      date of entry thereof; or

    

    (3)
      Perfect an appeal of such judgment and cause the execution of such judgment
      to
      be stayed during the appeal, providing such financial reserves as may be
      required under generally accepted accounting principles.

    

    (B)
      If a
      writ or warrant of attachment or any similar process is issued by any court
      against all or any material portion of the property of HMO, and such writ or
      warrant of attachment or any similar process is not released or bonded within
      thirty (30) days after its entry, HHSC may terminate the Contract in accordance
      with this Section.

    

    (8)
      Termination for insolvency.

    

    (A)
      HHSC
      may terminate the Contract at any time if HMO:

    

    (1)
      Files
      for bankruptcy;

    (2)
      Becomes or is declared insolvent, or is the subject of any proceedings related
      to its liquidation, insolvency, or the appointment of a receiver or similar
      officer for it;

    

    (3)
      Makes
      an assignment for the benefit of all or substantially all of its creditors;
      or

    

    (4)
      Enters into an Contract for the composition, extension, or readjustment of
      substantially all of its obligations.

     

    (B)
      HMO
      agrees to pay for all reasonable expenses of HHSC including the cost of counsel,
      incident to:

    

    (1)
      The
      enforcement of payment of all obligations of the HMO by any action or
      participation in, or in connection with a case or proceeding under Chapters
      7,
      11, or 13 of the United States Bankruptcy Code, or any successor
      statute;

    

    (2)
      A
      case or proceeding involving a receiver or other similar officer duly appointed
      to handle the HMO's business; or

    

    (3)
      A
      case or proceeding in a State court initiated by HHSC when previous collection
      attempts have been unsuccessful.

    

    (9)
      Termination for HMO’S material breach of the Contract. HHSC
      will
      have the right to terminate the Contract in whole or in part if HHSC determines,
      at its sole discretion, that HMO has materially breached the
      Contract.  HHSC will provide at least thirty (30) days advance written
      notice of such termination.

     

    Section
      12.04 Termination by HMO.

    

    (a)
      Failure to pay. HMO may terminate this Contract if HHSC fails to pay the HMO
      undisputed charges when due as required under this
      Contract.  Retaining premium, recoupment, sanctions, or penalties that
      are allowed under this Contract or that result from the HMO’s failure to perform
      or the HMO’s default under the terms of this Contract is not cause for
      termination.  Termination for failure to pay does not release HHSC
      from the obligation to pay undisputed charges for services provided prior to
      the
      termination date. If HHSC fails to pay undisputed charges when due, then the
      HMO
      may submit a notice of intent to terminate for failure to pay in accordance
      with
      the requirements of Subsection 12.04(d). If HHSC pays all
      undisputed amounts then due within thirty (30)­days after receiving the
      notice of intent to terminate,

    

    the
      HMO
      cannot proceed with termination of the Contract under this Article.

    

    (b)
      Change to HHSC Uniform Managed Care  Manual. HMO
      may
      terminate this agreement if the Parties are unable to resolve a dispute
      concerning a material and substantive change to the HHSC Uniform Managed Care
      Manual (a change that materially and substantively alters the HMO’s ability to
      fulfill its obligations
      under the Contract).  HMO must submit a notice of intent to terminate
      due to a material and substantive change in the HHSC Uniform Managed Care Manual
      no later than thirty (30) days after the effective date of the policy
      change.  HHSC will not enforce the policy change during the period of
      time between the receipt of the notice of intent to terminate and the effective
      date of termination.

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    (c)
      Change to Capitation Rate. If HHSC proposes a modification to the Capitation
      Rate that is unacceptable to the HMO, the HMO may terminate the
      Contract.  HMO must submit a written notice of intent to terminate due
      to a change in the Capitation Rate no later than thirty (30) days after HHSC’s
      notice of the proposed change. HHSC will not enforce the rate change during
      the
      period of time
      between the receipt of the notice of intent to terminate and the effective
      date
      of termination.

    

    (d)
      Notice of intent to terminate. In
      order
      to terminate the Contract pursuant to this Section, HMO must give HHSC at least
      ninety (90)
      days
      written notice of intent to terminate.  The termination date will be
      calculated as the last day of the month following ninety (90) days from the
      date
      the notice of intent to terminate is received by HHSC.

    

    Section
      12.05 Termination by mutual agreement.

    This
      Contract may be terminated by mutual written agreement of the
      Parties.

     

    Section
      12.06 Effective date of termination.

    Except
      as
      otherwise provided in this Contract, termination will be effective as of the
      date specified in the notice of termination.

     

    Section
      12.07 Extension of termination effective
      date.

    The
      Parties may extend the effective date of termination one or more times by mutual
      written agreement.

     

    Section
      12.08 Payment and other provisions at Contract
      termination.

    

    (a)
      In
      the event of termination pursuant to this Article, HHSC will pay the Capitation
      Payment for Services and Deliverables rendered through the effective date of
      termination.  All pertinent provisions of the Contract will form the
      basis of settlement.

    

    (b)
      HMO
      must provide HHSC all reasonable access to records, facilities, and
      documentation as is required to efficiently and expeditiously close out the
      Services and Deliverables provided under this Contract.

    

    (c)
      HMO
      must prepare a Turnover Plan, which is acceptable to and approved by
      HHSC.  The Turnover Plan will be implemented during the time period
      between receipt of notice and the termination date.

    

    Section
      12.09 Modification of Contract in the event of
      remedies.

     HHSC
      may propose a modification of this Contract in response to the imposition of
      a
      remedy under this Article. Any modifications under this Section must be
      reasonable, limited to the matters causing the exercise of a remedy, in writing,
      and executed in accordance with Article 8. HMO must negotiate
      such proposed modifications in good faith.

     

    Section
      12.10 Turnover assistance.

    Upon
      receipt of notice of termination of the Contract by HHSC, HMO will provide
      any
      turnover assistance reasonably necessary to enable HHSC or its designee to
      effectively close out the Contract and move the work to another vendor or to
      perform the work itself.

     

    Section
      12.11 Rights upon termination or expiration of
      Contract.

    In
      the
      event that the Contract is terminated for any reason, or upon its expiration,
      HHSC will, at HHSC's discretion, retain ownership of any and all associated
      work
      products, Deliverables and/or documentation in whatever form that they
      exist.

     

    Section
      12.12 HMO responsibility for associated
      costs.

    If
      HHSC
      terminates the Contract for Cause, the HMO will be responsible to HHSC for
      all
      reasonable costs incurred by HHSC, the State of Texas, or any of its
      administrative agencies to replace the HMO.  These costs include, but
      are not limited to, the costs of procuring a substitute vendor and the cost
      of
      any claim or litigation that is reasonably attributable to HMO’s failure to
      perform any Service in accordance with the terms of the Contract

     

    Section
      12.13 Dispute resolution.

    

    (a)
      General agreement of the Parties. The Parties mutually agree that the interests
      of fairness, efficiency, and good business practices are best served when the
      Parties employ all reasonable and informal means to resolve any dispute under
      this Contract. The Parties express their mutual commitment to using all
      reasonable and informal means
      of
      resolving disputes prior to invoking a remedy provided elsewhere in this
      Section.

    

    (b)
      Duty
      to negotiate in good faith. Any dispute that in the judgment of any Party to
      this Contract may materially or substantially affect the performance of any
      Party will be reduced to writing and delivered to the other Party. The Parties
      must then negotiate in good faith and use every reasonable effort to resolve
      such dispute and the Parties shall not resort to any formal proceedings unless
      they have reasonably determined that a negotiated resolution is

    not
      possible. The resolution of any dispute disposed of by Contract between the
      Parties shall be reduced to
      writing and delivered to all Parties within ten (10) Business Days.

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    (c)
      Claims for breach of Contract.

    

    (1)
      General requirement. HMO’s claim for breach of this Contract will be
      resolved in accordance with the dispute resolution process established by HHSC
      in accordance with Chapter 2260, Texas Government Code.

    

    (2)
      Negotiation of claims. The Parties expressly agree that the HMO’s claim
      for breach of this Contract that the Parties cannot resolve in the ordinary
      course of business or through the use of all reasonable and informal means
      will
      be submitted to the negotiation process provided in Chapter 2260, Subchapter
      B,
      Texas Government Code.

    

    (A)
      To
      initiate the process, HMO must submit written notice to HHSC that specifically
      states that HMO invokes the provisions of Chapter 2260, Subchapter B, Texas
      Government Code.  The notice must comply with the requirements of
      Title 1, Chapter 392, Subchapter B of the Texas Administrative
      Code.

    

    (B)
      The
      Parties expressly agree that the HMO’s compliance with Chapter 2260, Subchapter
      B, Texas Government Code, will be a condition precedent to the filing of a
      contested case proceeding under Chapter 2260, Subchapter C, of the Texas
      Government Code.

    

    (3)
      Contested case proceedings. The contested case process provided in
      Chapter 2260, Subchapter C, Texas Government Code, will be HMO’s sole and
      exclusive process for seeking a remedy for any and all alleged breaches of
      contract by HHSC if the Parties are unable to resolve their disputes under
      Subsection (c)(2) of this Section. The
      Parties expressly agree that compliance with the contested case process provided
      in Chapter 2260, Subchapter C, Texas Government Code, will be a condition
      precedent to seeking consent to sue from the Texas Legislature under Chapter
      107, Civil Practices & Remedies Code. Neither the execution of this Contract
      by HHSC nor any other conduct of any representative of HHSC relating to this
      Contract shall be considered a waiver of HHSC’s sovereign immunity to
      suit.

    

    (4)
      HHSC rules. The submission, processing and resolution of HMO’s claim is
      governed by the rules adopted by HHSC pursuant to Chapter 2260, Texas Government
      Code, found at Title 1, Chapter 392, Subchapter B of the Texas Administrative
      Code.

    

    (5)
      HMO’s duty to perform. Neither the occurrence of an event constituting
      an alleged breach of contract nor the pending status of any claim for breach
      of
      contract is grounds for the suspension of performance, in whole or in part,
      by
      HMO of any duty or obligation with respect to the performance of this
Contract.
      Any changes to the Contract as a result of a dispute resolution will be
      implemented in accordance with Article 8 (“Amendments and
      Modifications”).

     

    Section
      12.14 Liability of HMO.

    

    (a)
      HMO
      bears all risk of loss or damage to HHSC or the State due to:

    

    (1)
      Defects in Services or Deliverables;

    

    (2)
      Unfitness or obsolescence of Services or Deliverables; or

    

    (3)
      The
      negligence or intentional misconduct of HMO or its employees, agents,
      Subcontractors, or representatives.

    

    (b)
      HMO
      must, at the HMO’s own expense, defend with counsel approved by HHSC, indemnify,
      and hold harmless HHSC and State employees, officers, directors, contractors
      and
      agents from and against any losses, liabilities, damages, penalties, costs,
      fees, including without limitation reasonable attorneys' fees, and expenses
      from
      any claim or action for property damage, bodily injury or death, to the extent
      caused by or arising from the negligence or intentional misconduct of the HMO
      and its employees, officers, agents, or Subcontractors.  HHSC will not
      unreasonably withhold approval of counsel selected by HMO.

    

    (c)
      HMO
      will not be liable to HHSC for any loss, damages or liabilities attributable
      to
      or arising from the failure of HHSC or any state agency to perform a service
      or
      activity in connection with this Contract.

    

    Article
      13. Assurances & Certifications

    Section
      13.01 Proposal certifications.

    HMO
      acknowledges its continuing obligation to comply with the requirements of the
      following certifications contained in its Proposal, and will immediately notify
      HHSC of any changes in circumstances affecting these
      certifications:

    

    (1)
      Federal lobbying;

    

    (2)
      Debarment and suspension;

    

    (3)
      Child
      support; and

    

    (4)
      Nondisclosure statement.

    

    Section
      13.02 Conflicts of interest.

    (a)
      Representation. HMO agrees to comply with applicable state and federal laws,
      rules, and regulations regarding conflicts of interest in the performance of
      its
      duties under this Contract. HMO warrants that it has no interest and will not
      acquire any direct or indirect interest that would
      conflict in any manner or degree with its performance under this
      Contract.

    (b)
      General duty regarding conflicts of interest. HMO will establish safeguards
      to
      prohibit employees from using their positions for a purpose that constitutes
      or
      presents the appearance of personal or organizational conflict of interest,
      or
      personal gain. HMO will operate with complete independence and objectivity
      without actual, potential or apparent conflict of interest with respect to
      the
activities
      conducted under this Contract with the State of Texas.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Section
      13.03 Organizational conflicts of interest.

    (a)
      Definition. An organizational conflict of interest is a set of facts or
      circumstances, a relationship, or other situation under which a HMO, or a
      Subcontractor has past, present, or currently planned personal or

    financial
      activities or interests that either directly or indirectly:

    

    (1)
      Impairs or diminishes the HMO’s, or Subcontractor’s ability to render impartial
      or objective assistance or advice to HHSC; or

    

    (2)
      Provides the HMO or Subcontractor an unfair competitive advantage in future
      HHSC
      procurements (excluding the award of this Contract).

    

    

    (b)
      Warranty. Except as otherwise disclosed and approved by HHSC prior to the
      Effective Date of the Contract, HMO warrants that, as of the Effective Date
      and
      to the best of its knowledge and belief, there are no relevant facts or
      circumstances that could give rise to an organizational conflict of interest
      affecting this Contract. HMO affirms that it has neither given, nor intends
      to
      give, at any time hereafter, any economic opportunity, future employment, gift,
      loan, gratuity, special discount, trip, favor, or service to a public servant
      or
      any employee or representative of same, at any time during the procurement
      process or in connection
      with the procurement process except as allowed under relevant state and federal
      law.

    

    (c)
      Continuing duty to disclose.

    

    (1)
      HMO
      agrees that, if after the Effective Date, HMO discovers or is made aware of
      an
      organizational conflict of interest, HMO will immediately and fully disclose
      such interest in writing to the HHSC project manager.  In addition,
      HMO must promptly disclose any relationship that might be perceived or
      represented as a conflict after its discovery by HMO or by HHSC as a potential
      conflict.  HHSC reserves the right to make a final determination
      regarding the existence of conflicts of interest, and HMO agrees to abide by
      HHSC’s decision.

    

    (2)
      The
      disclosure will include a description of the action(s) that HMO has taken or
      proposes to take to avoid or mitigate such conflicts.

    

    

    (d)
      Remedy. If HHSC determines that an organizational conflict of interest exists,
      HHSC may, at its discretion, terminate the Contract pursuant to
Subsection 12.03(b)(9). If HHSC determines that HMO was aware
      of an organizational conflict of interest before the award of this Contract
      and
      did not disclose the conflict to the contracting officer, such nondisclosure
      will be considered a material breach of the Contract.  Furthermore,
      such breach may be submitted to the Office of the Attorney General, Texas Ethics
      Commission,
      or appropriate State or Federal law enforcement officials for further
      action.

    

    (e)
      Flow
      down obligation. HMO must include the provisions of this Section in all
      Subcontracts for work to be performed similar to the service provided by HMO,
      and the terms "Contract,"
      "HMO," and "project manager" modified appropriately to preserve the State's
      rights.

     

    Section
      13.04 HHSC personnel recruitment prohibition.

    HMO
      has
      not retained or promised to retain any person or company, or utilized or
      promised to utilize a consultant that participated in HHSC’s development of
      specific criteria of the RFP or who participated in the selection of the HMO
      for
      this Contract. Unless
      authorized in writing by HHSC, HMO will not recruit or employ any HHSC
      professional or technical personnel who have worked on projects relating to
      the
      subject matter of this Contract, or who have had any influence on decisions
      affecting the subject matter of this Contract, for two (2) years following
      the
      completion of this Contract.

     

    Section
      13.05 Anti-kickback provision.

    HMO
      certifies that it will comply with the Anti-Kickback Act of 1986, 41 U.S.C.
      §51-58 and Federal Acquisition Regulation 52.203-7, to the extent
      applicable.

     

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

    In
      accordance with Section 403.055 of the Texas Government Code, HMO agrees that
      any payments due to HMO under the Contract will be first applied toward any
      debt
      and/or back taxes HMO owes State of Texas.  HMO further agrees that
      payments will be so applied until such debts and back taxes are paid in
      full.

     

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

    Article
      IX, Section 163 of the General Appropriations Act for the 1998/1999 state fiscal
      biennium prohibits an agency that receives an appropriation under either Article
      II or V of the General Appropriations Act from awarding a contract with the
      owner, operator, or administrator of a facility that has had a license,
      certificate, or permit revoked by
      another Article II or V agency. HMO certifies it is not ineligible for an award
      under this provision.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Section
      13.08 Outstanding debts and judgments.

    HMO
      certifies that it is not presently indebted to the State of Texas, and that
      HMO
      is not subject to an outstanding judgment in a suit by State of Texas against
      HMO for collection of the balance. For purposes of this Section, an indebtedness
      is any amount sum of money that is due and owing to the State of Texas and
      is
      not currently under dispute. A false statement regarding HMO’s status will be
      treated as a material breach of this Contract and may be grounds for termination
      at the option of HHSC.

     

    Article
      14. Representations & Warranties

    Section
      14.01 Authorization.

    

     (a)
      The execution, delivery and performance of this Contract has been duly
      authorized by HMO and no additional approval, authorization or consent of any
      governmental or regulatory agency is required to be obtained in order for HMO
      to
      enter into this Contract and perform its obligations under this
      Contract.

    

    (b)
      HMO
      has obtained all licenses, certifications, permits, and authorizations necessary
      to perform the Services under this Contract and currently is in good standing
      with all regulatory agencies that regulate any or all aspects of HMO’s
      performance of this Contract. HMO will maintain all required certifications,
      licenses, permits, and authorizations during the term of this
      Contract.

    

    Section
      14.02 Ability to perform.

     HMO
      warrants that it has the financial resources to fund the capital expenditures
      required under the Contract without advances by HHSC or assignment of any
      payments by HHSC to a financing source.

     

    Section
      14.03 Minimum Net Worth.

    The
      HMO
      has, and will maintain throughout the life of this Contract, minimum net worth
      to the greater of (a) $1,500,000; (b) an amount equal to the sum of twenty-five
      dollars ($25) times the number of all enrollees including Members; or (c) an
      amount that complies with standards adopted by TDI. Minimum net worth means
      the
      excess total admitted assets over total liabilities, excluding liability for
      subordinated debt issued in compliance with Chapter 843 of the Texas Insurance
      Code.

     

    Section
      14.04 Insurer solvency.

    (a)
      The
      HMO must be and remain in full compliance with all applicable state and federal
      solvency requirements for basic-service health maintenance organizations,
      including but not limited to, all reserve requirements, net worth standards,
      debt-to-equity ratios, or other debt limitations. In the event the HMO fails
      to
      maintain such compliance, HHSC, without limiting any other rights it may have
      by

    law
      or
      under the Contract, may terminate the Contract.

    

    (b)
      If
      the HMO becomes aware of any impending changes to its financial or business
      structure that could adversely impact its compliance with the requirements
      of
      the Contract or its ability to pay its debts as they come due, the HMO must
      notify HHSC immediately in writing.

    

    (c)
      The
      HMO must have a plan and take appropriate measures to ensure adequate provision
      against the risk of insolvency as required by TDI. Such provision must be
      adequate to provide for the following in the event of insolvency:

    

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

    

    (2)
      payments to unaffiliated health care providers and affiliated healthcare
      providers whose Contracts do not contain Member “hold harmless” clauses
      acceptable to the TDI;

    

    (3)
      continuation of Covered Services for the duration of the Contract Period for
      which a capitation has been paid for a Member;

    

    (4)
      provision against the risk of insolvency must be made by establishing adequate
      reserves, insurance or other guarantees in full compliance with all financial
      requirements of TDI and the Contract.

    

     Should
      TDI determine that there is an immediate risk of insolvency or the HMO is unable
      to provide Covered Services to its Members, HHSC, without limiting any other
      rights it may have by law, or under the Contract, may terminate the
      Contract.

     

    Section
      14.05 Workmanship and performance.

    

    (a)
      All
      Services and Deliverables provided under this Contract will be provided in
      a
      manner consistent with the standards of quality and integrity as outlined in
      the
      Contract.

    

    (b)
      All
      Services and Deliverables must meet or exceed the required levels of performance
      specified in or pursuant to this Contract.

    

    (c)
      HMO
      will perform the Services and provide the Deliverables in a workmanlike manner,
      in accordance with best practices and high professional standards used in
      well-managed operations performing services similar to the services described
      in
      this Contract.

    

    Section
      14.06 Warranty of deliverables.

    HMO
      warrants that Deliverables developed and delivered under this Contract will
      meet
      in all material respects the specifications as described in the Contract during
      the period following its acceptance by HHSC, through the term of the Contract,
      including any subsequently negotiated by HMO and HHSC. HMO will
      promptly repair or replace any such Deliverables not in compliance with this
      warranty at no charge to HHSC.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Section
      14.07 Compliance with Contract.

    HMO
      will
      not take any action substantially or materially inconsistent with any of the
      terms and conditions set forth in this Contract without the express written
      approval of HHSC.

     

    Section
      14.08 Technology Access

    

    (a)
      HMO
      expressly acknowledges that State funds may not be expended in connection with
      the purchase of an automated information system unless that system meets certain
      statutory requirements relating to accessibility by persons with visual
      impairments.  Accordingly, HMO represents and warrants to HHSC that
      this technology is capable, either by virtue of features included within the
      technology or because it is readily adaptable by use with other technology,
      of:

    

    (1)
      Providing equivalent access for effective use by both visual and non-visual
      means;

    

    (2)
      Presenting information, including prompts used for interactive communications,
      in formats intended for non-visual use; and

    

    (3)
      Being
      integrated into networks for obtaining, retrieving, and disseminating
      information used by individuals who are not blind or visually
      impaired.

    

    (b)
      For
      purposes of this Section, the phrase "equivalent access" means a substantially
      similar ability to communicate with or make use of the technology, either
      directly by features incorporated within the technology or by other reasonable
      means such as assistive devices or services that would constitute reasonable
      accommodations under the Americans with Disabilities Act or similar State or
      Federal laws.  Examples of methods by which equivalent access may be
      provided include, but are not limited to, keyboard alternatives to mouse
      commands and other means of navigating graphical displays, and customizable
      display appearance.

    

    (c)
      In
      addition, all technological solutions offered by the HMO must comply with the
      requirements of  Texas Government Code §531.0162.  This
      includes, but is not limited to providing technological solutions that meet
      federal accessibility standards for persons with disabilities, as
      applicable.

    

    Article
      15. Intellectual Property

    Section
      15.01 Infringement and misappropriation.

    (a)
      HMO
      warrants that all Deliverables provided by HMO will not infringe or
      misappropriate any right of, and will be free of any claim of, any third person
      or entity based on copyright, patent, trade secret, or other intellectual
      property rights.

    

    (b)
      HMO
      will, at its expense, defend with counsel approved by HHSC, indemnify, and
      hold
      harmless HHSC, its employees, officers, directors, contractors, and agents
      from
      and against any losses, liabilities, damages, penalties, costs, fees, including
      without limitation reasonable attorneys’ fees and expenses, from any claim or
      action against HHSC that is based on a claim of breach of the warranty set
      forth
      in the preceding paragraph.  HHSC will promptly notify HMO in writing
      of the claim, provide HMO a copy of all information received by HHSC with
      respect to the claim, and cooperate with HMO in defending or settling the
      claim.  HHSC will not unreasonably withhold, delay or condition
      approval of counsel selected by the HMO.

    

    (c)
      In
      case the Deliverables, or any one or part thereof, is in such action held to
      constitute an infringement or misappropriation, or the use thereof is enjoined
      or restricted or if a proceeding appears to HMO to be likely to be brought,
      HMO
      will, at its own expense, either:

    

    (1)
      Procure for HHSC the right to continue using the Deliverables; or

    

    (2)
      Modify or replace the Deliverables to comply with the Specifications and to
      not
      violate any intellectual property rights.

    

    If
      neither of the alternatives set forth in (1) or (2) above are available to
      the
      HMO on commercially reasonable terms, HMO may require that HHSC return the
      allegedly infringing Deliverable(s) in which case HMO will refund all amounts
      paid for all such Deliverables.

     

    Section
      15.02 Exceptions.

    HMO
      is
      not responsible for any claimed breaches of the warranties set forth in Section
      15.01 to the extent caused by:

    

    (a)
      Modifications made to the item in question by anyone other than HMO or its
      Subcontractors, or modifications made by HHSC or its contractors working at
      HMO’s direction or in accordance with the specifications; or

    

    (b)
      The
      combination, operation, or use of the item with other items if HMO did not
      supply or approve for use with the item; or

    

    (c)
      HHSC’s failure to use any new or corrected versions of the item made available
      by HMO.

    

    Section
      15.03 Ownership and Licenses

    

    (a)
      Definitions.

    

    For
      purposes of this Section 15.03, the following terms have the meanings set forth
      below:

    

    (1)
      “Custom Software” means any software developed by the
      HMO: for HHSC; in connection with the Contract; and with funds received from
      HHSC.  The term does not include HMO Proprietary Software or Third
      Party Software.

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    (2)
      “HMO Proprietary Software” means software:

    

    (i)
      developed by the HMO prior to the Effective Date of the Contract, or (ii)
      software developed by the HMO after the Effective Date of the Contract that
      is
      not developed: for HHSC; in connection with the Contract; and with funds
      received from HHSC.

    

    (3)
      “Third Party Software” means software that is: developed
      for general commercial use; available to the public; or not developed for
      HHSC.  Third Party Software includes without limitation: commercial
      off-the-shelf software; operating system software; and application software,
      tools, and utilities.

    

    (b)
      Deliverables. The Parties agree that any Deliverable, including without
      limitation the Custom Software, will be the exclusive property of
      HHSC.

    

    (c)
      Ownership rights.

    

    (1)
      HHSC
      will own all right, title, and interest in and to its Confidential Information
      and the Deliverables provided by the HMO, including without limitation the
      Custom Software and associated documentation.  For purposes of this
      Section 15.03, the Deliverables will not include HMO Proprietary Software or
      Third Party Software.  HMO will take all actions necessary and
      transfer ownership of the Deliverables to HHSC, including, without limitation,
      the Custom Software and associated documentation prior to Contract
      termination.

    

    (2)
      HMO
      will furnish such Deliverables, upon request of HHSC, in accordance with
      applicable State law. All Deliverables, in whole and in part, will be deemed
      works made for hire of HHSC for all purposes of copyright law, and copyright
      will belong solely to HHSC. To the extent that any such Deliverable does not
      qualify as a work for hire under applicable law, and to the extent that the
      Deliverable includes materials subject to copyright, patent, trade secret,
      or
      other proprietary right protection, HMO agrees to assign, and hereby assigns,
      all right, title, and interest in and to Deliverables, including without
      limitation all copyrights, inventions, patents, trade secrets, and other
      proprietary rights therein (including renewals thereof) to HHSC.

    

    (3)
      HMO
      will, at the expense of HHSC, assist HHSC or its nominees to obtain copyrights,
      trademarks, or patents for all such Deliverables in the United States and any
      other countries.  HMO agrees to execute all papers and to give all
      facts known to it necessary to secure United States or foreign country
      copyrights and patents, and to transfer or cause to transfer to HHSC all the
      right, title, and interest in and to such Deliverables. HMO also agrees not
      to
      assert any moral rights under applicable copyright law with regard to such
      Deliverables.

     

    (d)
      License Rights HHSC will have a royalty-free and non-exclusive license to access
      the HMO Proprietary Software and associated documentation during the term of
      the
      Contract. HHSC will also have ownership and unlimited rights to use, disclose,
      duplicate, or publish all information and data developed, derived, documented,
      or furnished by HMO under or resulting from the Contract.  Such data
      will include all results, technical information, and materials developed for
      and/or obtained by HHSC from HMO in the performance of the Services hereunder,
      including but not limited to all reports, surveys, plans, charts, recordings
      (video and/or sound), pictures, drawings, analyses, graphic representations,
      computer printouts, notes and memoranda, and documents whether finished or
      unfinished, which result from or are
      prepared in connection with the Services performed as a result of the
      Contract.

    

    (e)
      Proprietary Notices HMO will reproduce and include HHSC’s copyright and other
      proprietary notices and product identifications
      provided by HMO on such copies, in whole or in part, or on any form of the
      Deliverables.

    

    (f)
      State
      and Federal Governments In accordance with 45 C.F.R. §95.617, all appropriate
      State and Federal agencies will have a royalty-free, nonexclusive, and
      irrevocable license to reproduce, publish, translate, or otherwise use, and
      to
      authorize others to use for Federal Government purposes all materials, the
      Custom Software and modifications thereof, and associated documentation
      designed, developed, or installed with federal financial participation under
      the
      Contract, including but not limited to those materials covered by copyright,
      all
software
      source and object code, instructions, files, and documentation.

     

    Article
      16. Liability

    Section
      16.01 Property damage.

    

    (a)
      HMO
      will protect HHSC’s real and personal property from damage arising from HMO’s,
      its agent’s, employees’ and Subcontractors’ performance of the Contract, and HMO
      will be responsible for any loss, destruction, or damage to  HHSC’s
      property that results from or is caused by HMO’s, its agents’, employees’ or
      Subcontractors’ negligent or wrongful acts or omissions.  Upon the
      loss of, destruction of, or damage to any property of HHSC, HMO will notify
      the
      HHSC Project Manager thereof and, subject to direction from the Project Manager
      or her or his designee, will take all reasonable steps to protect that property
      from further damage.

    

    (b)
      HMO
      agrees to observe and encourage its employees and agents to observe safety
      measures and proper operating procedures at HHSC sites at all
      times.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    (c)
      HMO
      will distribute a policy statement to all of its employees and agents that
      directs the employee or agent to promptly report to HHSC or to HMO any special
      defect or unsafe condition encountered while on HHSC premises.  HMO
      will promptly report to HHSC any special defect or an unsafe condition it
      encounters or otherwise learns about.

     

    Section
      16.02 Risk of Loss.

    During
      the period Deliverables are in transit and in possession of HMO, its carriers
      or
      HHSC prior to being accepted by HHSC, HMO will bear the risk of loss or damage
      thereto, unless such loss or damage is caused by the negligence or intentional
      misconduct of HHSC. After HHSC accepts a Deliverable, the risk of loss or damage
      to the Deliverable will be borne by HHSC, except loss or damage attributable
      to
      the negligence or intentional misconduct of HMO’s agents, employees or
      Subcontractors.

     

    Section
      16.03 Limitation of HHSC’s Liability.

    HHSC
      WILL
      NOT BE LIABLE FOR ANY INCIDENTAL, INDIRECT, SPECIAL, OR CONSEQUENTIAL DAMAGES
      UNDER CONTRACT, TORT (INCLUDING NEGLIGENCE), OR OTHER LEGAL
      THEORY.  THIS WILL APPLY REGARDLESS OF THE CAUSE OF ACTION AND EVEN IF
      HHSC HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.  HHSC’S
      LIABILITY TO HMO UNDER THE CONTRACT WILL NOT EXCEED THE TOTAL CHARGES TO BE
      PAID
      BY HHSC TO HMO UNDER THE CONTRACT, INCLUDING CHANGE ORDER PRICES AGREED TO
      BY
      THE PARTIES OR OTHERWISE ADJUDICATED. HMO’s
      remedies are governed by the provisions in Article 12.

     

    Article
      17. Insurance & Bonding

    Section
      17.01 Insurance Coverage.

    (a)
      Statutory and General Coverage

    HMO
      will
      maintain the following insurance coverage.

    

    (1)
      Standard Worker's Compensation Insurance coverage;

    

    (2)
      Automobile Liability;

    

    (3)
      Comprehensive Liability Insurance including Bodily Injury coverage of
      $100,000.00 per each occurrence and Property Damage Coverage of $25,000.00
      per
      each occurrence; and

    

    (4)
      General Liability Insurance of at least $1,000,000.00 per occurrence and
      $5,000,000.00 in the aggregate.

    

    If
      HMO’s
      current Comprehensive General Liability insurance coverage does not meet the
      above stated requirements,
      HMO will obtain excess liability insurance to compensate for the difference
      in
      the coverage amounts.

    

    (b)
      Professional Liability Coverage.

    

    (1)
      HMO
      must maintain, or cause its Network Providers to maintain, Professional
      Liability Insurance for each Network Provider of $100,000.00 per occurrence
      and
      $300,000.00 in the aggregate, or the limits required by the hospital at which
      the Network Provider has admitting privileges.

    

    (2)
      HMO
      must maintain an Umbrella Professional Liability Insurance Policy for the
      greater of $3,000,000.00 or an amount (rounded to the nearest $100,000.00)
      that
      represents the number of Members enrolled in the HMO in the first month of
      the
      applicable State Fiscal Year multiplied by $150.00, not to exceed
      $10,000,000.00.

    

    (c)
      General Requirements for All Insurance Coverage

    

    (1)
      Except as provided herein, all exceptions to the Contract’s insurance
      requirements must be approved in writing by HHSC. HHSC’s written approval is not
      required in the following situations:

    

    (A)
      An
      HMO or a Network Provider is not required to obtain the insurance coverage
      described in Section 17.01 if the HMO or Network Provider qualifies as a state
      governmental unit or municipality under the Texas Tort Claims Act, and is
      required to comply with, and subject to the provisions of, the Texas Tort Claims
      Act.

    

    (B)
      An
      HMO may waive the Professional Liability Insurance requirement described in
      Section 17.01(b)(1) for a Network Provider of Community-based Long Term Care
      Services.  An HMO may not waive this requirement if the Network
      Provider provides other Covered Services in addition to Community-based Long
      Term Care Services, or if a Texas licensing entity requires the Network Provider
      to carry such Professional Liability coverage.   An HMO that
      waives the Professional Liability Insurance requirement for a Network Provider
      pursuant to this provision is not required to obtain such coverage on behalf
      of
      the Network Provider.

    

    (2)
      HMO
      or the Network Provider is responsible for any and all deductibles stated in
      the
      insurance policies.

    

    (3)Insurance
      coverage must be issued by insurance companies authorized to conduct business
      in
      the State of Texas.

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    (4)
      Insurance coverage must name HHSC as an additional insured with the following
      exceptions: Standard Workers’ Compensation Insurance maintained by the HMO, and
      Professional Liability Insurance maintained by Network Providers.

    

    (5)
      Insurance coverage kept by the HMO must be maintained throughout the Term of
      the
      Contract, and until HHSC’s final acceptance of all Services and Deliverables.
      Failure to maintain such insurance coverage will constitute a material breach
      of
      this Contract.

    

    (6)
      With
      the exception of Professional Liability Insurance maintained by Network
      Providers, the insurance policies described in this Section must have extended
      reporting periods of two years.  When policies are renewed or
      replaced, the policy retroactive date must coincide with, or precede, the
      Contract Effective Date.

    

    (7)
      With
      the exception of Professional Liability Insurance maintained by Network
      Providers, the insurance policies described in this Section must provide that
      prior written notice to be given to HHSC at least thirty (30) calendar days
      before coverage is substantially changed, canceled, or
      non-renewed.  HMO must submit a new coverage binder to HHSC to ensure
      no break in coverage.

    

    (8)
      The
      Parties expressly understand and agree that any insurance coverages and limits
      furnished by HMO will in no way expand or limit HMO’s liabilities and
      responsibilities specified within the Contract documents or by applicable
      law.

    

    (9)
      HMO
      expressly understands and agrees that any insurance maintained by HHSC will
      apply in excess of and not contribute to insurance provided by HMO under the
      Contract.

    

    (10)
      If
      HMO, or its Network Providers, desire additional coverage, higher limits of
      liability, or other modifications for its own protection, HMO or its Network
      Providers will be responsible for the acquisition and cost of such additional
      protection.  Such additional protection will not be an Allowable
      Expense under this Contract.

    

    (d)
      Proof
      of Insurance Coverage

     

    (1)
      Except as provided in Section 17.01(d)(2), the HMO must furnish the HHSC Project
      Manager original Certificates of Insurance evidencing the required insurance
      coverage on or before the Effective Date of the Contract.  If
      insurance coverage is renewed during the Term of the Contract, the HMO must
      furnish the HHSC Project Manager renewal certificates of insurance, or such
      similar evidence, within five (5) Business Days of renewal.  The
      failure of HHSC to obtain such evidence
      from HMO will not be deemed to be a waiver by HHSC and HMO will remain under
      continuing obligation to maintain and provide proof of insurance
      coverage.

     

    (2)
      The
      HMO is not required to furnish the HHSC Project Manager proof of Professional
      Liability Insurance maintained by Network Providers on or before the Effective
      Date of the Contract, but must provide such information upon HHSC’s request
      during the Term of the Contract.

     

    Section
      17.02 Performance Bond.

    

    (a)
      Beginning on the Operational Start Date of the Contract, and each year
      thereafter, the HMO must obtain a performance bond with a one (1) year
      term.  The performance bond must continue to be in effect for one (1)
      year following the expiration of the one (1) year term.  HMO must
      obtain and maintain the annual performance bonds in the form prescribed by
      HHSC
      and approved by TDI, naming HHSC as Obligee, securing HMO’s faithful performance
      of the terms and conditions of this Contract. The annual performance bonds
      must
      comply with Chapter 843 of the Texas Insurance Code and 28 T.A.C.
§11.1805.  The annual performance bond(s) must be issued in the amount
      of $100,000.00 for each applicable HMO Program within each Service Area that
      the
      HMO covers under this Contract. All performance bonds must be issued by a surety
      licensed by TDI, and specify cash payment as the sole remedy.  HMO
      must deliver the initial performance bond to HHSC prior to the Operational
      Start
      Date of the Contract, and each renewal performance bond prior to the first
      day
      of the State Fiscal Year.

    

    (b)
      Since
      the CHIP Perinatal Program is a sub­program of the CHIP Program, neither a
      separate performance bond for the CHIP Perinatal Program nor a combined
      performance bond for the CHIP and CHIP Perinatal Programs is
      required.  The same bond that the HMO obtains for its CHIP Program
      within a particular Service Area also will cover the HMO’s CHIP Perinatal
      Program, if applicable, in that same Service Area.

    

    Section
      17.03 TDI Fidelity Bond

    The
      HMO
      will secure and maintain throughout the life of the Contract a fidelity bond
      in
      compliance with Chapter 843 of the Texas Insurance Code and 28 T.A.C.
§11.1805.  The HMO must promptly provide HHSC with copies of the bond
      and any amendments or renewals thereto.

    
       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Subject:
        Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 6
Version 1.8

      
        DOCUMENT
          HISTORY LOG

        
          	
                  STATUS1

                	
                  DOCUMENT
                    REVISION2

                	
                  EFFECTIVE
                    DATE

                	
                  DESCRIPTION3

                
	
                  Baseline

                	
                  n/a

                	 	
                  Initial
                    version Attachment B-1, Section 6

                
	
                  Revision

                	
                  1.1

                	
                  June
                    30, 2006

                	
                  Revised
                    version of the Attachment B-1, Section 6, that includes provisions
                    applicable to MCOs participating in the STAR+PLUS Program. 

                   

                  Section
                    6.3.2.1, Experience Rebate Reward, is modified to delete references
                    to the
                    selected performance indicators and the Quality Challenge Pool.
                    

                   

                  Section
                    6.3.2.2, Performance-Based Capitation Rate, is modified to include
                    STAR+PLUS and to add Additional STAR+PLUS Performance Indicators.
                    

                   

                  Section
                    6.3.2.3, Quality Challenge Award, is modified to include STAR+PLUS.
                    Section 6.3.2.5, STAR+PLUS Hospital Inpatient Performance Based
                    Capitation
                    Rate: Hospital Inpatient Stay Cost Incentives and Disincentives,
                    is added.
                    

                   

                  Section
                    6.3.2.5.1, STAR+PLUS Hospital Inpatient Disincentive – Administrative Fee
                    at Risk, is added. 

                   

                  Section
                    6.3.2.5.2, STAR+PLUS Hospital Inpatient Incentive – Shared Savings Award,
                    is added.

                
	
                  Revision

                	
                  1.2

                	
                  September
                    1, 2006

                	
                  Revised
                    version of the Attachment B-1, Section 6, that includes provisions
                    applicable to MCOs participating in the STAR and CHIP Programs.
                    

                   

                  Section
                    6.3.2.2, Performance-Based Capitation Rate, modifies the standard
                    performance indicator for the Behavioral Health Hotline to change
                    the
                    maximum abandonment rate from 5% to 7% (except in the Dallas
                    Core Service
                    Area). 

                   

                  Section
                    6.3.2.3, Quality Challenge Award, is modified to reflect the
                    new start
                    date for the Quality Challenge Award, which will not be implemented
                    until
                    State Fiscal Year 2008.

                
	
                  Revision

                	
                  1.3

                	
                  September
                    1, 2006

                	
                  Revised
                    version of the Attachment B-1, Section 6, that includes provisions
                    applicable to MCOs participating in the CHIP Perinatal Program.
                    

                   

                  Section
                    6.3.2.1 modified to clarify that the Experience Rebate Reward
                    incentive
                    may apply to the CHIP Perinatal Program at a later
                    date.   

                   

                  Section
                    6.3.2.2 modified to clarify that the Performance-based Capitation
                    Rate
                    will not apply for the CHIP Perinatal Program in SFY
                    2007.

                
	
                  Revision

                	
                  1.4

                	
                  September
                    1, 2006

                	
                  Contract
                    amendment did not revise Attachment B-1 Section 6 – Premium Payment,
                    Incentives, and Disincentives

                

        

        
        

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        Subject:
          Attachment
          B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 6 Version
          1.8

        
          	
                  Revision

                	
                  1.5

                	
                  January
                    1, 2007

                	
                  Contract
                    amendment did not revise Attachment B-1 Section 6 – Premium Payment,
                    Incentives, and Disincentives

                
	
                  Revision

                	
                  1.6

                	
                  February
                    1, 2007

                	
                  Revised
                    version of the Attachment B-1, Section 6, that includes provisions
                    applicable to MCOs participating in the STAR+PLUS Program. 

                   

                  Section
                    6.3.2.5 is modified to clarify the months included in Rate Period
                    1.

                
	
                  Revision

                	
                  1.7

                	
                  July
                    1, 2007

                	
                  Contract
                    amendment did not revise Attachment B-1 Section 6 – Premium Payment,
                    Incentives, and Disincentives

                
	
                  Revision

                	
                  1.8

                	
                  September
                    1, 2007

                	
                  Section
                    6.3 is modified as a result of SB 10 legislation and the Frew
                    litigation
                    to prohibit HMOs from passing down financial disincentives or
                    sanctions to
                    providers. 

                   

                  Section
                    6.3.1.1 is modified as a result of the Frew litigation to allow
                    HHSC to
                    post information regarding poor HMO performance on the HHSC website.
                    

                   

                  Section
                    6.3.2.2 is modified to clarify language regarding the Performance
                    Indicator Dashboard and the reapportionment of points for the
                    1% at-risk
                    premium. 

                   

                  Section
                    6.3.2.3 is modified as a result of the Frew litigation to clarify
                    language. 

                   

                  New
                    Section 6.3.2.6 is added as a result of the Frew litigation to
                    clarify
                    requirements for additional incentives and
                    disincentives.

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

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

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

                

        

        
        

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        6.
          Premium Payment, Incentives, and Disincentives

        This
          section documents how the Capitation Rates are developed and describes
          performance incentives and disincentives related to HHSC’s value-based
          purchasing approach.  For further information, HMOs should refer to
          the HHSC Uniform Managed Care Contract Terms and
          Conditions.

         

        Under
          the
          HMO Contracts, health care coverage for Members will be provided on a fully
          insured basis. The HMO must provide the Services and Deliverables, including
          Covered Services to enrolled Members in order for monthly Capitation Payments
          to
          be paid by HHSC. Attachment B­1, Section 8 includes the
          HMO’s financial responsibilities regarding out-of-network Emergency Services
          and
          Medically Necessary Covered Services not available through Network
          Providers.

         

        6.1
          Capitation Rate Development

        Refer
          to
Attachment A, HHSC Uniform Managed Care Contract Terms
& Conditions, Article 10, “Terms & Conditions of Payment,” for
          information concerning Capitation Rate development.

         

        6.2
          Financial Payment Structure and Provisions

        HHSC
          will
          pay the HMO monthly Capitation Payments based on the number of eligible
          and
          enrolled Members. HHSC will calculate the monthly Capitation Payments by
          multiplying the number of Member Months times the applicable monthly Capitation
          Rate by Member Rate Cell. The HMO must provide the Services and Deliverables,
          including Covered Services to Members, described in the Contract for monthly
          Capitation Payments to be paid by HHSC.

         

        The
          HMO
          must understand and expressly assume the risks associated with the performance
          of the duties and responsibilities under the Contract, including the failure,
          termination, or suspension of funding to HHSC, delays or denials of required
          approvals, cost of claims incorrectly paid by the HMO, and cost overruns
          not
          reasonably attributable to HHSC. The HMO must further agree that no other
          charges for tasks, functions, or activities that are incidental or ancillary
          to
          the delivery of the Services and Deliverables will be sought from HHSC
          or any
          other state agency, nor will the failure of HHSC or any other party to
          pay for
          such incidental or ancillary services entitle the HMO to withhold Services
          or
          Deliverables due under the Contract.

         

        6.2.1
          Capitation Payments

        The
          HMO
          must refer to the HHSC Uniform Managed Care Contract Terms &
Conditions for information and Contract requirements on
          the:

        1)
          Time
          and Manner of Payment,

        2)
          Adjustments to Capitation Payments,

        3)
          Delivery Supplemental Payment, and

        4)
          Experience Rebate.

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        6.3
          Performance Incentives and Disincentives

        HHSC
          introduces several financial and non-financial performance incentives and
          disincentives through this Contract. These incentives and disincentives
          are
          subject to change by HHSC over the course of the Contract Period. The
          methodologies required to implement these strategies will be refined by
          HHSC
          after collaboration with contracting HMOs through a new incentives workgroup
          to
          be established by HHSC.  HMO is prohibited from passing down financial
          disincentives and/or sanctions imposed on the HMO to health care providers,
          except on an individual basis and related to the individual provider’s
          inadequate performance.

         

        6.3.1
          Non-financial Incentives

        6.3.1.1
          Performance Profiling

        HHSC
          intends to distribute information on key performance indicators to HMOs
          on a
          regular basis, identifying an HMO’s performance, and comparing that performance
          to other HMOs, and HHSC standards and/or external Benchmarks. HHSC will
          recognize HMOs that attain superior performance and/or improvement by
          publicizing their achievements. For example, HHSC may post information
          concerning exceptional performance on its website, where it will be available
          to
          both stakeholders and members of the public. Likewise, HHSC may post its
          final
          determination regarding poor performance or HMO peer group performance
          comparisons on its website, where it will be available to both stakeholders
          and
          members of the public.

         

        6.3.1.2
          Auto-assignment Methodology for Medicaid HMOs

        HHSC
          may
          also revise its auto-assignment methodology during the Contract Period
          for new
          Medicaid Members who do not select an HMO (Default Members). The new assignment
          methodology would reward those HMOs that demonstrate superior performance
          and/or
          improvement on one or more key dimensions of performance. In establishing
          the
          assignment methodology, HHSC will employ a subset of the performance indicators
          contained within the Performance Indicator Dashboard. At
          present, HHSC intends to recognize those HMOs that exceed the minimum geographic
          access standards defined within Attachment B-1, Section 8 and the
          Performance Indicator Dashboard. 

         

        HHSC
          may
          also use its assessment of HMO performance on annual quality improvement
          goals
          (described in Attachment B-1, Section 8) in developing the
          assignment methodology. The methodology would disproportionately assign
          Default
          Members to the HMO(s) in a given Service Area that performed comparably
          favorably on the selected performance indicators.

        HHSC
          anticipates that it will not implement a performance-based auto-assignment
          algorithm before September 1, 2007. HHSC will invite HMO comments on potential
          approaches prior to implementation of the new performance-based auto-assignment
          algorithm.

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        6.3.2
          Financial Incentives and Disincentives

        6.3.2.1
          Experience Rebate Reward

        HHSC
          historically has required HMOs to provide HHSC with an Experience Rebate
          (see
          the Uniform Managed Care Contract Terms and Conditions, Article 10.11)
          when there has been an aggregate excess of Revenues over Allowable
          Expenses. During the Contract Period, should the HMO experience an aggregate
          excess of Revenues over Allowable Expenses across STAR and CHIP HMO Programs
          and
          Service Areas, HHSC will allow the HMO to retain that portion of the aggregate
          excess of Revenues over Allowable Expenses that is equal to or less than
          3.5% of
          the total Revenue for the period should the HMO demonstrate superior performance
          on selected performance indicators.  The retention of 3.5% of revenue
          exceeds the retention of 3.0% of revenue that would otherwise be afforded
          to a
          HMO without demonstrated superior performance on these performance indicators
          relative to other HMOs. HHSC will develop the methodology for determining
          the
          level of performance necessary for an HMO to retain the additional 0.5%
          of
          revenue after consultation with HMOs. The finalized methodology will be
          added to
          the Uniform Managed Care Manual.

         

        HHSC
          will
          calculate the Experience Rebate Reward after it has calculated the HMO’s at-risk
          Capitation Rate payment, as described below in Section 6.3.2.2.
          HHSC will calculate whether a HMO is eligible for the Experience Rebate
          Reward
          prior to the 90-day Financial Statistical Report (FSR) filing.

         

        HHSC
          anticipates that it will not implement the incentive for Rate Period 1
          of the
          Contract.  HHSC will invite HMO comments on potential approaches prior
          to implementation of the new performance-based Experience Rebate
          Reward.  HHSC may also implement this incentive option for the
          STAR+PLUS and CHIP Perinatal programs in the future.

         

        6.3.2.2
          Performance-Based Capitation Rate

        Beginning
          in State Fiscal Year 2007 of the Contract, HHSC will place each STAR and
          CHIP
          HMO at risk for 1% of the Capitation Rate(s). Beginning in State Fiscal
          Year
          2008 of the Contract, HHSC will also place each STAR+PLUS HMO at risk for
          1% of
          the Capitation Rate(s).  HHSC retains the right to vary the percentage
          of the Capitation Rate placed at risk in a given Rate Period. HHSC will
          not
          place CHIP Perinatal HMOs at risk for 1% of the Capitation Rate(s) in State
          Fiscal Year 2007, but reserves this right in subsequent State Fiscal
          Years.

         

        As
          noted
          in Section 6.2, HHSC will pay the HMO monthly Capitation Payments based
          on the
          number of eligible and enrolled Members. HHSC will calculate the monthly
          Capitation Payments by multiplying the number of Member months times the
          applicable monthly Capitation Rate by Member rate cell.  At the end of
          each Rate Period, HHSC will evaluate if the HMO has demonstrated that it
          has
          fully met the performance expectations for which the HMO is at
          risk.  Should the HMO fall short on some or all of the performance
          expectations, HHSC will adjust a future monthly Capitation Payment by an
          appropriate portion of the 1% at-risk amount.  HMOs will be able to
          earn variable percentages up to 100% of the 1% at-risk Capitation Rate.
          HHSC’s
          objective is that all HMOs achieve performance levels that enable them
          to
          receive the full at-risk amount.

         

        HHSC
          will
          determine the extent to which the HMO has met the performance expectations
          by
          assessing the HMO’s performance for each applicable HMO Program relative to
          performance targets for the rate period. HHSC will conduct separate accounting
          for each HMO Program’s at-risk Capitation Rate amount.

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        HHSC
          will
          identify no more than 10 at-risk performance indicators for each HMO Program.
          Some of the performance indicators will be standard across the HMO Programs
          while others may apply to only one of the HMO Programs.

         

        HHSC’s
          at-risk performance indicators may include some or all of the following
          measures. The specific performance indicators, periods of data collection,
          and
          associated points are detailed in the HHSC Uniform Managed Care Manual.
The minimum percentage targets identified in this section
          were
          developed based, in part, on the HHSC HMO Program objective of ensuring
          access
          to care and quality of care, past performance of the HHSC HMOs, and performance
          of Medicaid and CHIP HMOs nationally on HEDIS and CAHPS measures of plan
          performance. The Performance Indicator Dashboard includes a
          more detailed listing of performance indicators by Program and is included
          in
          the HHSC Uniform Managed Care Manual.

         

        Standard
          Performance Indicators:

        1  98%
          of
          Clean Claims are properly Adjudicated within 30 calendar days.

        2  The
          Member Services Hotline abandonment rate does not exceed 7%.

        3  The
          Behavioral Health Hotline abandonment rate does not exceed 7%.1

        4  The
          Provider Services Hotline abandonment rate does not exceed 7%.

        

        Additional
          STAR Performance Indicators

        1  90%
          of
          child Members have access to at least one child-appropriate PCP with an
          Open
          Panel within 30 miles travel distance.

        2  90%
          of
          adult Members have access to at least one adult-appropriate PCP with an
          Open
          Panel within 30 miles travel distance.

        3  36%
          of
          age-qualified child Members receive six or more well-child visits (in the
          first
          15 months of life.

        4  56%
          of
          age-qualified child Members receive at least one well-child visit in the
          3rd,
          4th, 5th, or 6th year of life.

        5  72%
          of
          pregnant women Members receive a prenatal care visit in the first trimester
          or
          within 42 days of enrollment.

        

        Additional
          CHIP Performance Indicators

        

        1.           90%
          of child Members have access to at least one child-appropriate PCP with
          an Open
          Panel within 30 miles travel distance.

        2.           90%
          of child Members have access to at least one otolaryngologist (ENT) within
          75
          miles travel distance.

        3.           56%
          of age-qualified child Members receive at least one well-child visit in
          the 3rd,
          4th, 5th, or 6th year of life

        4.           38%
          of adolescents receive an annual well visit.

         

        1
          Will not apply in
          the Dallas Core Service Area.  Points will be allocated
          proportionately over the remaining standard performance indicators.

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        Additional
          STAR+PLUS Performance Indicators

        1  57%
          of
          adult Members report no problem with delays in getting approval from the
          HMO

        2  90%
          of
          adult Members have access to at least one adult-appropriate PCP with an
          Open
          Panel within 30 miles travel distance

        3  62%
          of
          adult Members report no problem in getting a referral to a Specialty
          Physician

        4  47%
          of
          adult Members report no problem getting needed Special Therapy (physical
          therapy, occupational therapy, and speech therapy) from the HMO

        5  57%
          of
          adult Members report no problem getting needed Behavioral Health Services
          from
          the HMO

        

        Failure
          to timely provide HHSC with necessary data related to the calculation of
          the
          performance indicators will result in HHSC’s assignment of a zero percent
          performance rate for each related performance indicator.

         

        For
          any
          Member survey-based indicators that are included in the 1% at-risk premium
          that
          yield response rates deemed by HHSC to be too low to yield credible data,
          HHSC
          will reapportion points across the remaining measures.

         

        Actual
          plan rates will be rounded to the nearest whole number. HHSC will calculate
          performance assessment for the at-risk portion of the capitation payments
          by
          summing all earned points and converting them to a percentage.  For
          example, an HMO that earns 92 points will earn 92% of the at-risk Capitation
          Rate. HHSC will apply the premium assessment of 8% of the at-risk Capitation
          Rate as a reduction to the monthly Capitation Payment ninety days after
          the end
          of the contract period.

         

        HMOs
          will
          report actual Capitation Payments received on the Financial Statistical
          Report
          (FSR). Actual Capitation Payments received include all of the at-risk Capitation
          Payment paid to the HMO. Any performance assessment based on performance
          for a
          contract period will appear on the second final (334-day) FSR for that
          contract
          period.

         

        HHSC
          will
          evaluate the performance-based Capitation Rate methodology annually in
          consultation with HMOs. HHSC may then modify the methodology it deems necessary
          and appropriate to motivate, recognize, and reward HMOs for
          performance.  The methodologies for Rate Periods 1 and 2 will be
          included in the HHSC Uniform Managed Care Manual.

         

        6.3.2.3
          Quality Challenge Award

        Data
          collection for the Quality Challenge Award will begin on September 1, 2006;
          however, the Quality Challenge Award will not be implemented until State
          Fiscal
          Year 2008. Should one or more HMOs be unable to earn the full amount of
          the
          performance-based at-risk portion of the Capitation Rate, HHSC will reallocate
          the funds through the HMO Program’s Quality Challenge

        Award.
          HHSC will use these funds to reward HMOs that demonstrate superior clinical
          quality, service delivery, access to care, and/or Member satisfaction,
          HHSC will
          determine the number of HMOs that will receive Quality Challenge Award
          funds
          annually based on the amount of the funds to be reallocated.  Separate
          Quality Challenge Award payments will be made for each of the HMO Programs.
          As
          with the performance-based Capitation Rate, each HMO will be evaluated
          separately for each HMO Program.  HHSC intends to evaluate HMO
          performance annually on some combination of performance indicators in order
          to
          determine which HMOs demonstrate superior performance.  In no event
          will a distribution from the Quality Challenge Award, plus any other incentive
          payments made in accordance with the HMO Contract, when combined with the
          Capitation Rate payments, exceed 105% of the Capitation Rate payments to
          an
          HMO.

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        Information
          about the data collection period to be used and each indicator that will
          be
          considered for any specific time period can be found in the HHSC Uniform
          Managed Care Manual.

         

        6.3.2.4 Remedies
          and Liquidated Damages

        All
          areas
          of responsibility and all requirements in the Contract will be subject
          to
          performance evaluation by HHSC. Any and all responsibilities or requirements
          not
          fulfilled may have remedies and HHSC will assess either actual or liquidated
          damages. Refer to Attachment A, HHSC Uniform Managed Care Contract Terms
          and Conditions and Attachment B-5 for performance
          standards that carry liquidated damage values.

         

        6.3.2.5 STAR+PLUS
          Hospital Inpatient Performance-Based Capitation Rate: Hospital Inpatient
          Stay
          Cost Incentives & Disincentives

        Effective
          as of the STAR+PLUS Operational Start Date, HHSC will place at-risk a portion
          of
          the HMO’s Medicaid-Only Capitation Rate. Settlements for Inpatient Stay costs
          will be calculated by the State after the end of each State Fiscal Year
          (SFY)
          using three (3) months of completed Hospital paid data for the preliminary
          settlement and 11 months of completed data for the final settlement. The
          SFY
          2006 Fee-for-Service (FFS) Inpatient Hospital per-member-per-month (PMPM)
          rate
          will be projected for Rate Period 1 (February 1, 2007 through August 31,
          2007)
          for the first settlement. Adjustments for the projection will include trending
          and risk adjustment.  The base and final inpatient hospital PMPM rate
          will be calculated separately for each HMO, Service Area, and Rate Cell.
          Harris
          County is excluded from the Harris Service Area calculations.

         

        6.3.2.5.1 STAR+PLUS
          Hospital Inpatient Disincentive - Administrative Fee at
          Risk

        HHSC
          has
          assumed that STAR+PLUS HMOs will achieve a 22% reduction in projected FFS
          Hospital Inpatient Stay costs, for the Medicaid-Only population, through
          the
          implementation of the STAR+PLUS model.  HMOs achieving savings beyond
          22% will be eligible for the STAR+PLUS Shared Savings Award described in
          Section 6.3.2.5.2. The HMO will be at-risk for savings less
          than 22%.

         

        The
          maximum risk to the HMO will be equal to 50% of the difference between
          15%
          Hospital inpatient savings and 22% Hospital inpatient savings. The disincentive
          for savings above 15%, but still less than 22% will be equal to 50% of
          the
          difference between the level of achieved savings
          and 22%. HHSC retains the right to vary the disincentive percentage in
          a given
          Rate Period by Contract amendment.

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        6.3.2.5.2
          STAR+PLUS Hospital Inpatient Incentive – Shared Savings
          Award

        HMOs
          that
          exceed the 22% reduction in Inpatient Stay costs incurred by STAR+PLUS
          Members
          specified in Section 6.3.2.5.1 will be eligible to obtain a 20%
          share of the savings achieved beyond the 22% target. HHSC will determine
          the
          extent to which the HMO has met and exceeded the performance expectation
          in the
          manner described within Section 6.3.2.5. Should HHSC determine
          that the HMO exceeded the 22% target, HHSC will adjust a future monthly
          Capitation Payment upward by 20% of the calculated savings. This shared
          savings
          award is limited to 5% of the HMO’s capitation in accordance with Federal
          Balance Budget Act requirements and is calculated off of total of STAR+PLUS
          Capitation Payment. An HMO will be subject to contractual remedies and
          determined ineligible for the award, if a HHSC audit reveals that the HMO
          has
          inappropriately averted Medically Necessary Inpatient Stay admissions and
          potentially endangered Member safety.

         

        6.3.2.6
          Additional Incentives and Disincentives

        HHSC
          will
          evaluate all performance-based incentives and disincentive methodologies
          annually and in consultation from the HMOs.  HHSC may then modify the
          methodologies as needed, as funds become available, or as mandated by court
          decree, statute, or rule in an effort to motivate, recognize, and reward
          HMOs
          for performance.

         

        Information
          about the data collection period to be used, performance indicators selected
          or
          developed, or HMO ranking methodologies used for any specific time period
          will
          be found in the HHSC Uniform Managed Care
          Manual.

      

    

    
       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        

        Subject:
          Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 7
          Version 1.8

        DOCUMENT
          HISTORY LOG

        
          	
                  STATUS1

                	
                  DOCUMENT
                    REVISION2

                	
                  EFFECTIVE
                    DATE

                	
                  DESCRIPTION3

                
	
                  Baseline

                	
                  n/a

                	 	
                  Initial
                    version Attachment B-1, Section 7

                
	
                  Revision

                	
                  1.1

                	
                  June
                    30, 2006

                	
                  Revised
                    version of the Attachment B-1, Section 7, that includes provisions
                    applicable to MCOs participating in the STAR+PLUS Program. Sections
                    7.1 to
                    7.3 modified to include STAR+PLUS.

                
	
                  Revision

                	
                  1.2

                	
                  September
                    1, 2006

                	
                  Revised
                    version of the Attachment B-1, Section 7, that includes provisions
                    applicable to MCOs participating in the STAR and CHIP Programs.
                    Section
                    7.3.1.7, Operations Readiness, changes reference from “Operational Date”
                    to “Effective Date.”

                
	
                  Revision

                	
                  1.3

                	
                  September
                    1, 2006

                	
                  Revised
                    version of the Attachment B-1, Section 7, that includes provisions
                    applicable to MCOs participating in the CHIP Perinatal Program.
                    Sections
                    7.2, 7.3, and 7.3.1.2 through 7.3.1.7 modified to include the
                    CHIP
                    Perinatal Program.

                
	
                  Revision

                	
                  1.4

                	
                  September
                    1, 2006

                	
                  Contract
                    amendment did not revise Attachment B-1 Section 7 – Transition Phase
                    Requirements

                
	
                  Revision

                	
                  1.5

                	
                  January
                    1, 2007

                	
                  Contract
                    amendment did not revise Attachment B-1 Section 7 – Transition Phase
                    Requirements

                
	
                  Revision

                	
                  1.6

                	
                  February
                    1, 2007

                	
                  Contract
                    amendment did not revise Attachment B-1 Section 7 – Transition Phase
                    Requirements

                
	
                  Revision

                	
                  1.7

                	
                  July
                    1, 2007

                	
                  Section
                    7.3.1.9 is modified to add a cross-reference to Attachment B-1,
                    Sections
                    8.1.1.2 and 8.1.18.

                
	
                  Revision

                	
                  1.8

                	
                  September
                    1, 2007

                	
                  Contract
                    amendment did not revise Attachment B-1 Section 7 – Transition Phase
                    Requirements

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

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

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

                

        

        
        

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        

        7.
          Transition Phase Requirements

        7.1
          Introduction

        This
          Section presents the scope of work for the Transition Phase of the Contract,
          which includes those activities that must take place between the time of
          Contract award and the Operational Start Date.

         

        The
          Transition Phase will include a Readiness Review of each HMO, which must
          be
          completed successfully prior to a HMO’s Operational Start Date for each
          applicable HMO Program. HHSC may, at its discretion, postpone the Operational
          Start Date of the Contract for any such HMO that fails to satisfy all Transition
          Phase requirements.

         

        If
          for
          any reason, a HMO does not fully meet the Readiness Review prior to the
          Operational Start Date, and HHSC has not approved a delay in the Operational
          Start Date or approved a delay in the HMO’s compliance with the applicable
          Readiness Review requirement, then HHSC shall impose remedies and either
          actual
          or liquidated damages. If the HMO is a current HMO Contractor, HHSC may
          also
          freeze enrollment into the HMO’s plan for any of its HMO Programs. Refer to
          the HHSC Uniform Managed Care Contract Terms and Conditions (Attachment
          A) and the Liquidated Damages Matrix (Attachment B-5)
          for additional information.

         

        7.2
          Transition Phase Scope for HMOs

        STAR,
          STAR+PLUS and CHIP HMOs must meet the Readiness Review requirements established
          by HHSC no later than 90 days prior to the Operational Start Date for each
          applicable HMO Program. CHIP Perinatal HMOS must meet the Readiness Review
          requirements established by HHSC not later than 60 days prior to the Operational
          Start Date for the CHIP Perinatal Program.  HMO agrees to provide all
          materials required to complete the readiness review by the dates established
          by
          HHSC and its Contracted Readiness Review Vendor.

         

        7.3
          Transition Phase Schedule and Tasks

        The
          Transition Phase will begin after both Parties sign the Contract.  The
          start date for the STAR and CHIP Transition Phase is November 15,
          2005.  The start date for the STAR+PLUS Transition Phase is June 30,
          2006. The start date for the CHIP Perinate Transition Phase is September
          1,
          2006.

         

        The
          Transition Phase must be completed no later than the agreed upon Operational
          Start Date(s) for each HMO Program and Service Area.  The HMO may be
          subject to liquidated damages for failure to meet the agreed upon Operational
          Start Date (see Attachment B-5).

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        7.3.1
          Transition Phase Tasks

        The
          HMO
          has overall responsibility for the timely and successful completion of
          each of
          the Transition Phase tasks. The HMO is responsible for clearly specifying
          and
          requesting information needed from HHSC, other HHSC contractors, and Providers
          in a manner that does not delay the schedule or work to be
          performed.

         

        7.3.1.1
          Contract Start-Up and Planning

        HHSC
          and
          the HMO will work together during the initial Contract start-up phase
          to:

        •  define
          project management and reporting standards;

        •  establish
          communication protocols between HHSC and the HMO;

        •  establish
          contacts with other HHSC contractors;

        •  establish
          a schedule for key activities and milestones; and

        •  clarify
          expectations for the content and format of Contract Deliverables.

        

        The
          HMO
          will be responsible for developing a written work plan, referred to as
          the
          Transition/Implementation Plan, which will be used to monitor progress
          throughout the Transition Phase. An updated and detailed Transition
          /Implementation Plan will be due to HHSC.

         

        7.3.1.2
          Administration and Key HMO Personnel

        No
          later
          than the Effective Date of the Contract, the HMO must designate and identify
          Key
          HMO Personnel that meet the requirements in HHSC Uniform Managed Care
          Contract Terms & Conditions, Article 4.  The HMO will
          supply HHSC with resumes of each Key HMO Personnel as well as organizational
          information that has changed relative to the HMO’s Proposal, such as updated job
          descriptions and updated organizational charts, (including updated Management
          Information System (MIS) job descriptions and an updated MIS staff
          organizational chart), if applicable. If the HMO is using a Material
          Subcontractor(s), the HMO must also provide the organizational chart for
          such
          Material Subcontractor(s).

         

        No
          later
          than the Contract execution date, STAR+PLUS HMOs must update the information
          above and provide any additional information as it relates to the STAR+PLUS
          Program.

         

        No
          later
          than the Contract execution date, CHIP Perinatal HMOs must update the
          information above and provide any additional information as it relates
          to the
          CHIP Perinatal Program.

         

        7.3.1.3
          Financial Readiness Review

        In
          order
          to complete a Financial Readiness Review, HHSC will require that HMOs update
          information submitted in their proposals.  Note: STAR+PLUS and/or CHIP
          Perinatal HMOs who have already submitted proposal updates for HHSC’s review for
          STAR and/or CHIP, must either verify that the information has not changed
          and
          that it applies to STAR+PLUS and/or the CHIP Perinatal
          Program or provide updated information for STAR+PLUS by July 10, 2006 and
          for
          the CHIP Perinatal Program by September 1, 2006. This information will
          include
          the following:

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        Contractor
          Identification and Information

        1  The
          Contractor’s legal name, trade name, or any other name under which the
          Contractor does business, if any.

        2  The
          address and telephone number of the Contractor’s headquarters
          office.

        3  A
          copy of
          its current Texas Department of Insurance Certificate of Authority to provide
          HMO or ANHC services in the applicable Service Area(s).  The
          Certificate of Authority must include all counties in the Service Area(s)
          for
          which the Contractor is proposing to serve HMO Members.

        4  Indicate
          with a “Yes-HMO”, “Yes-ANHC” or “No” in the applicable cell(s) of the Column B
          of the following chart whether the Contractor is currently certified by
          TDI as
          an HMO or ANHC in all counties in each of the CSAs in
          which the Contractor proposes to participate in one or more of the HHSC
          HMO
          Programs. If the Contractor is not proposing to serve a CSA for a particular
          HMO
          Program, the Contractor should leave the applicable cells in the table
          empty.

        

        Table
          2: TDI Certificate of Authority in Proposed HMO Program
          CSAs

        
          	
                  Column
                    A

                	
                  Column
                    B

                	
                  Column
                    C

                
	
                  Core
                    Service Area (CSA)

                	
                  TDI
                    Certificate of Authority

                	
                  Counties/Partial
                    Counties without a TDI Certificate of
                    Authority

                
	
                  Bexar

                	 	 
	
                  Dallas

                	 	 
	
                  El
                    Paso

                	 	 
	
                  Harris

                	 	 
	
                  Lubbock

                	 	 
	
                  Nueces

                	 	 
	
                  Tarrant

                	 	 
	
                  Travis

                	 	 
	
                  Webb

                	 	 

        

        
        

        

        If
          the
          Contractor is not currently certified by TDI as an HMO
          or ANHC in any one or more counties in a proposed CSA, the Contractor must
          identify such entire counties in Column C for each CSA. For each county
          listed
          in Column C, the Contractor must document that it applied to TDI for such
          certification of authority prior to the submission of a Proposal for this
          RFP.
          The Contractor shall indicate the date that it applied for such certification
          and the status of its application to get TDI certification in the relevant
          counties in this section of its submission to HHSC.

         

        5.           For
          Contractors serving any CHIP and CHIP Perinatal OSAs, indicate with a “Yes-HMO”,
“Yes-ANHC” or “No” in the applicable cell(s) of the Column C of the following
          chart whether the Contractor is currently certified by TDI as an HMO or
          ANHC in
          the entire county in the OSA. If the Contractor is not proposing to serve
          an
          OSA, the Contractor should leave the applicable cells in the table
          empty.

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        Table
          3: TDI Certificate of Authority in Proposed HMO Program
          OSAs

        
          	 	
                  CHIP
                    Program

                
	
                  Column
                    A

                	
                  Column
                    B

                	
                  Column
                    C

                
	
                  Core
                    Service Area (CSA)

                	
                  Affiliated
                    CHIP OSA

                	
                  TDI
                    Certificate of Authority

                
	
                  Bexar

                	 	 
	
                  El
                    Paso

                	 	 
	
                  Harris

                	 	 
	
                  Lubbock

                	 	 
	
                  Nueces

                	 	 
	
                  Travis

                	 	 

        

        
        

        

        
          	 	
                  CHIP
                    Perinatal Program

                
	
                  Column
                    A

                	
                  Column
                    B

                	
                  Column
                    C

                
	
                  Core
                    Service Area (CSA)

                	
                  Affiliated
                    CHIP OSA

                	
                  TDI
                    Certificate of Authority

                
	
                  Bexar

                	 	 
	
                  El
                    Paso

                	 	 
	
                  Harris

                	 	 
	
                  Lubbock

                	 	 
	
                  Nueces

                	 	 
	
                  Travis

                	 	 

        

        
        

        

        For
          each
          county listed in Column C, the Contractor must document that it applied
          to TDI
          for such certification of authority prior to the submission of a Proposal
          for
          this RFP. The Contractor shall indicate the date that it applied for such
          certification and the status of its application to get TDI certification
          in the
          relevant counties in this section of its submission to HHSC.

        

        6.           If
          the Contractor proposes to participate in STAR or STAR+PLUS and seeks to
          be
          considered as an organization meeting the requirements of Section §533.004(a) or
          (e) of the Texas Government Code, describe how the Contractor meets the
          requirements of §§533.004(a)(1), (a)(2), (a)(3), or (e) for each proposed
          Service Areas.

        7.           The
          type of ownership (proprietary, partnership, corporation).

        8.           The
          type of incorporation (for profit, not-for-profit, or non-profit) and whether
          the Contractor is publicly or privately owned.

        9.           If
          the Contractor is an Affiliate or Subsidiary, identify the parent
          organization.

        10.
          If
          any change of ownership of the Contractor’s company is anticipated during the 12
          months following the Proposal due date, the Contractor must describe the
          circumstances of such change and indicate when the change is likely to
          occur.

        11.
          The
          name and address of any sponsoring corporation or others who provide financial
          support to the Contractor and type of support, e.g., guarantees, letters
          of
          credit, etc. Indicate if there are maximum limits of the additional financial
          support.

        12.
          The
          name and address of any health professional that has at least a five percent
          financial interest in the Contractor and the type of financial
          interest.

        13.
          The
          names of officers and directors.

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        14.
          The
          state in which the Contractor is incorporated and the state(s) in which
          the
          Contractor is licensed to do business as an HMO. The Contractor must also
          indicate the state where it is commercially domiciled, if
          applicable.

        15.
          The
          Contractor’s federal taxpayer identification number.

        16.
          The
          Contractor’s Texas Provider Identifier (TPI) number if the Contractor is
          Medicaid-enrolled in Texas.

        17.
          Whether the Contractor had a contract terminated or not renewed for
          non-performance or poor performance within the past five years. In such
          instance, the Contractor must describe the issues and the parties involved,
          and
          provide the address and telephone number of the principal terminating party.
          The
          Contractor must also describe any corrective action taken to prevent any
          future
          occurrence of the problem leading to the termination.

        18.
          A
          current Certificate of Good Standing issued by the Texas Comptroller of
          Public
          Accounts, or an explanation for why this form is not applicable to the
          Contractor.

        19.
          Whether the Contractor has ever sought, or is currently seeking, National
          Committee for Quality Assurance (NCQA) or American Accreditation HealthCare
          Commission (URAC) accreditation status, and if it has or is,
          indicate:

        •  its
          current NCQA or URAC accreditation status;

        •  if
          NCQA
          or URAC accredited, its accreditation term effective dates; and

        •  if
          not
          accredited, a statement describing whether and when NCQA or URAC accreditation
          status was ever denied the Contractor.

         

        Material
          Subcontractor Information

        A
          Material Subcontractor means any entity retained by the HMO to provide
          all or
          part of the HMO Administrative Services where the value of the subcontracted
          HMO
          Administrative Service(s) exceeds $100,000 per fiscal year. HMO Administrative
          Services are those services or functions other than the direct delivery
          of
          Covered Services necessary to manage the delivery of and payment for Covered
          Services.  HMO Administrative Services include but are not limited to
          Network, utilization, clinical and/or quality management, service authorization,
          claims processing, Management Information System (MIS) operation and
          reporting.  The term Material Subcontractor does not include Providers
          in the HMO’s Provider Network.

         

        Contractors
          must submit the following for each proposed Material Subcontractor, if
          any:

        

        1.           A
          signed letter of commitment from each Material Subcontractor that states
          the
          Material Subcontractor’s willingness to enter into a Subcontractor agreement
          with the Contractor and a statement of work for activities to be subcontracted.
          Letters of Commitment must be provided on the Material Subcontractor’s official
          company letterhead and signed by an official with the authority to bind
          the
          company for the subcontracted work. The Letter of Commitment must state,
          if
          applicable, the company’s certified HUB status.

        2.           The
          Material Subcontractor’s legal name, trade name, or any other name under which
          the Material Subcontractor does business, if any.

        3.           The
          address and telephone number of the Material Subcontractor’s headquarters
          office.

        4.           The
          type of ownership (e.g., proprietary, partnership, corporation).

        5.           The
          type of incorporation (i.e., for profit, not-for-profit, or non-profit)
          and
          whether the Material Subcontractor is publicly or privately owned.

        6.           If
          a Subsidiary or Affiliate, the identification of the parent
          organization.

        7.           The
          name and address of any sponsoring corporation or others who provide financial
          support to the Material Subcontractor and type of support, e.g., guarantees,
          letters of credit, etc. Indicate if there are maximum limits of the additional
          financial support.

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        8.           The
          name and address of any health professional that has at least a five percent
          (5%) financial interest in the Material Subcontractor and the type of financial
          interest.

        9.           The
          state in which the Material Subcontractor is incorporated, commercially
          domiciled, and the state(s) in which the organization is licensed to do
          business.

        10.
          The
          Material Subcontractor’s Texas Provider Identifier if Medicaid-enrolled in
          Texas.

        11.
          The
          Material Subcontractor’s federal taxpayer identification number.

        12.
          Whether the Material Subcontractor had a contract terminated or not renewed
          for
          non­performance or poor performance within the past five
          years.  In such instance, the Contractor must describe the issues and
          the parties involved, and provide the address and telephone number of the
          principal terminating party. The Contractor must also describe any corrective
          action taken to prevent any future occurrence of the problem leading to
          the
          termination.

        13.
          Whether the Material Subcontractor has ever sought, or is currently seeking,
          National Committee for Quality Assurance (NCQA) or American Accreditation
          HealthCare Commission (URAC) accreditation or certification status, and
          if it
          has or is, indicate:

        •  its
          current NCQA or URAC accreditation or certification status;

        •  if
          NCQA
          or URAC accredited or certified, its accreditation or certification term
          effective dates; and

        •  if
          not
          accredited, a statement describing whether and when NCQA or URAC accreditation
          status was ever denied the Material Subcontractor.

          

        Organizational
          Overview

        1.  Submit
          an
          organizational chart (labeled Chart A), showing the corporate structure
          and
          lines of responsibility and authority in the administration of the Bidder’s
          business as a health plan.

        2.  Submit
          an
          organizational chart (labeled Chart B) showing the Texas organizational
          structure and how it relates to the proposed Service Area(s), including
          staffing
          and functions performed at the local level. If Chart A represents the entire
          organizational structure, label the submission as Charts A and B.

        3.  Submit
          an
          organizational chart (labeled Chart C) showing the Management Information
          System
          (MIS) staff organizational structure and how it relates to the proposed
          Service
          Area(s) including staffing and functions performed at the local
          level.

        4.  If
          the
          Bidder is proposing to use a Material Subcontractor(s), the Bidder shall
          include
          an organizational chart demonstrating how the Material Subcontractor(s)
          will be
          managed within the Bidder’s Texas organizational structure, including the
          primary individuals at the Bidder’s organization and at each Material
          Subcontractor organization responsible for overseeing such Material Subcontract.
          This information may be included in Chart B, or in a separate organizational
          chart(s).

        5.  Submit
          a
          brief narrative explaining the organizational charts submitted, and highlighting
          the key functional responsibilities and reporting requirements of each
          organizational unit relating to the Bidder’s proposed management of the HMO
          Program(s), including its management of any proposed Material
          Subcontractors.

        

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        Other
          Information

        1.  Briefly
          describe any regulatory action, sanctions, and/or fines imposed by any
          federal
          or Texas regulatory entity or a regulatory entity in another state within
          the
          last 3 years, including a description of any letters of deficiencies, corrective
          actions, findings of non­compliance, and/or sanctions. Please indicate which
          of these actions or fines, if any, were related to Medicaid or CHIP programs.
          HHSC may, at its option, contact these clients or regulatory agencies and
          any
          other individual or organization whether or not identified by the
          Contractor.

        2.  No
          later
          than ten (10) days after the Contract Effective Date, submit documentation
          that
          demonstrates that the HMO has secured the required insurance and bonds
          in
          accordance with TDI requirements and Attachment B-1, Section 8.

        3.  Submit
          annual audited financial statement for fiscal years 2004 and 2005 (2005
          to be
          submitted no later than six months after the close of the fiscal
          year).

        4.  Submit
          an
          Affiliate Report containing a list of all Affiliates and for HHSC’s prior review
          and approval, a schedule of all transactions with Affiliates that, under
          the
          provisions of the Contract, will be allowable as expenses in the FSR Report
          for
          services provided to the HMO by the Affiliate. Those should include financial
          terms, a detailed description of the services to be provided, and an estimated
          amount that will be incurred by the HMO for such services during the Contract
          Period.

        

        7.3.1.4
          System Testing and Transfer of Data

        The
          HMO
          must have hardware, software, network and communications systems with the
          capability and capacity to handle and operate all MIS systems and subsystems
          identified in Attachment B-1, Section 8.1.18. For example, the
          HMO’s MIS system must comply with the Health Insurance Portability and
          Accountability Act of 1996 (HIPAA) as indicated in
Section

        8.1.18.4.

         

        During
          this Readiness Review task, the HMO will accept into its system any and
          all
          necessary data files and information available from HHSC or its
          contractors.  The HMO will install and test all hardware, software,
          and telecommunications required to support the Contract.  The HMO will
          define and test modifications to the HMO’s system(s) required to support the
          business functions of the Contract.

         

        The
          HMO
          will produce data extracts and receive all electronic data transfers and
          transmissions. STAR and CHIP HMOs must be able to demonstrate the ability
          to
          produce an EQRO (currently, Institute for Child Health Policy (ICHP)) encounter
          file by April 1, 2006, and the 837-encounter file by August 1,
          2006.  STAR+PLUS HMOs must be able to demonstrate the ability to
          produce the STAR+PLUS encounter file by the STAR+PLUS Operational Start
          Date and
          the 837- encounter file by September 1, 2007. CHIP Perinatal HMOs who have
          already demonstrated the ability to produce an EQRO encounter file and
          837-encounter file for the CHIP Program are not required to produce separate
          files for the CHIP Perinatal Program.

         

        If
          any
          errors or deficiencies are evident, the HMO will develop resolution procedures
          to address problems identified.  The HMO will provide HHSC, or a
          designated vendor, with test data files for systems and interface testing
          for
          all external interfaces.  This includes testing of the required
telephone
          lines for Providers and Members and any necessary connections to the HHSC
          Administrative Services Contractor and the External Quality Review
          Organization.  The HHSC Administrative Services Contractor will
          provide enrollment test files to new HMOs that do not have previous HHSC
          enrollment files. The HMO will demonstrate its system capabilities and
          adherence
          to Contract specifications during readiness review.

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        7.3.1.5
          System Readiness Review

        The
          HMO
          must assure that systems services are not disrupted or interrupted during
          the
          Operations Phase of the Contract. The HMO must coordinate with HHSC and
          other
          contractors to ensure the business and systems continuity for the processing
          of
          all health care claims and data as required under this contract.

         

        The
          HMO
          must submit to HHSC, descriptions of interface and data and process flow
          for
          each key business processes described in Section 8.1.18.3,
          System-wide Functions.

         

        The
          HMO
          must clearly define and document the policies and procedures that will
          be
          followed to support day-to-day systems activities. The HMO must develop,
          and
          submit for State review and approval, the following information by December
          14,
          2005 for STAR and CHIP, by July 31, 2006 for STAR+PLUS:

        

        1.
          Joint
          Interface Plan.

        

        2.
          Disaster Recovery Plan

        

        3.
          Business Continuity Plan

        

        4.
          Risk
          Management Plan, and

        

        5.
          Systems Quality Assurance Plan.

        

        Separate
          plans are not required for CHIP Perinatal HMOs.

         

        7.3.1.6
          Demonstration and Assessment of System Readiness

        The
          HMO
          must provide documentation on systems and facility security and provide
          evidence
          or demonstrate that it is compliant with HIPAA. The HMO shall also provide
          HHSC
          with a summary of all recent external audit reports, including findings
          and
          corrective actions, relating to the HMO’s proposed systems, including any SAS70
          audits that have been conducted in the past three years. The HMO shall
          promptly
          make additional information on the detail of such system audits available
          to
          HHSC upon request.

         

        In
          addition, HHSC will provide to the HMO a test plan that will outline the
          activities that need to be performed by the HMO prior to the Operational
          Start
          Date of the Contract. The HMO must be prepared to assure and demonstrate
          system
          readiness. The HMO must execute system readiness test cycles to include
          all
          external data interfaces, including those with Material
          Subcontractors.

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        HHSC,
          or
          its agents, may independently test whether the HMO’s MIS has the capacity to
          administer the STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO business,
          as
          applicable to the HMO. This Readiness Review of a HMO’s MIS may include a desk
          review and/or an onsite
          review. HHSC may request from the HMO additional documentation to support
          the
          provision of STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO Services,
          as
          applicable to the HMO. Based in part on the HMO’s assurances of systems
          readiness, information contained in the Proposal, additional documentation
          submitted by the HMO, and any review conducted by HHSC or its agents, HHSC
          will
          assess the HMO’s understanding of its responsibilities and the HMO’s capability
          to assume the MIS functions required under the Contract.

         

        The
          HMO
          is required to provide a Corrective Action Plan in response to any Readiness
          Review deficiency no later than ten (10) calendar days after notification
          of any
          such deficiency by HHSC. If the HMO documents to HHSC’s satisfaction that the
          deficiency has been corrected within ten

        (10)
          calendar days of such deficiency notification by HHSC, no Corrective Action
          Plan
          is required.

         

        7.3.1.7
          Operations Readiness

        The
          HMO
          must clearly define and document the policies and procedures that will
          be
          followed to support day-to-day business activities related to the provision
          of
          STAR, STAR+PLUS, CHIP, and/or CHIP Perinatal HMO Services, including
          coordination with contractors.  The HMO will be responsible for
          developing and documenting its approach to quality assurance.

         

        Readiness
          Review. Includes all plans to be implemented in one or more Service
          Areas on the anticipated Operational Start Date. At a minimum, the HMO
          shall,
          for each HMO Program:

        

        1.           Develop
          new, or revise existing, operations procedures and associated documentation
          to
          support the HMO’s proposed approach to conducting operations activities in
          compliance with the contracted scope of work.

        

        2.           Submit
          to HHSC, a listing of all contracted and credentialed Providers, in a HHSC
          approved format including a description of additional contracting and
          credentialing activities scheduled to be completed before the Operational
          Start
          Date.

        

        3.           Prepare
          and implement a Member Services staff training curriculum and a Provider
          training curriculum.

        

        4.           Prepare
          a Coordination Plan documenting how the HMO will coordinate its business
          activities with those activities performed by HHSC contractors and the
          HMO’s
          Material Subcontractors, if any. The Coordination Plan will include
          identification of coordinated activities and protocols for the Transition
          Phase.

        

        5.           Develop
          and submit to HHSC the draft Member Handbook, draft Provider Manual, draft
          Provider Directory, and draft Member Identification Card for HHSC’s review and
          approval. The materials must at a minimum meet the requirements specified
          in
Section 8.1.5
          and include the Critical Elements to be defined in the HHSC
          Uniform Managed Care Manual.

        

        6.           Develop
          and submit to HHSC the HMO’s proposed Member complaint and appeals processes for
          Medicaid, CHIP, and CHIP Perinatal as applicable to the HMO’s Program
          participation.

        7.           Provide
          sufficient copies of the final Provider Directory to the HHSC Administrative
          Services Contractor in sufficient time to meet the enrollment
          schedule.

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        8.           Demonstrate
          toll-free telephone systems and reporting capabilities for the Member Services
          Hotline, the Behavioral Health Hotline, and the Provider Services
          Hotline.

        9.           Submit
          a written Fraud and Abuse Compliance Plan to HHSC for approval no later
          than 30
          days after the Contract Effective Date.  See Section
          8.1.19, Fraud and Abuse, for the requirements of the plan, including
          new requirements for special investigation units. As part of the Fraud
          and Abuse
          Compliance Plan, the HMO shall:

        •  designate
          executive and essential personnel to attend mandatory training in fraud
          and
          abuse detection, prevention and reporting. Executive and essential fraud
          and
          abuse personnel means HMO staff persons who supervise staff in the following
          areas: data collection, provider enrollment or disenrollment, encounter
          data,
          claims processing, utilization review, appeals or grievances, quality assurance
          and marketing, and who are directly involved in the decision-making and
          administration of the fraud and abuse detection program within the
          HMO.  The training will be conducted by the Office of Inspector
          General, Health and Human Services Commission, and will be provided free
          of
          charge.  The HMO must schedule and complete training no later than 90
          days after the Effective Date.

        •  designate
          an officer or director within the organization responsible for carrying
          out the
          provisions of the Fraud and Abuse Compliance Plan.

        •  The
          HMO
          is held to the same requirements and must ensure that, if this function
          is
          subcontracted to another entity, the subcontractor also meets all the
          requirements in this section and the Fraud and Abuse section as stated
          in
Attachment B-1, Section 8.

        •  Note:
          STAR+PLUS HMOs who have already submitted and received HHSC’s approval for their
          Fraud and Abuse Compliance Plans must submit acknowledgement that the HMO’s
          approved Fraud and Abuse Compliance Plan also applies to the STAR+PLUS
          program,
          or submit a revised Fraud and Abuse Compliance Plan for HHSC’s approval, with an
          explanation of changes to be made to incorporate the STAR+PLUS program
          into the
          plan, by July 10, 2006.

        •  CHIP
          Perinatal HMOs who have already submitted and received HHSC’s approval for their
          Fraud and Abuse Compliance Plans must submit acknowledgement that the HMO’s
          approved Fraud and Abuse Compliance Plan also applies to the CHIP Perinatal
          Program, or submit a revised Fraud and Abuse Compliance Plan for HHSC’s
          approval, with an explanation of changes to be made to incorporate the
          CHIP
          Perinatal program into the plan, by September 15, 2006.

        •  Complete
          hiring and training of STAR+PLUS Service Coordination staff, no later than
          45
          days prior to the STAR+PLUS Operational Start Date.

         

        During
          the Readiness Review, HHSC may request from the HMO certain operating procedures
          and updates to documentation to support the provision of STAR, STAR+PLUS,
          CHIP,
          and/or CHIP Perinatal HMO Services.  HHSC will assess the HMO’s
          understanding of its responsibilities and the HMO’s capability to assume the
          functions required under the Contract, based in part on the HMO’s assurances of
          operational readiness, information contained in the Proposal, and in Transition
          Phase documentation submitted by the HMO.

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        The
          HMO
          is required to promptly provide a Corrective Action Plan and/or Risk Mitigation
          Plan as requested by HHSC in response to Operational Readiness Review
          deficiencies identified by the HMO or by HHSC or its agent.  The HMO
          must promptly alert HHSC of deficiencies, and must correct a deficiency
          or
          provide a Corrective Action Plan and/or Risk Mitigation Plan no later than
          ten
          (10) calendar days after HHSC’s notification of deficiencies. If the Contractor
          documents to HHSC’s satisfaction that the deficiency has been corrected within
          ten (10) calendar days of such deficiency notification by HHSC, no Corrective
          Action Plan is required.

         

        7.3.1.8
          Assurance of System and Operational Readiness

        In
          addition to successfully providing the Deliverables described in Section
          7.3.1, the HMO must assure HHSC that all processes, MIS systems, and
          staffed functions are ready and able to successfully assume responsibilities
          for
          operations prior to the Operational Start Date. In particular, the HMO
          must
          assure that Key HMO Personnel, Member Services staff, Provider Services
          staff,
          and MIS staff are hired and trained, MIS systems and interfaces are in
          place and
          functioning properly, communications procedures are in place, Provider
          Manuals
          have been distributed, and that Provider training sessions have occurred
          according to the schedule approved by HHSC.

         

        7.3.1.9
          Post-Transition

        The
          HMO
          will work with HHSC, Providers, and Members to promptly identify and resolve
          problems identified after the Operational Start Date and to communicate
          to HHSC,
          Providers, and Members, as applicable, the steps the HMO is taking to resolve
          the problems.

         

        If
          a HMO
          makes assurances to HHSC of its readiness to meet Contract requirements,
          including MIS and operational requirements, but fails to satisfy requirements
          set forth in this Section, or as otherwise required pursuant to the Contract,
          HHSC may, at its discretion do any of the following in accordance with
          the
          severity of the non-compliance and the potential impact on Members and
          Providers:

        1.  freeze
          enrollment into the HMO’s plan for the affected HMO Program(s) and Service
          Area(s);

        2.  freeze
          enrollment into the HMO’s plan for all HMO Programs or for all Service Areas of
          an affected HMO Program;

        3.  impose
          contractual remedies, including liquidated damages; or

        4.  pursue
          other equitable, injunctive, or regulatory relief.

        

        Refer
          to
Attachment B-1, Sections 8.1.1.2 and 8.1.18
          for additional information regarding HMO Readiness Reviews during the Operations
          Phase.

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    Subject:
      Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8
Version 1.8

    DOCUMENT
      HISTORY LOG

    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	
              Baseline

            	
              n/a

            	 	
              Initial
                version Attachment B-1, Section 8

            
	
              Revision

            	
              1.1

            	
              June
                30, 2006

            	
              Revised
                version of the Attachment B-1, Section 8, that includes provisions
                applicable to MCOs participating in the STAR+PLUS Program. Section
                8.1.1.1, Performance Evaluation, is modified to include STAR+PLUS
                Performance Improvement Goals.  Section 8.1.2, Covered Services,
                is modified to include Functionally Necessary Community Long-term
                Care
                Services for STAR+PLUS. Section 8.1.2.1 Value-Added Services, is
                modified
                to add language allowing for the HMO to distinguish between the Dual
                Eligible and non-Dual Eligible populations. Section 8.1.2.2 Case-by-Case
                Added Services, is modified to clarify for STAR+Plus members it is
                based
                on functionality. Section 8.1.3, Access to Care, is modified to include
                STAR+PLUS Functional Necessity and 1915(c) Nursing Facility Waiver
                clarifications. Section 8.1.4, Provider Network, is modified to include
                STAR+PLUS.  Section 8.1.4.2, Primary Care Providers, is modified
                to include STAR+PLUS Section 8.1.4.8, Provider Reimbursement, is
                modified
                to include Functionally Necessary Long-term care services for STAR+PLUS.
                Section 8.1.7.7, Provider Profiling, is modified to include STAR+PLUS.
                Sections 8.1.12 and 8.1.12.2, Services for People with Special Health
                Care
                Needs, are modified to include STAR+PLUS. Section 8.1.13, Service
                Management for Certain Populations, is modified to include STAR+PLUS.
                Section 8.1.14, Disease Management, is modified to include STAR+PLUS.
                Section 8.2, Additional Medicaid HMO Scope of Work, is modified to
                include
                STAR+PLUS. Section 8.3, Additional STAR+PLUS Scope of Work, is
                added.

            
	
              Revision

            	
              1.2

            	
              September
                1, 2006

            	
              Revised
                version of Attachment B-1, Section 8, that includes provisions applicable
                to MCOs participating in the STAR and CHIP Programs. Section 8.1.1.1,
                Performance Evaluation, is modified to clarify that the HMOs goals
                are
                Service Area and Program specific; when the percentages for Goals
                1 and 2
                are to be negotiated; and when Goal 3 is to be
                negotiated.

            

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Subject:
      Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8
Version 1.8

    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	 	 	 	
              Section
                8.1.2.1, Value-Added Services, is modified to add language allowing
                for
                the addition of two Value-added Services during the Transition Phase
                of
                the Contract and to clarify the effective dates for Value Added Services
                for the Transition Phase and the Operation Phase of the Contract.
                Section
                8.1.3.2, Access to Network Providers, is modified to delete references
                to
                Open Panels. Section 8.1.4, Provider Network, is modified to clarify
                that
                “Out-of-Network reimbursement arrangements” with certain providers must be
                in writing. Section 8.1.5.1, Member Materials, is modified to clarify
                the
                date that the member ID card and the member handbook are to be sent
                to
                members. Section 8.1.5.6, Member Hotline, is modified to clarify
                the
                hotline performance requirements. Section 8.1.17.2, Financial Reporting
                Requirements, is modified to clarify that the Bonus Incentive Plan
                refers
                to the Employee Bonus Incentive Plan. It has also been modified to
                clarify
                the reports and deliverable due dates and to change the name of the
                Claims
                Summary Lag Report and clarify that the report format has been moved
                to
                the Uniform Managed Care Manual. Section 8.1.18.5, Claims Processing
                Requirements, is modified to revise the claims processing requirements
                and
                move many of the specifics to the Uniform Managed Care Manual. Section
                8.1.20, Reporting Requirements, is modified to clarify the reports
                and
                deliverable due dates.  Section 8.1.20.2, Reports, is modified
                to delete the Claims Data Specifications Report, amend the All Claims
                Summary Report, and add two new provider-related reports to the contract.
                Section 8.2.2.10, Cooperation with Immunization Registry, is added
                to
                comply with legislation, SB 1188 sec. 6(e)(1), 79th Legislature,
                Regular
                Session, 2005. Section 8.2.2.11, Case Management for Children and
                Pregnant
                Women, is added. Section 8.2.5.1, Provider Complaints, is modified
                to
                include the 30­day resolution requirement. Section 8.2.10.2,
                Non-Reimbursed Arrangements with Local Public Health Entities, is
                modified
                to update the requirements and delete the requirement for an MOU.
                Section
                8.2.11, Coordination with Other State Health and Human Services (HHS)
                Programs, is modified to update the requirements and delete the
                requirement for an MOU. Section 8.4.2, CHIP Provider Complaint and
                Appeals, is modified to include the 30-day resolution
                requirement.

            
	
              Revision

            	
              1.3

            	
              September
                1, 2006

            	
              Revised
                version of Attachment B-1, Section 8, that includes provisions applicable
                to MCOs participating in the CHIP Perinatal
                Program.

            

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Subject:
      Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8
Version 1.8

    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	 	 	 	
              Section
                8.1.1.1, Performance Evaluation, is modified to clarify that HHSC
                will
                negotiate and implement Performance Improvement Goals for the first
                full
                State Fiscal Year following the CHIP Perinatal Operational Start
                Date
                Section 8.1.2, Covered Services is amended to: (a) clarify that Fee
                For
                Service will pay the Hospital costs for CHIP Perinate Newborns; (b)
                add a
                reference to new Attachment B-2.2 concerning covered services; (c)
                add
                CHIP Perinate references where appropriate.  Section 8.1.2.2
                Case-by-Case Added Services, is modified to clarify that this does
                not
                apply to the CHIP Perinatal Program.  Section 8.1.3, Access to
                Care, is amended to include emergency services limitations. Section
                8.1.3.2, Access to Network Providers, is amended to include the Provider
                access standards for the CHIP Perinatal Program.  Section
                8.1.4.2 Primary Care Providers, is modified to clarify the development
                of
                the PCP networks between the CHIP Perinates and the CHIP Perinate
                Newborns. Section 8.1.4.6 Provider Manual, Materials and Training,
                modified to include the CHIP Perinatal Program Section 8.1.4.9 Termination
                of Provider Contracts modified to include the CHIP Perinatal Program.
                Section 8.1.5.2 Member Identification (ID) Card, modified to include
                the
                CHIP Perinatal Program. Section 8.1.5.3 Member Handbook, modified
                to
                include the CHIP Perinatal Program. Section 8.1.5.4 Provider Directory,
                modified to include the CHIP Perinatal Program. Section 8.1.5.6 Member
                Hotline, modified to include the CHIP Perinatal Program. Section
                8.1.5.7
                Member Education, modified to include the CHIP Perinatal Program.
                Section
                8.1.5.9 Member Complaint and Appeal Process, modified to include
                the CHIP
                Perinatal Program. Section 8.1.7.7, Provider Profiling, is modified
                to
                include the CHIP Perinatal Program. Section 8.1.12, Services for
                People
                with Special Health Care Needs, modified to clarify between CHIP
                Perinatal
                Program and CHIP Perinatal Newborn. Section 8.1.13, Service Management
                for
                Certain Populations, modified to clarify the CHIP Perinatal Program.
                Section 8.1.15, Behavioral Health (BH) Network and Services, modified
                to
                clarify between CHIP Perinatal and Perinate members. Section 8.1.17.2,
                Financial Reporting Requirements, modified to include the CHIP Perinatal
                Program. Section 8.1.18.3, System-wide Functions, modified to include
                the
                CHIP Perinatal Program. Section 8.1.18.5, Claims Processing Requirements,
                modified to include the CHIP Perinatal
                Program.

            

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Subject:
      Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8
Version 1.8

    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	 	 	 	
              Section
                8.1.19, Fraud and Abuse, modified to include the CHIP Perinatal Program
                Section 8.1.20.2, Provider Termination Report and Provider Network
                Capacity Report, is modified to include the CHIP Perinatal Program.
                Section 8.5, Additional Scope of Work for CHIP Perinatal Program
                HMOs, is
                added to Attachment B-1.

            
	
              Revision

            	
              1.4

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-1, Section 8­Operations Phase
                Requirements.

            
	
              Revision

            	
              1.5

            	
              January
                1, 2007

            	
              Revised
                version of the Attachment B-1, Section 8, that includes provisions
                applicable to MCOs participating in the STAR and STAR+PLUS Program.
                Section 8.1.2 is modified to include a reference to STAR and STAR+PLUS
                covered services.  Section 8.1.20.2 is modified to update the
                references to the Uniform Managed Care Manual for the “Summary Report of
                Member Complaints and Appeals” and the “Summary Report of Provider
                Complaints.” Section 8.2.2.5 is modified to require the Provider to
                coordinate with the Regional Health Authority. Section 8.2.4 is amended
                to
                clarify cost settlements and encounter rates for Federally Qualified
                Health Centers (FQHCs) and Rural Health Clinics (RHCs) for STAR and
                STAR+PLUS service areas.  Section 8.3.2.4 is amended to clarify
                the timeframe for initial STAR+PLUS assessments. Section 8.3.3 is
                amended
                to: (1) clarify the use of the DHS Form 2060; (2) require the HMO
                to
                complete the Individual Service Plan (ISP), Form 3671 for each Member
                receiving 1915(c) Nursing Facility Waiver Services; (3) require HMOs
                to
                complete Form 3652 and Form 3671annually at reassessment; (4) allow
                the
                HMOs to administer the Minimum Data Set for Home Care (MDS-HC) instrument
                for non­waiver STAR+PLUS Members over the course of the first year of
                operation; (5) allow HMOs to submit other supplemental assessment
                instruments.  Section 8.3.4 is modified to include the criteria
                for participation in 1915(c) nursing facility waiver
                services.  Section 8.3.4.3 is amended to remove the six-month
                timeframe for Nursing Facility Cost Ceiling.  Deletes provision
                stating DADS Commissioner may grant exceptions in individual cases.
                Section 8.3.5 is amended to delete the requirement that HMOs use
                the
                Consumer Directed Services option for the delivery of Personal Attendant
                Services. The new language provides HMOs with three options for delivering
                these services.  The options are described in the following new
                subsections: 8.3.5.1, Personal Attendant Services Delivery Option
–
                Self-Directed Model; 8.3.5.2, Personal Attendant Services Delivery
                Option
                – Agency Model, Self-Directed; and 8.3.5.3, Personal Attendant Services
                Delivery Option – Agency Model. Section 8.3.7.3 is modified to reflect the
                changes made by the HMO workgroup regarding enhanced payments for
                attendant care.  The section also includes a reference to new
                Attachment B-7, which

            

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Subject:
      Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8
Version 1.8

    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	 	 	 	
              contains
                the HMO’s methodology for implementing and paying the enhanced
                payments.

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

            	
              Revised
                version of the Attachment B-1, Section 8, that includes provisions
                applicable to MCOs participating in the STAR+PLUS and CHIP Perinatal
                Programs. Section 8.1 is modified to clarify the Operational Start
                Date of
                the STAR+PLUS Program. Section 8.1.3.2 is modified to allow exceptions
                to
                hospital access standards on a case-by-case basis only for HMOs
                participating in the CHIP Perinatal Program. Section 8.3.3 is modified
                to
                clarify when the 12-month period begins for the STAR+PLUS HMOs to
                complete
                the MDS-HC instruments for non-1915(c) Nursing Facility Waiver Members
                who
                are receiving Community-based Long-term Care Services.

            
	
              Revision

            	
              1.7

            	
              July
                1, 2007

            	
              New
                Section 8.1.1.2 is added to require the HMOs to pay for any additional
                readiness reviews beyond the original ones conducted before the
                Operational Start Date. Section 8.1.5.5 is modified to add a requirement
                that all HMOs must list Home Health Ancillary providers on their
                websites,
                with an indicator for Pediatric services. Section 8.1.17.2 is modified
                to
                remove the requirement that the Claims Lag Report separate claims
                by
                service categories. Section 8.1.18 is modified to update the
                cross-references to sections of the contract addressing remedies
                and
                damages and to add cross-references to sections of the contract addressing
                Readiness Reviews. Section 8.1.18.5 is modified to require the HMO
                to make
                an electronic funds transfer payment process available when processing
                claims for Medically Necessary covered STAR+PLUS services. Section
                8.1.19
                is modified to comply with a new federal law that requires entities
                that
                receive or make Medicaid payments of at least $5 million annually
                to
                educate employees, contractors and agents and to implement policies
                and
                procedures for detecting and preventing fraud, waste and
                abuse.  Section 8.1.20.2 is modified to require Provider
                Termination Reports for STAR+PLUS as required by the Dashboard. The
                amendment also requires Claims Summary Reports be submitted by
                claim  type. Section 8.2.7.5 is modified to comply with the
                settlement agreement in the Alberto N. litigation. Section
                8.3.4.3 is modified to remove references to the cost cap for 1915(c)
                Nursing Facility Waiver services.

            
	
              Revision

            	
              1.8

            	
              September
                1, 2007

            	
              Section
                8.1.2.1 is modified to reflect legislative changes required by SB
                10.
                Section 8.1.3.2 is modified to reflect legislative changes required
                by SB
                10. Section 8.1.5.6 is modified to comply with the Frew litigation
                corrective action plans. New Section 8.1.5.6.1 is added to comply
                with the
                Frew litigation corrective action plans. Section 8.1.5.7 is modified
                to
                comply with the Frew litigation corrective action
                plans.

            

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Subject:
      Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 8
Version 1.8

    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            	 
	 	 	 	
              Section
                8.1.11 is modified to delete language included in error and to clarify
                the
                coverage for children in foster care.   Section 8.1.13 is
                added to comply with the Frew litigation corrective action plans.
                Section
                8.1.17.2 is modified to reflect legislative changes required by SB
                10.
                Section 8.1.20.2 is modified to comply with the Frew litigation corrective
                action plans by adding two new reports: Medicaid Medical Check-ups
                Report
                and Medicaid FWC Report. Section 8.2.2.3 is modified to comply with
                Frew
                litigation correction action plans. New Section 8.2.2.12 is added
                to
                comply with the Frew litigation correction action plans to enhance
                care
                for children of Migrant Farmworkers. Section 8.2.4 is modified to
                clarify
                cost settlement requirements and encounter and payment reporting
                requirements for the Nueces Service Area and the STAR+PLUS Service
                Areas.
                Section 8.2.7.4 is amended to reflect the new fair hearings process
                for
                Medicaid Members that will be effective 9/1/07.   Section
                8.2.11 is modified to comply with the Frew litigation corrective
                action
                plans.

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

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

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

            

    

    
    

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    8.
      OPERATIONS PHASE REQUIREMENTS

    This
      Section is designed to provide HMOs with sufficient information to understand
      the HMOs' responsibilities. This Section describes scope of work requirements
      for the Operations Phase of the Contract.

    Section
      8.1 includes the general scope of work that applies to the STAR,
      STAR+PLUS, CHIP, and CHIP Perinatal HMO Programs.

    Section
      8.2 includes the additional Medicaid scope of work that applies only
      to
      the STAR and STAR+PLUS HMOs.

    Section
      8.3 includes the additional scope of work that applies only to
      STAR+PLUS HMOs.

    Section
      8.4 includes the additional scope of work that applies only to CHIP
      HMOs.

    Section
      8.5 includes the additional scope of work that applies only to CHIP
      Perinatal HMOs.

    The
      Section does not include detailed information on the STAR, STAR+PLUS, CHIP,
      and
      CHIP Perinatal HMO Program requirements, such as the time frame and format
      for
      all reporting requirements.  HHSC has included this information in the
Uniform Managed Care Contract Terms and Conditions
(Attachment A) and the Uniform Managed Care
      Manual. HHSC reserves the right to modify these documents as it deems
      necessary using the procedures set forth in the Uniform Managed Care
      Contract Terms and Conditions.

     

    8.1
      General Scope of Work

    In
      each
      HMO Program Service Area, HHSC will select HMOs for each HMO Program to provide
      health care services to Members. The HMO must be licensed by the Texas
      Department of Insurance (TDI) as an HMO or an ANHC in all zip codes in the
      respective Service Area(s).

    Coverage
      for benefits will be available to enrolled Members effective on the Operational
      Start Date. The Operational Start Date is September 1, 2006 for STAR and CHIP
      HMOs, January 1, 2007 for CHIP Perinatal HMOs, and February 1, 2007 for the
      STAR+PLUS HMOs.

     

    8.1.1
      Administration and Contract Management

    The
      HMO
      must comply, to the satisfaction of HHSC, with (1) all provisions set forth
      in
      this Contract, and (2) all applicable provisions of state and federal laws,
      rules, regulations, and waivers.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.1.1.1
      Performance Evaluation

    The
      HMO
      must identify and propose to HHSC, in writing, no later than May 1st of each
      State
      Fiscal Year (SFY) after the Operational Start Date, annual HMO Performance
      Improvement Goals for the next fiscal year, as well as measures and time frames
      for demonstrating that such goals are being met.  Performance
      Improvement Goals must be based on HHSC priorities and identified opportunities
      for improvement (see Attachment B-4, Performance Improvement
      Goals). The Parties will negotiate such Performance Improvement Goals,
      the measures that will be used to assess goal achievement, and the time frames
      for completion, which will be incorporated into the Contract. If HHSC and the
      HMO cannot agree on the Performance Improvement Goals, measures, or time frames,
      HHSC will set the goals, measures, or time frames.

    For
      State
      Fiscal Year 2007, HHSC has established three overarching goals for each Program.
      These overarching goals are as follows:

    Goal
      1 (STAR and CHIP) Improve Access to Primary Care Services for
      Members

    Goal
      2 (STAR and CHIP) Improve Access to Behavioral Health Services for
      Members,

    Goal
      3 (STAR Only) Improve Access to Clinically Appropriate Alternatives
      to  Emergency Room Services Outside of Regular Office Hours (CHIP
      Only)  Improve Current Member Understanding About the CHIP Benefit
      Renewal Processes

    Note:  The
      HMO is required to propose customized sub-goals specific to the HMO’s Service
      Areas and Programs for all overarching goals.  The sub-goals must be
      approved by HHSC as part of the negotiation process.

    The
      specific percentages of expected achievement for each sub-goal will be
      negotiated by HHSC and the HMO before the Operational Start Date.

    For
      STAR+PLUS HMOs, HHSC will negotiate and implement Performance Improvement Goals
      for the first full fiscal year following the STAR+PLUS Operational Start
      Date.  One standard STAR+PLUS goal will relate to Consumer-Directed
      Services. STAR+PLUS improvement goals for SFY2008 will be included in
Attachment B-4.1.

    For
      CHIP
      Perinatal HMOs, HHSC will negotiate and implement Performance Improvement Goals
      for the first full State Fiscal Year following the CHIP Perinatal Operational
      Start Date.

    The
      HMO
      must participate in semi-annual Contract Status Meetings (CSMs) with HHSC for
      the primary purpose of reviewing progress toward the achievement of annual
      Performance Improvement Goals and Contract requirements.  HHSC may
      request additional CSMs, as it deems necessary to address areas of
      noncompliance.  HHSC will provide the HMO with reasonable advance
      notice of additional CSMs, generally at least five (5) business
      days.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    The
      HMO
      must provide to HHSC, no later than 14 business days prior to each semi-annual
      CSM, one electronic copy of a written update, detailing and documenting the
      HMO’s progress toward meeting the annual Performance Improvement Goals or other
      areas of noncompliance.

    HHSC
      will
      track HMO performance on Performance Improvement Goals.  It will also
      track other key facets of HMO performance through the use of a
Performance Indicator Dashboard (see HHSC’s Uniform Managed Care
      Manual). HHSC will compile the Performance Indicator Dashboard based on
      HMO submissions, data from the External Quality Review Organization (EQRO),
      and
      other data available to HHSC.  HHSC will share the Performance
      Indicator Dashboard with the HMO on a quarterly basis.

     

    8.1.1.2
      Additional HMO Readiness Reviews

    During
      the Operations Phase, a HMO that chooses to make a change to any operational
      system or undergo any major transition may be subject to an additional Readiness
      Review(s).  HHSC will determine whether the proposed changes will
      require a desk review and/or an onsite review.  The HMO is responsible
      for all costs incurred by HHSC or its authorized agent to conduct an onsite
      Readiness Review.

    Refer
      to
Attachment B-1, Section 7 and Attachment B-1, Section
      8.1.18 for additional information regarding HMO Readiness Reviews.
      Refer to Attachment A, Section 4.08(c) for information
      regarding Readiness Reviews of the HMO’s Material Subcontractors.

     

    8.1.2
      Covered Services

    The
      HMO
      is responsible for authorizing, arranging, coordinating, and providing Covered
      Services in accordance with the requirements of the Contract. The HMO must
      provide Medically Necessary Covered Services to all Members beginning on the
      Member’s date of enrollment regardless of pre-existing conditions, prior
      diagnosis and/or receipt of any prior health care services. STAR+PLUS HMOs
      must
      also provide Functionally Necessary Community Long-term Care Services to all
      Members beginning on the Member’s date of enrollment regardless of
      pre­existing conditions, prior diagnosis and/or receipt of any prior health
      care services. The HMO must not impose any pre-existing condition limitations
      or
      exclusions or require Evidence of Insurability to provide coverage to any
      Member.

    The
      HMO
      must provide full coverage for Medically Necessary Covered Services to all
      Members and, for STAR+PLUS Members, Functionally Necessary Community Long-term
      Care Services, without regard to the Member’s:

    

    1.
      previous coverage, if any, or the reason for termination of such
      coverage;

    2.
      health
      status;

    3.
      confinement in a health care facility; or

    4.
      for
      any other reason.

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Please
      Note:

     

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

    (STAR+PLUS
      HMOs): A Member cannot change from one STAR+PLUS HMO to another STAR+PLUS HMO
      during an inpatient hospital stay. The STAR+PLUS HMO is responsible for
      authorization and management of the inpatient hospital stay until the time
      of
      discharge, or until such time that there is a loss of Medicaid
      eligibility.  STAR+PLUS HMOs are responsible for professional charges
      during every month for which the HMO receives a full capitation for a
      Member.

    A
      Member
      cannot change from one STAR+PLUS HMO to another STAR+PLUS HMO during a nursing
      facility stay.

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

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

    The
      HMO
      must not practice discriminatory selection, or encourage segregation among
      the
      total group of eligible Members by excluding, seeking to exclude, or otherwise
      discriminating against any group or class of individuals.

    Covered
      Services for all Medicaid HMO Members are listed in Attachments B-2 and
      B-2.1 of the Contract (STAR and STAR+PLUS Covered Services). As noted
      in Attachments B-2 and B-2.1, all Medicaid HMOs must provide
      Covered Services described in the most recent Texas Medicaid Provider
      Procedures Manual (Provider Procedures Manual), the THSteps
      Manual (a supplement to the Provider Procedures Manual), and in all
Texas Medicaid Bulletins, which update the Provider Procedures
      Manual except for those services identified in Section 8.2.2.8
      as non-capitated services. A description of CHIP Covered Services and exclusions
      is provided in Attachment B-2 of the Contract. A description of
      CHIP Perinatal Program Covered Services and exclusions is provided in
Attachment B-2.2 of the Contract. Covered Services are subject
      to change due to changes in federal and state law, changes in Medicaid, CHIP
      or
      CHIP Perinatal Program policy, and changes in medical practice, clinical
      protocols, or technology.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.1.2.1
      Value-added Services

    HMOs
      may
      propose additional services for coverage. These are referred to as “Value-added
      Services.” Value-added Services may be actual Health Care Services, benefits, or
      positive incentives that HHSC determines will promote healthy lifestyles and
      improved health outcomes among Members.  Value-added Services that
      promote healthy lifestyles should target specific weight loss, smoking
      cessation, or other programs approved by HHSC. Temporary phones, cell phones,
      additional transportation benefits, and extra home health services may be
      Value-added Services, if approved by HHSC.  Best practice approaches
      to delivering Covered Services are not considered Value-added
      Services.

    If
      offered, Value-added Services must be offered to all mandatory STAR, and CHIP
      and CHIP Perinatal HMO Members within the applicable HMO Program and Service
      Area. For STAR+PLUS Acute Care services, the HMO may distinguish between the
      Dual Eligible and non-Dual Eligible populations. Value-added Services do not
      need to be consistent across more than one HMO Program or across more than
      one
      Service Area. Value-added Services that are approved by HHSC during the
      contracting process will be included in the Contract’s scope of
      services.

    The
      HMO
      must provide Value-added Services at no additional cost to HHSC. The HMO must
      not pass on the cost of the Value-added Services to Providers. The HMO must
      specify the conditions and parameters regarding the delivery of the Value-added
      Services in the HMO’s Marketing Materials and Member Handbook, and must clearly
      describe any limitations or conditions specific to the Value-added
      Services.

    Transition
      Phase.  During the Transition Phase, HHSC will offer a
      one-time opportunity for the HMO to propose two additional Value-added Services
      to its list of current, approved Value-added Services. (See Attachment
      B-3, Value-Added Services). HHSC will establish the requirements and
      the timeframes for submitting the two additional proposed Value-added
      Services.

    During
      this HHSC-designated opportunity, the HMO may propose either to add new
      Value-added Services or to enhance its current, approved Value-added
      Services.  The HMO may propose two additional Value-added Services per
      HMO Program, and the services do not have to be the same for each HMO
      Program.  HHSC will review the proposed additional services and, if
      appropriate, will approve the additional Value-added Services, which will be
      effective on the Operational Start Date. The HMO’s Contract will be amended to
      reflect the additional, approved Value-added Services.

    The
      HMO
      does not have to add Value-added Services during the HHSC-designated
      opportunity, but this will be the only time during the Transition Phase for
      the
      HMO to add Value-added Services. At no time during the Transition Phase will
      the
      HMO be allowed to delete, limit or restrict any of its current, approved
      Value-added Services.

    Operations
      Phase. During the Operations Phase, Value-added Services can be added
      or removed only by written amendment of the Contract one time per fiscal year
      to
      be effective September 1 of the fiscal year, except when services are amended
      by
      HHSC during the fiscal year.  This will allow HHSC to coordinate with
      annual revisions to HHSC’s HMO Comparison Charts for Members. A HMO’s request to
      add or delete a Value-added Service must be submitted

    to
      HHSC
      by May 1 of each year to be effective September 1 for the following contract
      period. (For STAR and CHIP, see Attachment B-3, Value-Added
      Services. For STAR+PLUS, see Attachment B-3.1, STAR+PLUS
      Value-Added Services. For CHIP Perinatal, see Attachment B-3.2,
      CHIP Perinatal Value-Added Services.)

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    A
      HMO’s
      request to add a Value-added Service must:

    a  Define
      and describe the proposed Value-added Service;

    b  Specify
      the Service Areas and HMO Programs for the proposed Value-added
      Service;

    c  Identify
      the category or group of mandatory Members eligible to receive the Value-added
      Service if it is a type of service that is not appropriate for all mandatory
      Members;

    d  Note
      any
      limits or restrictions that apply to the Value-added Service;

    e  Identify
      the Providers responsible for providing the Value-added Service;

    f  Describe
      how the HMO will identify the Value-added Service in administrative (Encounter)
      data;

    g  Propose
      how and when the HMO will notify Providers and mandatory Members about the
      availability of such Value-added Service;

    h  Describe
      how a Member may obtain or access the Value-added Service; and

    i  Include
      a
      statement that the HMO will provide such Value-added Service for at least 12
      months from the September 1 effective date.

    

    A
      HMO
      cannot include a Value-added Service in any material distributed to mandatory
      Members or prospective mandatory Members until the Parties have amended the
      Contract to include that Value-added Service. If a Value-added Service is
      deleted by amendment, the HMO must notify each mandatory Member that the service
      is no longer available through the HMO. The HMO must also revise all materials
      distributed to prospective mandatory Members to reflect the change in
      Value-added Services.

     

    8.1.2.2
      Case-by-Case Added Services

    Except
      as
      provided below, the HMO may offer additional benefits that are outside the
      scope
      of services to individual Members on a case-by-case basis, based on Medical
      Necessity, cost-effectiveness, the wishes of the Member/Member’s family, the
      potential for improved health status of the Member, and for STAR+PLUS Members
      based on functional necessity.

    Section
      8.1.2.2, Case-by-Case Added Services, does not apply to the CHIP Perinatal
      Program.

     

    8.1.3
      Access to Care

    All
      Covered Services must be available to Members on a timely basis in accordance
      with medically appropriate guidelines, and consistent with generally accepted
      practice parameters, requirements in this Contract. The HMO must comply with
      the
      access requirements as established by the Texas Department of Insurance (TDI)
      for all HMOs doing business in Texas, except as otherwise required by this
      Contract. Medicaid HMOs must be responsive to the possibility of increased
      Members due to the phase-out of the PCCM model in Service Areas where adequate
      HMO coverage exists.

    The
      HMO
      must provide coverage for Emergency Services to Members 24 hours a day and
      7
      days a week, without regard to prior authorization or the Emergency Service
      provider’s contractual relationship with the HMO. The HMO’s policy and
      procedures, Covered Services, claims adjudication methodology, and reimbursement
      performance for Emergency Services must comply with all applicable state and
      federal laws and regulations, whether the provider is in-network or
      Out-of-Network. A HMO is not responsible for payment for unauthorized
      non-emergency services provided to a Member by Out-of-Network
      providers.

    The
      HMO
      must also have an emergency and crisis Behavioral Health Services Hotline
      available 24 hours a day, 7 days a week, toll-free throughout the Service Area.
      The Behavioral Health Services Hotline must meet the requirements described
      in
Section 8.1.15. For Medicaid Members, a HMO must provide
      coverage for Emergency Services in compliance with 42 C.F.R. §438.114, and as
      described in more detail in Section 8.2.2.1. The HMO may
      arrange Emergency Services and crisis Behavioral Health Services through mobile
      crisis teams.

    For
      CHIP
      Members, Emergency Services, including emergency Behavioral Health Services,
      must be provided in accordance with the Texas Insurance Code and TDI
      regulations.

    For
      the
      CHIP Perinatal Program, refer to Attachment B-2.2 for description of emergency
      services for CHIP Perinates and CHIP Perinate Newborns.

    For
      the
      STAR, STAR+PLUS, and CHIP Programs, and for CHIP Perinate Newborns, HMO must
      require, and make best efforts to ensure, that PCPs are accessible to Members
24
      hours a day, 7 days a week and that its Network Primary Care Providers (PCPs)
      have after-hours telephone availability that is consistent with, Section
      8.1.4. CHIP Perinatal HMOs are not required to establish PCP Networks
      for CHIP Perinates.

    The
      HMO
      must provide that if Medically Necessary Covered Services are not available
      through Network physicians or other Providers, the HMO must, upon the request
      of
      a Network physician or other Provider, within the time appropriate to the
      circumstances relating to the delivery of the services and the condition of
      the
      patient, but in no event to exceed five business days after receipt of
      reasonably requested documentation, allow a referral to a non-network physician
      or provider. The HMO must fully reimburse the non-network provider in accordance
      with the Out-of-Network methodology for Medicaid as defined by HHSC, and for
      CHIP, at the usual and customary rate defined by TDI in 28 T.A.C. Section
      11.506.

    The
      Member will not be responsible for any payment for Medically Necessary Covered
      Services, including Functionally Necessary Covered Services, other
      than:

    

    (1)
      HHSC-specified co-payments for CHIP Members, where applicable; and

    

    (2)
      STAR+PLUS Members who qualify for 1915(c) Nursing Facility Waiver services
      and
      enter a 24-hour setting will be required to pay the provider of care room and
      board costs and any income in excess of the personal needs allowance, as
      established by HHSC.  If the HMO provides Members who do not qualify
      for the 1915(c) Nursing Facility Waiver services
      in a 24-hour setting as an alternative to nursing facility or hospitalization,
      the Member will be required to pay the provider of care room and board costs
      and
      any income in excess of the personal needs allowance, as established by
      HHSC.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.1.3.1
      Waiting Times for Appointments

    Through
      its Provider Network composition and management, the HMO must ensure that
      appointments for the following types of Covered Services are provided within
      the
      time frames specified below. In all cases below, “day” is defined as a calendar
      day.

    1  Emergency
      Services must be provided upon Member presentation at the service delivery
      site,
      including at non-network and out-of-area facilities;

    2  Urgent
      care, including urgent specialty care, must be provided within 24 hours of
      request.

    3  Routine
      primary care must be provided within 14 days of request;

    4  Initial
      outpatient behavioral health visits must be provided within 14 days of
      request;

    5  Routine
      specialty care referrals must be provided within 30 days of
      request;

    6  Pre-natal
      care must be provided within 14 days of request, except for high-risk
      pregnancies or new Members in the third trimester, for whom an appointment
      must
      be offered within five days, or immediately, if an emergency
      exists;

    7  Preventive
      health services for adults must be offered to a Member within 90 days of
      request; and

    8  Preventive
      health services for children, including well-child check-ups should be offered
      to Members in accordance with the American Academy of Pediatrics (AAP)
      periodicity schedule. Please note that for Medicaid Members, HMOs should use
      the
      THSteps Program modifications to the AAP periodicity schedule. For newly
      enrolled Members under age 21, overdue or upcoming well-child checkups,
      including THSteps medical checkups, should be offered as soon as practicable,
      but in no case later than 14 days of enrollment for newborns, and no later
      than
      60 days of enrollment for all other eligible child Members.

    

    8.1.3.2
      Access to Network Providers

    The
      HMO’s
      Network shall have within its Network, PCPs in sufficient numbers, and with
      sufficient capacity, to provide timely access to regular and preventive
      pediatric care and THSteps services to all child Members in accordance with
      the
      waiting times for appointments in Section

     

    8.1.3.1
      PCP
      Access: At a minimum, the HMO must ensure that all Members have access
      to an age-appropriate PCP in the Provider Network with an Open Panel within
      30
      miles of the Member’s residence. For the purposes of assessing compliance with
      this requirement, an internist who provides primary care to adults only is
      not
      considered an age-appropriate PCP choice for a Member under age 21, and a
      pediatrician is not considered an age-appropriate choice for a Member age 21
      and
      over.   Note: This provision does not apply to CHIP Perinates,
      but it does apply to CHIP Perinate Newborns.

     

    OB/GYN
      Access and CHIP Perinatal Program Provider Access: STAR, STAR+PLUS and
      CHIP Program Network:  at a minimum, STAR, STAR+PLUS and CHIP HMOs
      must ensure that all female Members have access to an OB/GYN in the Provider
      Network within 75 miles of the

    Member’s
      residence. (If the OB/GYN is acting as the Member’s PCP, the HMO must follow the
      access requirements for the PCP.) The HMO must allow female Members to select
      an
      OB/GYN within its Provider Network. A female Member who selects an OB/GYN must
      be allowed direct access to the OB/GYN’s health care services without a referral
      from the Member’s PCP or a prior authorization. A pregnant Member with 12 weeks
      or less remaining before the expected delivery date must be allowed to remain
      under the Member’s current OB/GYN care though the Member’s post-partum checkup,
      even if the OB/GYN provider is, or becomes, Out-of-Network.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    CHIP
      Perinatal Program Network:  At a minimum, CHIP Perinatal HMOs must
      ensure that CHIP Perinates have access to a Provider of perinate services within
      75 miles of the Member’s residence if the Member resides in an urban area and
      within 125 miles of the Member’s residence if the Member resides in a rural
      area.

     

    Outpatient
      Behavioral Health Service Provider Access: At a minimum, the HMO must
      ensure that all Members except CHIP Perinates have access to an outpatient
      Behavioral Health Service Provider in the Network within 75 miles of the
      Member’s residence. Outpatient Behavioral Health Service Providers must include
      Masters and Doctorate-level trained practitioners practicing independently
      or at
      community mental health centers, other clinics or at outpatient hospital
      departments. A Qualified Mental Health Provider (QMHP), as defined and
      credentialed by the Texas Department of State Health Services standards (T.A.C.
      Title 25, Part I, Chapter 412), is an acceptable outpatient behavioral health
      provider as long as the QMHP is working under the authority of an MHMR entity
      and is supervised by a licensed mental health professional or
      physician.

     

    Other
      Specialist Physician Access: At a minimum, the HMO must ensure that all
      Members except CHIP Perinates have access to a Network specialist physician
      within 75 miles of the Member’s residence for common medical specialties. For
      adult Members, common medical specialties shall include general surgery,
      cardiology, orthopedics, urology, and ophthalmology. For child Members, common
      medical specialties shall include orthopedics and otolaryngology. In addition,
      all Members must be allowed to: 1) select an in-network opthalmologist or
      therapeutic optometrist to provide eye Health Care Services, other than surgery,
      and 2) have access without a PCP referral to eye Health Care Services from
      a
      Network specialist who is an ophthalmologist or therapeutic optometrist for
      non-surgical services.

     

    Hospital
      Access: The HMO must ensure that all Members have access to an Acute
      Care hospital in the Provider Network within 30 miles of the Member’s
      residence.  For HMOs participating in the CHIP Perinatal Program,
      exceptions to this access standard may be requested on a case-by­case basis
      and must have HHSC approval.

     

    All
      other Covered Services, except for services provided in the Member’s
      residence: At a minimum, the HMO must ensure that all Members have
      access to at least one Network Provider for each of the remaining Covered
      Services described in Attachment B-2, within 75 miles of the
      Member’s residence. This access requirement includes, but is not limited to,
      specialists, specialty hospitals, psychiatric hospitals, diagnostic and
      therapeutic services, and single or limited service health care physicians
      or
      Providers, as applicable to the HMO Program.

    The
      HMO
      is not precluded from making arrangements with physicians or providers outside
      the HMO’s Service Area for Members to receive a higher level of skill or
      specialty than the level

    available
      within the Service Area, including but not limited to, treatment of cancer,
      burns, and cardiac diseases. HHSC may consider exceptions to the above
      access-related requirements when an HMO has established, through utilization
      data provided to HHSC, that a normal pattern for securing health care services
      within an area does not meet these standards, or when an HMO is providing care
      of a higher skill level or specialty than the level which is available within
      the Service Area such as, but not limited to, treatment of cancer, burns, and
      cardiac diseases.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.1.3.3
      Monitoring Access

    The
      HMO
      is required to systematically and regularly verify that Covered Services
      furnished by Network Providers are available and accessible to Members in
      compliance with the standards described in Sections 8.1.3.1 and
      8.1.3.2, and for Covered Services furnished by PCPs, the standards
      described in Section 8.1.4.2.

    The
      HMO
      must enforce access and other Network standards required by the Contract and
      take appropriate action with Providers whose performance is determined by the
      HMO to be out of compliance.

     

    8.1.4
      Provider Network

    The
      HMO
      must enter into written contracts with properly credentialed Providers as
      described in this Section. The Provider contracts must comply with the
Uniform Managed Care Manual’s requirements.

    The
      HMO
      must maintain a Provider Network sufficient to provide all Members with access
      to the full range of Covered Services required under the Contract. The HMO
      must
      ensure its Providers and subcontractors meet all current and future state and
      federal eligibility criteria, reporting requirements, and any other applicable
      rules and/or regulations related to the Contract.

    The
      Provider Network must be responsive to the linguistic, cultural, and other
      unique needs of any minority, elderly, or disabled individuals, or other special
      population in the Service Areas and HMO Programs served by the HMO, including
      the capacity to communicate with Members in languages other than English, when
      necessary, as well as with those who are deaf or hearing impaired.

    The
      HMO
      must seek to obtain the participation in its Provider Network of qualified
      providers currently serving the Medicaid and CHIP Members in the HMO’s proposed
      Service Area(s).

     

    NOTE:
      The following Provider descriptions do not require STAR+PLUS HMOs to contract
      with Hospital providers for Inpatient Stay services. STAR+PLUS HMOs are
      required, however, to contract with Hospitals for Outpatient Hospital
      Services.

     

    All
      Providers: All Providers must be licensed in the State of Texas to
      provide the Covered Services for which the HMO is contracting with the Provider,
      and not be under sanction or exclusion from the Medicaid program. All Acute
      Care
      Providers serving Medicaid Members must be enrolled as Medicaid providers and
      have a Texas Provider Identification Number (TPIN). Long-term Care Providers
      are
      not required to have a TPIN but must have a LTC Provider

    number.  Providers
      must also have a National Provider Identifier (NPI) in accordance with the
      timelines established in 45 C.F.R. Part 162, Subpart D (for most Providers,
      the
      NPI must be in place by May 23, 2007.)

     

    Inpatient
      hospital and medical services: The HMO must ensure that Acute Care
      hospitals and specialty hospitals are available and accessible 24 hours per
      day,
      seven days per week, within the HMO’s Network to provide Covered Services to
      Members throughout the Service Area.

     

    Children’s
      Hospitals/hospitals with specialized pediatric services: The HMO must
      ensure Members access to hospitals designated as Children’s Hospitals by
      Medicare and hospitals with specialized pediatric services, such as teaching
      hospitals and hospitals with designated children’s wings, so that these services
      are available and accessible 24 hours per day, seven days per week, to provide
      Covered Services to Members throughout the Service Area. The HMO must make
      Out-of-Network reimbursement arrangements with a designated Children’s Hospital
      and/or hospital with specialized pediatric services in proximity to the Member’s
      residence, and such arrangements must be in writing, if the HMO does not include
      such hospitals in its Provider Network. Provider Directories, Member materials,
      and Marketing materials must clearly distinguish between hospitals designated
      as
      Children’s Hospitals and hospitals that have designated children’s
      units.

     

    Trauma:
      The HMO must ensure Members access to Texas Department of State Health Services
      (TDSHS) designated Level I and Level II trauma centers within the State or
      hospitals meeting the equivalent level of trauma care in the HMO’s Service Area,
      or in close proximity to such Service Area. The HMO must make Out-of-Network
      reimbursement arrangements with the DSHS-designated Level I and Level II trauma
      centers or hospitals meeting equivalent levels of trauma care, and such
      arrangements must be in writing, if the HMO does not include such a trauma
      center in its Provider Network.

     

    Transplant
      centers: The HMO must ensure Member access to HHSC-designated
      transplant centers or centers meeting equivalent levels of care. A list of
      HHSC-designated transplant centers can be found in the Procurement Library
      in
      Attachment H. The HMO must make Out-of-Network reimbursement arrangements with
      a
      designated transplant center or center meeting equivalent levels of care in
      proximity to the Member’s residence, and such arrangements must be in writing,
      if the HMO does not include such a center in its Provider Network.

     

    Hemophilia
      centers: The HMO must ensure Member access to hemophilia centers
      supported by the Centers for Disease Control (CDC). A list of these hemophilia
      centers can be found at http://www.cdc.gov/ncbddd/hbd/htc_list.htm. The HMO
      must
      make Out-of-Network reimbursement arrangements with a CDC-supported hemophilia
      center, and such arrangements must be in writing, if the HMO does not include
      such a center in its Provider Network.

     

    Physician
      services: The HMO must ensure that Primary Care Providers are available
      and accessible 24 hours per day, seven days per week, within the Provider
      Network. The HMO must contract with a sufficient number of participating
      physicians and specialists within each Service Area to comply with the access
      requirements throughout Section 8.1.3 and meet the needs of
      Members for all Covered Services.

    The
      HMO
      must ensure that an adequate number of participating physicians have admitting
      privileges at one or more participating Acute Care hospitals in the Provider
      Network to ensure that necessary admissions are made.  In no case may
      there be less than one in-network PCP with admitting privileges available and
      accessible 24 hours per day, seven days per week for each Acute Care hospital
      in
      the Provider Network.

    The
      HMO
      must ensure that an adequate number of participating specialty physicians have
      admitting privileges at one or more participating hospitals in the HMO’s
      Provider Network to ensure necessary admissions are made.  The HMO
      shall require that all physicians who admit to hospitals maintain hospital
      access for their patients through appropriate call coverage.

     

    Laboratory
      services: The HMO must ensure that in-network reference laboratory
      services must be of sufficient size and scope to meet the non-emergency and
      emergency needs of the enrolled population and the access requirements
      in Section 8.1.3. Reference laboratory specimen procurement
      services must facilitate the provision of clinical diagnostic services for
      physicians, Providers and Members through the use of convenient reference
      satellite labs in each Service Area, strategically located specimen collection
      areas in each Service Area, and the use of a courier system under the management
      of the reference lab. For Medicaid Members, THSteps requires that laboratory
      specimens obtained as part of a THSteps medical checkup visit must be sent
      to
      the TDSHS Laboratory.

     

    Diagnostic
      imaging: The HMO must ensure that diagnostic imaging services are
      available and accessible to all Members in each Service Area in accordance
      with
      the access standards in Section 8.1.3. The HMO must ensure that
      diagnostic imaging procedures that require the injection or ingestion of
      radiopaque chemicals are performed only under the direction of physicians
      qualified to perform those procedures.

     

    Home
      health services: The HMO must have a contract(s) with a home health
      Provider so that all Members living within the HMO’s Service Area will have
      access to at least one such Provider for home health Covered Services. (These
      services are provided as part of the Acute Care Covered Services, not the
      Community Long-term Care Services.)

     

    Community
      Long-term Care services: STAR+PLUS HMOs must have contracts with
      Community Long-term Care service Providers, so that all Members living within
      the Contractor’s Service Area will have access to Medically Necessary and
      Functionally Necessary Covered Services.

     

    8.1.4.1
      Provider Contract Requirements

    The
      HMO
      is prohibited from requiring a provider or provider group to enter into an
      exclusive contracting arrangement with the HMO as a condition for participation
      in its Provider Network.

    The
      HMO’s
      contract with health care Providers must be in writing, must be in compliance
      with applicable federal and state laws and regulations, and must include minimum
      requirements specified in the Uniform Managed Care Contract Terms and
      Conditions (Attachment A) and HHSC’s Uniform Managed Care
      Manual.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    The
      HMO
      must submit model Provider contracts to HHSC for review during Readiness
      Review.  HHSC retains the right to reject or require changes to any
      model Provider contract that does not comply with HMO Program requirements
      or
      the HHSC-HMO Contract.

     

    8.1.4.2
      Primary Care Providers

    The
      HMO’s
      PCP Network may include Providers from any of the following practice areas:
      General Practice; Family Practice; Internal Medicine; Pediatrics;
      Obstetrics/Gynecology (OB/GYN); Certified Nurse Midwives (CNM) and Physician
      Assistants (PAs) practicing under the supervision of a physician; Federally
      Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and similar
      community clinics; and specialist physicians who are willing to provide a
      Medical Home to selected Members with special needs and conditions. Section
      533.005(a)(13), Government Code, requires the HMO to use Pediatric and Family
      Advanced Practice Nurses practicing under the supervision of a physician as
      PCPs
      in its Provider Network for STAR and STAR+PLUS.

    CHIP
      Perinatal HMOs are not required to develop PCP Networks for CHIP Perinates.
      CHIP
      Perinatal HMOs may use the same PCP Network for CHIP Members and CHIP Perinatal
      Newborns.

    An
      internist or other Provider who provides primary care to adults only is not
      considered an age-appropriate PCP choice for a Member under age 21. An internist
      or other Provider who provides primary care to adults and children may be a
      PCP
      for children if:

    1  the
      Provider assumes all HMO PCP responsibilities for such Members in a specific
      age
      group under age 21,

    2  the
      Provider has a history of practicing as a PCP for the specified age group as
      evidenced by the Provider’s primary care practice including an established
      patient population under age 20 and within the specified age range,
      and

    3  the
      Provider has admitting privileges to a local hospital that includes admissions
      to pediatric units.

    

    A
      pediatrician is not considered an age-appropriate choice for a Member age 21
      and
      over.

    The
      PCP
      for a Member with disabilities, Special Health Care Needs, or Chronic or Complex
      Conditions may be a specialist physician who agrees to provide PCP services
      to
      the Member. The specialty physician must agree to perform all PCP duties
      required in the Contract and PCP duties must be within the scope of the
      specialist’s license. Any interested person may initiate the request through the
      HMO for a specialist to serve as a PCP for a Member with disabilities, Special
      Health Care Needs, or Chronic or Complex Conditions. The HMO shall handle such
      requests in accordance with 28 T.A.C. Part 1, Chapter 11, Subchapter
      J.

    PCPs
      who
      provide Covered Services for STAR, CHIP, and CHIP Perinatal Newborns must either
      have admitting privileges at a Hospital that is part of the HMO’s Provider
      Network or make referral arrangements with a Provider who has admitting
      privileges to a Network Hospital. STAR+PLUS PCPs must either have admitting
      privileges at a Medicaid Hospital or make referral arrangements with a Provider
      who has admitting privileges to a Medicaid Hospital.

    The
      HMO
      must require, through contract provisions, that PCPs are accessible to Members
      24 hours a day, 7 days a week. The HMO is encouraged to include in its Network
      sites that offer primary care services during evening and weekend hours. The
      following are acceptable and unacceptable telephone arrangements for contacting
      PCPs after their normal business hours.

     

    Acceptable
      after-hours coverage:

    1  The
      office telephone is answered after-hours by an answering service, which meets
      language requirements of the Major Population Groups and which can contact
      the
      PCP or another designated medical practitioner.  All calls answered by
      an answering service must be returned within 30 minutes;

    2  The
      office telephone is answered after normal business hours by a recording in
      the
      language of each of the Major Population Groups served, directing the patient
      to
      call another number to reach the PCP or another provider designated by the
      PCP.
      Someone must be available to answer the designated provider’s telephone. Another
      recording is not acceptable; and

    3  The
      office telephone is transferred after office hours to another location where
      someone will answer the telephone and be able to contact the PCP or another
      designated medical practitioner, who can return the call within 30
      minutes.

    

    Unacceptable
      after-hours coverage:

    1  The
      office telephone is only answered during office hours;

    2  The
      office telephone is answered after-hours by a recording that tells patients
      to
      leave a message;

    3  The
      office telephone is answered after-hours by a recording that directs patients
      to
      go to an Emergency Room for any services needed; and

    4  Returning
      after-hours calls outside of 30 minutes.

    

    The
      HMO
      must require PCPs, through contract provisions or Provider Manual, to provide
      children under the age of 21 with preventive services in accordance with the
      AAP
      recommendations for CHIP Members and CHIP Perinate Newborns, and the THSteps
      periodicity schedule published in the THSteps Manual for Medicaid Members.
      The
      HMO must require PCPs, through contract provisions or Provider Manual, to
      provide adults with preventive services in accordance with the U.S. Preventive
      Services Task Force requirements. The HMO must make best efforts to ensure
      that
      PCPs follow these periodicity requirements for children and adult Members.
      Best
      efforts must include, but not be limited to, Provider education, Provider
      profiling, monitoring, and feedback activities.

    The
      HMO
      must require PCPs, through contract provisions or Provider Manual, to assess
      the
      medical needs of Members for referral to specialty care providers and provide
      referrals as needed. PCPs must coordinate Members’ care with specialty care
      providers after referral. The HMO must make best efforts to ensure that PCPs
      assess Member needs for referrals and make such referrals. Best efforts must
      include, but not be limited to, Provider education activities and review of
      Provider referral patterns.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.1.4.3
      PCP Notification

    The
      HMO
      must furnish each PCP with a current list of enrolled Members enrolled or
      assigned to that Provider no later than five (5) working days after the HMO
      receives the Enrollment File from the HHSC Administrative Services Contractor
      each month. The HMO may offer and provide such enrollment information in
      alternative formats, such as through access to a secure Internet site, when
      such
      format is acceptable to the PCP.

     

    8.1.4.4
      Provider Credentialing and Re-credentialing

    The
      HMO
      must review, approve and periodically recertify the credentials of all
      participating physician Providers and all other licensed Providers who
      participate in the HMO’s Provider Network. The HMO may subcontract with another
      entity to which it delegates such credentialing activities if such delegated
      credentialing is maintained in accordance with the National Committee for
      Quality Assurance (NCQA) delegated credentialing requirements and any comparable
      requirements defined by HHSC.

    At
      a
      minimum, the scope and structure of a HMO’s credentialing and re-credentialing
      processes must be consistent with recognized HMO industry standards such as
      those provided by NCQA and relevant state and federal regulations including
      28
      T.A.C. §11.1902, relating to credentialing of providers in HMOs, and as an
      additional requirement for Medicaid HMOs, 42 C.F.R. §438.214(b). The initial
      credentialing process, including application, verification of information,
      and a
      site visit (if applicable), must be completed before the effective date of
      the
      initial contract with the physician or Provider. The re-credentialing process
      must occur at least every three years.

    The
      re-credentialing process must take into consideration Provider performance
      data
      including, but not be limited to, Member Complaints and Appeals, quality of
      care, and utilization management.

     

    8.1.4.5
      Board Certification Status

    The
      HMO
      must maintain a policy with respect to Board Certification for PCPs and
      specialty physicians that encourage participation of board certified PCPs and
      specialty physicians in the Provider Network. The HMO must make information
      on
      the percentage of Board-certified PCPs in the Provider Network and the
      percentage of Board-certified specialty physicians, by specialty, available
      to
      HHSC upon request.

     

    8.1.4.6
      Provider Manual, Materials and Training

    The
      HMO
      must prepare and issue a Provider Manual(s), including any necessary specialty
      manuals (e.g., behavioral health) to all existing Network
      Providers.  For newly contracted Providers, the HMO must issue copies
      of the Provider Manual(s) within five (5) working days from inclusion of the
      Provider into the Network. The Provider Manual must contain sections relating
      to
      special requirements of the HMO Program(s) and the enrolled populations in
      compliance with the requirements of this Contract.

    HHSC
      or
      its designee must approve the Provider Manual, and any substantive revisions
      to
      the Provider Manual, prior to publication and distribution to
      Providers.  The Provider Manual must contain the critical elements
      defined in the 

     

    Uniform
      Managed Care Manual. HHSC’s initial review of the Provider Manual is
      part of the Operational Readiness Review described in Attachment B-1,
      Section 7.

    The
      HMO
      must provide training to all Providers and their staff regarding the
      requirements of the Contract and special needs of Members. The HMO’s Medicaid,
      CHIP and/or CHIP Perinatal Program training must be completed within 30 days
      of
      placing a newly contracted Provider on active status. The HMO must provide
      on-going training to new and existing Providers as required by the HMO or HHSC
      to comply with the Contract. The HMO must maintain and make available upon
      request enrollment or attendance rosters dated and signed by each attendee
      or
      other written evidence of training of each Provider and their
      staff.

    The
      HMO
      must establish ongoing Provider training that includes, but is not limited
      to,
      the following issues:

    1  Covered
      Services and the Provider’s responsibilities for providing and/or coordinating
      such services. Special emphasis must be placed on areas that vary from
      commercial coverage rules (e.g., Early Intervention services, therapies and
      DME/Medical Supplies); and for Medicaid, making referrals and coordination
      with
      Non-capitated Services;

    2  Relevant
      requirements of the Contract;

    3  The
      HMO’s
      quality assurance and performance improvement program and the Provider’s role in
      such a program; and

    4  The
      HMO’s
      policies and procedures, especially regarding in-network and Out-of-Network
      referrals.

    

    Provider
      Materials produced by the HMO, relating to Medicaid Managed Care, the CHIP
      Program, and/or the CHIP Perinatal Program must be in compliance with State
      and
      Federal laws and requirements of the HHSC Uniform Managed Care Contract
      Terms and Conditions. HMO must make available any provider materials to
      HHSC upon request.

     

    8.1.4.7
      Provider Hotline

    The
      HMO
      must operate a toll-free telephone line for Provider inquiries from 8 a.m.
      to 5
      p.m. local time for the Service Area, Monday through Friday, except for
      State-approved holidays. The Provider Hotline must be staffed with personnel
      who
      are knowledgeable about Covered Services and each applicable HMO Program, and
      for Medicaid, about Non-capitated Services.

    The
      HMO
      must ensure that after regular business hours the line is answered by an
      automated system with the capability to provide callers with operating hours
      information and instructions on how to verify enrollment for a Member with
      an
      Urgent Condition or an Emergency Medical Condition. The HMO must have a process
      in place to handle after-hours inquiries from Providers seeking to verify
      enrollment for a Member with an Urgent Condition or an Emergency Medical
      Condition, provided, however, that the HMO and its Providers must not require
      such verification prior to providing Emergency Services.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    The
      HMO
      must ensure that the Provider Hotline meets the following minimum performance
      requirements for all HMO Programs and Service Areas:

    

    1.
      99% of
      calls are answered by the fourth ring or an automated call pick-up system is
      used;

    

    2.
      no
      more than one percent of incoming calls receive a busy signal;

    

    3.
      the
      average hold time is 2 minutes or less; and

    

    4.
      the
      call abandonment rate is 7% or less.

    

    The
      HMO
      must conduct ongoing call quality assurance to ensure these standards are met.
      The Provider Hotline may serve multiple HMO Programs if Hotline staff is
      knowledgeable about all of the HMO’s Programs. The Provider Hotline may serve
      multiple Service Areas if the Hotline staff is knowledgeable about all such
      Service Areas, including the Provider Network in such Service
      Areas.

    The
      HMO
      must monitor its performance regarding Provider Hotline standards and submit
      performance reports summarizing call center performance for the Hotline as
      indicated in Section

    8.1.20.
      If the HMO subcontracts with a Behavioral Health Organization (BHO) that is
      responsible for Provider Hotline functions related to Behavioral Health
      Services, the BHO’s Provider Hotline must meet the requirements in
Section 8.1.4.7.

     

    8.1.4.8
      Provider Reimbursement

    The
      HMO
      must make payment for all Medically Necessary Covered Services provided to
      all
      Members for whom the HMO is paid a capitation.  A STAR+PLUS HMO must
      also make payment for all Functionally Necessary Covered Services provided
      to
      all Members for whom the HMO is paid a capitation. The HMO must ensure that
      claims payment is timely and accurate as described in Section 8.1.18.5.
The HMO must require tax identification numbers from all
      participating
      Providers. The HMO is required to do back-up withholding from all payments
      to
      Providers who fail to give tax identification numbers or who give incorrect
      numbers.

     

    8.1.4.9
      Termination of Provider Contracts

    Unless
      prohibited or limited by applicable law, at least 15 days prior to the effective
      date of the HMO’s termination of contract of any participating Provider the HMO
      must notify the HHSC Administrative Services Contractor and notify affected
      current Members in writing.  Affected Members include all Members in a
      PCP’s panel and all Members who have been receiving ongoing care from the
      terminated Provider, where ongoing care is defined as two or more visits for
      home-based or office-based care in the past 12 months.

    For
      the
      CHIP and CHIP Perinatal Programs, the HMO’s process for terminating Provider
      contracts must comply with the Texas Insurance Code and TDI
      regulations.

     

    8.1.5
      Member Services

    The
      HMO
      must maintain a Member Services Department to assist Members and Members’ family
      members or guardians in obtaining Covered Services for Members. The HMO must
      maintain employment standards and requirements (e.g., education, training,
      and
      experience) for Member
      Services Department staff and provide a sufficient number of staff for the
      Member Services Department to meet the requirements of this Section, including
      Member Hotline response times, and Linguistic Access capabilities, see 8.1.5.6
      Member Hotline Requirements.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.1.5.1
      Member Materials

    The
      HMO
      must design, print and distribute Member identification (ID) cards and a Member
      Handbook to Members.  Within five business days following the receipt
      of an Enrollment File from the HHSC Administrative Services Contractor, the
      HMO
      must mail a Member’s ID card and Member Handbook to the Case Head or Account
      Name for each new Member. When the Case Head or Account Name is on behalf of
      two
      or more new Members, the HMO is only required to send one Member Handbook.
      The
      HMO is responsible for mailing materials only to those Members for whom valid
      address data are contained in the Enrollment File.

    The
      HMO
      must design, print and distribute a Provider Directory to the HHSC
      Administrative Services Contractor as described in Section
      8.1.5.4.

    Member
      materials must be at or below a 6th grade reading level as measured by the
      appropriate score on the Flesch reading ease test. Member materials must be
      available in English, Spanish, and the languages of other Major Population
      Groups making up 10% or more of the managed care eligible population in the
      HMO’s Service Area, as specified by HHSC.  HHSC will provide the HMO
      with reasonable notice when the enrolled population reaches 10% within the
      HMO’s
      Service Area. All Member materials must be available in a format accessible
      to
      the visually impaired, which may include large print, Braille, and
      audiotapes.

    The
      HMO
      must submit member materials to HHSC for approval prior to use or
      mailing.  HHSC will identify any required changes to the Member
      materials within 15 business days.  If HHSC has not responded to the
      Contractor by the fifteenth day, the Contractor may proceed to use the submitted
      materials.  HHSC reserves the right to require discontinuation of any
      Member materials that violate the terms of the Uniform Managed Care
      Terms and Conditions, including but not limited to “Marketing Policies
      and Procedures” as described in the Uniform Managed Care
      Manual.

     

    8.1.5.2
      Member Identification (ID) Card

    All
      Member ID cards must, at a minimum, include the following
      information:

    1  the
      Member’s name;

    2  the
      Member’s Medicaid, CHIP or CHIP Perinatal Program number;

    3  the
      effective date of the PCP assignment (excluding CHIP Perinates);

    4  the
      PCP’s
      name, address (optional for all products), and telephone number (excluding
      CHIP
      Perinates);

    5  the
      name
      of the HMO;

    6  the
      24-hour, seven (7) day a week toll-free Member services telephone number and
      BH
      Hotline number operated by the HMO; and

    7  any
      other
      critical elements identified in the Uniform Managed Care
      Manual.

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    The
      HMO
      must reissue the Member ID card if a Member reports a lost card, there is a
      Member name change, if the Member requests a new PCP, or for any other reason
      that results in a change to the information disclosed on the ID
      card.  CHIP Perinatal HMOs must issue Member ID cards to both CHIP
      Perinates and CHIP Perinate Newborns.

     

    8.1.5.3
      Member Handbook

    HHSC
      must
      approve the Member Handbook, and any substantive revisions, prior to publication
      and distribution. As described in Attachment B-1, Section 7,
      the HMO must develop and submit to HHSC the draft Member Handbook for approval
      during the Readiness Review and must submit a final Member Handbook
      incorporating changes required by HHSC prior to the Operational Start
      Date.

    The
      Member Handbook for each applicable HMO Program must, at a minimum, meet the
      Member materials requirements specified by Section 8.1.5.1
      above and must include critical elements in the Uniform Managed Care
      Manual. CHIP Perinatal HMOs must issue Member Handbooks to both CHIP
      Perinates and CHIP Perinate Newborns.  The Member Handbook for CHIP
      Perinate Newborns may be the same as that used for CHIP.

    The
      HMO
      must produce a revised Member Handbook, or an insert informing Members of
      changes to Covered Services upon HHSC notification and at least 30 days prior
      to
      the effective date of such change in Covered Services. In addition to modifying
      the Member materials for new Members, the HMO must notify all existing Members
      of the Covered Services change during the time frame specified in this
      subsection.

     

    8.1.5.4
      Provider Directory

    The
      Provider Directory for each applicable HMO Program, and any substantive
      revisions, must be approved by HHSC prior to publication and distribution.
      The
      HMO is responsible for submitting draft Provider directory updates to HHSC
      for
      prior review and approval if changes other than PCP information or clerical
      corrections are incorporated into the Provider Directory.

    As
      described in Attachment B-1, Section 7, during the Readiness
      Review, the HMO must develop and submit to HHSC the draft Provider Directory
      template for approval and must submit a final Provider Directory incorporating
      changes required by HHSC prior to the Operational Start Date. Such draft and
      final Provider Directories must be submitted according to the deadlines
      established in Attachment B-1, Section 7.

    The
      Provider Directory for each applicable HMO Program must, at a minimum, meet
      the
      Member Materials requirements specified by Section 8.1.5.1
      above and must include critical elements in the Uniform Managed Care
      Manual. The Provider Directory must include only Network Providers
      credentialed by the HMO in accordance with Section 8.1.4.4. If
      the HMO contracts with limited Provider Networks, the Provider Directory must
      comply with the requirements of 28 T.A.C.
      §11.1600(b)(11), relating to the disclosure and notice of limited Provider
      Networks.

    CHIP
      Perinatal HMOs must develop Provider Directories for both CHIP Perinates and
      CHIP Perinate Newborns. The Provider Directory for CHIP Perinate Newborns may
      be
      the same as that used for the CHIP Program.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    The
      HMO
      must update the Provider Directory on a quarterly basis. The HMO must make
      such
      update available to existing Members on request, and must provide such update
      to
      the HHSC Administrative Services Contractor at the beginning of each state
      fiscal quarter. HHSC will consult with the HMOs and the HHSC Administrative
      Services Contractors to discuss methods for reducing the HMO’s administrative
      costs of producing new Provider Directories, including considering submission
      of
      new Provider Directories on a semi-annual rather than a quarterly basis if
      a HMO
      has not made major changes in its Provider Network, as determined by HHSC.
      HHSC
      will establish weight limits for the Provider Directories. Weight limits may
      vary by Service Area. HHSC will require HMOs that exceed the weight limits
      to
      compensate HHSC for postage fees in excess of the weight limits.

    The
      HMO
      must send the most recent Provider Directory, including any updates, to Members
      upon request. The HMO must, at least annually, include written and verbal offers
      of such Provider Directory in its Member outreach and education
      materials.

     

    8.1.5.5
      Internet Website

    The
      HMO
      must develop and maintain, consistent with HHSC standards and Section 843.2015
      of the Texas Insurance Code and other applicable state laws, a website to
      provide general information about the HMO’s Program(s), its Provider Network,
      its customer services, and its Complaints and Appeals process. The HMO may
      develop a page within its existing website to meet the requirements of this
      section. The HMO must maintain a Provider Directory for its HMO Program(s)
      on
      the HMO’s website with designation of open versus closed panels. All HMOs must
      list Home Health Ancillary providers on their websites, with an indicator for
      Pediatric services if provided. The HMO’s website must comply with the Marketing
      Policies and Procedures for each applicable HHSC HMO Program.

    The
      website’s HMO Program content must be:

    1  Written
      in Major Population Group languages (which under this contract include only
      English and Spanish);

    2  Culturally
      appropriate;

    3  Written
      for understanding at the 6th grade reading level; and

    4  Be
      geared
      to the health needs of the enrolled HMO Program population.

    

    To
      minimize download and “wait times,” the website must avoid tools or techniques
      that require significant memory or disk resources or require special
      intervention on the customer side to install plug-ins or additional software.
      Use of proprietary items that would require a specific browser are not
      allowed.  HHSC strongly encourages the use of tools that take
      advantage of efficient data access methods and reduce the load on the server
      or
      bandwidth.

     

    8.1.5.6
      Member Hotline

    The
      HMO
      must operate a toll-free hotline that Members can call 24 hours a day, seven
      (7)
      days a week. The Member Hotline must be staffed with personnel who are
      knowledgeable about its HMO Program(s) and Covered Services, between the hours
      of 8:00 a.m. to 5:00 p.m. local time for the Service Area, Monday through
      Friday, excluding state-approved holidays.

    The
      HMO
      must ensure that after hours, on weekends, and on holidays the Member Services
      Hotline is answered by an automated system with the capability to provide
      callers with operating hours and instructions on what to do in cases of
      emergency. All recordings must be in English and in Spanish. A voice mailbox
      must be available after hours for callers to leave messages. The HMO’s Member
      Services representatives must return member calls received by the automated
      system on the next working day.

    If
      the
      Member Hotline does not have a voice-activated menu system, the HMO must have
      a
      menu system that will accommodate Members who cannot access the system through
      other physical means, such as pushing a button.

    The
      HMO
      must ensure that its Member Service representatives treat all callers with
      dignity and respect the callers’ need for privacy. At a minimum, the HMO’s
      Member Service representatives must be:

    

    1.           Knowledgeable
      about Covered Services;

    

    2.           Able
      to answer non-technical questions pertaining to the role of the PCP, as
      applicable;

    

    3.           Able
      to answer non-clinical questions pertaining to referrals or the process for
      receiving authorization for procedures or services;

    

    4.           Able
      to give information about Providers in a particular area;

    

    5.           Knowledgeable
      about Fraud, Abuse, and Waste and the requirements to report any conduct that,
      if substantiated, may constitute Fraud, Abuse, or Waste in the HMO
      Program;

    

    6.           Trained
      regarding Cultural Competency;

    

    7.           Trained
      regarding the process used to confirm the status of persons with Special Health
      Care Needs;

    

    8.           For
      Medicaid members, able to answer non-clinical questions pertaining to accessing
      Non-capitated Services.

    

    9.           For
      Medicaid Members, trained regarding: a) the emergency prescription process
      and
      what steps to take to immediately address problems when pharmacies do not
      provide a 72-hour supply of emergency medicines; and b) DME processes for
      obtaining services and how to address common problems.

    

    10.
      For
      CHIP Members, able to give correct cost-sharing information relating to
      premiums, co-pays or deductibles, as applicable. (Cost-sharing does not apply
      to
      CHIP Perinates or CHIP Perinate Newborns.)

    

    Hotline
      services must meet Cultural Competency requirements and must appropriately
      handle calls from non-English speaking (and particularly, Spanish-speaking)
      callers, as well as calls from individuals who are deaf or hard-of-hearing.
      To
      meet these requirements, the HMO must employ bilingual Spanish-speaking Member
      Services representatives and must secure the services of other contractors
      as
      necessary to meet these requirements.

    The
      HMO
      must process all incoming Member correspondence and telephone inquiries in
      a
      timely and responsive manner. The HMO cannot impose maximum call duration limits
      but must allow calls to be of sufficient length to ensure adequate information
      is provided to the Member. The HMO must ensure that the toll-free Member Hotline
      meets the following minimum performance requirements for all HMO Programs and
      Service Areas:

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    1  99%
      of
      calls are answered by the fourth ring or an automated call pick-up
      system;

    2  no
      more
      than one percent (1%) of incoming calls receive a busy signal;

    3  at
      least
      80% of calls must be answered by toll-free line staff within 30 seconds measured
      from the time the call is placed in queue after selecting an option;
      and

    4  the
      call
      abandonment rate is 7% or less.

    

    The
      HMO
      must conduct ongoing quality assurance to ensure these standards are
      met.

    The
      Member Services Hotline may serve multiple HMO Programs if Hotline staff is
      knowledgeable about all of the HMO’s Medicaid and/or CHIP Programs. The Member
      Services Hotline may serve multiple Service Areas if the Hotline staff is
      knowledgeable about all such Service Areas, including the Provider Network
      in
      each Service Area.

    The
      HMO
      must monitor its performance regarding HHSC Member Hotline standards and submit
      performance reports summarizing call center performance for the Member Hotline
      as indicated in Section 8.1.20 and the Uniform Managed
      Care Manual.

     

    8.1.5.6.1
      Nurseline

    HMO
      is
      encouraged to train staff at its 24-hour nurse hotline about: a) emergency
      prescription process and what steps to take to immediately address Medicaid
      Members’ problems when pharmacies do not provide a 72-hour supply of emergency
      medicines; and b) DME processes for obtaining services and how to address common
      problems.  The 24-hour nurse hotline will attempt to respond
      immediately to problems concerning emergency medicines by means at its disposal,
      including explaining the rules to Medicaid Members so that they understand
      their
      rights and, if need be, by offering to contact the pharmacy that is refusing
      to
      fill the prescription to explain the 72-hour supply policy and DME
      processes.

     

    8.1.5.7
      Member Education

    The
      HMO
      must, at a minimum, develop and implement health education initiatives that
      educate Members about:

    

    1.           How
      the HMO system operates, including the role of the PCP;

    

    2.           Covered
      Services, limitations and any Value-added Services offered by the
      HMO;

    

    3.           The
      value of screening and preventive care, and

    

    4.           How
      to obtain Covered Services, including:

    a    Emergency
      Services;

    b    Accessing
      OB/GYN
      and specialty care;

    c    Behavioral
      Health Services; 

    d    Disease
      Management programs; 

    e    Service
      Coordination, treatment for pregnant women, Members with Special Health Care
      Needs, including Children with Special Health Care Needs; and other special
      populations; 

    f    Early
      Childhood Intervention (ECI) Services;

    g    Screening
      and preventive services, including well-child care (THSteps medical checkups
      for
      Medicaid Members);

    h    For
      CHIP
      Members, Member co-payments

    i    Suicide
      prevention;

    j    Identification
      and health education related to Obesity; and

    k    Obtaining
      72 hour supplies of emergency prescriptions from pharmacies enrolled with HHSC
      as Medicaid providers.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    The
      HMO
      must provide a range of health promotion and wellness information and activities
      for Members in formats that meet the needs of all Members. The HMO must propose,
      implement, and assess innovative Member education strategies for wellness care
      and immunization, as well as general health promotion and prevention. The HMO
      must conduct wellness promotion programs to improve the health status of its
      Members. The HMO may cooperatively conduct health education classes for all
      enrolled Members with one or more HMOs also contracting with HHSC in the Service
      Area. The HMO must work with its Providers to integrate health education,
      wellness and prevention training into the care of each Member.

    The
      HMO
      also must provide condition and disease-specific information and educational
      materials to Members, including information on its Service Management and
      Disease Management programs described in Section 8.1.13 and Section
      8.1.  Condition- and disease-specific information must be
      oriented to various groups within the managed care eligible population, such
      as
      children, the elderly, persons with disabilities and non-English speaking
      Members, as appropriate to the HMO’s Medicaid, CHIP and/or CHIP Perinatal
      Program(s).

     

    8.1.5.8
      Cultural Competency Plan

    The
      HMO
      must have a comprehensive written Cultural Competency Plan describing how the
      HMO will ensure culturally competent services, and provide Linguistic Access
      and
      Disability-related Access. The Cultural Competency Plan must describe how the
      individuals and systems within the HMO will effectively provide services to
      people of all cultures, races, ethnic backgrounds, and religions as well as
      those with disabilities in a manner that recognizes, values, affirms, and
      respects the worth of the individuals and protects and preserves the dignity
      of
      each. The HMO must submit the Cultural Competency Plan to HHSC for Readiness
      Review. Modifications and amendments to the plan must be submitted to HHSC
      no
      later than 30 days prior to implementation. The Plan must also be made available
      to the HMO’s Network of Providers.

     

    8.1.5.9
      Member Complaint and Appeal Process

    The
      HMO
      must develop, implement and maintain a system for tracking, resolving, and
      reporting Member Complaints regarding its services, processes, procedures,
      and
      staff. The HMO must ensure that Member Complaints are resolved within 30
      calendar days after receipt. The HMO is subject to remedies, including
      liquidated damages, if at least 98 percent of Member Complaints are not resolved
      within 30 days of receipt of the Complaint by the HMO. Please see the
Uniform Managed Care Contract Terms & Conditions and
Attachment B-5, Deliverables/Liquidated Damages
      Matrix.

    The
      HMO
      must develop, implement and maintain a system for tracking, resolving, and
      reporting Member Appeals regarding the denial or limited authorization of a
      requested service, including the type or level of service and the denial, in
      whole or in part, of payment for service. Within this

    process,
      the HMO must respond fully and completely to each Appeal and establish a
      tracking mechanism to document the status and final disposition of each
      Appeal.

    The
      HMO
      must ensure that Member Appeals are resolved within 30 calendar days, unless
      the
      HMO can document that the Member requested an extension or the HMO shows there
      is a need for additional information and the delay is in the Member's interest.
      The HMO is subject to liquidated damages if at least 98 percent of Member
      Appeals are not resolved within 30 days of receipt of the Appeal by the HMO.
      Please see the Uniform Managed Care Contract Terms & Conditions
and Attachment B-5, Deliverables/Liquidated Damages
      Matrix.

    Medicaid
      HMOs must follow the Member Complaint and Appeal Process described in
Section .2.6.
      CHIP and CHIP Perinatal HMOs must comply with the CHIP Complaint and Appeal
      Process described in Sections 8.4.2 and 8.5.2,
respectively.

     

    8.1.6
      Marketing and Prohibited Practices

    The
      HMO
      and its Subcontractors must adhere to the Marketing Policies and Procedures
      as
      set forth by HHSC in the Contract, and the HHSC Uniform Managed Care
      Manual.

     

    8.1.7
      Quality Assessment and Performance Improvement

    The
      HMO
      must provide for the delivery of quality care with the primary goal of improving
      the health status of Members and, where the Member’s condition is not amenable
      to improvement, maintain the Member’s current health status by implementing
      measures to prevent any further decline in condition or deterioration of health
      status. The HMO must work in collaboration with Providers to actively improve
      the quality of care provided to Members, consistent with the Quality Improvement
      Goals and all other requirements of the Contract. The HMO must provide
      mechanisms for Members and Providers to offer input into the HMO’s quality
      improvement activities.

     

    8.1.7.1
      QAPI Program Overview

    The
      HMO
      must develop, maintain, and operate a quality assessment and performance
      improvement (QAPI) Program consistent with the Contract, and TDI requirements,
      including 28

    T.A.C.
      §11.1901(a)(5) and §11.1902. Medicaid HMOs must also meet the requirements of
      42

    C.F.R.
      §438.240.

    The
      HMO
      must have on file with HHSC an approved plan describing its QAPI Program,
      including how the HMO will accomplish the activities required by this section.
      The HMO must submit a QAPI Program Annual Summary in a format and timeframe
      specified by HHSC or its designee. The HMO must keep participating physicians
      and other Network Providers informed about the QAPI Program and related
      activities. The HMO must include in Provider contracts a requirement securing
      cooperation with the QAPI.

    The
      HMO
      must approach all clinical and non-clinical aspects of quality assessment and
      performance improvement based on principles of Continuous Quality Improvement
      (CQI)/Total Quality Management (TQM) and must:

    1  Evaluate
      performance using objective quality indicators;

    2  Foster
      data-driven decision-making;

    3  Recognize
      that opportunities for improvement are unlimited;

    4  Solicit
      Member and Provider input on performance and QAPI activities;

    5  Support
      continuous ongoing measurement of clinical and non-clinical effectiveness and
      Member satisfaction;

    6  Support
      programmatic improvements of clinical and non-clinical processes based on
      findings from on-going measurements; and

    7  Support
      re-measurement of effectiveness and Member satisfaction, and continued
      development and implementation of improvement interventions as
      appropriate.

    

    8.1.7.2
      QAPI Program Structure

    The
      HMO
      must maintain a well-defined QAPI structure that includes a planned systematic
      approach to improving clinical and non-clinical processes and outcomes. The
      HMO
      must designate a senior executive responsible for the QAPI Program and the
      Medical Director must have substantial involvement in QAPI Program activities.
      At a minimum, the HMO must ensure that the QAPI Program structure:

    1  Is
      organization-wide, with clear lines of accountability within the
      organization;

    2  Includes
      a set of functions, roles, and responsibilities for the oversight of QAPI
      activities that are clearly defined and assigned to appropriate individuals,
      including physicians, other clinicians, and non-clinicians;

    3  Includes
      annual objectives and/or goals for planned projects or activities including
      clinical and non-clinical programs or initiatives and measurement activities;
      and

    4  Evaluates
      the effectiveness of clinical and non-clinical initiatives.

    

    8.1.7.3
      Clinical Indicators

    The
      HMO
      must engage in the collection of clinical indicator data. The HMO must use
      such
      clinical indicator data in the development, assessment, and modification of
      its
      QAPI Program.

     

    8.1.7.4
      QAPI Program Subcontracting

    If
      the
      HMO subcontracts any of the essential functions or reporting requirements
      contained within the QAPI Program to another entity, the HMO must maintain
      a
      file of the subcontractors. The file must be available for review by HHSC or
      its
      designee upon request.

     

    8.1.7.5
      Behavioral Health Integration into QAPI Program

    If
      the
      HMO provides Behavioral Health Services within the Covered Services as defined
      in Attachments B-2, B-2.1, and B-2.2, it must integrate
      behavioral health into its QAPI Program and include a systematic and on-going
      process for monitoring, evaluating, and improving the

    quality
      and appropriateness of Behavioral Health Services provided to Members. The
      HMO
      must collect data, and monitor and evaluate for improvements to physical health
      outcomes resulting from behavioral health integration into the Member’s overall
      care.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.1.7.6
      Clinical Practice Guidelines

    The
      HMO
      must adopt not less than two evidence-based clinical practice guidelines for
      each applicable HMO Program. Such practice guidelines must be based on valid
      and
      reliable clinical evidence, consider the needs of the HMO’s Members, be adopted
      in consultation with contracting health care professionals, and be reviewed
      and
      updated periodically, as appropriate. The HMO must develop practice guidelines
      based on the health needs and opportunities for improvement identified as part
      of the QAPI Program.

    The
      HMO
      may coordinate the development of clinical practice guidelines with other HHSC
      HMOs to avoid providers in a Service Area receiving conflicting practice
      guidelines from different HMOs.

    The
      HMO
      must disseminate the practice guidelines to all affected Providers and, upon
      request, to Members and potential Members.

    The
      HMO
      must take steps to encourage adoption of the guidelines, and to measure
      compliance with the guidelines, until such point that 90% or more of the
      Providers are consistently in compliance, based on HMO measurement findings.
      The
      HMO must employ substantive Provider motivational incentive strategies, such
      as
      financial and non-financial incentives, to improve Provider compliance with
      clinical practice guidelines. The HMO’s decisions regarding utilization
      management, Member education, coverage of services, and other areas included
      in
      the practice guidelines must be consistent with the HMO’s clinical practice
      guidelines.

     

    8.1.7.7
      Provider Profiling

    The
      HMO
      must conduct PCP and other Provider profiling activities at least annually.
      As
      part of its QAPI Program, the HMO must describe the methodology it uses to
      identify which and how many Providers to profile and to identify measures to
      use
      for profiling such Providers.

    Provider
      profiling activities must include, but not be limited to:

    1  Developing
      PCP and Provider-specific reports that include a multi-dimensional assessment
      of
      a PCP or Provider’s performance using clinical, administrative, and Member
      satisfaction indicators of care that are accurate, measurable, and relevant
      to
      the enrolled population;

    2  Establishing
      PCP, Provider, group, Service Area or regional Benchmarks for areas profiled,
      where applicable, including STAR, STAR+PLUS, CHIP and CHIP Perinatal
      Program-specific Benchmarks, where appropriate; and

    3  Providing
      feedback to individual PCPs and Providers regarding the results of their
      performance and the overall performance of the Provider Network.

    

    8.1.7.8
      Network Management

    The
      HMO
      must:

    1  Use
      the
      results of its Provider profiling activities to identify areas of improvement
      for individual PCPs and Providers, and/or groups of Providers;

    2  Establish
      Provider-specific quality improvement goals for priority areas in which a
      Provider or Providers do not meet established HMO standards or improvement
      goals;

    3  Develop
      and implement incentives, which may include financial and non-financial
      incentives, to motivate Providers to improve performance on profiled measures;
      and

    4  At
      least
      annually, measure and report to HHSC on the Provider Network and individual
      Providers’ progress, or lack of progress, towards such improvement
      goals.

    

    8.1.7.9
      Collaboration with the EQRO

    The
      HMO
      will collaborate with HHSC’s external quality review organization (EQRO) to
      develop studies, surveys, or other analytical approaches that will be carried
      out by the EQRO.  The purpose of the studies, surveys, or other
      analytical approaches is to assess the quality of care and service provided
      to
      Members and to identify opportunities for HMO improvement. To facilitate this
      process, the HMO will supply claims data to the EQRO in a format identified
      by
      HHSC in consultation with HMOs, and will supply medical records for focused
      clinical reviews conducted by the EQRO. The HMO must also work collaboratively
      with HHSC and the EQRO to annually measure selected HEDIS measures that require
      chart reviews. During the first year of operations, HHSC anticipates that the
      selected measures will include, at a minimum, well-child visits and
      immunizations, appropriate use of asthma medications, measures related to
      Members with diabetes, and control of high blood pressure.

     

    8.1.8
      Utilization Management

    The
      HMO
      must have a written utilization management (UM) program description, which
      includes, at a minimum:

    1  Procedures
      to evaluate the need for Medically Necessary Covered Services;

    2  The
      clinical review criteria used, the information sources, the process used to
      review and approve the provision of Covered Services;

    3  The
      method for periodically reviewing and amending the UM clinical review criteria;
      and

    4  The
      staff
      position functionally responsible for the day-to-day management of the UM
      function.

    

    The
      HMO
      must make best efforts to obtain all necessary information, including pertinent
      clinical information, and consult with the treating physician as appropriate
      in
      making UM determinations.

    The
      HMO
      must issue coverage determinations, including adverse determinations, according
      to the following timelines:

    

    •  Within
      three (3) business days after receipt of the request for authorization of
      services;

    •  Within
      one (1) business day for concurrent hospitalization decisions; and

    •  Within
      one (1) hour for post-stabilization or life-threatening conditions, except
      that
      for Emergency Medical Conditions and Emergency Behavioral Health Conditions,
      the
      HMO must not require prior authorization.

    

    The
      HMO’s
      UM Program must include written policies and procedures to ensure:

    

    1.           Consistent
      application of review criteria that are compatible with Members’ needs and
      situations;

    

    2.           Determinations
      to deny or limit services are made by physicians under the direction of the
      Medical Director;

    

    3.           Appropriate
      personnel are available to respond to utilization review inquiries 8:00 a.m.
      to
5:00
      p.m., Monday through Friday, with a telephone system capable of accepting
      utilization review inquiries after normal business hours. The HMO must respond
      to calls within one business day;

    

    4.           Confidentiality
      of clinical information; and

    

    5.           Quality
      is not adversely impacted by financial and reimbursement-related processes
      and
      decisions.

    

    For
      HMOs
      with preauthorization or concurrent review programs, qualified medical
      professionals must supervise preauthorization and concurrent review
      decisions.

    The
      HMO
      UM Program must include polices and procedures to:

    1  Routinely
      assess the effectiveness and the efficiency of the UM Program;

    2  Evaluate
      the appropriate use of medical technologies, including medical procedures,
      drugs
      and devices;

    3  target
      areas of suspected inappropriate service utilization;

    4  Detect
      over- and under-utilization;

    5  Routinely
      generate Provider profiles regarding utilization patterns and compliance with
      utilization review criteria and policies;

    6  Compare
      Member and Provider utilization with norms for comparable
      individuals;

    7  Routinely
      monitor inpatient admissions, emergency room use, ancillary, and out-of-area
      services;

    8  Ensure
      that when Members are receiving Behavioral Health Services from the local mental
      health authority that the HMO is using the same UM guidelines as those
      prescribed for use by Local Mental Health Authorities by MHMR which are
      published at: http://www.mhmr.state.tx.us/centraloffice/behavioralhealthservices/RDMClinGuide.html

    ;
      and

    9.           Refer
      suspected cases of provider or Member Fraud, Abuse, or Waste to the Office
      of
      Inspector General (OIG) as required by Section
      8.1.19.

     

    8.1.9
      Early Childhood Intervention (ECI)

    The
      HMO
      must ensure that Network Providers are educated regarding their responsibility
      under federal laws (e.g., 20 U.S.C. §1435 (a)(5); 34 C.F.R. §303.321(d)) to
      identify and refer any Member age three (3) or under suspected of having a
      developmental disability or delay, or who is at risk of delay, to the designated
      ECI program for screening and assessment within two (2) working days from the
      day the Provider identifies the Member.  The HMO must use written
      educational materials developed or approved by the Department of Assistive
      and
      Rehabilitative Services – Division for Early Childhood Intervention Services for
      these “child find” activities. Eligibility for ECI services will be determined
      by the local ECI program using the criteria contained in 40 T.A.C.
§108.25.

    The
      HMO
      must contract with qualified ECI Providers to provide ECI services to Members
      under age three who have been determined eligible for ECI services. The HMO
      must
      permit Members to self refer to local ECI Service Providers without requiring
      a
      referral from the Member’s PCP. The HMO’s policies and procedures, including its
      Provider Manual, must include written policies and procedures for allowing
      such
      self-referral to ECI providers.

    The
      HMO
      must coordinate and cooperate with local ECI programs in the development and
      implementation of the Individual Family Service Plan (IFSP), including on-going
      case management and other non-capitated services required by the Member’s IFSP.
      The IFSP is an agreement developed by the interdisciplinary team that consists
      of the ECI Case Manager/Service Coordinator, the Member/family, and other
      professionals who participated in the Member’s evaluation or are providing
      direct services to the Member, and may include the Member’s Primary Care
      Physician (PCP) with parental consent. The IFSP identifies the Member’s present
      level of development based on assessment, describes the services to be provided
      to the child to meet the needs of the child and the family, and identifies
      the
      person or persons responsible for each service required by the plan. The IFSP
      shall be transmitted by the ECI Provider to the HMO and the PCP with parental
      consent to enhance coordination of the plan of care. The IFSP may be included
      in
      the Member’s medical record.

    Cooperation
      with the ECI program includes covering medical diagnostic procedures and
      providing medical records required to perform developmental assessments and
      developing the IFSP within the 45-day timeline established in federal rule
      (34
      C.F.R. §303.342(a)). The HMO must require compliance with these requirements
      through Provider contract provisions. The HMO must not withhold authorization
      for the provision of such medical diagnostic procedures. The HMO must promptly
      provide to the ECI program, relevant medical records available to the
      HMO.

    The
      interdisciplinary team will determine Medical Necessity for health and
      Behavioral Health Services as approved by the Member’s PCP. The HMO must
      require, through contract provisions, that all Medically Necessary health and
      Behavioral Health Services contained in the Member’s IFSP are provided to the
      Member in the amount, duration, scope and service setting established by the
      IFSP. The HMO must allow services to be provided by a non-network provider
      if a
      Network Provider is not available to provide the services in the amount,
      duration, scope and service setting as required by the IFSP. The HMO cannot
      modify the plan of care or alter the amount, duration, scope, or service setting
      required by the Member’s IFSP. The HMO cannot create unnecessary barriers for
      the Member to obtain IFSP services, including requiring prior

    authorization
      for the ECI assessment or establishing insufficient authorization periods for
      prior authorized services.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.1.10
      Special Supplemental Nutrition Program for Women, Infants, and
      Children

    (WIC)
      - Specific Requirements

    The
      HMO
      must, by contract, require its Providers to coordinate with the Special
      Supplemental Nutrition Program for Women, Infants, and Children (WIC) to provide
      medical information necessary for WIC eligibility determinations, such as
      height, weight, hematocrit or hemoglobin. The HMO must make referrals to WIC
      for
      Members potentially eligible for WIC. The HMO may use the nutrition education
      provided by WIC to satisfy certain health education requirements of the
      Contract.

     

    8.1.11
      Coordination with Texas Department of Family and Protective
      Services

    The
      HMO
      must cooperate and coordinate with the Texas Department of Family and Protective
      Services (TDFPS) (formerly the Department of Protective and Regulatory Services)
      for the care of a child who is receiving services from or has been placed in
      the
      conservatorship of TDFPS.

    The
      HMO
      must comply with all provisions related to Covered Services, including
      Behavioral Health Services, in the following documents:

    •  A
      court
      order (Order) entered by a Court of Continuing Jurisdiction placing a child
      under the protective custody of TDFPS.

    •  A
      TDFPS
      Service Plan entered by a Court of Continuing Jurisdiction placing a child
      under
      the protective custody of TDFPS.

    •  A
      TDFPS
      Service Plan voluntarily entered into by the parents or person having legal
      custody of a Member and TDFPS.

    

    The
      HMO
      cannot deny, reduce, or controvert the Medical Necessity of any health or
      Behavioral Health Services included in an Order. The HMO may participate in
      the
      preparation of the medical and behavioral care plan prior to TDFPS submitting
      the health care plan to the Court. Any modification or termination of
      court-ordered services must be presented and approved by the court having
      jurisdiction over the matter.

    A
      Member
      or the parent or guardian whose rights are subject to an Order or Service Plan
      cannot use the HMO’s Complaint or Appeal processes, or the HHSC Fair Hearing
      process to Appeal the necessity of the Covered Services.

    The
      HMO
      must include information in its Provider Manuals and training materials
      regarding:

    1  Providing
      medical records to TDFPS;

    2  Scheduling
      medical and Behavioral Health Services appointments within 14 days unless
      requested earlier by TDFPS; and

    3  Recognition
      of abuse and neglect, and appropriate referral to TDFPS.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    The
      HMO
      must continue to provide all Covered Services to a Member receiving services
      from, or in the protective custody of, TDFPS until the Member has been;(1)
      disenrolled from the HMO due to loss of Medicaid managed care eligibility;
      or
      (2) enrolled in HHSC’s managed care program for children in foster care, once
      the program is implemented.

     

    8.1.12
      Services for People with Special Health Care Needs

    This
      section applies to STAR, STAR+PLUS, CHIP HMOs. It applies to CHIP Perinatal
      HMOs
      with respect to their Perinate Newborn Members only.

     

    8.1.12.1
      Identification

    The
      HMO
      must develop and maintain a system and procedures for identifying Members with
      Special Health Care Needs (MSHCN), including people with disabilities or chronic
      or complex medical and behavioral health conditions and Children with Special
      Health Care Needs (CSHCN)1.

    The
      HMO
      must contact Members pre-screened by the HHSC Administrative Services Contractor
      as MSHCN to determine whether they meet the HMO’s MSHCN assessment criteria, and
      to determine whether the Member requires special services described in this
      section. The HMO must provide information to the HHSC Administrative Services
      Contractor that identifies Members who the HMO has assessed to be MSHCN,
      including any Members pre-screened by the HHSC Administrative Services
      Contractor and confirmed by the HMO as a MSHCN. The information must be
      provided, in a format and on a timeline to be specified by HHSC in the
Uniform Managed Care Manual, and updated with newly identified
      MSHCN by the 10th day of each month. In the event that a MSHCN changes HMOs,
      the
      HMO must provide the receiving contractor information concerning the results
      of
      the HMO’s identification and assessment of that Member’s needs, to prevent
      duplication of those activities.

     

    8.1.12.2
      Access to Care and Service Management

    Once
      identified, the HMO must have effective systems to ensure the provision of
      Covered Services to meet the special preventive, primary Acute Care, and
      specialty health care needs appropriate for treatment of the individual Member’s
      condition(s).  All STAR+PLUS Members are considered to be
      MSHCN.

    The
      HMO
      must provide access to identified PCPs and specialty care Providers with
      experience serving MSHCN. Such Providers must be board-qualified or
      board-eligible in their specialty. The HMO may request exceptions from HHSC
      for
      approval of traditional providers who are not board-qualified or board-eligible
      but who otherwise meet the HMO’s credentialing requirements.

     

    For
      services to CSHCN, the HMO must have Network PCPs and specialty care Providers
      that have demonstrated experience with CSHCN in pediatric specialty centers
      such
      as children’s hospitals, teaching hospitals, and tertiary care
      centers.

    The
      HMO
      is responsible for working with MSHCN, their families and legal guardians if
      applicable, and their health care providers to develop a seamless package of
      care in which primary, Acute Care, and specialty service needs are met through
      a
      Service Plan that is understandable to the Member, or, when applicable, the
      Member’s legal guardian.

    The
      HMO
      is responsible for providing Service Management to develop a Service Plan and
      ensure MSHCN, including CSHCN, have access to treatment by a multidisciplinary
      team when the Member’s PCP determines the treatment is Medically Necessary, or
      to avoid separate and fragmented evaluations and service plans. The team must
      include both physician and non-physician providers determined to be necessary
      by
      the Member’s PCP for the comprehensive treatment of the Member. The team
      must:

    1  Participate
      in hospital discharge planning;

    2  Participate
      in pre-admission hospital planning for non-emergency
      hospitalizations;

    3  Develop
      specialty care and support service recommendations to be incorporated into
      the
      Service Plan; and

    4  Provide
      information to the Member, or when applicable, the Member’s legal guardian
      concerning the specialty care recommendations.

    

    MSHCN,
      their families, or their health providers may request Service Management from
      the HMO. The HMO must make an assessment of whether Service Management is needed
      and furnish Service Management when appropriate. The HMO may also recommend
      to a
      MSHCN, or to a CSHCN’s family, that Service Management be furnished if the HMO
      determines that Service Management would benefit the Member.

    The
      HMO
      must provide information and education in its Member Handbook and Provider
      Manual about the care and treatment available in the HMO’s plan for Members with
      Special Health Care Needs, including the availability of Service
      Management.

    The
      HMO
      must have a mechanism in place to allow Members with Special Health Care Needs
      to have direct access to a specialist as appropriate for the Member’s condition
      and identified needs, such as a standing referral to a specialty physician.
      The
      HMO must also provide MSHCN with access to non-primary care physician
      specialists as PCPs, as required by 28 T.A.C. §11.900 and Section
      8.1.

    The
      HMO
      must implement a systematic process to coordinate Non-capitated Services, and
      enlist the involvement of community organizations that may not be providing
      Covered Services but are otherwise important to the health and wellbeing of
      Members. The HMO also must make a best effort to establish relationships with
      State and local programs and community organizations, such as those listed
      below, in order to make referrals for MSHCN and other Members who need community
      services:

    

    •           Community
      Resource Coordination Groups (CRCGs);

    •           Early
      Childhood Intervention (ECI) Program;

    •           Local
      school districts (Special Education);

    •           Texas
      Department of Transportation’s Medical Transportation Program
      (MTP);

    •           Texas
      Department of Assistive and Rehabilitative Services (DARS) Blind Children’s
      Vocational Discovery and Development Program;

    •           Texas
      Department of State Health (DSHS) services, including community mental health
      programs, the Title V Maternal and Child Health and Children with Special Health
      Care Needs (CSHCN) Programs, and the Program for Amplification of Children
      of
      Texas (PACT);

    •           Other
      state and local agencies and programs such as food stamps, and the Women,
      Infants, and Children’s (WIC) Program;

    •           Civic
      and religious organizations and consumer and advocacy groups, such as United
      Cerebral Palsy, which also work on behalf of the MSHCN population.

    __________________________

    
      1
        CSHCN is a term
        often used to refer to a services program for children with special health
        care
        needs administered by DSHS, and described in 25 TAC, Part 1, Section 38.1.
        Although children served through this program may also be served by Medicaid
        or
        CHIP, the reference to “CSHCN” in this Contract does not refer to children
        served through this program.

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    8.1.13
      Service Management for Certain Populations

    The
      HMO
      must have service management programs and procedures for the following
      populations, as applicable to the HMO’s Medicaid and/or CHIP Program(s) (See
      CHIP Perinatal Program Covered Services, Attachment B-2.2, for
      the applicability of these services to the CHIP Perinatal Program):

    1  High-cost
      catastrophic cases;

    2  Women
      with high-risk pregnancies (STAR and STAR+PLUS Programs only);

    3  Individuals
      with mental illness and co-occurring substance abuse; and

    4  FWC
      (STAR
      and STAR+PLUS Programs only).

    

    8.1.14
      Disease Management (DM)

    The
      HMO
      must provide, or arrange to have provided to Members, comprehensive disease
      management services consistent with state statutes and regulations. Such DM
      services must be part of person-based approach to DM and holistically address
      the needs of persons with multiple chronic conditions. The HMO must develop
      and
      implement DM services that relate to chronic conditions that are prevalent
      in
      HMO Program Members. In the first year of operations, STAR, STAR+PLUS and CHIP
      HMOs must have DM Programs that address Members with chronic conditions to
      be
      identified by HHSC and included within the Uniform Managed Care
      Manual. HHSC will not identify the Members with chronic
      conditions.  The HMO must implement policies and procedures to ensure
      that Members that require DM services are identified and enrolled in a program
      to provide such DM services. The HMO must develop and maintain screening and
      evaluation procedures for the early detection, prevention, treatment, or
      referral of participants at risk for or diagnosed with chronic conditions
      identified by HHSC and included within the Uniform Managed Care
      Manual. The HMO must ensure that all Members identified for DM are
      enrolled into a DM Program with the opportunity to opt out of these services
      within 30 days while still maintaining access to all other Covered
      Services.

    The
      DM
      Program(s) must include:

    

    1.           Patient
      self-management education;

    2.           Provider
      education;

    3.           Evidence-based
      models and minimum standards of care;

    4.           Standardized
      protocols and participation criteria;

    5.           Physician-directed
      or physician-supervised care;

    6.           Implementation
      of interventions that address the continuum of care;

    7.           Mechanisms
      to modify or change interventions that are not proven effective;
      and

    8.           Mechanisms
      to monitor the impact of the DM Program over time, including both the clinical
      and the financial impact.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    The
      HMO
      must maintain a system to track and monitor all DM participants for clinical,
      utilization, and cost measures.

    The
      HMO
      must provide designated staff to implement and maintain DM Programs and to
      assist participating Members in accessing DM services. The HMO must educate
      Members and Providers about the HMO’s DM Programs and activities. Additional
      requirements related to the HMO’s Disease Management Programs and activities are
      found in the HHSC Uniform Managed Care Manual.

     

    8.1.14.1
      DM Services and Participating Providers

    At
      a
      minimum, the HMO must:

    1  Implement
      a system for Providers to request specific DM interventions;

    2  Give
      Providers information, including differences between recommended prevention
      and
      treatment and actual care received by Members enrolled in a DM Program, and
      information concerning such Members’ adherence to a service plan;
      and

    3  For
      Members enrolled in a DM Program, provide reports on changes in a Member’s
      health status to their PCP.

    

    8.1.14.2
      HMO DM Evaluation

    HHSC
      or
      its EQRO will evaluate the HMO’s DM Program.

     

    8.1.15
      Behavioral Health (BH) Network and Services

    The
      requirements in this sub-section pertain to all HMOs except: (1) the STAR HMOs
      in the Dallas CSA, whose Members receive Behavioral Health Services through
      the
      NorthSTAR Program, and (2) the CHIP Perinatal Program HMOs with respect to
      their
      Perinate Members.

    The
      HMO
      must provide, or arrange to have provided, to Members all Medically Necessary
      Behavioral Health (BH) Services as described in Attachments B-2, B-2.1,
      and B-2.2. All BH Services must be provided in conformance with the
      access standards included in Section 8.1.3. For Medicaid HMOs,
      BH Services are described in more detail in the Texas Medicaid Provider
      Procedures Manual and the Texas Medicaid Bulletins.
      When assessing Members for BH Services, the HMO and its Network Behavioral
      Health Service Providers must use the DSM-IV multi-axial classification. HHSC
      may require use of other assessment instrument/outcome

    measures
      in addition to the DSM-IV. Providers must document DSM-IV and assessment/outcome
      information in the Member’s medical record.

     

    8.1.15.1
      BH Provider Network

    The
      HMO
      must maintain a Behavioral Health Services Provider Network that includes
      psychiatrists, psychologists, and other Behavioral Health Service Providers.
      The
      Provider Network must include Behavioral Health Service Providers with
      experience serving special populations among the HMO Program(s)’ enrolled
      population, including, as applicable, children and adolescents, persons with
      disabilities, the elderly, and cultural or linguistic minorities, to ensure
      accessibility and availability of qualified Providers to all Members in the
      Service Area.

     

    8.1.15.2
      Member Education and Self-referral for Behavioral Health
      Services

    The
      HMO
      must maintain a Member education process to help Members know where and how
      to
      obtain Behavioral Health Services.

    The
      HMO
      must permit Members to self refer to any in-network Behavioral Health Services
      Provider without a referral from the Member’s PCP. The HMOs’ policies and
      procedures, including its Provider Manual, must include written policies and
      procedures for allowing such self- referral to BH services.

    The
      HMO
      must permit Members to participate in the selection of the appropriate
      behavioral health individual practitioner(s) who will serve them and must
      provide the Member with information on accessible in-network Providers with
      relevant experience.

     

    8.1.15.3
      Behavioral Health Services Hotline

    This
      Section includes Hotline functions pertaining to Members. Requirements for
      Provider Hotlines are found in Section 8.1.4.7. The HMO must
      have an emergency and crisis Behavioral Health Services Hotline staffed by
      trained personnel 24 hours a day, 7 days a week, toll-free throughout the
      Service Area.  Crisis hotline staff must include or have access to
      qualified Behavioral Health Services professionals to assess behavioral health
      emergencies. Emergency and crisis Behavioral Health Services may be arranged
      through mobile crisis teams. It is not acceptable for an emergency intake line
      to be answered by an answering machine.

    The
      HMO
      must operate a toll-free hotline as described in Section 8.1.5.6
to handle Behavioral Health-related calls. The HMO may operate
      one
      hotline to handle emergency and crisis calls and routine Member calls. The
      HMO
      cannot impose maximum call duration limits and must allow calls to be of
      sufficient length to ensure adequate information is provided to the Member.
      Hotline services must meet Cultural Competency requirements and provide
      linguistic access to all Members, including the interpretive services required
      for effective communication.

    The
      Behavioral Health Services Hotline may serve multiple HMO Programs Hotline
      staff
      is knowledgeable about all of the HMO Programs. The Behavioral Health Services
      Hotline may serve multiple Service Areas if the Hotline staff is knowledgeable
      about all such Service Areas, including the Behavioral Health Provider Network
      in each Service Area. The HMO must ensure

    that
      the
      toll-free Behavioral Health Services Hotline meets the following minimum
      performance requirements for all HMO Programs and Service Areas:

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    1  99%
      of
      calls are answered by the fourth ring or an automated call pick-up
      system;

    2  No
      incoming calls receive a busy signal;

    3  At
      least
      80% of calls must be answered by toll-free line staff within 30 seconds measured
      from the time the call is placed in queue after selecting an option;
      and

    4  The
      call
      abandonment rate is 7% or less.

    

    The
      HMO
      must conduct on-going quality assurance to ensure these standards are
      met.

    The
      HMO
      must monitor the HMO’s performance against the Behavioral Health Services
      Hotline standards and submit performance reports summarizing call center
      performance as indicated in Section 8.1.20 and the
Uniform Managed Care Manual.

     

    8.1.15.4
      Coordination between the BH Provider and the PCP

    The
      HMO
      must require, through contract provisions, that PCPs have screening and
      evaluation procedures for the detection and treatment of, or referral for,
      any
      known or suspected behavioral health problems and disorders. PCPs may provide
      any clinically appropriate Behavioral Health Services within the scope of their
      practice.

    The
      HMO
      must provide training to network PCPs on how to screen for and identify
      behavioral health disorders, the HMO’s referral process for Behavioral Health
      Services and clinical coordination requirements for such services. The HMO
      must
      include training on coordination and quality of care such as behavioral health
      screening techniques for PCPs and new models of behavioral health
      interventions.

    The
      HMO
      shall develop and disseminate policies regarding clinical coordination between
      Behavioral Health Service Providers and PCPs. The HMO must require that
      Behavioral Health Service Providers refer Members with known or suspected and
      untreated physical health problems or disorders to their PCP for examination
      and
      treatment, with the Member’s or the Member’s legal guardian’s consent.
      Behavioral Health Providers may only provide physical health care services
      if
      they are licensed to do so. This requirement must be specified in all Provider
      Manuals.

    The
      HMO
      must require that behavioral health Providers send initial and quarterly (or
      more frequently if clinically indicated) summary reports of a Members’
behavioral health status to the PCP, with the Member’s or the Member’s legal
      guardian’s consent. This requirement must be specified in all Provider
      Manuals.

     

    8.1.15.5
      Follow-up after Hospitalization for Behavioral Health
      Services

    The
      HMO
      must require, through Provider contract provisions, that all Members receiving
      inpatient psychiatric services are scheduled for outpatient follow-up and/or
      continuing treatment prior to discharge. The outpatient treatment must occur
      within seven (7) days from the date of

    discharge.
      The HMO must ensure that Behavioral Health Service Providers contact Members
      who
      have missed appointments within 24 hours to reschedule
      appointments.

     

    8.1.15.6
      Chemical Dependency

    The
      HMO
      must comply with 28 T.A.C. §3.8001 et seq., regarding utilization
      review for Chemical Dependency Treatment. Chemical Dependency Treatment must
      conform to the standards set forth in 28 T.A.C. Part 1, Chapter 3, Subchapter
      HH.

     

    8.1.15.7
      Court-Ordered Services

    “Court-Ordered
      Commitment” means a commitment of a Member to a psychiatric facility for
      treatment that is ordered by a court of law pursuant to the Texas Health and
      Safety Code, Title VII, Subtitle C.

    The
      HMO
      must provide inpatient psychiatric services to Members under the age of 21,
      up
      to the annual limit, who have been ordered to receive the services by a court
      of
      competent jurisdiction under the provisions of Chapters 573 and 574 of the
      Texas
      Health and Safety Code, relating to Court-Ordered Commitments to psychiatric
      facilities. The HMO is not obligated to cover placements as a condition of
      probation, authorized by the Texas Family Code.

    The
      HMO
      cannot deny, reduce or controvert the Medical Necessity of inpatient psychiatric
      services provided pursuant to a Court-ordered Commitment for Members under
      age
      21. Any modification or termination of services must be presented to the court
      with jurisdiction over the matter for determination.

    A
      Member
      who has been ordered to receive treatment under the provisions of Chapter 573
      or
      574 of the Texas Health and Safety Code can only Appeal the commitment through
      the court system.

     

    8.1.15.8
      Local Mental Health Authority (LMHA)

    The
      HMO
      must coordinate with the Local Mental Health Authority (LMHA) and state
      psychiatric facility regarding admission and discharge planning, treatment
      objectives and projected length of stay for Members committed by a court of
      law
      to the state psychiatric facility.

    Medicaid
      HMOs are required to comply with additional Behavioral Health Services
      requirements relating to coordination with the LMHA and care for special
      populations. These Medicaid HMO requirements are described in Section
      8.2.8.

     

    8.1.16
      Financial Requirements for Covered Services

    The
      HMO
      must pay for or reimburse Providers for all Medically Necessary Covered Services
      provided to all Members. The HMO is not liable for cost incurred in connection
      with health care rendered prior to the date of the Member’s Effective Date of
      Coverage in that HMO.  A Member may receive collateral health benefits
      under a different type of insurance such as workers compensation or personal
      injury protection under an automobile policy. If a Member is entitled to
      coverage for specific services payable under another insurance plan and the
      HMO
      paid for such

    Covered
      Services, the HMO may obtain reimbursement from the responsible insurance entity
      not to exceed 100% of the value of Covered Services paid.

     

    8.1.17
      Accounting and Financial Reporting Requirements

    The
      HMO’s
      accounting records and supporting information related to all aspects of the
      Contract must be accumulated in accordance with Generally Accepted Accounting
      Principles (GAAP) and the cost principles contained in the Cost Principles
      Document in the Uniform Managed Care Manual. The State will not
      recognize or pay services that cannot be properly substantiated by the HMO
      and
      verified by HHSC.

    The
      HMO
      must:

    1  Maintain
      accounting records for each applicable HMO Program separate and apart from
      other
      corporate accounting records;

    2  Maintain
      records for all claims payments, refunds and adjustment payments to providers,
      capitation payments, interest income and payments for administrative services
      or
      functions and must maintain separate records for medical and administrative
      fees, charges, and payments;

    3  Maintain
      an accounting system that provides an audit trail containing sufficient
      financial documentation to allow for the reconciliation of billings, reports,
      and financial statements with all general ledger accounts; and

    4  Within
      60
      days after Contract execution, submit an accounting policy manual that includes
      all proposed policies and procedures the HMO will follow during the duration
      of
      the Contract. Substantive modifications to the accounting policy manual must
      be
      approved by HHSC.

    

    The
      HMO
      agrees to pay for all reasonable costs incurred by HHSC to perform an
      examination, review or audit of the HMO’s books pertaining to the
      Contract.

    8.1.17.1
      General Access to Accounting Records

    The
      HMO
      must provide authorized representatives of the Texas and federal government
      full
      access to all financial and accounting records related to the performance of
      the
      Contract.

    The
      HMO
      must:

    

    1.           Cooperate
      with the State and federal governments in their evaluation, inspection, audit,
      and/or review of accounting records and any necessary supporting
      information;

    

    2.           Permit
      authorized representatives of the State and federal governments full access,
      during normal business hours, to the accounting records that the State and
      the
      Federal government determine are relevant to the Contract. Such access is
      guaranteed at all times during the performance and retention period of the
      Contract, and will include both announced and unannounced inspections, on-site
      audits, and the review, analysis, and reproduction of reports produced by the
      HMO;

    

    3.           Make
      copies of any accounting records or supporting documentation relevant to the
      Contract available to HHSC or its agents within ten (10) business days of
      receiving a

    written
      request from HHSC for specified records or information. If such documentation
      is
      not made available as requested, the HMO agrees to reimburse HHSC for all costs,
      including, but not limited to, transportation, lodging, and subsistence for
      all
      State and federal representatives, or their agents, to carry out their
      inspection, audit, review, analysis, and reproduction functions at the
      location(s) of such accounting records; and

    4.           Pay
      any and all additional costs incurred by the State and federal government that
      are the result of the HMO’s failure to provide the requested accounting records
      or financial information within ten (10) business days of receiving a written
      request from the State or federal government.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.1.17.2
      Financial Reporting Requirements

    HHSC
      will
      require the HMO to provide financial reports by HMO Program and by Service
      Area
      to support Contract monitoring as well as State and Federal reporting
      requirements. HHSC will consult with HMOs regarding the format and frequency
      of
      such reporting. All financial information and reports that are not
      Member-specific are property of HHSC and will be public record. Any deliverable
      or report in Section 8.1.17.2 without a specified due date is due quarterly
      on
      the last day of the month. Where the due date states 30 days, the HMO is to
      provide the deliverable by the last day of the month following the end of the
      reporting period.  Where the due date states 45 days, the HMO is to
      provide the deliverable by the 15th day of the second month following the end
      of
      the reporting period.

    CHIP
      Perinatal Program data must be reported, and the data will be integrated into
      existing CHIP Program financial reports.  Except for the Financial
      Statistical Report, no separate CHIP Perinatal Program reports are
      required.  For all other CHIP financial reports, where appropriate,
      HHSC will designate specific attributes within the CHIP Program financial
      reports that the CHIP Perinatal HMOs must complete to allow HHSC to extract
      financial data particular to the CHIP Perinatal Program.

    HHSC’s
      Uniform Managed Care Manual will govern the timing, format and
      content for the following reports.

     

    Audited
      Financial Statement –The HMO must provide the annual audited financial
      statement, for each year covered under the Contract, no later than June 30.
      The
      HMO must provide the most recent annual financial statements, as required by
      the
      Texas Department of Insurance for each year covered under the Contract, no
      later
      than March 1.

     

    Affiliate
      Report – The HMO must submit an Affiliate Report to HHSC if this
      information has changed since the last report submission. The report must
      contain the following:

    1  A
      list of
      all Affiliates, and

    2  For
      HHSC’s prior review and approval, a schedule of all transactions with Affiliates
      that, under the provisions of the Contract, will be allowable as expenses in
      the
      FSR Report for services provided to the HMO by the Affiliate. Those should
      include financial terms, a detailed description of the services to be provided,
      and an estimated amount that will be incurred by the HMO for such services
      during the Contract Period.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Employee
      Bonus and/or Incentive Payment Plan – If a HMO intends to include
      Employee Bonus or Incentive Payments as allowable administrative expenses,
      the
      HMO must furnish a written Employee Bonus and/or Incentive Payments Plan to
      HHSC
      so it may determine whether such payments are allowable administrative expenses
      in accordance with Cost Principles Document in the Uniform Managed Care
      Manual. The written plan must include a description of the HMO’s
      criteria for establishing bonus and/or incentive payments, the methodology
      to
      calculate bonus and/or incentive payments, and the timing of bonus and/or
      incentive payments. The Bonus and/or Incentive Payment Plan and description
      must
      be submitted to HHSC for approval no later than 30 days after the Effective
      Date
      of the Contract and any Contract renewal. If the HMO substantively revises
      the
      Employee Bonus and/or Incentive Payment Plan, the HMO must submit the revised
      plan to HHSC for prior review and approval.

     

    Claims
      Lag Report - The HMO must submit Claims Lag Report as a Contract
      year-to-date report. The report must be submitted quarterly by the last day
      of
      the month following the reporting period. The report must be submitted to HHSC
      in a format specified by HHSC. The report format is contained in the
Uniform Managed Care Manual Chapter 5, Section
      5.6.2.  The report must disclose the amount of incurred claims each
      month and the amount paid each month.

     

    DSP
      Report - The HMO must submit a monthly Delivery Supplemental Payment
      (DSP) Report that includes the data elements specified by HHSC in the format
      specified by HHSC. HHSC will consult with contracted HMOs prior to revising
      the
      DSP Report data elements and requirements. The DSP Report must include only
      unduplicated deliveries and only deliveries for which the HMO has made a
      payment, to either a hospital or other provider.

     

    Form
      CMS-1513 - The HMO must file an original Form CMS-1513 prior to
      beginning operations regarding the HMO’s control, ownership, or affiliations. An
      updated Form CMS-1513 must also be filed no later than 30 days after any change
      in control, ownership, or affiliations.

     

    FSR
      Reports – The HMO must file quarterly and annual Financial-Statistical
      Reports (FSR) in the format and timeframe specified by HHSC. HHSC will include
      FSR format and directions in the Uniform Managed Care Manual.
      The HMO must incorporate financial and statistical data of delegated networks
      (e.g., IPAs, ANHCs, Limited Provider Networks), if any, in its FSR Reports.
      Administrative expenses reported in the FSRs must be reported in accordance
      with
      the Cost Principles Document in the Uniform Managed Care
      Manual. Quarterly FSR reports are due no later than 30 days after the
      end of the quarter and must provide information for the current quarter and
      year-to-date information through the current quarter. The first annual FSR
      report must reflect expenses incurred through the 90th day after the end of
      the
      fiscal year.  The first annual report must be filed on or before the
      120th day after the end of each fiscal year and accompanied by an actuarial
      opinion by a qualified actuary who is in good standing with the American Academy
      of Actuaries. Subsequent annual reports must reflect data completed through
      the
      334th day after the end of each fiscal year and must be filed on or before
      the
      365th day following the end of each fiscal year.

    HHSC
      will
      post all FSRs on the HHSC website.

    CHIP
      Perinatal HMOs are required to submit separate FSRs for the CHIP Perinatal
      Program following the instructions outlined above and in the Uniform
      Managed Care Manual.

     

    Out-of-Network
      Utilization Reports – The HMO must file quarterly Out-of Network
      Utilization Reports in the format and timeframe specified by
      HHSC.  HHSC will include the report format and directions in the
Uniform Managed Care Manual. Quarterly reports are due 30 days
      after the end of each quarter.

     

    HUB
      Reports – Upon contract award, the HMO must attend a post award meeting
      in Austin, Texas, at a time specified by HHSC, to discuss the development and
      submission of a Client Services HUB Subcontracting Plan for inclusion and the
      HMO’s good faith efforts to notify HUBs of subcontracting opportunities. The HMO
      must maintain its HUB Subcontracting Plan and submit monthly reports documenting
      the HMO’s Historically Underutilized Business (HUB) program efforts and
      accomplishments to the HHSC HUB Office. The report must include a narrative
      description of the HMO’s program efforts and a financial report reflecting
      payments made to HUBs. HMOs must use the formats included in HHSC’s
Uniform Managed Care Manual for the HUB monthly reports. The
      HMO must comply with HHSC’s standard Client Services HUB Subcontracting Plan
      requirements for all subcontractors.

     

    IBNR
      Plan -The HMO must furnish a written IBNR Plan to manage
      incurred-but-not-reported (IBNR) expenses, and a description of the method
      of
      insuring against insolvency, including information on all existing or proposed
      insurance policies. The Plan must include the methodology for estimating IBNR.
      The plan and description must be submitted to HHSC no later than 60 days after
      the Effective Date of the Contract. Substantive changes to a HMO’s IBNR plan and
      description must be submitted to HHSC no later than 30 days before the HMO
      implements changes to the IBNR plan.

     

    Medicaid
      Disproportionate Share Hospital (DSH) Reports – Medicaid HMOs must file
      preliminary and final Medicaid DSH reports, required by HHSC to identify and
      reimburse hospitals that qualify for Medicaid DSH funds. The preliminary and
      final DSH reports must include the data elements and be submitted in the form
      and format specified by HHSC in the Uniform Managed Care
      Manual. The preliminary DSH reports are due on or before June 1 of the
      year following the state fiscal reporting year. The final DSH reports are due
      no
      later than July 15 of the year following the state fiscal reporting year. This
      reporting requirement does not apply to CHIP or CHIP Perinatal Program HMOs.
      For
      STAR+PLUS, HMOs will include only outpatient services in the DSH
      report.

     

    TDI
      Examination Report - The HMO must furnish a copy of any TDI Examination
      Report, including the financial, market conduct, target exam, quality of care
      components, and corrective action plans and responses, no later than 10 days
      after receipt of the final report from TDI.

     

    TDI
      Filings – The HMO must submit annual figures for controlled risk-based
      capital, as well as its quarterly financial statements, both as required by
      TDI.

     

    Registration
      Statement (also known as the “Form B”) - If the HMO is a part of an
      insurance holding company system, the HMO must submit to HHSC a complete
      registration statement, also known as Form B, and all amendments to this form,
      and any other information filed by such insurer with the insurance regulatory
      authority of its domiciliary jurisdiction.

     

    Section
      1318 Financial Disclosure Report - The HMO must file an original CMS
      Public Health Service (PHS) Section 1318 Financial Disclosure Report prior
      to
      the start of Operations and an

    updated
      CMS PHS Section 1318 Financial Disclosure Report no later than 30 days after
      the
      end of each Contract Year and no later than 30 days after entering into,
      renewing, or terminating a relationship with an affiliated party.

     

    Third
      Party Recovery (TPR) Reports - The HMO must file TPR Reports in
      accordance with the format developed by HHSC in the Uniform Managed Care
      Manual. HHSC will require the HMO to submit TPR reports no more often
      than quarterly.  TPR reports must include total dollars recovered from
      third party payers for each HMO Program for services to the HMO’s Members, and
      the total dollars recovered through coordination of benefits, subrogation,
      and
      worker’s compensation. For CHIP HMOs, the TPR Reports only apply if the HMO
      chooses to engage in TPR activities.

     

    8.1.18
      Management Information System Requirements

    The
      HMO
      must maintain a Management Information System (MIS) that supports all functions
      of the HMO’s processes and procedures for the flow and use of HMO data. The HMO
      must have hardware, software, and a network and communications system with
      the
      capability and capacity to handle and operate all MIS subsystems for the
      following operational and administrative areas:

    

    1.
      Enrollment/Eligibility Subsystem;

    

    2.
      Provider Subsystem;

    

    3.
      Encounter/Claims Processing Subsystem;

    

    4.
      Financial Subsystem;

    

    5.
      Utilization/Quality Improvement Subsystem;

    

    6.
      Reporting Subsystem;

    

    7.
      Interface Subsystem; and

    

    8.
      TPR
      Subsystem, as applicable to each HMO Program.

    

    The
      MIS
      must enable the HMO to meet the Contract requirements, including all applicable
      state and federal laws, rules, and regulations. The MIS must have the capacity
      and capability to capture and utilize various data elements required for HMO
      administration.

    HHSC
      will
      provide the HMO with pharmacy data on the HMO’s Members on a weekly basis
      through the HHSC Vendor Drug Program, or should these services be outsourced,
      through the Pharmacy Benefit Manager. HHSC will provide a sample format of
      pharmacy data to contract awardees.

    The
      HMO
      must have a system that can be adapted to changes in Business Practices/Policies
      within the timeframes negotiated by the Parties. The HMO is expected to cover
      the cost of such systems modifications over the life of the
      Contract.

    The
      HMO
      is required to participate in the HHSC Systems Work Group.

    The
      HMO
      must provide HHSC prior written notice of major systems changes, generally
      within 90 days, and implementations, including any changes relating to Material
      Subcontractors, in accordance with the requirements of this Contract and the
      Uniform Managed Care Terms and Conditions.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    The
      HMO
      must provide HHSC any updates to the HMO’s organizational chart relating to MIS
      and the description of MIS responsibilities at least 30 days prior to the
      effective date of the change. The HMO must provide HHSC official points of
      contact for MIS issues on an on-going basis.

    HHSC,
      or
      its agent, may conduct a Systems Readiness Review to validate the HMO’s ability
      to meet the MIS requirements as described in Attachment B-1, Section
      7. The System Readiness Review may include a desk review and/or an
      onsite review and must be conducted for the following events:

    1  A
      new
      plan is brought into the HMO Program;

    2  An
      existing plan begins business in a new Service Area;

    3  An
      existing plan changes location;

    4  An
      existing plan changes its processing system, including changes in Material
      Subcontractors performing MIS or claims processing functions; and

    5  An
      existing plan in one or two HHSC HMO Programs is initiating a Contract to
      participate in any additional HMO Programs.

    

    If
      for
      any reason, a HMO does not fully meet the MIS requirements, then the HMO must,
      upon request by HHSC, either correct such deficiency or submit to HHSC a
      Corrective Action Plan and Risk Mitigation Plan to address such deficiency
      as
      requested by HHSC. Immediately upon identifying a deficiency, HHSC may impose
      remedies and either actual or liquidated damages according to the severity
      of
      the deficiency. HHSC may also freeze enrollment into the HMO’s plan for any of
      its HMO Programs until such deficiency is corrected. Refer to Attachment
      A, Article 12 and Attachment B-5 for additional
      information regarding remedies and damages.  Refer to
      Attachment B-1, Section 7 and Attachment B-1, Section 8.1.1.2
      for additional information regarding HMO Readiness Reviews. Refer to
      Attachment A, Section 4.08(c) for information regarding
      Readiness Reviews of the HMO’s Material Subcontractors.

     

    8.1.18.1
      Encounter Data

    The
      HMO
      must provide complete Encounter Data for all Covered Services, including
      Value-added Services. Encounter Data must follow the format, and data elements
      as described in the HIPAA-compliant 837 format. HHSC will specify the method
      of
      transmission, and the submission schedule, in the Uniform Managed Care
      Manual. The HMO must submit monthly Encounter Data transmissions, and
      include all Encounter Data and Encounter Data adjustments processed by the
      HMO.
      Encounter Data quality validation must incorporate assessment standards
      developed jointly by the HMO and HHSC. The HMO must make original records
      available for inspection by HHSC for validation purposes. Encounter Data that
      do
      not meet quality standards must be corrected and returned within a time period
      specified by HHSC.

    In
      addition to providing Encounter Data in the 837 format described above, HMOs
      must submit an Encounter Data file to HHSC's EQRO, in the format provided in
      the
Uniform Managed Care Manual. This additional submission
      requirement is time-limited and may not be required for the entire term of
      the
      Contract.

    For
      reporting Encounters and fee-for-service claims to HHSC, the HMO must use the
      procedure codes, diagnosis codes, and other codes as directed by HHSC. Any
      exceptions will be considered

    on
      a
      code-by-code basis after HHSC receives written notice from the HMO requesting
      an
      exception. The HMO must also use the provider numbers as directed by HHSC for
      both Encounter and fee-for-service claims submissions, as
      applicable.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.1.18.2
      HMO Deliverables related to MIS Requirements

    At
      the
      beginning of each state fiscal year, the HMO must submit for HHSC’s review and
      approval any modifications to the following documents:

    1  Joint
      Interface Plan;

    2  Disaster
      Recovery Plan;

    3  Business
      Continuity Plan;

    4  Risk
      Management Plan; and

    5  Systems
      Quality Assurance Plan.

    

    The
      HMO
      must submit such modifications to HHSC according to the format and schedule
      identified the HHSC Uniform Managed Care Manual.

     

    8.1.18.3
      System-wide Functions

    The
      HMO’s
      MIS system must include key business processing functions and/or features,
      which
      must apply across all subsystems as follows:

    

    1.           Process
      electronic data transmission or media to add, delete or modify membership
      records with accurate begin and end dates;

    

    2.           Track
      Covered Services received by Members through the system, and accurately and
      fully maintain those Covered Services as HIPAA-compliant Encounter
      transactions;

    

    3.           Transmit
      or transfer Encounter Data transactions on electronic media in the HIPAA format
      to the contractor designated by HHSC to receive the Encounter Data;

    

    4.           Maintain
      a history of changes and adjustments and audit trails for current and
      retroactive data;

    

    5.           Maintain
      procedures and processes for accumulating, archiving, and restoring data in
      the
      event of a system or subsystem failure;

    

    6.           Employ
      industry standard medical billing taxonomies (procedure codes, diagnosis
      codes)  to describe services delivered and Encounter transactions
      produced;

    

    7.           Accommodate
      the coordination of benefits;

    

    8.           Produce
      standard Explanation of Benefits (EOBs);

    

    9.           Pay
      financial transactions to Providers in compliance with federal and state laws,
      rules and regulations;

    

    10.
      Ensure that all financial transactions are auditable according to GAAP
      guidelines.

    

    11.
      Relate and extract data elements to produce report formats (provided within
      the
Uniform Managed Care Manual) or otherwise required by
      HHSC;

    

    12.
      Ensure that written process and procedures manuals document and describe all
      manual and automated system procedures and processes for the MIS;

    

    13.
      Maintain and cross-reference all Member-related information with the most
      current Medicaid, CHIP or CHIP Perinatal Program Provider number;
      and

    

    14.
      Ensure that the MIS is able to integrate pharmacy data from HHSC’s Drug Vendor
      file (available through the Virtual Private Network (VPN)) into the HMO’s Member
      data.

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.1.18.4
      Health Insurance Portability and Accountability Act (HIPAA)
      Compliance

    The
      HMO’s
      MIS system must comply with applicable certificate of coverage and data
      specification and reporting requirements promulgated pursuant to the Health
      Insurance Portability and Accountability Act (HIPAA) of 1996, P.L. 104-191
      (August 21, 1996), as amended or modified. The HMO must comply with HIPAA EDI
      requirements. HMO’s enrollment files must be in the 834 HIPAA-compliant format.
      Eligibility inquiries must be in the 270/271 format and all claims and
      remittance transactions in the 837/835 format.

    The
      HMO
      must provide its Members with a privacy notice as required by HIPAA. The HMO
      must provide HHSC with a copy of its privacy notice for filing.

     

    8.1.18.5
      Claims Processing Requirements

    The
      HMO
      must process and adjudicate all provider claims for Medically Necessary Covered
      Services that are filed within the time frames specified in the Uniform
      Managed Care Manual. The HMO is subject to remedies, including
      liquidated damages and interest, if the HMO does not process and adjudicate
      claims within the timeframes listed in the Uniform Managed Care
      Manual.

    The
      HMO
      must administer an effective, accurate, and efficient claims payment process
      in
      compliance with federal laws and regulations, applicable state laws and rules,
      the Contract, and the Uniform Managed Care Manual. In addition,
      a Medicaid HMO must be able to accept and process provider claims in compliance
      with the Medicaid Provider Procedures Manual and The Texas Medicaid
      Bulletin.

    The
      HMO
      must maintain an automated claims processing system that registers the date
      a
      claim is received by the MCO, the detail of each claim transaction (or action)
      at the time the transaction occurs, and has the capability to report each claim
      transaction by date and type to include interest payments.  The claims
      system must maintain information at the claim and line detail
      level.  The claims system must maintain adequate audit trails and
      report accurate claims performance measures to HHSC.

    The
      HMO’s
      claims system must maintain online and archived files. The HMO must keep online
      automated claims payment history for the most current 18 months.  The
      HMO must retain other financial information and records, including all original
      claims forms, for the time period established in Attachment A, Section
      9.01. All claims data must be easily sorted and produced in formats as
      requested by HHSC.

    The
      HMO
      must offer its Providers/Subcontractors the option of submitting and receiving
      claims information through electronic data interchange (EDI) that allows for
      automated processing and adjudication of claims. EDI processing must be offered
      as an alternative to the filing of paper claims. Electronic claims must use
      HIPAA-compliant electronic formats.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    The
      HMO
      must make an electronic funds transfer (EFT) payment process (for direct
      deposit) available to in-network providers when processing claims for Medically
      Necessary covered STAR+PLUS services.

    The
      HMO
      may deny a claim submitted by a provider for failure to file in a timely manner
      as provided for in the Uniform Managed Care Manual. The HMO
      must not pay any claim submitted by a provider excluded or suspended from the
      Medicare, Medicaid, CHIP or CHIP Perinatal programs for Fraud, Abuse, or
      Waste.  The HMO must not pay any claim submitted by a Provider that is
      on payment hold under the authority of HHSC or its authorized agent(s), or
      who
      has pending accounts receivable with HHSC.

    The
      HMO
      is subject to the requirements related to coordination of benefits for secondary
      payors in the Texas Insurance Code Section 843.349 (e) and (f).

    The
      HMO
      must notify HHSC of major claim system changes in writing no later than 90
      days
      prior to implementation. The HMO must provide an implementation plan and
      schedule of proposed changes. HHSC reserves the right to require a desk or
      on-site readiness review of the changes.

    The
      HMO
      must inform all Network Providers about the information required to submit
      a
      claim at least 30 days prior to the Operational Start Date and as a provision
      within the HMO/Provider contract. The HMO must make available to Providers
      claims coding and processing guidelines for the applicable provider type.
      Providers must receive 90 days notice prior to the HMO’s implementation of
      changes to claims guidelines.

     

    8.1.19
      Fraud and Abuse

    A
      HMO is
      subject to all state and federal laws and regulations relating to Fraud, Abuse,
      and Waste in health care and the Medicaid and CHIP programs. The HMO must
      cooperate and assist HHSC and any state or federal agency charged with the
      duty
      of identifying, investigating, sanctioning or prosecuting suspected Fraud,
      Abuse
      or Waste. The HMO must provide originals and/or copies of all records and
      information requested and allow access to premises and provide records to the
      Inspector General for the Texas Health and Human Services System, HHSC or its
      authorized agent(s), the Centers for Medicare and Medicaid Services (CMS),
      the
      U.S. Department of Health and Human Services (DHHS), Federal Bureau of
      Investigation, TDI, or other units of state government. The HMO must provide
      all
      copies of records free of charge.

    The
      HMO
      must submit a written Fraud and Abuse compliance plan to the Office of Inspector
      General at HHSC for approval (See Attachment B-1, Section 7 for
      requirements regarding timeframes for submitting the original plan.) The plan
      must ensure that all officers, directors, managers and employees know and
      understand the provisions of the HMO’s Fraud and Abuse compliance plan. The plan
      must include the name, address, telephone number, electronic mail address,
      and
      fax number of the individual(s) responsible for carrying out the
      plan.

    The
      written Fraud and Abuse compliance plan must:

    

    1  Contain
      procedures designed to prevent and detect potential or suspected Abuse, Fraud
      and Waste in the administration and delivery of services under the
      Contract;

    2  Contain
      a
      description of the HMO’s procedures for educating and training personnel to
      prevent Fraud, Abuse, or Waste;

    3  Include
      provisions for the confidential reporting of plan violations to the designated
      person within the HMO’s organization and ensure that the identity of an
      individual reporting violations is protected from retaliation;

    4  Include
      provisions for maintaining the confidentiality of any patient information
      relevant to an investigation of Fraud, Abuse, or Waste;

    5  Provide
      for the investigation and follow-up of any allegations of Fraud, Abuse, or
      Waste
      and contain specific and detailed internal procedures for officers, directors,
      managers and employees for detecting, reporting, and investigating Fraud and
      Abuse compliance plan violations;

    6  Require
      that confirmed violations be reported to the Office of Inspector General (OIG);
      and

    7  Require
      any confirmed violations or confirmed or suspected Fraud, Abuse, or Waste under
      state or federal law be reported to OIG.

    

    If
      the
      HMO contracts for the investigation of allegations of Fraud, Abuse, or Waste
      and
      other types of program abuse by Members or Providers, the plan must include
      a
      copy of the subcontract; the names, addresses, telephone numbers, electronic
      mail addresses, and fax numbers of the principals of the subcontracted entity;
      and a description of the qualifications of the subcontracted
      entity.  Such subcontractors must be held to the requirements stated
      in this Section.

    The
      HMO
      must designate executive and essential personnel to attend mandatory training
      in
      Fraud and Abuse detection, prevention and reporting. Designated executive and
      essential personnel means the HMO staff persons who supervise staff in the
      following areas: data collection, provider enrollment or disenrollment,
      encounter data, claims processing, utilization review, appeals or grievances,
      quality assurance and marketing, and who are directly involved in the
      decision-making and administration of the Fraud and Abuse detection program
      within the HMO. The training will be conducted by the OIG free of charge. The
      HMO must schedule and complete training no later than 90 days after the
      Effective Date of the Contract. If the HMO updates or modifies its written
      Fraud
      and Abuse compliance plan, the HMO must train its executive and essential
      personnel on these updates or modifications no later than 90 days after the
      effective date of the updates or modifications.

    The
      HMO
      must designate an officer or director in its organization with responsibility
      and authority to carry out the provisions of the Fraud and Abuse compliance
      plan. A HMO’s failure to report potential or suspected Fraud or Abuse may result
      in sanctions, cancellation of the Contract, and/or exclusion from participation
      in the Medicaid, CHIP or CHIP Perinatal HMO Programs. The HMO must allow the
      OIG, HHSC, its agents, or other governmental units to conduct private interviews
      of the HMO’s personnel, subcontractors and their personnel, witnesses, and
      Members with regard to a confirmed violation. The HMO’s personnel and it
      subcontractors must reasonably cooperate, to the satisfaction of HHSC, by being
      available in person for interviews, consultation, grand jury proceedings,
      pre-trial conferences, hearings, trials and in any other process, including
      investigations, at the HMO’s and subcontractors’ own expense.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Additional
      Requirements for STAR and STAR+PLUS HMOs:

     

    In
      accordance with Section 1902(a)(68) of the Social Security Act, STAR and
      STAR+PLUS HMOs that receive or make annual Medicaid payments of at least $5
      million must:

    1  Establish
      written policies for all employees, managers, officers, contractors,
      subcontractors, and agents of the HMO, which provide detailed information about
      the False Claims Act, administrative remedies for false claims and statements,
      any state laws pertaining to civil or criminal penalties for false claims,
      and
      whistleblower protections under such laws, as described in Section
      1902(a)(68)(A).

    2  Include
      as part of such written policies, detailed provisions regarding the HMO’s
      policies and procedures for detecting and preventing fraud, waste, and
      abuse.

    3  Include
      in any employee handbook a specific discussion of the laws described in Section
      1902(a)(68)(A), the rights of employees to be protected as whistleblowers,
      and
      the HMO’s policies and procedures for detecting and preventing fraud, waste, and
      abuse.

    

    8.1.20
      Reporting Requirements

    The
      HMO
      must provide and must require its subcontractors to provide:

    1  All
      information required under the Contract, including but not limited to, the
      reporting requirements or other information related to the performance of its
      responsibilities hereunder as reasonably requested by the HHSC; and

    2  Any
      information in its possession sufficient to permit HHSC to comply with the
      Federal Balanced Budget Act of 1997 or other Federal or state laws, rules,
      and
      regulations. All information must be provided in accordance with the timelines,
      definitions, formats and instructions as specified by HHSC. Where practicable,
      HHSC may consult with HMOs to establish time frames and formats reasonably
      acceptable to both parties.

    

    Any
      deliverable or report in Section 8.1.20 without a specified due date is due
      quarterly on the last day of the month following the end of the reporting
      period. Where the due date states 30 days, the HMO is to provide the deliverable
      by the last day of the month following the end of the reporting
      period.  Where the due date states 45 days, the HMO is to provide the
      deliverable by the 15th day of the second month following the end of the
      reporting period.

    The
      HMO’s
      Chief Executive and Chief Financial Officers, or persons in equivalent
      positions, must certify that financial data, Encounter Data and other
      measurement data has been reviewed by the HMO and is true and accurate to the
      best of their knowledge after reasonable inquiry.

     

    8.1.20.1
      HEDIS and Other Statistical Performance Measures

    The
      HMO
      must provide to HHSC or its designee all information necessary to analyze the
      HMO’s provision of quality care to Members using measures to be determined by
      HHSC in consultation with the HMO. Such measures must be consistent with HEDIS
      or other externally based measures or measurement sets, and involve collection
      of information beyond that present in Encounter Data. The Performance
      Indicator Dashboard, found in the Uniform Managed Care
      Manual provides additional information on the role of the HMO and the
      EQRO in the collection and calculation of HEDIS, CAHPS, and other performance
      measures.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.1.20.2
      Reports

    The
      HMO
      must provide the following reports, in addition to the Financial Reports
      described in Section 8.1.17 and those reporting requirements
      listed elsewhere in the Contract. The HHSC Uniform Managed Care
      Manual will include a list of all required reports, and a description
      of the format, content, file layout and submission deadlines for each
      report.

    For
      the
      following reports, CHIP Perinatal Program data will be integrated into existing
      CHIP Program reports.  Generally, no separate CHIP Perinatal Program
      reports are required. Where appropriate, HHSC will designate specific attributes
      within the CHIP Program reports that the CHIP Perinatal HMOs must complete
      to
      allow HHSC to extract data particular to the CHIP Perinatal
      Program.

     

    Claims
      Summary Report - The HMO must submit quarterly Claims Summary Reports
      to HHSC by HMO Program, Service Area and claim type by the 30th day following
      the
      end of the reporting period unless otherwise specified. Claim Types include
      facility and/or professional services for Acute Care, Behavioral Health, Vision,
      and Long Term Services and Supports. Within each claim type, claims data must
      be
      reported separately on the UB and CMS 1500 claim forms.  The format
      for the Claims Summary Report is contained in Chapter 5, Section 5.6.1 of the
      Uniform Managed Care Manual.

     

    QAPI
      Program Annual Summary Report - The HMO must submit a QAPI Program
      Annual Summary in a format and timeframe as specified in the Uniform Managed
      Care Manual.

     

    Fraudulent
      Practices Report - Utilizing the HHSC-Office of Inspector General (OIG)
      fraud referral form, the HMO’s assigned officer or director must report and
      refer all possible acts of waste, abuse or fraud to the HHSC-OIG within 30
      working days of receiving the reports of possible acts of waste, abuse or fraud
      from the HMO’s Special Investigative Unit (SIU).  The report and
      referral must include: an investigative report identifying the allegation,
      statutes/regulations violated or considered, and the results of the
      investigation; copies of program rules and regulations violated for the time
      period in question; the estimated overpayment identified; a summary of the
      interviews conducted; the encounter data submitted by the provider for the
      time
      period in question; and all supporting documentation obtained as the result
      of
      the investigation. This requirement applies to all reports of possible acts
      of
      waste, abuse and fraud.

    Additional
      reports required by the Office of the Inspector General relating to waste,
      abuse
      or fraud are listed in the HHSC Uniform Managed Care
      Manual.

     

    Provider
      Termination Report: (CHIP (including integrated CHIP Perinatal Program data),
      STAR, and STAR+PLUS)

    MCO
      must
      submit a quarterly report that identifies any providers who cease to participate
      in MCO's provider network, either voluntarily or involuntarily. The report
      must
      be submitted to HHSC in the format specified by HHSC, no later than 30 days
      after the end of the reporting period.

     

    PCP
      Network & Capacity Report: (CHIP only (including integrated CHIP Perinatal
      Program data))

    For
      the
      CHIP Program, MCO must submit a quarterly report listing all unduplicated PCPs
      in the MCO's Provider Network.  For the CHIP Perinatal Program, the
      Perinatal Newborns are assigned PCPs that are part of the CHIP PCP Network.
      The
      report must be submitted to HHSC in the format specified by HHSC, no later
      than
      30 days after the end of the reporting quarter.

     

    Summary
      Report of Member Complaints and Appeals - The HMO must submit quarterly
      Member Complaints and Appeals reports. The HMO must include in its reports
      Complaints and Appeals submitted to its subcontracted risk groups (e.g., IPAs)
      and any other subcontractor that provides Member services. The HMO must submit
      the Complaint and Appeals reports electronically on or before 45 days following
      the end of the state fiscal quarter, using the format specified by HHSC in
      the
HHSC Uniform Managed Care Manual, Chapter 5.4.2.

    HHSC
      may
      direct the CHIP Perinatal HMOs to provide segregated Member Complaints and
      Appeals reports on an as-needed basis.

     

    Summary
      Report of Provider Complaints - The HMO must submit Provider complaints
      reports on a quarterly basis. The HMO must include in its reports complaints
      submitted by providers to its subcontracted risk groups (e.g., IPAs) and any
      other subcontractor that provides Provider services. The complaint reports
      must
      be submitted electronically on or before 45 days following the end of the state
      fiscal quarter, using the format specified by HHSC in the HHSC

     

    Uniform
      Managed Care Manual, Chapter 5.4.2.

    HHSC
      may
      direct the CHIP Perinatal HMOs to provide segregated Provider Complaints and
      Appeals reports on an as-needed basis.

     

    Hotline
      Reports - The HMO must submit, on a quarterly basis, a status report
      for the Member Hotline, the Behavioral Health Services Hotline, and the Provider
      Hotline in comparison with the performance standards set out in Sections

     

    8.1.5.6,
      8.1.14.3, and 8.1.4.7. The HMO shall submit such reports using a format
      to be prescribed by HHSC in consultation with the HMOs.

    If
      the
      HMO is not meeting a hotline performance standard, HHSC may require the HMO
      to
      submit monthly hotline performance reports and implement corrective actions
      until the hotline performance standards are met. If a HMO has a single hotline
      serving multiple Service Areas, multiple HMO Programs, or multiple hotline
      functions, (i.e. Member, Provider, Behavioral Health Services hotlines), HHSC
      may request on an annual basis that the HMO submit certain hotline response
      information by HMO Program, by Service Area, and by hotline function, as
      applicable to the HMO. HHSC may also request this type of hotline information
      if
      a HMO is not meeting a hotline performance standard.

    The
      HMO
      must follow all applicable Joint Interface Plans (JIPs) and all required file
      submissions for HHSC’s Administrative Services Contractor, External Quality
      Review Organization (EQRO) and HHSC Medicaid Claims
      Administrator.  The JIPs can be accessed through the Uniform Managed
      Care Manual.

     

    Medicaid
      Medical Check-ups Report – Medicaid HMOs must submit an annual report
      that identifies:

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    (1)
      the
      total number of new Members under the age of 21 who are still enrolled with
      the
      HMO after 90 days;

    

    (2)
      the
      number and percent of new Members under the age of 21 still enrolled with the
      HMO after 90 days who get medical check-ups within 90 days of enrollment into
      the HMO;

    

    (3)
      the
      total number of Members under the age of 21 who have been enrolled
      continuously with the HMO for 90 days or more (excluding the new Members);
      and

    

    (4)
      the
      number and percent of Members under the age of 21 who have been enrolled
      continuously for 90 days or more with the HMO (excluding the new
      Members)  who get timely, age-appropriate medical
      check-ups.

    

    HMOs
      must
      also document and report those Members refusing to obtain the
      check-ups.  The documentation must include the reason the Member
      refused the check-up or the reason the check­up was not received. For
      purposes of the Medicaid Medical Check-ups Report, “new Members” are Members who
      have not previously been enrolled in the HMO that is preparing the
      report.

    The
      timeframe, format, and details of the report will be described in the
      Uniform Managed Care Manual.

     

    Medicaid
      FWC Report – Beginning in September 2008, Medicaid HMOs must submit an
      annual report, in the timeframe and format described in the Uniform Managed
      Care
      Manual, about the identification of and delivery of services to children of
      Migrant Farmworkers (FWC).  The report will include a description and
      results of the each of the following:

    

    (1)
      the
      HMO’s efforts to identify as many community and statewide groups that work with
      FWC as possible within its Service Areas;

    

    (2)
      the
      HMO’s efforts to coordinate and cooperate with as many of such groups as
      possible; and

    

    (3)
      the
      HMO’s efforts to encourage the community groups to assist in the identification
      of  FWC.

    

    The
      HMO
      will maintain accurate, current lists of all identified FWC
      Members.

     

    8.2
      Additional Medicaid HMO Scope of Work

    The
      following provisions apply to any HMO participating in the STAR or STAR+PLUS
      HMO
      Program.

     

    8.2.1
      Continuity of Care and Out-of-Network Providers

    The
      HMO
      must ensure that the care of newly enrolled Members is not disrupted or
      interrupted. The HMO must take special care to provide continuity in the care
      of
      newly enrolled Members whose health or behavioral health condition has been
      treated by specialty care providers or whose health could be placed in jeopardy
      if Medically Necessary Covered Services are disrupted or
      interrupted.

    The
      HMO
      must allow pregnant Members with 12 weeks or less remaining before the expected
      delivery date to remain under the care of the Member’s current OB/GYN through
      the Member’s postpartum checkup, even if the provider is Out-of-Network. If a
      Member wants to change her OB/GYN to one who is in the Network, she must be
      allowed to do so if the Provider to whom she wishes to transfer agrees to accept
      her in the last trimester of pregnancy.

    The
      HMO
      must pay a Member’s existing Out-of-Network providers for Medically Necessary
      Covered Services until the Member’s records, clinical information and care can
      be transferred to a Network Provider, or until such time as the Member is no
      longer enrolled in that HMO, whichever is shorter. Payment to Out-of-Network
      providers must be made within the time period required for Network
      Providers.  The HMO must comply with out-of-network provider
      reimbursement rules as adopted by HHSC.

    This
      Article does not extend the obligation of the HMO to reimburse the Member’s
      existing Out­of-Network providers for on-going care for:

    1  More
      than
      90 days after a Member enrolls in the HMO’s Program, or

    2  For
      more
      than nine (9) months in the case of a Member who, at the time of enrollment
      in
      the HMO, has been diagnosed with and receiving treatment for a terminal illness
      and remains enrolled in the HMO.

    

    The
      HMO’s
      obligation to reimburse the Member’s existing Out-of-Network provider for
      services provided to a pregnant Member with 12 weeks or less remaining before
      the expected delivery date extends through delivery of the child, immediate
      postpartum care, and the follow-up checkup within the first six weeks of
      delivery.

    The
      HMO
      must provide or pay Out-of-Network providers who provide Medically Necessary
      Covered Services to Members who move out of the Service Area through the end
      of
      the period for which capitation has been paid for the Member.

    The
      HMO
      must provide Members with timely and adequate access to Out-of-Network services
      for as long as those services are necessary and covered benefits not available
      within the network, in accordance with 42 C.F.R. §438.206(b)(4). The HMO will
      not be obligated to provide a Member with access to Out-of-Network services
      if
      such services become available from a Network Provider.

    The
      HMO
      must ensure that each Member has access to a second opinion regarding the use
      of
      any Medically Necessary Covered Service. A Member must be allowed access to
      a
      second opinion from a Network Provider or Out-of-Network provider if a Network
      Provider is not available, at no cost to the Member, in accordance with 42
      C.F.R. §438.206(b)(3).

     

    8.2.2
      Provisions Related to Covered Services for Medicaid
      Members

     

    8.2.2.1
      Emergency Services

    HMO
      policy and procedures, Covered Services, claims adjudication methodology, and
      reimbursement performance for Emergency Services must comply with all applicable
      state and

    federal
      laws, rules, and regulations including 42 C.F.R. §438.114, whether the provider
      is in-network or Out-of-Network. HMO policies and procedures must be consistent
      with the prudent layperson definition of an Emergency Medical Condition and
      the
      claims adjudication processes required under the Contract and 42 C.F.R.
§438.114.

    The
      HMO
      must pay for the professional, facility, and ancillary services that are
      Medically Necessary to perform the medical screening examination and
      stabilization of a Member presenting with an Emergency Medical Condition or
      an
      Emergency Behavioral Health Condition to the hospital emergency department,
      24
      hours a day, 7 days a week, rendered by either the HMO's Network or
      Out-of-Network providers.

    The
      HMO
      cannot require prior authorization as a condition for payment for an Emergency
      Medical Condition, an Emergency Behavioral Health Condition, or labor and
      delivery. The HMO cannot limit what constitutes an Emergency Medical Condition
      on the basis of lists of diagnoses or symptoms. The HMO cannot refuse to cover
      Emergency Services based on the emergency room provider, hospital, or fiscal
      agent not notifying the Member’s PCP or the HMO of the Member’s screening and
      treatment within 10 calendar days of presentation for Emergency Services. The
      HMO may not hold the Member who has an Emergency Medical Condition liable for
      payment of subsequent screening and treatment needed to diagnose the specific
      condition or stabilize the patient. The HMO must accept the emergency physician
      or provider’s determination of when the Member is sufficiently stabilized for
      transfer or discharge.

    A
      medical
      screening examination needed to diagnose an Emergency Medical Condition must
      be
      provided in a hospital based emergency department that meets the requirements
      of
      the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 C.F.R.
§§489.20, 489.24 and 438.114(b)&(c)). The HMO must pay for the emergency
      medical screening examination, as required by 42 U.S.C. §1395dd. The HMO must
      reimburse for both the physician's services and the hospital's Emergency
      Services, including the emergency room and its ancillary services.

    When
      the
      medical screening examination determines that an Emergency Medical Condition
      exists, the HMO must pay for Emergency Services performed to stabilize the
      Member. The emergency physician must document these services in the Member's
      medical record. The HMO must reimburse for both the physician's and hospital's
      emergency stabilization services including the emergency room and its ancillary
      services.

    The
      HMO
      must cover and pay for Post-Stabilization Care Services in the amount, duration,
      and scope necessary to comply with 42 C.F.R. §438.114(b)&(e) and 42 C.F.R.
§422.113(c)(iii). The HMO is financially responsible for post-stabilization
      care
      services obtained within or outside the Network that are not pre-approved by
      a
      Provider or other HMO representative, but administered to maintain, improve,
      or
      resolve the Member’s stabilized condition if:

    1  The
      HMO
      does not respond to a request for pre-approval within 1 hour;

    2  The
      HMO
      cannot be contacted; or

    3  The
      HMO
      representative and the treating physician cannot reach an agreement concerning
      the Member’s care and a Network physician is not available for consultation. In
      this situation, the HMO must give the treating physician the opportunity to
      consult with a Network physician and the treating physician may continue with
      care of the patient until an HMO physician is reached. The HMO’s financial
      responsibility ends as follows:

    

    the
      HMO
      physician with privileges at the treating hospital assumes responsibility for
      the Member’s care; the HMO physician assumes responsibility for the Member’s
      care through transfer; the HMO representative and the treating physician reach
      an agreement concerning the Member’s care; or the Member is
      discharged.

     

    8.2.2.2
      Family Planning - Specific Requirements

    The
      HMO
      must require, through Provider contract provisions, that Members requesting
      contraceptive services or family planning services are also provided counseling
      and education about the family planning and family planning services available
      to Members. The HMO must develop outreach programs to increase community support
      for family planning and encourage Members to use available family planning
      services.

    The
      HMO
      must ensure that Members have the right to choose any Medicaid participating
      family planning provider, whether the provider chosen by the Member is in or
      outside the Provider Network. The HMO must provide Members access to information
      about available providers of family planning services and the Member’s right to
      choose any Medicaid family planning provider. The HMO must provide access to
      confidential family planning services.

    The
      HMO
      must provide, at minimum, the full scope of services available under the Texas
      Medicaid program for family planning services. The HMO will reimburse family
      planning agencies the Medicaid fee-for service amounts for family planning
      services, including Medically Necessary medications, contraceptives, and
      supplies not covered by the Vendor Drug Program and will reimburse
      Out-of-Network family planning providers in accordance with HHSC’s
      administrative rules.

    The
      HMO
      must provide medically approved methods of contraception to Members, provided
      that the methods of contraception are Covered Services. Contraceptive methods
      must be accompanied by verbal and written instructions on their correct use.
      The
      HMO must establish mechanisms to ensure all medically approved methods of
      contraception are made available to the Member, either directly or by referral
      to a subcontractor.

    The
      HMO
      must develop, implement, monitor, and maintain standards, policies and
      procedures for providing information regarding family planning to Providers
      and
      Members, specifically regarding State and federal laws governing Member
      confidentiality (including minors). Providers and family planning agencies
      cannot require parental consent for minors to receive family planning services.
      The HMO must require, through contractual provisions, that subcontractors have
      mechanisms in place to ensure Member’s (including minor’s) confidentiality for
      family planning services.

     

    8.2.2.3
      Texas Health Steps (EPSDT)

    The
      HMO
      must develop effective methods to ensure that children under the age of 21
      receive THSteps services when due and according to the recommendations
      established by the AAP and the THSteps periodicity schedule for children. The
      HMO must arrange for THSteps services for all eligible Members except when
      a
      Member knowingly and voluntarily declines or refuses services after receiving
      sufficient information to make an informed decision.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    HMO
      must
      have mechanisms in place to ensure that all newly enrolled newborns receive
      an
      appointment for a THSteps checkup within 14 days of enrollment and all other
      eligible child Members receive a THSteps checkup within 60 days of enrollment,
      if one is due according to the AAP periodicity schedule.

    The
      HMO
      must ensure that Members are provided information and educational materials
      about the services available through the THSteps Program, and how and when
      they
      may obtain the services. The information should tell the Member how they can
      obtain dental benefits, transportation services through the Texas Department
      of
      Transportation’s Medical Transportation Program, and advocacy assistance from
      the HMO. The HMO will encourage Medicaid-enrolled pharmacies to also become
      Medicaid-enrolled durable medical equipment (DME) providers.

    The
      HMO
      must provide appropriate training to all Network Providers and Provider staff
      in
      the Providers’ area of practice regarding the scope of benefits available and
      the THSteps Program. Training must include:

    1  THSteps
      benefits,

    2  The
      periodicity schedule for THSteps medical checkups and
      immunizations,

    3  The
      required elements of THSteps medical checkups,

    4  Providing
      or arranging for all required lab screening tests (including lead screening),
      and Comprehensive Care Program (CCP) services available under the THSteps
      program to Members under age 21 years.

    

    HMO
      must
      also educate and train Providers regarding the requirements imposed on HHSC
      and
      contracting HMOs under the Consent Decree entered in Frew v. Hawkins, et.
      al., Civil Action No. 3:93CV65, in the United States District Court for the
      Eastern District of Texas, Paris Division. Providers should be educated and
      trained to treat each THSteps visit as an opportunity for a comprehensive
      assessment of the Member.

    The
      HMO
      must provide outreach to Members to ensure they receive prompt services and
      are
      effectively informed about available THSteps services. Each month, the HMO
      must
      retrieve from the HHSC Administrative Services Contractor Bulletin Board System
      a list of Members who are due and overdue THSteps services. Using these lists
      and its own internally generated list, the HMO will contact such Members to
      obtain the service as soon as possible. The HMO outreach staff must coordinate
      with DSHS THSteps outreach staff to ensure that Members have access to the
      Medical Transportation Program, and that any coordination with other agencies
      is
      maintained.

    The
      HMO
      must cooperate and coordinate with the State, outreach programs and THSteps
      regional program staff and agents to ensure prompt delivery of services to
      children of migrant farm workers and other migrant populations who may
      transition into and out of the HMO’s Program more rapidly and/or unpredictably
      than the general population.

    The
      HMO
      must have mechanisms in place to ensure that all newborn Members have an initial
      newborn checkup before discharge from the hospital and again within two weeks
      from the time of birth. The HMO must require Providers to send all THSteps
      newborn screens to the DSHS Bureau of Laboratories or a DSHS certified
      laboratory. Providers must include detailed identifying information for all
      screened newborn Members and the Member’s mother to allow

    DSHS
      to
      link the screens performed at the hospital with screens performed at the
      two-week follow-up.

    All
      laboratory specimens collected as a required component of a THSteps checkup
      (see
      Medicaid Provider Procedures Manual for age-specific requirements) must be
      submitted to the DSHS Laboratory for analysis. The HMO must educate Providers
      about THSteps Program requirements for submitting laboratory tests to the DSHS
      Bureau of Laboratories.

    The
      HMO
      must make an effort to coordinate and cooperate with existing community and
      school-based health and education programs that offer services to school-aged
      children in a location that is both familiar and convenient to the Members.
      The
      HMO must make a good faith effort to comply with Head Start’s requirement that
      Members participating in Head Start receive their THSteps checkup no later
      than
      45 days after enrolling into either program.

    The
      HMO
      must educate Providers on the Immunization Standard Requirements set forth
      in
      Chapter 161, Health and Safety Code; the standards in the ACIP Immunization
      Schedule; the AAP Periodicity Schedule for CHIP Members; and the DSHS
      Periodicity Schedule for Medicaid Members. The HMO shall educate Providers
      that
      Medicaid Members under age 21 must be immunized during the THSteps checkup
      according to the DSHS routine immunization schedule. The HMO shall also educate
      Providers that the screening provider is responsible for administration of
      the
      immunization and should not refer children to Local Health Departments to
      receive immunizations.

    The
      HMO
      must educate Providers about, and require Providers to comply with, the
      requirements of Chapter 161, Health and Safety Code, relating to the Texas
      Immunization Registry (ImmTrac), to include parental consent on the Vaccine
      Information Statement.

    The
      HMO
      must require all THSteps Providers to submit claims for services paid (either
      on
      a capitated or fee-for service basis) on the HCFA 1500 claim form and use the
      HIPAA compliant code set required by HHSC.

    Encounter
      Data will be validated by chart review of a random sample of THSteps eligible
      enrollees against monthly Encounter Data reported by the HMO. HHSC or its
      designee will conduct chart reviews to validate that all screens are performed
      when due and as reported, and that reported data is accurate and timely.
      Substantial deviation between reported and charted Encounter Data could result
      in the HMO and/or Network Providers being investigated for potential Fraud,
      Abuse, or Waste without notice to the HMO or the Provider.

     

    8.2.2.4
      Perinatal Services

    The
      HMO’s
      perinatal health care services must ensure appropriate care is provided to
      women
      and infant Members of the HMO from the preconception period through the infant’s
      first year of life. The HMO’s perinatal health care system must comply with the
      requirements of the Texas Health and Safety Code, Chapter 32 (the Maternal
      and
      Infant Health Improvement Act) and administrative rules codified at 25 T.A.C.
      Chapter 37, Subchapter M.

    The
      HMO
      must have a perinatal health care system in place that, at a minimum, provides
      the following services:

    

    1  Pregnancy
      planning and perinatal health promotion and education for reproductive- age
      women;

    2  Perinatal
      risk assessment of non-pregnant women, pregnant and postpartum women, and
      infants up to one year of age;

    3  Access
      to
      appropriate levels of care based on risk assessment, including emergency
      care;

    4  Transfer
      and care of pregnant women, newborns, and infants to tertiary care facilities
      when necessary;

    5  Availability
      and accessibility of OB/GYNs, anesthesiologists, and neonatologists capable
      of
      dealing with complicated perinatal problems; and

    6  Availability
      and accessibility of appropriate outpatient and inpatient facilities capable
      of
      dealing with complicated perinatal problems.

    

    The
      HMO
      must have a process to expedite scheduling a prenatal appointment for an
      obstetrical exam for a TP40 Member no later than two weeks after receiving
      the
      daily Enrollment File verifying the Member’s enrollment into the
      HMO.

    The
      HMO
      must have procedures in place to contact and assist a pregnant/delivering Member
      in selecting a PCP for her baby either before the birth or as soon as the baby
      is born.

    The
      HMO
      must provide inpatient care and professional services relating to labor and
      delivery for its pregnant/delivering Members, and neonatal care for its newborn
      Members at the time of delivery and for up to 48 hours following an
      uncomplicated vaginal delivery and 96 hours following an uncomplicated Caesarian
      delivery.

    The
      HMO
      must Adjudicate provider claims for services provided to a newborn Member in
      accordance with HHSC’s claims processing requirements using the proxy ID number
      or State-issued Medicaid ID number. The HMO cannot deny claims based on a
      provider’s non-use of State-issued Medicaid ID number for a newborn Member. The
      HMO must accept provider claims for newborn services based on mother’s name
      and/or Medicaid ID number with accommodations for multiple births, as specified
      by the HMO.

    The
      HMO
      must notify providers involved in the care of pregnant/delivering women and
      newborns (including Out-of-Network providers and hospitals) of the HMO’s prior
      authorization requirements. The HMO cannot require a prior authorization for
      services provided to a pregnant/delivering Member or newborn Member for a
      medical condition that requires Emergency Services, regardless of when the
      emergency condition arises.

     

    8.2.2.5
      Sexually Transmitted Diseases (STDs) and Human Immunodeficiency Virus
      (HIV)

    The
      HMO
      must provide STD services that include STD/HIV prevention, screening,
      counseling, diagnosis, and treatment. The HMO is responsible for implementing
      procedures to ensure that Members have prompt access to appropriate services
      for
      STDs, including HIV. The HMO must allow Members access to STD services and
      HIV
      diagnosis services without prior authorization or referral by a
      PCP.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    The
      HMO
      must comply with Texas Family Code Section 32.003, relating to consent to
      treatment by a child. The HMO must provide all Covered Services required to
      form
      the basis for a diagnosis by the Provider as well as the STD/HIV treatment
      plan.

    The
      HMO
      must make education available to Providers and Members on the prevention,
      detection and effective treatment of STDs, including HIV.

    The
      HMO
      must require Providers to report all confirmed cases of STDs, including HIV,
      to
      the local or regional health authority according to 25 T.A.C. §§97.131 - 97.134,
      using the required forms and procedures for reporting STDs. The HMO must require
      the Providers to coordinate with the HHSC regional health authority to ensure
      that Members with confirmed cases of syphilis, chancroid, gonorrhea, chlamydia
      and HIV receive risk reduction and partner elicitation/notification
      counseling.

    The
      HMO
      must have established procedures to make Member records available to public
      health agencies with authority to conduct disease investigation, receive
      confidential Member information, and provide follow up activities.

    The
      HMO
      must require that Providers have procedures in place to protect the
      confidentiality of Members provided STD/HIV services. These procedures must
      include, but are not limited to, the manner in which medical records are to
      be
      safeguarded, how employees are to protect medical information, and under what
      conditions information can be shared. The HMO must inform and require its
      Providers who provide STD/HIV services to comply with all state laws relating
      to
      communicable disease reporting requirements. The HMO must implement policies
      and
      procedures to monitor Provider compliance with confidentiality
      requirements.

    The
      HMO
      must have policies and procedures in place regarding obtaining informed consent
      and counseling Members provided STD/HIV services.

     

    8.2.2.6
      Tuberculosis (TB)

    The
      HMO
      must provide Members and Providers with education on the prevention, detection
      and effective treatment of tuberculosis (TB). The HMO must establish mechanisms
      to ensure all procedures required to screen at-risk Members and to form the
      basis for a diagnosis and proper prophylaxis and management of TB are available
      to all Members, except services referenced in Section 8.2.2.8
      as Non-Capitated Services. The HMO must develop policies and procedures to
      ensure that Members who may be or are at risk for exposure to TB are screened
      for TB. An at-risk Member means a person who is susceptible to TB because of
      the
      association with certain risk factors, behaviors, drug resistance, or
      environmental conditions. The HMO must consult with the local TB control program
      to ensure that all services and treatments are in compliance with the guidelines
      recommended by the American Thoracic Society (ATS), the Centers for Disease
      Control and Prevention (CDC), and DSHS policies and standards.

    The
      HMO
      must implement policies and procedures requiring Providers to report all
      confirmed or suspected cases of TB to the local TB control program within one
      working day of identification, using the most recent DSHS forms and procedures
      for reporting TB. The HMO must provide access to Member medical records to
      DSHS
      and the local TB control program for all confirmed and suspected TB cases upon
      request.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    The
      HMO
      must coordinate with the local TB control program to ensure that all Members
      with confirmed or suspected TB have a contact investigation and receive Directly
      Observed Therapy (DOT). The HMO must require, through contract provisions,
      that
      Providers report to DSHS or the local TB control program any Member who is
      non-compliant, drug resistant, or who is or may be posing a public health
      threat. The HMO must cooperate with the local TB control program in enforcing
      the control measures and quarantine procedures contained in Chapter 81 of the
      Texas Health and Safety Code.

    The
      HMO
      must have a mechanism for coordinating a post-discharge plan for follow-up
      DOT
      with the local TB program. The HMO must coordinate with the DSHS South Texas
      Hospital and Texas Center for Infectious Disease for voluntary and court-ordered
      admission, discharge plans, treatment objectives and projected length of stay
      for Members with multi-drug resistant TB.

     

    8.2.2.7
      Objection to Provide Certain Services

    In
      accordance with 42 C.F.R. §438.102, the HMO may file an objection to providing,
      reimbursing for, or providing coverage of, a counseling or referral service
      for
      a Covered Service based on moral or religious grounds. The HMO must work with
      HHSC to develop a work plan to complete the necessary tasks and determine an
      appropriate date for implementation of the requested changes to the requirements
      related to Covered Services. The work plan will include timeframes for
      completing the necessary Contract and waiver amendments, adjustments to
      Capitation Rates, identification of the HMO and enrollment materials needing
      revision, and notifications to Members.

    In
      order
      to meet the requirements of this section, the HMO must notify HHSC of grounds
      for and provide detail concerning its moral or religious objections and the
      specific services covered under the objection, no less than 120 days prior
      to
      the proposed effective date of the policy change.

     

    8.2.2.8
      Medicaid Non-capitated Services

    The
      following Texas Medicaid programs and services have been excluded from HMO
      Covered Services. Medicaid Members are eligible to receive these Non-capitated
      Services on a Fee-for-Service basis from Texas Medicaid providers. HMOs should
      refer to relevant chapters in the Provider Procedures Manual
      and the Texas Medicaid Bulletins for more
      information.

    

    1.           THSteps
      dental (including orthodontia);

    2.           Early
      Childhood Intervention (ECI) case management/service coordination;

    3.           DSHS
      targeted case management;

    4.           DSHS
      mental health rehabilitation;

    5.           DSHS
      case management for Children and Pregnant Women;

    6.           Texas
      School Health and Related Services (SHARS);

    7.           Department
      of Assistive and Rehabilitative Services Blind Children’s Vocational Discovery
      and Development Program;

    8.           Tuberculosis
      services provided by DSHS-approved providers (directly observed therapy and
      contact investigation);

    9.           Vendor
      Drug Program (out-of-office drugs);

    10.
      Texas
      Department of Transportation Medical Transportation;

    11.
      DADS
      hospice services (all Members are disenrolled from their health plan upon
      enrollment into hospice except STAR+PLUS members receiving 1915(c) Nursing
      Facility Waiver services that are not covered by the Hospice
      Program);

    12.
      Audiology services and hearing aids for children (under age 21) (hearing
      screening services are provided through the THSteps Program and are capitated)
      through PACT (Program for Amplification for Children of Texas).

    13.
      For
      STAR+PLUS, Inpatient Stays are Non-capitated Services.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.2.2.9
      Referrals for Non-capitated Services

    Although
      Medicaid HMOs are not responsible for paying or reimbursing for Non-capitated
      Services, HMOs are responsible for educating Members about the availability
      of
      Non-capitated Services, and for providing appropriate referrals for Members
      to
      obtain or access these services. The HMO is responsible for informing Providers
      that bills for all Non-capitated Services must be submitted to HHSC’s Claims
      Administrator for reimbursement.

     

    8.2.2.10
      Cooperation with Immunization Registry

    The
      HMO
      must work with HHSC and health care providers to improve the immunization rate
      of Medicaid clients and the reporting of immunization information for inclusion
      in the Texas Immunization Registry, called “ImmTrac.”

     

    8.2.2.11
      Case Management for Children and Pregnant Women

    The
      HMO
      must educate Members and Providers on the services available through Case
      Management for Children and Pregnant Women (CPW) as described on the program’s
      website at http://www.dshs.state.tx.us/caseman/default.shtm. An HMO may
      provide information about CPW’s website and basic information about CPW services
      in order to meet this requirement. CPW information and materials must be
      included in the HMO’s Provider Manual, Member Handbook and Provider
      orientations.  The information and materials must also inform
      Providers that the disclosure of medical records or information between
      Providers, HMO’s and CPW case managers does not require a medical release form
      from the Member.

    The
      HMO
      must coordinate services with CPW regarding a Member’s health care needs that
      are identified by CPW and referred to the HMO.  Upon receipt of a
      referral or assessment from a CPW case manager, the HMO’s designated staff are
      required to review the assessment and determine, based on the HMO’s policies,
      the appropriate level of health care and services.  The HMO’s staff
      must also coordinate with the Member’s family, Member’s Primary Care Provider
      (PCP), in and Out-of-Network Providers, agencies, and the HMO’s utilization
      management staff to ensure that the health care and services identified are
      properly referred, authorized, scheduled and provided within a timely
      manner.

    The
      HMO
      must ensure that access to medically necessary health care needed by the Member
      is available within the standards established by HHSC for respective
      care.  HMOs are not required to arrange or provide for any covered or
      non-covered services identified in the CPW assessment.  The decision
      whether to authorize these services is made by the HMO.  Within five
      (5) business days of identifying any non-covered health care services or other
      services that the Member may need, the HMO’s staff must report to the CPW case
      manager which items/services will not be

    performed
      by the HMO. Additionally, within ten (10) business days after all of the
      authorized services have been provided, the HMO’s staff must follow-up with CPW
      case manager to report the provision of services.  The HMO’s staff
      must ensure that all services provided to a Member by an HMO Provider are
      reported to the Member’s PCP.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    The
      CPW
      program requires its contracted case managers to coordinate with the HMO and
      the
      HMO’s PCPs. The HMO should report problems regarding CPW referrals, assessments
      or coordination activities to HHSC for follow-up with CPW program
      staff.

     

    8.2.2.12
      Children of Migrant Farmworkers (FWC)

    The
      HMO
      must cooperate and coordinate with the State, outreach programs, and THSteps
      regional program staff and agents to ensure prompt delivery of services, in
      accordance with the timeframes in this Contract, to FWC Members and other
      migrant populations who may transition into and out of the HMO more rapidly
      and/or unpredictably than the general population.

    The
      HMO
      must provide accelerated services to FWC Members.  For purposes of
      this section, “accelerated services” are services that are provided to a child
      of a migrant farm worker prior to their leaving Texas to work in other
      states.   Accelerated services include the provision of
      preventive Health Care Services that will be due during the time the FWC Member
      is out of Texas. The need for accelerated services must be determined on a
      case-by-case and according to the FWC Member’s age, periodicity schedule and
      health care needs.

    The
      HMO
      must develop a plan annually for the process it will use to identify FWC and
      for
      the methods that will be used to provide accelerated services and submit an
      annual certification that the HMO will comply with the plan.  The plan
      for FY2008 must be submitted for HHSC approval no later than December 1, 2007
      and implemented by February 1, 2008.  The plan must include at a
      minimum:

    •  Identification
      of community and statewide groups that work with FWC Members within the HMO’s
      Service Areas;

    •  Participation
      of the community groups in assisting with the identification of FWC
      Members;

    •  Appropriate
      aggressive efforts to reach each identified FWC to provide timely medical
      checkups and follow up care if needed;

    •  Methods
      to maintain accurate, current lists of all identified FWC Members;

    •  Methods
      that the HMO and its Subcontractors will implement to maintain the
      confidentiality of information about the identity of FWC; and

    •  Methods
      to provide accelerated services to FWC.

    

    8.2.3
      Medicaid Significant Traditional Providers

    In
      the
      first three (3) years of a Medicaid HMO Program operating in a Service Area,
      the
      HMO must seek participation in its Network from all Medicaid Significant
      Traditional Providers (STPs) defined by HHSC in the applicable Service Area
      for
      the applicable HMO Program.  For STAR

    HMOs,
      the
      Medicaid STP requirements only apply in the Nueces Service Area.  For
      STAR+PLUS HMOs, the Medicaid STP requirements apply to all Service Areas, except
      Harris County within the Harris Service Area.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Medicaid
      STPs are defined as PCPs and, for STAR+PLUS, Community-based Long Term Care
      providers in a county, that, when listed by provider type by county in
      descending order by unduplicated number of clients, served the top 80% of
      unduplicated clients. Hospitals receiving Disproportionate Share Hospital (DSH)
      funds are also considered STPs in the Service Area in which they are
      located.  Note that STAR+PLUS HMOs are not required to contract with
      Hospitals for Inpatient Stays, but are required to contract with Hospitals
      for
      Outpatient Hospital Services. The HHSC website includes a list of Medicaid
      STPs
      by Service Area.

    Because
      the STP lists were produced in FY2005, HHSC has developed an updated list for
      Long Term Care Providers. The list will be provided to HMOs and posted on HHSC’s
      website.

    The
      STP
      requirement will be in place for three years after the program has been
      implemented. During that time, providers who believe they meet the STP
      requirements may contact HHSC request HHSC’s consideration for STP
      status.  STAR+PLUS HMOs will be notified when Providers are added to
      the list of STPs for a Service Area.

    The
      HMO
      must give STPs the opportunity to participate in its Network for at least three
      (3) years commencing on the implementation date of Medicaid managed care in
      the
      Service Area. However, the STP provider must:

    1  Agree
      to
      accept the HMO’s Provider reimbursement rate for the provider type;
      and

    2  Meet
      the
      standard credentialing requirements of the HMO, provided that lack of board
      certification or accreditation by the Joint Commission on Accreditation of
      Health Care Organizations (JCAHO) is not the sole grounds for exclusion from
      the
      Provider Network.

    

    8.2.4
      Federally Qualified Health Centers (FQHCs) and Rural Health Clinics
      (RHCs)

    The
      HMO
      must make reasonable efforts to include FQHCs and RHCs (freestanding and
      hospital-based) in its Provider Network. The HMO must reimburse FQHCs and RHCs
      for health care services provided outside of regular business hours, as defined
      by HHSC in rules, including weekend days or holidays, at a rate that is equal
      to
      the allowable rate for those services as determined under Section 32.028, Human
      Resources Code, if the Member does not have a referral from their PCP. FQHCs
      or
      RHCs will receive a cost settlement from HHSC and must agree to accept initial
      payments from the HMO in an amount that is equal to or greater than the HMO’s
      payment terms for other Providers providing the same or similar services. Prior
      to September 1, 2007, cost settlements do not apply to the Nueces Service Area
      and the STAR+PLUS Service Areas.  The HMOs serving those Service Areas
      must pay the full encounter rates to the FQHCs and RHCs for claims accruing
      before September 1, 2007.  Cost settlements will apply to all STAR and
      STAR+PLUS Services Areas for claims accruing on or after September 1,
      2007.

    The
      HMO
      must submit monthly FQHC and RHC encounter and payment reports to all contracted
      FQHCs and RHCs, and FQHCs and RHCs with which there have been encounters, not
      later than

    21
      days
      from the end of the month for which the report is submitted. The format will
      be
      developed by HHSC and provided in the Uniform Managed Care
      Manual. The FQHC and RHC must validate the encounter and payment
      information contained in the report(s). The HMO and the FQHC/RHC must both
      sign
      the report(s) after each party agrees that it accurately reflects encounters
      and
      payments for the month reported. The HMO must submit the signed FQHC and RHC
      encounter and payment reports to HHSC not later than 45 days from the end of
      the
      reported month.  Encounter and payment reports will not be necessary
      for the Nueces Service Area and the STAR+PLUS Service Areas for claims accruing
      before September 1, 2007, since the HMOs in those Areas will be paying the
      full
      encounter rates to the FQHCs and RHCs.  Encounter and payment reports
      are necessary for these Service Areas for claims accruing on or after September
      1, 2007.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.2.5
      Provider Complaints and Appeals

     

    8.2.5.1
      Provider Complaints

    Medicaid
      HMOs must develop, implement, and maintain a system for tracking and resolving
      all Medicaid Provider complaints. Within this process, the HMO must respond
      fully and completely to each complaint and establish a tracking mechanism to
      document the status and final disposition of each Provider
      complaint.  The HMO must resolve Provider Complaints within 30 days
      from the date the Complaint is received.

     

    8.2.5.2
      Appeal of Provider Claims

    Medicaid
      HMOs must develop, implement, and maintain a system for tracking and resolving
      all Medicaid Provider appeals related to claims payment. Within this process,
      the Provider must respond fully and completely to each Medicaid Provider’s
      claims payment appeal and establish a tracking mechanism to document the status
      and final disposition of each Medicaid Provider’s claims payment
      appeal.

    Medicaid
      HMOs must contract with physicians who are not Network Providers to resolve
      claims disputes related to denial on the basis of medical necessity that remain
      unresolved subsequent to a Provider appeal. The determination of the physician
      resolving the dispute must be binding on the HMO and the Provider. The physician
      resolving the dispute must hold the same specialty or a related specialty as
      the
      appealing Provider. HHSC reserves the right to amend this process to include
      an
      independent review process established by HHSC for final determination on these
      disputes.

     

    8.2.6
      Member Rights and Responsibilities

    In
      accordance with 42 C.F.R. §438.100, all Medicaid HMOs must maintain written
      policies and procedures for informing Members of their rights and
      responsibilities, and must notify their Members of their right to request a
      copy
      of these rights and responsibilities. The Member Handbook must include
      notification of Member rights and responsibilities.

     

    8.2.7
      Medicaid Member Complaint and Appeal System

    The
      HMO
      must develop, implement, and maintain a Member Complaint and Appeal system
      that
      complies with the requirements in applicable federal and state laws and
      regulations, including 42

    C.F.R.
      §431.200, 42 C.F.R. Part 438, Subpart F, “Grievance System,” and the provisions
      of 1

    T.A.C.
      Chapter 357 relating to Medicaid managed care organizations.

    The
      Complaint and Appeal system must include a Complaint process, an Appeal process,
      and access to HHSC’s Fair Hearing System. The procedures must be the same for
      all Members and must be reviewed and approved in writing by HHSC or its
      designee.  Modifications and amendments to the Member Complaint and
      Appeal system must be submitted for HHSC’s approval at least 30 days prior to
      the implementation.

     

    8.2.7.1
      Member Complaint Process

    The
      HMO
      must have written policies and procedures for receiving, tracking, responding
      to, reviewing, reporting and resolving Complaints by Members or their authorized
      representatives. For purposes of this Section 8.2.7, an
“authorized representative” is any person or entity acting on behalf of the
      Member and with the Member’s written consent. A Provider may be an authorized
      representative.

    The
      HMO
      must resolve Complaints within 30 days from the date the Complaint is received.
      The HMO is subject to remedies, including liquidated damages, if at least 98
      percent of Member Complaints are not resolved within 30 days of receipt of
      the
      Complaint by the HMO. Please see the Uniform Managed Care Contract Terms
& Conditions and Attachment B-5, Deliverables/Liquidated
      Damages Matrix. The Complaint procedure must be the same for all
      Members under the Contract. The Member or Member’s authorized representative may
      file a Complaint either orally or in writing. The HMO must also inform Members
      how to file a Complaint directly with HHSC, once the Member has exhausted the
      HMO’s complaint process.

    The
      HMO
      must designate an officer of the HMO who has primary responsibility for ensuring
      that Complaints are resolved in compliance with written policy and within the
      required timeframe. For purposes of Section 8.2.7.2, an
“officer” of the HMO means a president, vice president, secretary,
      treasurer, or
      chairperson of the board for a corporation, the sole proprietor, the managing
      general partner of a partnership, or a person having similar executive authority
      in the organization.

    The
      HMO
      must have a routine process to detect patterns of Complaints. Management,
      supervisory, and quality improvement staff must be involved in developing policy
      and procedure improvements to address the Complaints.

    The
      HMO’s
      Complaint procedures must be provided to Members in writing and through oral
      interpretive services. A written description of the HMO’s Complaint procedures
      must be available in prevalent non-English languages for Major Population Groups
      identified by HHSC, at no more than a 6th grade reading level.

    The
      HMO
      must include a written description of the Complaint process in the Member
      Handbook. The HMO must maintain and publish in the Member Handbook, at least
      one
      local and one toll­

    free
      telephone number with TeleTypewriter/Telecommunications Device for the Deaf
      (TTY/TDD) and interpreter capabilities for making Complaints.

    The
      HMO’s
      process must require that every Complaint received in person, by telephone,
      or
      in writing must be acknowledged and recorded in a written record and logged
      with
      the following details:

    

    1.
      Date;

    

    2.
      Identification of the individual filing the Complaint;

    

    3.
      Identification of the individual recording the Complaint;

    

    4.
      Nature
      of the Complaint;

    

    5.
      Disposition of the Complaint (i.e., how the HMO resolved the
      Complaint);

    

    6.
      Corrective action required; and

    

    7.
      Date
      resolved.

    

    The
      HMO
      is prohibited from discriminating or taking punitive action against a Member
      or
      his or her representative for making a Complaint.

    If
      the
      Member makes a request for disenrollment, the HMO must give the Member
      information on the disenrollment process and direct the Member to the HHSC
      Administrative Services Contractor. If the request for disenrollment includes
      a
      Complaint by the Member, the Complaint will be processed separately from the
      disenrollment request, through the Complaint process.

    The
      HMO
      will cooperate with the HHSC’s Administrative Services Contractor and HHSC or
      its designee to resolve all Member Complaints. Such cooperation may include,
      but
      is not limited to, providing information or assistance to internal Complaint
      committees.

    The
      HMO
      must provide designated Member Advocates to assist Members in understanding
      and
      using the HMO’s Complaint system as described in Section
      8.2.7.9. The HMO’s Member Advocates must assist Members in writing or
      filing a Complaint and monitoring the Complaint through the HMO’s Complaint
      process until the issue is resolved.

     

    8.2.7.2
      Medicaid Standard Member Appeal Process

    The
      HMO
      must develop, implement and maintain an Appeal procedure that complies with
      state and federal laws and regulations, including 42 C.F.R.§ 431.200 and 42
      C.F.R. Part 438, Subpart F, “Grievance System.” An Appeal is a disagreement with
      an HMO Action as defined in HHSC’s Uniform Contract Terms and
      Conditions. The Appeal procedure must be the same for all
      Members.  When a Member or his or her authorized representative
      expresses orally or in writing any dissatisfaction or disagreement with an
      Action, the HMO must regard the expression of dissatisfaction as a request
      to
      Appeal an Action.

    A
      Member
      must file a request for an Appeal with the HMO within 30 days from receipt
      of
      the notice of the Action. The HMO is subject to remedies, including liquidated
      damages, if at least 98 percent of Member Appeals are not resolved within 30
      days of receipt of the Appeal by the HMO. Please see the Uniform Managed
      Care Contract Terms & Conditions and Attachment B-5, Deliverables/Liquidated
      Damages Matrix. To ensure continuation of currently authorized
      services, however, the Member must file the Appeal on or before the later of
      10
      days following

    the
      HMO’s
      mailing of the notice of the Action, or the intended effective date of the
      proposed Action. The HMO must designate an officer who has primary
      responsibility for ensuring that Appeals are resolved in compliance with written
      policy and within the 30-day time limit.

    The
      provisions of Article 21.58A, Texas Insurance Code, (to be recodified as Texas
      Insurance Code, Title 14, Chapter 4201), relating to a Member’s right to Appeal
      an Adverse Determination made by the HMO or a utilization review agent to an
      independent review organization, do not apply to a Medicaid recipient. Article
      21.58A is pre-empted by federal Fair Hearings requirements.

    The
      HMO
      must have policies and procedures in place outlining the Medical Director’s role
      in an Appeal of an Action. The Medical Director must have a significant role
      in
      monitoring, investigating and hearing Appeals. In accordance with 42 C.F.R.§
438.406, the HMO’s policies and procedures must require that individuals who
      make decisions on Appeals are not involved in any previous level of review
      or
      decision-making, and are health care professionals who have the appropriate
      clinical expertise in treating the Member’s condition or disease.

    The
      HMO
      must provide designated Member Advocates, as described in Section
      8.2.7.9, to assist Members in understanding and using the Appeal
      process. The HMO’s Member Advocates must assist Members in writing or filing an
      Appeal and monitoring the Appeal through the HMO’s Appeal process until the
      issue is resolved.

    The
      HMO
      must have a routine process to detect patterns of Appeals. Management,
      supervisory, and quality improvement staff must be involved in developing policy
      and procedure improvements to address the Appeals.

    The
      HMO’s
      Appeal procedures must be provided to Members in writing and through oral
      interpretive services. A written description of the Appeal procedures must
      be
      available in prevalent non-English languages identified by HHSC, at no more
      than
      a 6th grade reading level. The HMO must include a written description of the
      Appeals process in the Member Handbook. The HMO must maintain and publish in
      the
      Member Handbook at least one local and one toll-free telephone number with
      TTY/TDD and interpreter capabilities for requesting an Appeal of an
      Action.

    The
      HMO’s
      process must require that every oral Appeal received must be confirmed by a
      written, signed Appeal by the Member or his or her representative, unless the
      Member or his or her representative requests an expedited resolution. All
      Appeals must be recorded in a written record and logged with the following
      details:

    1)
      Date
      notice is sent; 

    2)
      Effective date of the Action; 

    3)
      Date
      the Member or his or her representative requested the
      Appeal;  

    4)
      Date
      the Appeal was followed up in writing;  

    5)
      Identification of the individual filing; 

    6)
      Nature
      of the Appeal; and 

    7)
      Disposition of the Appeal, and notice of disposition to Member.

    The
      HMO
      must send a letter to the Member within five (5) business days acknowledging
      receipt of the Appeal request. Except for the resolution of an Expedited Appeal
      as provided in Section 8.2.7.3, the HMO must complete the
      entire standard Appeal process within 30 calendar days after receipt of the
      initial written or oral request for Appeal. The timeframe for a standard Appeal
      may be extended up to 14 calendar days if the Member or his or her
      representative requests an extension; or the HMO shows that there is a need
      for
      additional information and how the delay is in the Member’s interest. If the
      timeframe is extended, the HMO must give the Member written notice of the reason
      for delay if the Member had not requested the delay. The HMO must designate
      an
      officer who has primary responsibility for ensuring that Appeals are resolved
      within these timeframes and in accordance with the HMO’s written
      policies.

    During
      the Appeal process, the HMO must provide the Member a reasonable opportunity
      to
      present evidence and any allegations of fact or law in person as well as in
      writing. The HMO must inform the Member of the time available for providing
      this
      information and that, in the case of an expedited resolution, limited time
      will
      be available.

    The
      HMO
      must provide the Member and his or her representative opportunity, before and
      during the Appeal process, to examine the Member’s case file, including medical
      records and any other documents considered during the Appeal process. The HMO
      must include, as parties to the Appeal, the Member and his or her representative
      or the legal representative of a deceased Member’s estate.

    In
      accordance with 42 C.F.R.§ 438.420, the HMO must continue the Member’s benefits
      currently being received by the Member, including the benefit that is the
      subject of the Appeal, if all of the following criteria are met:

    1  The
      Member or his or her representative files the Appeal timely as defined in this
      Contract:

    2  The
      Appeal involves the termination, suspension, or reduction of a previously
      authorized course of treatment;

    3  The
      services were ordered by an authorized provider;

    4  The
      original period covered by the original authorization has not expired;
      and

    5  The
      Member requests an extension of the benefits.

    

    If,
      at
      the Member’s request, the HMO continues or reinstates the Member’s benefits
      while the Appeal is pending, the benefits must be continued until one of the
      following occurs:

    1  The
      Member withdraws the Appeal;

    2  Ten
      (10)
      days pass after the HMO mails the notice resolving the Appeal against the
      Member, unless the Member, within the 10-day timeframe, has requested a Fair
      Hearing with continuation of benefits until a Fair Hearing decision can be
      reached; or

    3  A
      state
      Fair Hearing officer issues a hearing decision adverse to the Member or the
      time
      period or service limits of a previously authorized service has been
      met.

    

    In
      accordance with 42 C.F.R.§ 438.420(d), if the final resolution of the Appeal is
      adverse to the Member and upholds the HMO’s Action, then to the extent that the
      services were furnished to comply with the Contract, the HMO may recover such
      costs from the Member.

    If
      the
      HMO or State Fair Hearing Officer reverses a decision to deny, limit, or delay
      services that were not furnished while the Appeal was pending, the HMO must
      authorize or provide the disputed services promptly and as expeditiously as
      the
      Member’s health condition requires.

    If
      the
      HMO or State Fair Hearing Officer reverses a decision to deny authorization
      of
      services and the Member received the disputed services while the Appeal was
      pending, the HMO is responsible for the payment of services.

    The
      HMO
      is prohibited from discriminating or taking punitive action against a Member
      or
      his or her representative for making an Appeal.

     

    8.2.7.3
      Expedited Medicaid HMO Appeals

    In
      accordance with 42 C.F.R. §438.410, the HMO must establish and maintain an
      expedited review process for Appeals, when the HMO determines (for a request
      from a Member) or the provider indicates (in making the request on the Member’s
      behalf or supporting the Member’s request) that taking the time for a standard
      resolution could seriously jeopardize the Member’s life or health. The HMO must
      follow all Appeal requirements for standard Member Appeals as set forth in
      Section 8.2.7.2), except where differences are specifically
      noted. The HMO must accept oral or written requests for Expedited
      Appeals.

    Members
      must exhaust the HMO’s Expedited Appeal process before making a request for an
      expedited Fair Hearing. After the HMO receives the request for an Expedited
      Appeal, it must hear an approved request for a Member to have an Expedited
      Appeal and notify the Member of the outcome of the Expedited Appeal within
      3
      business days, except that the HMO must complete investigation and resolution
      of
      an Appeal relating to an ongoing emergency or denial of continued
      hospitalization: (1) in accordance with the medical or dental immediacy of
      the
      case; and (2) not later than one (1) business day after receiving the Member’s
      request for Expedited Appeal is received.

    Except
      for an Appeal relating to an ongoing emergency or denial of continued
      hospitalization, the timeframe for notifying the Member of the outcome of the
      Expedited Appeal may be extended up to 14 calendar days if the Member requests
      an extension or the HMO shows (to the satisfaction of HHSC, upon HHSC’s request)
      that there is a need for additional information and how the delay is in the
      Member’s interest. If the timeframe is extended, the HMO must give the Member
      written notice of the reason for delay if the Member had not requested the
      delay.

    If
      the
      decision is adverse to the Member, the HMO must follow the procedures relating
      to the notice in Section 8.2.7.5. The HMO is responsible for
      notifying the Member of his or her right to access an expedited Fair Hearing
      from HHSC. The HMO will be responsible for providing documentation to the State
      and the Member, indicating how the decision was made, prior to HHSC’s expedited
      Fair Hearing.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    The
      HMO
      is prohibited from discriminating or taking punitive action against a Member
      or
      his or her representative for requesting an Expedited Appeal.  The HMO
      must ensure that punitive action is neither taken against a provider who
      requests an expedited resolution or supports a Member’s request.

    If
      the
      HMO denies a request for expedited resolution of an Appeal, it
      must:

    

    (1)
      Transfer the Appeal to the timeframe for standard resolution, and

    

    (2)
      Make
      a reasonable effort to give the Member prompt oral notice of the denial, and
      follow up within two (2) calendar days with a written notice.

    

    8.2.7.4
      Access to Fair Hearing for Medicaid Members

    The
      HMO
      must inform Members that they have the right to access the Fair Hearing process
      at any time during the Appeal system provided by the HMO. In the case of an
      expedited Fair Hearing process, the HMO must inform the Member that he or she
      must first exhaust the HMO’s internal Expedited Appeal process prior to filing
      an Expedited Fair Hearing. The HMO must notify Members that they may be
      represented by an authorized representative in the Fair Hearing
      process.

    If
      a
      Member requests a Fair Hearing, the HMO will assist the Member in the completion
      of the request for Fair Hearing, and will submit the form electronically to
      the
      appropriate Fair Hearings office, within five business days of the Member's
      request.

    Upon
      notification that the Fair Hearing is set, the HMO will prepare an evidence
      packet for submission to the HHSC Fair Hearings staff and send a copy of the
      packet to the Member, in accordance with HHSC Fair Hearings
      requirements.

     

    8.2.7.5
      Notices of Action and Disposition of Appeals for Medicaid
      Members

    The
      HMO
      must notify the Member, in accordance with 1 T.A.C. Chapter 357, whenever the
      HMO takes an Action. The notice must, at a minimum, include any information
      required by 1

    T.A.C.
      Chapter 357 that relates to a managed care organization’s notice of Action and
      any information required by 42 C.F.R. §438.404 as directed by HHSC, including
      but not limited to:

    

    1.
      The
      dates, types and amount of service requested;

    2.
      The
      Action the HMO has taken or intends to take;

    3.
      The
      reasons for the Action (If the Action taken is based upon a determination that
      the requested service is not medically necessary, the HMO must provide an
      explanation of the medical basis for the decision, application of policy or
      accepted standards of medical practice to the individuals medical circumstances,
      in it’s notice to the member.);

    4.
      The
      Member’s right to access the HMO’s Appeal process.

    5.
      The
      procedures by which the Member may Appeal the HMO’s Action;

    6.
      The
      circumstances under which expedited resolution is available and how to request
      it;

    7.
      The
      circumstances under which a Member may continue to receive benefits pending
      resolution of the Appeal, how to request that benefits be continued, and the
      circumstances under which the Member may be required to pay the costs of these
      services;

    8.
      The
      date the Action will be taken;

    9.
      A
      reference to the HMO policies and procedures supporting the HMO’s
      Action;

    10.
      An
      address where written requests may be sent and a toll-free number that the
      Member can call to request the assistance of a Member representative, file
      an
      Appeal, or request a Fair Hearing;

    11.
      An
      explanation that Members may represent themselves, or be represented by a
      provider, a friend, a relative, legal counsel or another
      spokesperson;

    12.
      A
      statement that if the Member wants a Fair Hearing on the Action, the Member
      must
      make the request for a Fair Hearing within 90 days of the date on the notice
      or
      the right to request a hearing is waived;

    13.
      A
      statement explaining that the HMO must make its decision within 30 days from
      the
      date the Appeal is received by the HMO, or 3 business days in the case of an
      Expedited Appeal; and

    14.
      A
      statement explaining that the hearing officer must make a final decision within
      90 days from the date a Fair Hearing is requested.

     

    8.2.7.6
      Timeframe for Notice of Action

    In
      accordance with 42 C.F.R.§ 438.404(c), the HMO must mail a notice of Action
      within the following timeframes:

    

    1.           For
      termination, suspension, or reduction of previously authorized Medicaid-covered
      services, within the timeframes specified in 42 C.F.R.§§ 431.211, 431.213, and
      431.214;

    2.           For
      denial of payment, at the time of any Action affecting the claim;

    3.           For
      standard service authorization decisions that deny or limit services, within
      the
      timeframe specified in 42 C.F.R.§ 438.210(d)(1);

    4.           If
      the HMO extends the timeframe in accordance with 42 C.F.R. §438.210(d)(1), it
      must:

    5.           give
      the Member written notice of the reason for the decision to extend the timeframe
      and inform the Member of the right to file an Appeal if he or she disagrees
      with
      that decision; and

    6.           issue
      and carry out its determination as expeditiously as the Member’s health
      condition requires and no later than the date the extension
      expires;

    7.           For
      service authorization decisions not reached within the timeframes specified
      in
      42 C.F.R.§ 438.210(d) (which constitutes a denial and is thus an adverse
      Action), on the date that the timeframes expire; and

    8.
      For
      expedited service authorization decisions, within the timeframes specified
      in
      42

    C.F.R.
      438.210(d).

     

    8.2.7.7
      Notice of Disposition of Appeal

    In
      accordance with 42 C.F.R.§ 438.408(e), the HMO must provide written notice of
      disposition of all Appeals including Expedited Appeals. The written resolution
      notice must include the results and date of the Appeal resolution. For decisions
      not wholly in the Member’s favor, the notice must contain:

    1  The
      right
      to request a Fair Hearing;

    2  How
      to
      request a Fair Hearing;

    3  The
      circumstances under which the Member may continue to receive benefits pending
      a
      Fair Hearing;

    4  How
      to
      request the continuation of benefits;

    5  If
      the
      HMO’s Action is upheld in a Fair Hearing, the Member may be liable for the cost
      of any services furnished to the Member while the Appeal is pending;
      and

    6  Any
      other
      information required by 1 T.A.C. Chapter 357 that relates to a managed care
      organization’s notice of disposition of an Appeal.

    

    8.2.7.8
      Timeframe for Notice of Resolution of Appeals

    In
      accordance with 42 C.F.R.§ 438.408, the HMO must provide written notice of
      resolution of Appeals, including Expedited Appeals, as expeditiously as the
      Member’s health condition requires, but the notice must not exceed the timelines
      as provided in this Section for Standard or Expedited Appeals. For expedited
      resolution of Appeals, the HMO must make reasonable efforts to give the Member
      prompt oral notice of resolution of the Appeal, and follow up with a written
      notice within the timeframes set forth in this Section for Expedited Appeals.
      If
      the HMO denies a request for expedited resolution of an Appeal, the HMO must
      transfer the Appeal to the timeframe for standard resolution as provided in
      this
      Section, and make reasonable efforts to give the Member prompt oral notice
      of
      the denial, and follow up within two calendar days with a written
      notice.

     

    8.2.7.9
      Medicaid Member Advocates

    The
      HMO
      must provide Member Advocates to assist Members. Member Advocates must be
      physically located within the Service Area unless an exception is approved
      by
      HHSC. Member Advocates must inform Members of the following:

    1  Their
      rights and responsibilities,

    2  The
      Complaint process,

    3  The
      Appeal process,

    4  Covered
      Services available to them, including preventive services, and

    5  Non-capitated
      Services available to them.

    

    Member
      Advocates must assist Members in writing Complaints and are responsible for
      monitoring the Complaint through the HMO’s Complaint process.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Member
      Advocates are responsible for making recommendations to management on any
      changes needed to improve either the care provided or the way care is delivered.
      Member Advocates are also responsible for helping or referring Members to
      community resources available to meet Member needs that are not available from
      the HMO as Medicaid Covered Services.

     

    8.2.8
      Additional Medicaid Behavioral Health Provisions

     

    8.2.8.1
      Local Mental Health Authority (LMHA)

    Assessment
      to determine eligibility for rehabilitative and targeted DSHS case management
      services is a function of the LMHA. Covered Services must be provided to Members
      with severe and persistent mental illness (SPMI) and severe emotional
      disturbance (SED), when Medically Necessary, whether or not they are also
      receiving targeted case management or rehabilitation services through the
      LMHA.

    The
      HMO
      must enter into written agreements with all LMHAs in the Service Area that
      describe the process(es) that the HMO and LMHAs will use to coordinate services
      for Medicaid Members with SPMI or SED. The agreements will:

    

    1.           Describe
      the Behavioral Health Services indicated in detail in the Provider
      Procedures Manual and in the Texas Medicaid Bulletin,
      include the amount, duration, and scope of basic and Value-added Services,
      and
      the HMO’s responsibility to provide these services;

    

    2.           Describe
      criteria, protocols, procedures and instrumentation for referral of Medicaid
      Members from and to the HMO and the LMHA;

    

    3.           Describe
      processes and procedures for referring Members with SPMI or SED to the LMHA
      for
      assessment and determination of eligibility for rehabilitation or targeted
      case
      management services;

    

    4.           Describe
      how the LMHA and the HMO will coordinate providing Behavioral Health Services
      to
      Members with SPMI or SED;

    

    5.           Establish
      clinical consultation procedures between the HMO and LMHA including consultation
      to effect referrals and on-going consultation regarding the Member’s
      progress;

    

    6.           Establish
      procedures to authorize release and exchange of clinical treatment
      records;

    

    7.           Establish
      procedures for coordination of assessment, intake/triage, utilization
      review/utilization management and care for persons with SPMI or
      SED;

    

    8.           Establish
      procedures for coordination of inpatient psychiatric services (including Court-
      ordered Commitment of Members under 21) in state psychiatric facilities within
      the LMHA’s catchment area;

    

    9.           Establish
      procedures for coordination of emergency and urgent services to
      Members;

    

    10.
      Establish procedures for coordination of care and transition of care for new
      Members who are receiving treatment through the LMHA; and

    

    11.
      Establish that when Members are receiving Behavioral Health Services from the
      Local Mental Health Authority that the HMO is using the same UM guidelines
      as
      those prescribed for use by local mental health authorities by DSHS which are
      published at:
http://www.mhmr.state.tx.us/centraloffice/behavioralhealthservices/RDMClinGuide.html.

    

    The
      HMO
      must offer licensed practitioners of the healing arts (defined in 25 T.A.C.,
      Part 2, Chapter 419, Subchapter L), who are part of the Member’s treatment team
      for rehabilitation services, the opportunity to participate in the HMO’s
      Network. The practitioner must agree to accept the HMO’s Provider reimbursement
      rate, meet the credentialing requirements, and comply with all the terms and
      conditions of the HMO’s standard Provider contract.

    HMOs
      must
      allow Members receiving rehabilitation services to choose the licensed
      practitioners of the healing arts who are currently a part of the Member’s
      treatment team for rehabilitation services to provide Covered Services. If
      the
      Member chooses to receive these services from licensed practitioners of the
      healing arts who are part of the Member’s rehabilitation services treatment team
      but are not part of the HMO’s Network, the HMO must reimburse the Local Mental
      Health Authority through Out-of-Network reimbursement arrangements.

    Nothing
      in this section diminishes the potential for the Local Mental Health Authority
      to seek best value for rehabilitative services by providing these services
      under
      arrangement, where possible, as specified is 25 T.A.C. §419.455.

     

    8.2.9
      Third Party Liability and Recovery

    Medicaid
      HMOs are responsible for establishing a plan and process for recovering costs
      for services that should have been paid through a third party in accordance
      with
      State and Federal law and regulations. To recognize this requirement, capitation
      payments to the HMOs are reduced by the projected amount of TPR that the HMO
      is
      expected to recover.

    The
      HMOs
      must provide required reports as stated in Section 8.1.17.2,
Financial Reporting Requirements.

    After
      120-days from the date of service on any claim, encounter, or other Medicaid
      related payment by the HMO subject to Third Party Recovery, HHSC may attempt
      recovery independent of any HMO action.  HHSC will retain, in full,
      all funds received as a result of the state initiated recovery or subrogation
      action.

    HMOs
      shall provide a Member quarterly file, which contains the following information
      if available to the HMO: the Member name, address, claim submission address,
      group number, employer's mailing address, social security number, and date
      of
      birth for each subscriber or policyholder and each dependent of the subscriber
      or policyholder covered by the insurer.  The file shall be used for
      the purpose of matching the Texas Medicaid eligibility file against the HMO
      Member file to identify Medicaid clients enrolled in the HMO, which may not
      be
      known the Medicaid Program.

     

    8.2.10
      Coordination With Public Health Entities

     

    8.2.10.1
      Reimbursed Arrangements with Public Health Entities

    The
      HMO
      must make a good faith effort to enter into a subcontract for Covered Services
      with Public Health Entities. Possible Covered Services that could be provided
      by
      Public Health Entities include, but are not limited to, the following
      services:

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    1  Sexually
      Transmitted Diseases (STDs) services;

    2  Confidential
      HIV testing;

    3  Immunizations;

    4  Tuberculosis
      (TB) care;

    5  Family
      Planning services;

    6  THSteps
      medical checkups, and

    7  Prenatal
      services.

    

    These
      subcontracts must be available for review by HHSC or its designated agent(s)
      on
      the same basis as all other subcontracts. If the HMO is unable to enter into
      a
      contract with Public Health Entities, the HMO must document efforts to contract
      with Public Health Entities, and make such documentation available to HHSC
      upon
      request.

    HMO
      Contracts with Public Health Entities must specify the scope of responsibilities
      of both parties, the methodology and agreements regarding billing and
      reimbursements, reporting responsibilities, Member and Provider educational
      responsibilities, and the methodology and agreements regarding sharing of
      confidential medical record information between the Public Health Entity and
      the
      HMO or PCP.

    The
      HMO
      must:

    1  Identify
      care managers who will be available to assist public health providers and PCPs
      in efficiently referring Members to the public health providers, specialists,
      and health-related service providers either within or outside the HMO’s Network;
      and

    2  Inform
      Members that confidential healthcare information will be provided to the PCP,
      and educate Members on how to better utilize their PCPs, public health
      providers, emergency departments, specialists, and health-related service
      providers.

    

    8.2.10.2
      Non-Reimbursed Arrangements with Local Public Health
      Entities

    The
      HMO
      must coordinate with Public Health Entities in each Service Area regarding
      the
      provision of essential public health care services. In addition to the
      requirements listed above in Section 8.2.2, or otherwise required under state
      law or this contract, the HMO must meet the following requirements:

    1  Report
      to
      public health entities regarding communicable diseases and/or diseases that
      are
      preventable by immunization as defined by state law;

    2  Notify
      the local Public Health Entity, as defined by state law, of communicable disease
      outbreaks involving Members;

    3  Educate
      Members and Providers regarding WIC services available to Members;
      and

    4  Coordinate
      with local public health entities that have a child lead program, or with DSHS
      regional staff when the local public health entity does not have a child lead
      program, for follow-up of suspected or confirmed cases of childhood lead
      exposure.

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.2.11
      Coordination with Other State Health and Human Services (HHS)
      Programs

    The
      HMO
      must coordinate with other state HHS Programs in each Service Area regarding
      the
      provision of essential public health care services.  In addition to
      the requirements listed above in Section 8.2.2. or otherwise required under
      state law or this contract, the HMO must meet the following
      requirements:

    1  Require
      Providers to use the DSHS Bureau of Laboratories for specimens obtained as
      part
      of a THSteps medical checkup, including THSteps newborn screens, lead testing,
      and hemoglobin/hematocrit tests;

    2  Notify
      Providers of the availability of vaccines through the Texas Vaccines for
      Children Program;

    3  Work
      with
      HHSC and Providers to improve the reporting of immunizations to the statewide
      ImmTrac Registry;

    4  Educate
      Providers and Members about the Department of State Health Services (DSHS)
      Case
      Management for Children and Pregnant Women (CPW) services
      available;

    5  Coordinate
      services with CPW specifically in regard to an HMO Member’s health care needs
      that are identified by CPW and referred to the HMO;

    6  Participate,
      to the extent practicable, in the community-based coalitions with the
      Medicaid-funded case management programs in the Department of Assistive and
      Rehabilitative Services (DARS), the Department of Aging and Disability Services
      (DADS), and DSHS;

    7  Cooperate
      with activities required of state and local public health authorities necessary
      to conduct the annual population and community based needs
      assessment;

    8  Report
      all blood lead results, coordinate and follow-up of suspected or confirmed
      cases
      of childhood lead exposure with the Childhood Lead Poisoning Prevention Program
      in DSHS; and

    9  Coordinate
      with THSteps.

    

    8.2.12
      Advance Directives

    Federal
      and state law require HMOs and providers to maintain written policies and
      procedures for informing all adult Members 18 years of age and older about
      their
      rights to refuse, withhold or withdraw medical treatment and mental health
      treatment through advance directives (see Social Security Act §1902(a)(57) and
§1903(m)(1)(A)). The HMO’s policies and procedures must include written
      notification to Members and comply with provisions contained in 42 C.F.R.
§434.28 and 42 C.F.R. § 489, Subpart I, relating to advance directives for all
      hospitals, critical access hospitals, skilled nursing facilities, home health
      agencies, providers of home health care, providers of personal care services
      and
      hospices, as well as the following state laws and rules:

    

    1.           A
      Member’s right to self-determination in making health care
      decisions;

    

    2.           The
      Advance Directives Act, Chapter 166, Texas Health and Safety Code, which
      includes:

    

    a.           A
      Member’s right to execute an advance written directive to physicians and family
      or surrogates, or to make a non-written directive to administer, withhold or
      withdraw life-sustaining treatment in the event of a terminal or irreversible
      condition;

    b.   A
      Member’s right to make
      written and non-written out-of-hospital do-not­resuscitate (DNR)
      orders; 

    c.   A
      Member’s right to execute a Medical Power of Attorney to appoint an agent to
      make health care decisions on the Member’s behalf if the Member becomes incompetent;
      and

    

    3.           The
      Declaration for Mental Health Treatment, Chapter 137, Texas Civil Practice
      and
      Remedies Code, which includes: a Member’s right to execute a Declaration for
      Mental Health Treatment in a document making a declaration of preferences or
      instructions regarding mental health treatment.

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    The
      HMO
      must maintain written policies for implementing a Member’s advance directive.
      Those policies must include a clear and precise statement of limitation if
      the
      HMO or a Provider cannot or will not implement a Member’s advance
      directive.

    The
      HMO
      cannot require a Member to execute or issue an advance directive as a condition
      of receiving health care services. The HMO cannot discriminate against a Member
      based on whether or not the Member has executed or issued an advance
      directive.

    The
      HMO’s
      policies and procedures must require the HMO and subcontractors to comply with
      the requirements of state and federal law relating to advance directives. The
      HMO must provide education and training to employees and Members on issues
      concerning advance directives.

    All
      materials provided to Members regarding advance directives must be written
      at a
      7th - 8th
grade
      reading
      comprehension level, except where a provision is required by state or federal
      law and the provision cannot be reduced or modified to a 7th - 8th
      grade reading
      level because it is a reference to the law or is required to be included “as
      written” in the state or federal law.

    The
      HMO
      must notify Members of any changes in state or federal laws relating to advance
      directives within 90 days from the effective date of the change, unless the
      law
      or regulation contains a specific time requirement for
      notification.

     

    8.3
      Additional STAR+PLUS Scope of Work

     

    8.3.1
      Covered Community-Based Long-Term Care Services

    The
      HMO
      must ensure that STAR+PLUS Members needing Community Long-term Care Services
      are
      identified and that services are referred and authorized in a timely manner.
      The
      HMO must ensure that Providers of Community Long-term Care Services are licensed
      to deliver the service they provide. The inclusion of Community Long-term Care
      Services in a managed care model presents challenges, opportunities and
      responsibilities.

    Community
      Long-term Care Services may be necessary as a preventative service to avoid
      more
      expensive hospitalizations, emergency room visits, or institutionalization.
      Community Long-term Care Services should also be made available to Members
      to
      assure maintenance of the highest level of functioning possible in the least
      restrictive setting. A Member’s need for Community Long-term Care Services to
      assist with the activities of daily living must be considered as

    important
      as needs related to a medical condition. HMOs must provide Functionally
      Necessary Covered Services to Community Long-term Care Service
      Members.

     

    8.3.1.1 Community
      Based Long-Term Care Services Available to All Members

    The
      HMO
      shall enter into written contracts with Providers of Personal Assistance
      Services and Day Activity and Health Services (DAHS) to make them available
      to
      all STAR+PLUS Members.  These Providers must at a minimum, meet all of
      the following state licensure and certification requirements for providing
      the
      services in Attachment B-2.1, Covered Services.

     

    
      	
              Community
                Long-Term Care Services Available to All
                Members

            
	
              Service

            	
              Licensure
                and Certification Requirements

            	 
	
              Personal
                Attendant Services

            	
              The
                Provider must be licensed by the Texas Department of Human Services
                as a
                Home and Community Support Services Agency. The level of licensure
                required depends on the type of service delivered. NOTE: For primary
                home
                care and client managed attendant care, the agency may have only
                the
                Personal Assistance Services level of licensure.

            	 
	
              Day
                Activity and Health Services (DAHS)

            	
              The
                Provider must be licensed by the Texas Department of Human Services,
                Long
                Term Care Regulatory Division, as an adult day care provider. To
                provide
                DAHS, the Provider must provide the range of services required for
                DAHS.

            	 

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.3.1.2  1915(c)
      Nursing Facility Waiver Services Available to Members Who Qualify for 1915
      (c)
      Nursing Facility Waiver Services

    The
      1915(c) Nursing Facility Waiver provides Community Long-term Care Services
      to
      Medicaid Eligibles who are elderly and to adults with disabilities as a
      cost-effective alternative to living in a nursing facility. These Members must
      be age 21 or older, be a Medicaid recipient or be otherwise financially eligible
      for waiver services. To be eligible for 1915(c) Nursing Facility Waiver
      Services, a Member must meet income and resource requirements for Medicaid
      nursing facility care, and receive a determination from HHSC on the medical
      necessity of the nursing facility care. The HMO must make available to STAR+PLUS
      Members who meet the eligibility requirements the array of services allowable
      through HHSC’s CMS-approved 1915(c) Nursing Facility Waiver (see
Appendix B-2.1, STAR+PLUS Covered Services).

     

    
      	
              Community
                Long-Term Care Services Under the 1915(c) Nursing Facility
                Waiver

            
	
              Service

            	
              Licensure
                and Certification Requirements

            	 
	
              Personal
                Attendant Services

            	
              The
                Provider must be licensed by the Texas Department of Human Services
                as a
                Home and Community Support Services Agency. The level of licensure
                required depends on the type of service delivered. For Primary Home
                Care
                and Client Managed Attendant Care, the agency may have only the Personal
                Assistance Services level of licensure.

            	 

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      	
              Community
                Long-Term Care Services Under the 1915(c) Nursing Facility
                Waiver

            
	
              Service

            	
              Licensure
                and Certification Requirements

            	 
	
              Assisted
                Living

            	
              The
                Provider must be licensed by the Texas Department of Aging and Disability
                Services, Long Term Care Regulatory Division. The type of licensure
                determines what services may be provided.

            	 
	
              Emergency
                Response Service Provider

            	
              Texas
                Department of Aging and Disability Services (DADS) Standards for
                Emergency
                Response Services at 40 T.A.C. §52.201(a), and be licensed by the Texas
                Board of Private Investigators and Private Security Agencies, unless
                exempt from licensure.

            	 
	
              Adult
                Foster Home

            	
              TDSHS
                Provider standards for Adult Foster Care and TDSHS Rules at 40 T.A.C.
                §48.6032. Four bed homes also licensed under TDSHS Rules at 40 T.A.C.
                §481.8906. DFPS licensure in accordance with 24-hour Care Licensing
                requirements found in T.A.C., Title 40, Part 19, Chapter
                720.

            	 
	
              Home
                Delivered Meals

            	
              T.A.C.,
                Title 40, Part 1, Chapter 55.

            	 
	
              Physical
                Therapy

            	
              Licensed
                Physical Therapist through the Texas Board of Physical Therapy Examiners,
                Chapter 453.

            	 
	
              Occupational
                Therapy

            	
              Licensed
                Occupational Therapist through the Texas Board of Occupational Therapy
                Examiners, Chapter 454.

            	 
	
              Speech
                Therapy

            	
              Licensed
                Speech Therapist Through the Department of State Health
                Services.

            	 
	
              Consumer
                Directed Services

            	
              Home
                and Community Support Services Agency (HCSSA)

            	 
	
              Transition
                Assistance Services

            	
              No
                licensure or certification requirements.

            	 
	
              Minor
                Home Modification

            	
              No
                licensure or certification requirements.

            	 
	
              Adaptive
                Aids and Medicaid Equipment

            	
              No
                licensure or certification requirements.

            	 
	
              Medical
                supplies

            	
              No
                licensure or certification requirements.

            	 

    

    
    

    

    8.3.2
      Service Coordination

    The
      HMO
      must furnish a Service Coordinator to all STAR+PLUS Members who request one.
      The
      HMO should also furnish a Service Coordinator to a STAR+PLUS Member when the
      HMO
      determines one is required through an assessment of the Member’s health and
      support needs. The HMO must ensure that each STAR+PLUS Member has a qualified
      PCP who is responsible for overall clinical direction and, in conjunction with
      the Service Coordinator, serves as a central

    point
      of
      integration and coordination of Covered Services, including primary, Acute
      Care,
      long-term care and Behavioral Health Services.

    The
      Service Coordinator must work as a team with the PCP, and coordinate all
      STAR+PLUS Covered Services and any applicable Non-capitated Services with the
      PCP.  This requirement applies whether or not the PCP is in the HMO’s
      Network, as some STAR+PLUS Members dually eligible for Medicare may have a
      PCP
      that is not in the HMO’s Provider Network. In order to integrate the Member’s
      Acute Care and primary care, and stay abreast of the Member’s needs and
      condition, the Service Coordinator must also actively involve and coordinate
      with the Member’s primary and specialty care providers, including Behavioral
      Health Service providers, and providers of Non-capitated Services.

    STAR+PLUS
      Members dually eligible for Medicare will receive most prescription drug
      services through Medicare rather than Medicaid.  The Texas Vendor Drug
      Program will pay for a limited number of medications not covered by
      Medicare.

    The
      HMO
      must identify and train Members or their families to coordinate their own care,
      to the extent of the Member’s or the family’s capability and willingness to
      coordinate care.

     

    8.3.2.1  Service
      Coordinators

    The
      HMO
      must employ as Service Coordinators persons experienced in meeting the needs
      of
      vulnerable populations who have Chronic or Complex Conditions. Such Service
      Coordinators are Key HMO Personnel as described in Attachment
      A, HHSC’s Uniform Managed Care Contract Terms and Conditions,
      Section 4.02, and must meet the requirements set forth in
Section 4.04.1 of HHSC’s Uniform Managed Care Contract
      Terms and Conditions.

     

    8.3.2.2
      Referral to Community Organizations

    The
      HMO
      must provide information about and referral to community organizations that
      may
      not be providing STAR+PLUS Covered Services, but are otherwise important to
      the
      health and well being of Members. These organizations include, but are not
      limited to:

    1  State/federal
      agencies (e.g., those agencies with jurisdiction over aging, public health,
      substance abuse, mental health/retardation, rehabilitation, developmental
      disabilities, income support, nutritional assistance, family support agencies,
      etc.);

    2  social
      service agencies (e.g., Area Agencies on Aging, residential support agencies,
      independent living centers, supported employment agencies, etc.);

    3  city
      and
      county agencies (e.g., welfare departments, housing programs,
      etc.);

    4  civic
      and
      religious organizations; and

    5  consumer
      groups, advocates, and councils (e.g., legal aid offices, consumer/family
      support groups, permanency planning, etc.).

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.3.2.3
      Discharge Planning

    The
      HMO
      must have a protocol for quickly assessing the needs of Members discharged
      from
      a Hospital or other care or treatment facility.

    The
      HMO’s
      Service Coordinator must work with the Member’s PCP, the hospital discharge
      planner(s), the attending physician, the Member, and the Member’s family to
      assess and plan for the Member’s discharge. When long-term care is needed, the
      HMO must ensure that the Member’s discharge plan includes arrangements for
      receiving community-based care whenever possible. The HMO must ensure that
      the
      Member, the Member’s family, and the Member’s PCP are all well informed of all
      service options available to meet the Member’s needs in the
      community.

     

    8.3.2.4
      Transition Plan for New STAR+PLUS Members

    The
      HMO
      must provide a transition plan for Members enrolled in the STAR+PLUS
      Program.  HHSC, and/or the previous STAR+PLUS HMO contractor, will
      provide the HMO with detailed Care Plans, names of current providers, etc.,
      for
      newly enrolled Members already receiving long-term care services at the time
      of
      enrollment. The HMO must ensure that current providers are paid for Medically
      Necessary Covered Services that are delivered in accordance with the Member’s
      existing treatment/long-term care services plan after the Member has become
      enrolled in the HMO and until the transition plan is developed.

    The
      transition planning process must include, but is not limited to, the
      following:

    1  review
      of
      existing DADS long-term care services plans;

    2  preparation
      of a transition plan that ensures continuous care under the Member’s existing
      Care Plan during the transfer into the HMO’s Network while the HMO conducts an
      appropriate assessment and development of a new plan, if needed;

    3  if
      durable medical equipment or supplies had been ordered prior to enrollment
      but
      have not been received by the time of enrollment, coordination and
      follow-through to ensure that the Member receives the necessary supportive
      equipment and supplies without undue delay; and

    4  payment
      to the existing provider of service under the existing authorization until
      the
      HMO has completed the assessment and service plans and issued new
      authorizations.

    

    The
      HMO
      must review any existing care plan and develop a transition plan within 30
      days
      of receiving the Member’s enrollment. The transition plan will remain in place
      until the HMO contacts the Member and coordinates modifications to the Member’s
      current treatment/long-term care services plan. The HMO must ensure that the
      existing services continue and that there are no breaks in services. For initial
      implementation of the STAR+PLUS program in a Service Area, the HMO must complete
      this process within 90-days of the Member’s enrollment.

    The
      HMO
      must ensure that the Member is involved in the assessment process and fully
      informed about options, is included in the development of the care plan, and
      is
      in agreement with the plan when completed.

     

    8.3.2.5
      Centralized Medical Record and Confidentiality

    The
      Service Coordinator shall be responsible for maintaining a centralized record
      related to Member contacts, assessments and service authorizations. The HMO
      shall ensure that the organization of and documentation included in the
      centralized Member record meets all applicable professional standards ensuring
      confidentiality of Member records, referrals, and documentation of
      information.

    The
      HMO
      must have a systematic process for generating or receiving referrals and sharing
      confidential medical, treatment, and planning information across
      providers.

     

    8.3.2.6
      Nursing Facilities

    Nursing
      facility care, although a part of the care continuum, presents a challenge
      for
      managed care. Because of the process for becoming eligible for Medicaid
      assistance in a nursing facility, there is frequently a significant time gap
      between entry into the nursing home and determination of Medicaid
      eligibility.  During this gap from entry to Medicaid eligibility, the
      resident has “nested” in the facility and many of the community supports are no
      longer available. To require participation of all nursing facility residents
      would result in the HMO maintaining a Member in the nursing facility without
      many options for managing their health. For this reason, persons who qualify
      for
      Medicaid as a result of nursing facility residency are not enrolled in
      STAR+PLUS.

    The
      STAR+PLUS HMO must participate in the Promoting Independence initiative for
      such
      individuals. Promoting Independence (PI) is a philosophy that aged and disabled
      individuals remain in the most integrated setting to receive long-term care
      services. PI is Texas' response to the U.S. Supreme Court ruling in Olmstead
      v. L.C. that requires states to provide community-based services for
      persons with disabilities who would otherwise be entitled to institutional
      services, when:

    •  the
      state's treatment professionals determine that such placement is
      appropriate;

    •  the
      affected persons do not oppose such treatment; and

    •  the
      placement can be reasonably accommodated, taking into account the resources
      available to the state and the needs of others who are receiving state supported
      disability services.

    

    In
      accordance with legislative direction, the HMO must designate a point of contact
      to receive referrals for nursing facility residents who may potentially be
      able
      to return to the community through the use of 1915(c) Nursing Facility Waiver
      services. To be eligible for this option, an individual must reside in a nursing
      facility until a written plan of care for safely moving the resident back into
      a
      community setting has been developed and approved.

    A
      STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS Member
      for a total of four months. The nursing facility will bill the state directly
      for covered nursing facility services delivered while the Member is in the
      nursing facility.  See Section 8.3.2.7 for further
      information.

    The
      HMO
      is responsible for the Member at the time of nursing facility entry and must
      utilize the Service Coordinator staff to complete an assessment of the Member
      within 30 days of entry in the nursing facility, and develop a plan of care
      to
      transition the Member back into the community if possible. If at this initial
      review, return to the community is possible, the Service Coordinator will work
      with the resident and family to return the Member to the community using 1915(c)
      Waiver Services.

    If
      the
      initial review does not support a return to the community, the Service
      Coordinator will conduct a second assessment 90 days after the initial
      assessment to determine any changes in the individual’s condition or
      circumstances that would allow a return to the community. The Service
      Coordinator will develop and implement the transition plan.

    The
      HMO
      will provide these services as part of the Promoting Independence initiative.
      The HMO must maintain the documentation of the assessments completed and make
      them available for state review at any time.

    It
      is
      possible that the STAR+PLUS HMO will be unaware of the Member’s entry into a
      nursing facility. It is the responsibility of the nursing facility to review
      the
      Member’s Medicaid card upon entry into the facility and notify the HMO. The
      nursing facility is also required to notify HHSC of the entry of a new
      resident.

     

    8.3.2.7
      HMO Four-Month Liability for Nursing Facility Care

    A
      STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS Member
      for a total of four months.  The four months do not have to be
      consecutive. Upon completion of four months of nursing facility care, the
      individual will be disenrolled from the STAR+PLUS Program and the Medicaid
      Fee-for-Service program will provide Medicaid benefits. A STAR+PLUS Member
      may
      not change HMOs while in a nursing facility.

    Tracking
      the four months of liability is done through a counter system. The four-month
      counter starts with the Medicaid admission or on the 21st day of a Medicare
      stay. A partial month counts as a full month. In other words, the month in
      which
      the Medicaid admission occurs or the month on which the 21st day of the Medicare
      stay occurs, is counted as one of the four months.

    An
      amount
      will be included in the capitation rates to cover the cost of four months of
      nursing facility services (based upon experience from STAR+PLUS in Harris
      County) for the historical average number of admissions to nursing facilities.
      Nursing facility costs for STAR+PLUS in Harris County have accounted for less
      than one percent of premiums in recent years. HHSC believes that these costs
      will not deviate substantially from this experience.

    The
      HMO
      will be liable for the cost of care in a nursing facility care and, for
      Medicaid-only Members, the cost of all other Covered Services. The HMO will
      not
      maintain nursing facilities in its Network and will not reimburse the nursing
      facilities directly. Nursing facilities will use the traditional Fee-for-Service
      system of billing HHSC rather than billing the HMO. The HMO's liability will
      be
      established based on the amount paid through the Fee-for-Service billing system
      on behalf of the Member. HHSC will recoup those costs from the HMO by an offset
      to the monthly Capitation Payment. The offset will be recognized as a nursing
      facility expense.. The HMO will record the nursing facility liability recoupment
      as nursing facility expense on its

    Financial-Statistical
      Reports (FSR). The HMO will be responsible for direct payment of all non-nursing
      facility Medicaid expenses on behalf of the Member.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.3.3
      STAR+PLUS Assessment Instruments

    The
      HMO
      must have and use functional assessment instruments to identify Members with
      significant health problems, Members requiring immediate attention, and Members
      who need or are at risk of needing long-term care services. The HMO, a
      subcontractor, or a Provider may complete assessment instruments, but the HMO
      remains responsible for the data recorded.

    HMOs
      must
      use the DHS Form 2060, as amended or modified, to assess a Member’s need for
      Functionally Necessary Personal Attendant Services. The HMO may adapt the form
      to reflect the HMO’s name or distribution instructions, but the elements must be
      the same and instructions for completion must be followed without
      amendment.

    The
      DHS
      Form 2060 must be completed if a need or a change in Personal Attendant Services
      is warranted at the initial contact, at the annual reassessment, and anytime
      a
      Member requests the services or requests a change in services. The DHS Form
      2060
      must also be completed if the HMO determines the Member requires the services
      or
      requires a change in the Personal Attendant Services that are
      authorized.

    For
      Members and applicants seeking or needing the 1915(c) Nursing Facility Waiver
      services, the HMOs must use the DADS CARE Form 3652, as amended or modified,
      to
      assess Members and to supply current medical information for Medical Necessity
      determinations.  The HMO must also complete the Individual Service
      Plan (ISP), Form 3671 for each Member receiving 1915(c) Nursing Facility Waiver
      Services. The ISP is established for a one-year period.  After the
      initial ISP is established, the ISP must be completed on an annual basis and
      the
      end date or expiration date does not change.  Both of these forms
      (Form 3652 and Form 3671) must be completed annually at
      reassessment.  The HMO is responsible for tracking the end dates of
      the ISP to ensure that the Member is reassessed prior to the expiration
      date.  Note that the DADS CARE Form 3652 cannot be submitted earlier
      than 90 days prior to the expiration date of the ISP.

    HHSC
      has
      adopted a Minimum Data Set for Home Care (MDS-HC), which can be found in the
      HHSC Uniform Managed Care Manual.  HHSC may adopt new versions of this
      instrument as appropriate or as directed by CMS. The MDS-HC instrument must
      be
      completed and electronically submitted to HHSC in the specified format within
      30
      days of enrollment for every Member receiving Community-based Long-term Care
      Services, and then each year by the anniversary of the Member’s date of
      enrollment.

    The
      MDS-HC instrument must be completed and electronically submitted to HHSC in
      the
      specified format within 30 days of enrollment for every Member receiving
      Community-based Long-term Care Services.  Because of the large number
      of Members the HMOs will be receiving initially during the implementation period
      of the STAR+PLUS Program, HHSC is allowing the following:

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    •  For
      the
      1915(c) Nursing Facility Waiver Members, the MDS-HC instrument must be completed
      in conjunction with the annual reassessment.  The MDS-HC instrument
      must be completed annually at the time of reassessment for these
      Members.

    •  For
      the
      non-1915(c) Nursing Facility Waiver Members that are receiving Community-based
      Long-term Care Services, the HMO must submit a schedule for HHSC’s approval that
      provides a plan of how the MDS-HC instruments will be completed for these
      Members over a twelve-month period beginning on February 1, 2007.

    

    In
      addition to submitting the MDS-HC instrument to HHSC, the HMO may also submit
      other supplemental assessment instruments it elects to use.  As
      specialized MDS instruments are developed or adopted by HHSC for other living
      arrangements (e.g., assisted living), HHSC will notify HMO of the availability
      of the instrument and the date the HMO is required to begin using such
      instrument in the HHSC Uniform Managed Care Manual.  Any additional
      assessment instruments used by the HMO must be approved by HHSC.

     

    8.3.4
      1915(c) Nursing Facility Waiver Service Eligibility

    Recipients
      of 1915(c) Nursing Facility Waiver services must meet nursing facility criteria
      for participation in the waiver and must have a plan of care at initial
      determination of eligibility in which the plan’s annualized cost is equal to or
      less than the annualized cost of care if the individual were to enter a nursing
      facility.

     

    8.3.4.1
      For Members

    The
      HMO
      must notify HHSC when it initiates 1915(c) Nursing Facility Waiver eligibility
      testing on a STAR+PLUS Member. The HMO must apply risk criteria, complete the
      Form 3652 for Medical Necessity determination, complete the assessment
      documentation, and prepare a 1915(c) Nursing Facility Waiver Individual Service
      Plan (ISP) for each Member requesting 1915(c) Nursing Facility Waiver services
      and for Members the HMO has identified as needing 1915(c) Nursing Facility
      Waiver services. The HMO must provide HHSC the results of the assessment
      activities within 45 days of initiating the assessment process.

    HHSC
      will
      notify the Member and the HMO of the eligibility determination, which will
      be
      based on the information provided by the HMO. If the STAR+PLUS Member is
      eligible for 1915(c) Nursing Facility Waiver services, HHSC will notify the
      Member of the effective date of eligibility. If the Member is not eligible
      for
      1915(c) Nursing Facility Waiver services, HHSC will provide the Member
      information on right to Appeal the Adverse Determination. Regardless of the
      1915(c) Nursing Facility Waiver eligibility determination, HHSC will send a
      copy
      of the Member notice to the HMO.

     

    8.3.4.2
      For Medical Assistance Only (MAO) Non-Member Applicants

    Non-Member
      persons who are not eligible for Medicaid in the community may apply for
      participation in the 1915(c) Nursing Facility Waiver program under the financial
      and functional eligibility requirements for MAO. HHSC will inform the applicant
      that services are provided through an HMO and allow the applicant to select
      the
      HMO. HHSC will authorize the selected HMO to initiate pre-enrollment assessment
      services required under the 1915(c) Nursing Facility Waiver
      for the non-member. The HMO must complete Form 3652 for Medical Necessity
      determination, complete the assessment documentation, and prepare a 1915(c)
      Nursing Facility Waiver service plan for each applicant referred by HHSC. The
      initial home visit with the applicant must occur within 14 days of the receipt
      of the referral. The HMO must provide HHSC the results of the assessment
      activities within 45 days of the receipt of the referral.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    HHSC
      will
      notify the applicant and the HMO of the results of its eligibility
      determination. If the applicant is eligible, HHSC will notify the applicant
      and
      the HMO will be notified of the effective date of eligibility, which will be
      the
      first day of the month following the determination of eligibility. The HMO
      must
      initiate the Individual Service Plan (ISP) on the date of
      enrollment.

    If
      the
      applicant is not eligible, the HHSC notice will provide information on the
      applicant’s right to Appeal the Adverse Determination.  HHSC will also
      send notice to the HMO if the applicant is not eligible for 1915(c) Nursing
      Facility Waiver services.

     

    8.3.4.3
      Annual Reassessment

    Prior
      to
      the end date of the annual ISP, the HMO must initiate an annual reassessment
      to
      determine and validate continued eligibility for 1915(c) Nursing Facility Waiver
      services for each Member receiving such services. The HMO will be expected
      to
      complete the same activities for the annual reassessment as required for the
      initial eligibility determination, with the following exception: the HMO does
      not need to obtain a physician’s signature on the Form 3652 for the annual
      reassessment. Existing 1915(c) Nursing Facility Waiver clients may not be denied
      1915(c) Nursing Facility Waiver services solely on the basis that the proposed
      cost of the ISP will exceed the cost of care if the Member were in a nursing
      home if the following conditions are met:

    1  those
      services are required for that individual to live in the most integrated setting
      appropriate to his or her needs; and

    2  HHSC
      continues to comply with the cost-effectiveness requirements from the
      CMS.

    

    Individuals
      receiving waiver services through the Medically Dependent Children Program
      are
      covered by the provisions in this Section when they apply for transition to
      the
      1915(c) waiver program at age 21.

     

    8.3.5
      Personal Attendant Services

    There
      are
      three options available to STAR+PLUS Members desiring the delivery of Personal
      Attendant Services (PAS): 1) Self-Directed; 2) Agency Model, Self-Directed;
      and
      3) Agency Model. The HMO must provide information to all eligible Members on
      the
      three options and must provide Member orientation in the option selected by
      the
      Member.  The HMO will provide the information to any STAR+PLUS Member
      receiving Personal Attendant Services:

    •  at
      initial assessment;

    •  at
      annual
      reassessment or annual contact with the STAR+PLUS Member;

    •  at
      any
      time when a STAR+PLUS Member receiving PAS requests the information;
      and

    •  in
      the
      Member Handbook.

    

    The
      HMO
      must contract with providers who are able to offer PAS and must also
      educate/train the HMO Network Providers regarding the three PAS options. To
      participate as a PAS Network Provider, the Provider must have a contract with
      DADS for the delivery of PAS.  The HMO must assure compliance with the
      Texas Administrative Code in Title 40, Part 1, Chapter 41, Sections 41.101,
      41.103, and 41.105.  The HMO must include the requirements in the
      Provider Manual and in the STAR+PLUS Provider training.

     

    8.3.5.1
      Personal Attendant Services Delivery Option – Self-Directed
      Model

    In
      the
      Self-Directed Model, the Member or the Member’s legal guardian is the employer
      of record and retains control over the hiring, management, and termination
      of an
      individual providing Personal Attendant Services.  The Member is
      responsible for assuring that the employee meets the requirements for Personal
      Attendant Services, including the criminal history check. The Member uses a
      Home
      and Community Support Services (HCSS) agency to handle the employer-related
      administrative functions such as payroll, substitute (back-up), and filing
      tax-related reports of Personal Attendant Services.

     

    8.3.5.2
      Personal Attendant Services Delivery Option – Agency Model,
      Self-Directed

    In
      the
      Agency Model, Self-Directed, the Member or the Member’s legal guardian chooses a
      Home and Community Support Services (HCSS) agency in the HMO Provider Network
      who is the employer of record.  In this model, the Member selects the
      personal attendant from the HCSS agency’s personal attendant
      employees.  The personal attendant’s schedule is set up based on the
      Member input, and the Member manages the Personal Attendant
      Services.  The Member retains the right to supervise and train the
      personal attendant.  The Member may request a different personal
      attendant and the HCSS agency would be expected to honor the
      request.  The HCSS agency establishes the payment rate, benefits, and
      provides all administrative functions such as payroll, substitute (back-up),
      and
      filing tax-related reports of personal attendant services.

     

    8.3.5.3
      Personal Attendant Services Delivery Option – Agency Model

    In
      the
      Agency Model, the Member chooses a Home and Community Support Services (HCSS)
      agency to hire, manage, and terminate the individual providing Personal
      Attendant Services.  The HCSS agency is selected by the Member from
      the HCSS agencies in the HMO Provider Network.  The Service
      Coordinator and Member develop the schedule and send it to the HCSS agency.
      The
      Member retains the right to supervise and train the personal
      attendant.  The Member may request a different personal attendant and
      the HCSS agency would be expected to honor the request.  The HCSS
      agency establishes the payment rate, benefits, and provides all administrative
      functions such as payroll, substitute (back-up), and filing tax-related reports
      of personal attendant services.

     

    8.3.6
      Community Based Long-term Care Service Providers

    8.3.6.1
      Training

    The
      HMO
      must comply with Section 8.1.4.6 regarding Provider Manual and Provider training
      specific to the STAR+PLUS Program. The HMO must train all Community Long-term
      Care Service Providers regarding the requirements of the Contract and special
      needs of STAR+PLUS

    Members.
      The HMO must establish ongoing STAR+PLUS Provider training addressing the
      following issues at a minimum:

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    1  Covered
      Services and the Provider’s responsibilities for providing such services to
      STAR+PLUS Members and billing the HMO for such services. The HMO must place
      special emphasis on Community Long-term Care Services and STAR+PLUS
      requirements, policies, and procedures that vary from Medicaid Fee-for-Service
      and commercial coverage rules, including payment policies and
      procedures.

    2  Inpatient
      Stay hospital services and the authorization and billing of such services for
      STAR+PLUS Members.

    3  Relevant
      requirements of the STAR+PLUS Contract, including the role of the Service
      Coordinator;

    4  Processes
      for making referrals and coordinating Non-capitated Services;

    5  The
      HMO’s
      quality assurance and performance improvement program and the Provider’s role in
      such programs; and

    6  The
      HMO’s
      STAR+PLUS policies and procedures, including those relating to Network and
      Out-of-Network referrals.

    

    8.3.7.2
      LTC Provider Billing

    Long-term
      care providers are not required to utilize the billing systems that most medical
      facilities use on a regular basis. For this reason, the HMO must make
      accommodations to the claims processing system for such providers to allow
      for a
      smooth transition from traditional Medicaid to Managed Care
      Medicaid.

    HHSC
      will
      meet with HMOs to develop a standardized method long-term care
      billing.  All STAR+PLUS HMOs will be required to utilize the
      standardized method, which will be incorporated into the HHSC Uniform
      Managed Care Manual.

     

    8.3.7.3
      Rate Enhancement Payments for Agencies Providing Attendant
      Care

    All
      HMOs
      participating in the STAR+PLUS program must allow their Long-term Support
      Services (LTSS) Providers to participate in the STAR+PLUS Attendant Care
      Enhancement Program if the providers are currently participating in the enhanced
      payment program with the Department of Aging and Disability Services
      (DADS).  HMOs may choose not to offer participation to DADS-contracted
      providers who do not currently participate in the enhancement
      program.  Additionally, HMOs may choose to include Providers in the
      network who do not participate in the enhanced payment program.

    Attachment
      B-7, STAR+PLUS Attendant Care Enhanced Payment Methodology explains the
      methodology that the STAR+PLUS HMO will use to implement and pay the enhanced
      payments, including a description of the timing of the payments, in accordance
      with the requirements in the Uniform Managed Care Manual and
      the intent of the 2000-01 General Appropriations Act (Rider 27, House Bill
      1,
      76th
      Legislature, Regular Session, 1999) and T.A.C. Title 1, Part 15, Chapter
      355.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.3.7.4                      Payment
      for 1915(c) Nursing Facility Waiver Services for
      Non-Members

    Disenrolled
      Members: Occasionally, the Social Security Administration will place
      SSI recipients on hold for a short period of time, usually due failure to
      provide timely updates required for the continuation of SSI benefits. During
      this period, the recipients will not appear to be eligible for Medicaid or
      1915(c) Nursing Facility Waiver services. Often the Social Security
      Administration reinstates these Medicaid Eligibles retroactively without a
      break
      in Medicaid coverage. To deal with this situation, for at least thirty (30)
      days
      after disenrollment, the HMO will continue to authorize and pay for 1915(c)
      Nursing Facility Waiver services for disenrolled STAR+PLUS Members who appear
      to
      lose eligibility due to an administrative problem related to SSI. If at the
      end
      of the thirty (30) days, the Medicaid Eligible’s 1915(c) Nursing Facility Waiver
      eligibility is reinstated, the Medicaid Eligible will be manually enrolled
      into
      the STAR+PLUS HMO back to the date of disenrollment and the retroactive
      adjustment system will properly reimburse the HMO. If after thirty (30) days,
      the former STAR+PLUS Member continues to be ineligible for Medicaid, the
      individual will not be retroactively enrolled, and the HMO will bill HHSC for
      1915(c) Nursing Facility Waiver services rendered during this time.

     

    8.4                      Additional
      CHIP Scope of Work

    The
      following provisions only apply to HMOs participating in CHIP.

     

    8.4.1
      CHIP Provider Network

    In
      each
      Service Area, the HMO must seek to obtain the participation in its Provider
      Network of CHIP Significant Traditional Providers (STPs), defined by HHSC as
      PCP
      Providers currently serving the CHIP population and DSH hospitals. The
      Procurement Library includes CHIP STPs by Service Area.

    The
      HMO
      must give STPs the opportunity to participate in its Network if the
      STPs:

    1  Agree
      to
      accept the HMO’s Provider reimbursement rate for the provider type;
      and

    2  Meet
      the
      standard credentialing requirements of the HMO, provided that lack of board
      certification or accreditation by the Joint Commission on Accreditation of
      Health Care Organizations (JCAHO) is not the sole grounds for exclusion from
      the
      Provider Network.

    

    8.4.2
      CHIP Provider Complaint and Appeals

    CHIP
      Provider Complaints and Appeals are subject to disposition consistent with
      the
      Texas Insurance Code and any applicable TDI regulations.  The HMO must
      resolve Provider Complaints within 30 days from the date the Complaint is
      received.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    8.4.3
      CHIP Member Complaint and Appeal Process

    CHIP
      Member Complaints and Appeals are subject to disposition consistent with the
      Texas Insurance Code and any applicable TDI regulations.  HHSC will
      require the HMO to resolve Complaints and Appeals (that are not elevated to
      TDI)
      within 30 days from the date the Complaint or Appeal is received. The HMO is
      subject to remedies, including liquidated damages, if at least 98 percent of
      Member Complaints or Member Appeals are not resolved within 30 days of receipt
      of the Complaint or Appeal by the HMO. Please see the Uniform Managed
      Care Contract Terms & Conditions and Attachment B-5,
      Deliverables/Liquidated Damages Matrix. Any person, including those
      dissatisfied with a HMO’s resolution of a Complaint or Appeal, may report an
      alleged violation to TDI.

     

    8.4.4
      Dental Coverage for CHIP Members

    The
      HMO
      is not responsible for reimbursing dental providers for preventive and
      therapeutic dental services obtained by CHIP Members. However, medical and/or
      hospital charges, such as anesthesia, that are necessary in order for CHIP
      Members to access standard therapeutic dental services, are Covered Services
      for
      CHIP Members. The HMO must provide access to facilities and physician services
      that are necessary to support the dentist who is providing dental services
      to a
      CHIP Member under general anesthesia or intravenous (IV) sedation.

    The
      HMO
      must inform Network facilities, anesthesiologists, and PCPs what authorization
      procedures are required, and how Providers are to be reimbursed for the
      preoperative evaluations by the PCP and/or anesthesiologist and for the facility
      services. For dental-related medical Emergency Services, the HMO must reimburse
      in-network and Out-of-Network providers in accordance with federal and state
      laws, rules, and regulations.

     

    8.5
      Additional CHIP Perinatal Scope of Work

    The
      following provisions only apply to HMOs participating in CHIP Perinatal
      Program.

     

    8.5.1
      CHIP Perinatal Provider Network

    In
      each
      Service Area, the CHIP Perinatal HMO must seek to obtain the participation
      of
      Providers for CHIP Perinate Members.  CHIP Perinatal HMOs are
      encouraged to obtain the participation of Obstetricians/Gynecologists (OB/GYNs),
      Family Practice Physicians with experience in prenatal care, or other qualified
      health care Providers as CHIP Perinate Providers.

    See
      Sections 8.1.3.2, Access to Network Providers, and 8.1.4.2, Primary Care
      Providers, regarding distinctions in the provider networks for CHIP Perinates
      and CHIP Perinate Newborns.

     

    8.5.2
      CHIP Perinatal Program Provider Complaint and Appeals

    CHIP
      Perinatal Program Provider Complaints and Appeals are subject to disposition
      consistent with the Texas Insurance Code and any applicable TDI
      regulations.  The HMO must resolve Provider Complaints within 30 days
      from the date the Complaint is received.

     

    8.5.3
      CHIP Perinatal Program Member Complaint and Appeal Process

    CHIP
      Perinatal Program Member Complaints and Appeals are subject to disposition
      consistent with the Texas Insurance Code and any applicable TDI
      regulations.  HHSC will require the HMO to resolve Complaints and
      Appeals (that are not elevated to TDI) within 30 days from the date the
      Complaint or Appeal is received. Any person, including those dissatisfied with
      a
      HMO’s resolution of a Complaint or Appeal, may report an alleged violation to
      TDI.

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Contractual
      Document (CD)

    DOCUMENT
      HISTORY LOG

    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	
              Baseline

            	
              n/a

            	 	
              Initial
                version Attachment B-1, Section 7

            
	
              Revision

            	
              1.1

            	
              June
                30, 2006

            	
              Contract
                amendment to include STAR+PLUS program. No change to this
                Section.

            
	
              Revision

            	
              1.2

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-1 Section 9 – Turnover
                Requirements

            
	
              Revision

            	
              1.3

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-1 Section 9 – Turnover
                Requirements

            
	
              Revision

            	
              1.4

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B-1 Section 9 – Turnover
                Requirements

            
	
              Revision

            	
              1.5

            	
              January
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-1 Section 9 – Turnover
                Requirements

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-1 Section 9 – Turnover
                Requirements

            
	
              Revision

            	
              1.7

            	
              July
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-1 Section 9 – Turnover
                Requirements

            
	
              Revision

            	
              1.8

            	
              September
                1, 2007

            	
              Contract
                amendment did not revise Attachment B-1 Section 9 – Turnover
                Requirements

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

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

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

            

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Contractual
      Document (CD)

    Subject:
      Attachment B-1 – HHSC Joint Medicaid/CHIP HMO RFP, Section 9 Version
      1.8

    9.
      Turnover Requirements

    9.1
      Introduction

    This
      section presents the Turnover Requirements to which the HMO must agree. Turnover
      is defined as those activities that are required for the HMO to perform upon
      termination of the Contract in situations in which the HMO must transition
      Contract operations to HHSC or a subsequent Contractor.

    9.2
      Transfer of Data

    The
      HMO
      must transfer all data regarding the provision of Covered Services to Members
      to
      HHSC or a new HMO, at the sole discretion of HHSC and as directed by HHSC.
      All
      transferred data must be compliant with HIPAA.

    All
      relevant data must be received and verified by HHSC or the subsequent
      Contractor. If HHSC determines that not all of the data regarding the provision
      of Covered Services to Members was transferred to HHSC or the subsequent
      Contractor, as required, or the data is not HIPAA compliant, HHSC reserves
      the
      right to hire an independent contractor to assist HHSC in obtaining and
      transferring all the required data and to ensure that all the data are HIPAA
      compliant. The reasonable cost of providing these services will be the
      responsibility of the HMO.

    9.3
      Turnover Services

    Six
      months prior to the end of the Contract Period, including any extensions to
      such
      Period, the HMO must propose a Turnover Plan covering the possible turnover
      of
      the records and information maintained to either the State or a successor HMO.
      The Turnover Plan must be a comprehensive document detailing the proposed
      schedule, activities, and resource requirements associated with the turnover
      tasks. The Turnover Plan must be approved by HHSC.

    As
      part
      of the Turnover Plan, the HMO must provide HHSC with copies of all relevant
      Member and service data, documentation, or other pertinent information
      necessary, as determined by the HHSC, for HHSC or a subsequent Contractor to
      assume the operational activities successfully. This includes correspondence,
      documentation of ongoing outstanding issues, and other operations support
      documentation. The plan will describe the HMO’s approach and schedule for
      transfer of all data and operational support information, as applicable. The
      information must be supplied in media and format specified by the State and
      according to the schedule approved by the State.

    HHSC
      is
      not limited or restricted in the ability to require additional information
      from
      the HMO or modify the turnover schedule as necessary.

    9.4
      Post-Turnover Services

    Thirty
      (30) days following turnover of operations, the HMO must provide HHSC with
      a
      Turnover Results report documenting the completion and results of each step
      of
      the Turnover Plan. Turnover will not be considered complete until this document
      is approved by HHSC.

    If
      the
      HMO does not provide the required relevant data and reference tables,
      documentation, or other pertinent information necessary for HHSC or the
      subsequent Contractor to assume the operational activities successfully, the
      HMO
      agrees to reimburse the State for all reasonable costs, including, but not
      limited
      to, transportation, lodging, and subsistence for all state and federal
      representatives, or their agents, to carry out their inspection, audit, review,
      analysis, reproduction and transfer functions at the location(s) of such
      records.

    The
      HMO
      also agrees to pay any and all additional costs incurred by the State that
      are
      the result of the HMO’s failure to provide the requested records, data or
      documentation within the time frames agreed to in the Turnover
      Plan.

    The
      HMO
      must maintain all files and records related to Members and Providers for five
      years after the date of final payment under the Contract or until the resolution
      of all litigation, claims, financial management review or audit pertaining
      to
      the Contract, whichever is longer. The HMO agrees to repay any valid, undisputed
      audit exceptions taken by HHSC in any audit of the Contract.

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    Subject:
      Attachment B-2 – Covered Services Version 1.8

    DOCUMENT
      HISTORY LOG

    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	
              Baseline

            	
              n/a

            	 	
              Initial
                version Attachment B-2, Covered Services

            
	
              Revision

            	
              1.1

            	
              June
                30, 2006

            	
              Revised
                Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS
                Covered Services.

            
	
              Revision

            	
              1.2

            	
              September
                1. 2006

            	
              Revised
                Attachment B-2 to include provisions applicable to MCOs participating
                in
                the STAR and CHIP Programs. STAR Covered Services, Services Included
                under
                the HMO Capitation Payment, is modified to clarify the STAR covered
                services related to “optometry” and “vision.” CHIP Covered Services is
                modified to correct services related to artificial aids including
                surgical
                implants.

            
	
              Revision

            	
              1.3

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B­2, Covered
                Services.

            
	
              Revision

            	
              1.4

            	
              September
                1, 2006

            	
              Contract
                amendment did not revise Attachment B­2, Covered
                Services.

            
	
              Revision

            	
              1.5

            	
              January
                1, 2007

            	
              Contract
                amendment did not revise Attachment B­2, Covered
                Services.

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

            	
              Contract
                amendment did not revise Attachment B­2, Covered
                Services.

            
	
              Revision

            	
              1.7

            	
              July
                1, 2007

            	
              Contract
                amendment did not revise Attachment B­2, Covered
                Services.

            
	
              Revision

            	
              1.8

            	
              September
                1, 2007

            	
              CHIP
                Covered Services are modified to comply with legislative changes
                required
                by HB 109 to eliminate the 6 month enrollment period effective
                9/1/07.

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

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

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

            

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    STAR
      Covered Services

    The
      following is a non-exhaustive, high-level listing of Acute Care Covered Services
      included under the STAR Medicaid managed care program.

    Medicaid
      HMO Contractors are responsible for providing a benefit package to Members
      that
      includes all medically necessary services covered under the traditional,
      fee-for-service Medicaid programs except for Non-capitated Services provided
      to
      STAR Members outside of the HMO capitation and listed in Attachment B-1,
Section 8.2.2.8. Medicaid HMO Contractors must coordinate care
      for Members for these Non-capitated Services so that Members have access to
      a
      full range of medically necessary Medicaid services, both capitated and
      non-capitated. A Contractor may elect to offer additional acute care Value-added
      Services.

    The
      STAR
      Members are provided with three enhanced benefits compared to the traditional,
      fee-for­

    service
      Medicaid coverage:

    1)           waiver
      of the three-prescription per month limit;

    2)           waiver
      of the 30-day spell-of-illness limitation under fee-for-services;
      and

    3)           inclusion
      of an annual adult well check for patients 21 years of age and
      over.

    Medicaid
      HMO Contractors are responsible for providing a benefit package to Members
      that
      includes the waiver of the 30-day spell-of-illness limitation under
      fee-for-service and the inclusion of an annual adult well check for patients
      21
      years of age and over.  Prescription drug benefits to Medicaid HMO
      Members are provided outside of the HMO capitation.

    Bidders
      and Contractors should refer to the current Texas Medicaid Provider
      Procedures Manual and the bi-monthly Texas Medicaid
      Bulletin for a more inclusive listing of limitations and
      exclusions that apply to each Medicaid benefit category. (These documents can
      be
      accessed online at: http://www.tmhp.com.)

    The
      services listed in this Attachment are subject to modification based on Federal
      and State laws and regulations and Programs policy updates.

    Services
      included under the HMO capitation payment

    

    •           Ambulance
      services

    •           Audiology
      services, including hearing aids for adults (hearing aids for children are
      provided through the PACT program and are a non-capitated service)

    •           Behavioral
      Health Services, including: 

            Inpatient
      and
      outpatient mental health services for children (under age
      21)  

            Outpatient
      chemical
      dependency services for children (under age 21) 

            Detoxification
      services 

            Psychiatry
      services

            Counseling
      services
      for adults (21 years of age and over)

    •           Birthing
      center services

    •           Chiropractic
      services

    •           Dialysis

    •           Durable
      medical equipment and supplies

    •           Emergency
      Services

    •           Family
      planning services

    •           Home
      health care services

    •           Hospital
      services, including inpatient and outpatient

    •           Laboratory

    •           Medical
      check-ups and Comprehensive Care Program (CCP) Services for children (under
      age
      21) through the Texas Health Steps Program

    •           Podiatry

    •           Prenatal
      care

    •           Primary
      care services

    •           Radiology,
      imaging, and X-rays

    •           Specialty
      physician services

    •           Therapies
      – physical, occupational and speech

    •   
Transplantation
      of
      organs and tissues

    •           Vision
      (Includes optometry and glasses.  Contact lenses are only covered if
      they are medically necessary for vision correction, which can not be
      accomplished by glasses.)

    Subject:
      Attachment B-2 – Covered Services Version 1.8

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

    CHIP
      Covered Services

    Covered
      CHIP services must meet the CHIP definition of Medically Necessary Covered
      Services as defined in this Contract. There is no lifetime
      maximum on benefits; however, 12-month period or lifetime limitations do apply
      to certain services, as specified in the following chart.  Co-pays
      apply until a family reaches its specific cost-sharing maximum.

     

     

    
      	
              Covered
                Benefit

            	
              Description

            
	
              Inpatient
                General Acute and Inpatient Rehabilitation Hospital
                Services

            	
              Services
                include, but are not limited to, the following: 

               Hospital-provided
                Physician or Provider services 

               Semi-private
                room and board (or private if medically necessary as certified by
                attending) 

               General
                nursing care 

               Special
                duty nursing when medically necessary 

               ICU
                and services 

               Patient
                meals and special diets 

               Operating,
                recovery and other treatment rooms 

               Anesthesia
                and administration (facility technical component) 

               Surgical
                dressings, trays, casts, splints 

               Drugs,
                medications and biologicals 

               Blood
                or blood products that are not provided free-of-charge to the patient
                and
                their administration 

               X-rays,
                imaging and other radiological tests (facility technical
                component) 

               Laboratory
                and pathology services (facility technical component) 

               Machine
                diagnostic tests (EEGs, EKGs, etc.) 

               Oxygen
                services and inhalation therapy 

               Radiation
                and chemotherapy 

               Access
                to DSHS-designated Level III perinatal centers or Hospitals meeting
                equivalent levels of care 

               In-network
                or out-of-network facility and Physician services for a mother and
                her
                newborn(s) for a minimum of 48 hours following an uncomplicated vaginal
                delivery and 96 hours following an uncomplicated delivery by caesarian
                section. 

               Hospital,
                physician and related medical services, such as anesthesia, associated
                with dental care 

               Surgical
                implants 

               Other
                artificial aids including surgical implants 

               Implantable
                devices are covered under Inpatient and Outpatient services and do
                not
                count towards the DME 12-month period limit

            
	
              Skilled
                Nursing

            	
              Services
                include, but are not limited to, the following:

            
	
              Facilities

            	
                
                 Semi-private room and board

            
	
              (Includes
                Rehabilitation

            	
               Regular
                nursing services

            
	
              Hospitals)

            	
               Rehabilitation
                services 

               Medical
                supplies and use of appliances and equipment furnished by the
                facility

            
	
              Outpatient
                Hospital,

            	
              Services
                include, but are not limited to, the following services provided
                in
                a

            
	
              Comprehensive
                Outpatient

            	
              hospital
                clinic or emergency room, a clinic or health center,
                hospital-based

            
	
              Rehabilitation
                Hospital, Clinic

            	
              emergency
                department or an ambulatory health care setting:

            
	
              (Including
                Health Center) and

            	
               X-ray,
                imaging, and radiological tests (technical component)

            
	
              Ambulatory
                Health Care

            	
               Laboratory
                and pathology services (technical component)

            
	
              Center

            	
               Machine
                diagnostic tests 

               Ambulatory
                surgical facility services 

               Drugs,
                medications and biologicals

            

    

    
    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Subject:
      Attachment B-2 – Covered Services Version 1.8

    
      	
              Covered
                Benefit

            	
              Description

            
	 	
               Casts,
                splints, dressings 

               Preventive
                health services 

               Physical,
                occupational and speech therapy 

               Renal
                dialysis 

               Respiratory
                services 

               Radiation
                and chemotherapy 

               Blood
                or blood products that are not provided free-of-charge to the patient
                and
                the administration of these products 

               Facility
                and related medical services, such as anesthesia, associated with
                dental
                care, when provided in a licensed ambulatory surgical
                facility.  

               Surgical
                implants 

               Other
                artificial aids including surgical implants 

               Implantable
                devices are covered under Inpatient and Outpatient services and do
                not
                count towards the DME 12-month period limit

            
	
              Physician/Physician
                Extender Professional Services

            	
              Services
                include, but are not limited to, the following: 

               American
                Academy of Pediatrics recommended well-child exams and preventive
                health
                services (including, but not limited to, vision and hearing screening
                and
                immunizations) 

               Physician
                office visits, in-patient and out-patient services 

               Laboratory,
                x-rays, imaging and pathology services, including technical component
                and/or professional interpretation 

               Medications,
                biologicals and materials administered in Physician’s
                office 

               Allergy
                testing, serum and injections 

               Professional
                component (in/outpatient) of surgical services, including: -Surgeons
                and
                assistant surgeons for surgical procedures including appropriate
                follow-up
                care -Administration of anesthesia by Physician (other than surgeon)
                or
                CRNA -Second surgical opinions -Same-day surgery performed in a Hospital
                without an over-night stay -Invasive diagnostic procedures such as
                endoscopic examinations 

               Hospital-based
                Physician services (including Physician-performed technical and
                interpretive components) 

               In-network
                and out-of-network Physician services for a mother and her newborn(s)
                for
                a minimum of 48 hours following an uncomplicated vaginal delivery
                and 96
                hours following an uncomplicated delivery by caesarian
                section. 

               Physician
                services medically necessary to support a dentist providing dental
                services to a CHIP member such as general anesthesia or intravenous
                (IV)
                sedation.

            
	
              Durable
                Medical Equipment (DME), Prosthetic Devices and Disposable Medical
                Supplies

            	
              $20,000
                12-month period limit for DME, prosthetics, devices and disposable
                medical
                supplies (diabetic supplies and equipment are not counted against
                this
                ccap).  Services include DME (equipment which can withstand
                repeated use and is primarily and customarily used to serve a medical
                purpose, generally is not useful to a person in the absence of Illness,
                Injury, or Disability, and is appropriate for use in the home), including
                devices and supplies that are medically necessary and necessary for
                one or
                more activities of daily living and appropriate to assist in the
                treatment
                of a medical condition, including: 

               

               Orthotic
                braces and orthotics 

               Prosthetic
                devices such as artificial eyes, limbs, and
                braces  

               Prosthetic
                eyeglasses and contact lenses for the management of severe ophthalmologic
                disease 

               Hearing
                aids

            

    

    
    

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      	
              Covered
                Benefit

            	
              Description

            
	 	
               Diagnosis-specific
                disposable medical supplies, including diagnosis-specific prescribed
                specialty formula and dietary supplements.  (See Attachment
                A)

            
	
              Home
                and Community Health Services

            	
              Services
                that are provided in the home and community, including, but not limited
                to: 

               Home
                infusion 

               Respiratory
                therapy 

               Visits
                for private duty nursing (R.N., L.V.N.) 

               Skilled
                nursing visits as defined for home health purposes (may include R.N.
                or
                L.V.N.).  

               Home
                health aide when included as part of a plan of care during a period
                that
                skilled visits have been approved. 

               Speech,
                physical and occupational therapies. 

               Services
                are not intended to replace the CHILD'S caretaker or to provide relief
                for
                the caretaker 

               Skilled
                nursing visits are provided on intermittent level and not intended
                to
                provide 24-hour skilled nursing services 

               Services
                are not intended to replace 24-hour inpatient or skilled nursing
                facility
                services

            
	
              Inpatient
                Mental Health Services

            	
              Mental
                health services, including for serious mental illness, furnished
                in a
                free­standing psychiatric hospital, psychiatric units of general acute
                care hospitals and state-operated facilities, including, but not
                limited
                to: 

               Neuropsychological
                and psychological testing. 

               Inpatient
                mental health services are limited to: 

               45
                days 12-month inpatient limit 

               Includes
                inpatient psychiatric services, up to 12-month period limit, ordered
                by a
                court of competent jurisdiction under the provisions of Chapters
                573 and
                574 of the Texas Health and Safety Code, relating to court ordered
                commitments to psychiatric facilities. Court order serves as binding
                determination of medical necessity. Any modification or termination
                of
                services must be presented to the court with jurisdiction over the
                matter
                for determination 

               25
                days of the inpatient benefit can be converted to residential treatment,
                therapeutic foster care or other 24-hour therapeutically planned
                and
                structured services or sub-acute outpatient (partial hospitalization
                or
                rehabilitative day treatment) mental health services on the basis
                of
                financial equivalence against the inpatient per diem
                cost 

               20
                of the inpatient days must be held in reserve for inpatient use
                only 

               Does
                not require PCP referral

            
	
              Outpatient
                Mental Health Services

            	
              Mental
                health services, including for serious mental illness, provided on
                an
                outpatient basis, including, but not limited to: 

               Medication
                management visits do not count against the outpatient visit
                limit. 

               The
                visits can be furnished in a variety of community-based settings
                (including school and home-based) or in a state-operated
                facility 

               Up
                to 60 days 12-month period limit for rehabilitative day
                treatment 

               60
                outpatient visits 12-month period limit 

               60
                rehabilitative day treatment days can be converted to outpatient
                visits on
                the basis of financial equivalence against the day treatment per
                diem
                cost 

               60
                outpatient visits can be converted to skills training (psycho educational
                skills development) or rehabilitative day treatment on the basis
                of
                financial equivalence against the outpatient visit cost 

               Includes
                outpatient psychiatric services, up to 12-month period limit, ordered
                by a
                court of competent jurisdiction under the provisions
                of

            

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Subject:
      Attachment B-2 – Covered Services Version 1.8

    
      	
              Covered
                Benefit

            	
              Description

            
	 	
              Chapters
                573 and 574 of the Texas Health and Safety Code, relating to court
                ordered
                commitments to psychiatric facilities. Court order serves as binding
                determination of medical necessity. Any modification or termination
                of
                services must be presented to the court with jurisdiction over the
                matter
                for determination 

               Inpatient
                days converted to sub-acute outpatient services are in addition to
                the
                outpatient limits and do not count towards those limits 

               A
                Qualified Mental Health Professional (QMHP), as defined by and
                credentialed through Texas Department of State Health Services (DSHS)
                standards (TAC Title 25, Part II, Chapter 412), is a Local Mental
                Health
                Authorities provider. A QMHP must be working under the authority
                of an
                DSHS entity and be supervised by a licensed mental health professional
                or
                physician. QMHPs are acceptable providers as long as the services
                would be
                within the scope of the services that are typically provided by QMHPs.
                Those services include individual and group skills training (which
                can be
                components of interventions such as day treatment and in-home services),
                patient and family education, and crisis services 

               Does
                not require PCP referral

            
	
              Inpatient
                Substance Abuse Treatment Services

            	
              Services
                include, but are not limited to: 

               Inpatient
                and residential substance abuse treatment services including
                detoxification and crisis stabilization, and 24-hour residential
                rehabilitation programs 

               Does
                not require PCP referral 

               Medically
                necessary detoxification/stabilization services, limited to 14 days
                per
                12-month period. 

               24-hour
                residential rehabilitation programs, or the equivalent, up to 60
                days per
                12-month period 

               30
                days may be converted to partial hospitalization or intensive outpatient
                rehabilitation, on the basis of financial equivalence against the
                inpatient per diem cost  

               30
                days must be held in reserve for inpatient use only.

            
	
              Outpatient
                Substance Abuse Treatment Services

            	
               Services
                include, but are not limited to, the following: 

               Prevention
                and intervention services that are provided by physician and non-physician
                providers, such as screening, assessment and referral for chemical
                dependency disorders. 

               Intensive
                outpatient services is defined as an organized non-residential service
                providing structured group and individual therapy, educational services,
                and life skills training which consists of at least 10 hours per
                week for
                four to 12 weeks, but less than 24 hours per day 

               Outpatient
                treatment service is defined as consisting of at least one to two
                hours
                per week providing structured group and individual therapy, educational
                services, and life skills training 

               Outpatient
                treatment services up to a maximum of: 

               Intensive
                outpatient program (up to 12 weeks per 12-month period) 

               Outpatient
                services (up to six-months per 12-month period) 

               Does
                not require PCP referral

            
	
              Rehabilitation
                Services

            	
              Services
                include, but are not limited to, the following: 

               Habilitation
                (the process of supplying a child with the means to reach age-appropriate
                developmental milestones through therapy or treatment) and rehabilitation
                services include, but are not limited to the following: 

               Physical,
                occupational and speech therapy 

               Developmental
                assessment

            
	
              Hospice
                Care Services

            	
              Services
                include, but are not limited to:

            

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

       

    

    Subject:
      Attachment B-2 – Covered Services Version 1.8

    
      	
              Covered
                Benefit

            	
              Description

            
	 	
               Palliative
                care, including medical and support services, for those children
                who have
                six months or less to live, to keep patients comfortable during the
                last
                weeks and months before death 

               Treatment
                for unrelated conditions is unaffected 

               Up
                to a maximum of 120 days with a 6 month life expectancy 

               Patients
                electing hospice services waive their rights to treatment related
                to their
                terminal illnesses; however, they may cancel this election at
                anytime 

               Services
                apply to the hospice diagnosis

            
	
              Emergency
                Services, including Emergency Hospitals, Physicians, and Ambulance
                Services

            	
              HMO
                cannot require authorization as a condition for payment for emergency
                conditions or labor and delivery. Covered services include, but are
                not
                limited to, the following: 

               Emergency
                services based on prudent lay person definition of emergency health
                condition 

               Hospital
                emergency department room and ancillary services and physician services
                24
                hours a day, 7 days a week, both by in-network and out-of­network
                providers 

               Medical
                screening examination 

               Stabilization
                services 

               Access
                to DSHS designated Level 1 and Level II trauma centers or hospitals
                meeting equivalent levels of care for emergency
                services 

               Emergency
                ground, air and water transportation 

               Emergency
                dental services, limited to fractured or dislocated jaw, traumatic
                damage
                to teeth, and removal of cysts.

            
	
              Transplants

            	
              Services
                include, but are not limited to, the following: 

               Using
                up-to-date FDA guidelines, all non-experimental human organ and tissue
                transplants and all forms of non-experimental corneal, bone marrow
                and
                peripheral stem cell transplants, including donor medical
                expenses.

            
	
              Vision
                Benefit

            	
              The
                health plan may reasonably limit the cost of the
                frames/lenses.  Services include: 

               One
                examination of the eyes to determine the need for and prescription
                for
                corrective lenses per 12-month period, without
                authorization 

               One
                pair of non-prosthetic eyewear per 12-month period

            
	
              Chiropractic
                Services

            	
              Services
                do not require physician prescription and are limited to spinal
                subluxation

            
	
              Tobacco
                Cessation  Program

            	
              Covered
                up to $100 for a 12- month period limit for a plan- approved
                program 

               Health
                Plan defines plan-approved program. 

               May
                be subject to formulary requirements.

            
	
              [Value-added
                services]

            	
              See
                Attachment B-3

            

    

    
    

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     CHIP
      EXCLUSIONS FROM COVERED SERVICES

               Inpatient
      and outpatient infertility treatments or reproductive services other than
      prenatal care, labor and delivery, and care related to disease, illnesses,
      or
      abnormalities related to the reproductive system

               Personal
      comfort items including but not limited to personal care kits provided on
      inpatient admission, telephone, television, newborn infant photographs, meals
      for guests of patient, and other articles which are not required for the
      specific treatment of sickness or injury

               Experimental
      and/or investigational medical, surgical or other health care procedures or
      services which are not generally employed or recognized within the medical
      community

               Treatment
      or evaluations required by third parties including, but not limited to, those
      for schools, employment, flight clearance, camps, insurance or
      court

               Private
      duty nursing services when performed on an inpatient basis or in a skilled
      nursing facility.

               Mechanical
      organ replacement devices including, but not limited to artificial
      heart

               Hospital
      services and supplies when confinement is solely for diagnostic testing
      purposes, unless otherwise pre-authorized by Health Plan

               Prostate
      and mammography screening

               Elective
      surgery to correct vision

               Gastric
      procedures for weight loss

               Cosmetic
      surgery/services solely for cosmetic purposes

               Out-of-network
      services not authorized by the Health Plan except for emergency care and
      physician services for a mother and her newborn(s) for a minimum of 48 hours
      following an uncomplicated vaginal delivery and 96 hours following an
      uncomplicated delivery by caesarian section

               Services,
      supplies, meal replacements or supplements provided for weight control or the
      treatment of obesity, except for the services associated with the treatment
      for
      morbid obesity as part of a treatment plan approved by the Health
      Plan

               Acupuncture
      services, naturopathy and hypnotherapy

               Immunizations
      solely for foreign travel

               Routine
      foot care such as hygienic care

               Diagnosis
      and treatment of weak, strained, or flat feet and the cutting or removal of
      corns, calluses and toenails (this does not apply to the removal of nail roots
      or surgical treatment of conditions underlying corns, calluses or ingrown
      toenails)

               Replacement
      or repair of prosthetic devices and durable medical equipment due to misuse,
      abuse or loss when confirmed by the Member or the vendor

               Corrective
      orthopedic shoes

               Convenience
      items

               Orthotics
      primarily used for athletic or recreational purposes

               Custodial
      care (care that assists a child with the activities of daily living, such as
      assistance in walking, getting in and out of bed, bathing, dressing, feeding,
      toileting, special diet preparation, and medication supervision that is usually
      self-administered or provided by a parent. This care does not require the
      continuing attention of trained medical or paramedical personnel.) This
      exclusion does not apply to hospice services.

               Housekeeping

               Public
      facility services and care for conditions that federal, state, or local law
      requires be provided in a public facility or care provided while in the custody
      of legal authorities

               Services
      or supplies received from a nurse, which do not require the skill and training
      of a nurse

               Vision
      training and vision therapy

               Reimbursement
      for school-based physical therapy, occupational therapy, or speech therapy
      services are not covered except when ordered by a Physician/PCP

               Donor
      non-medical expenses

               Charges
      incurred as a donor of an organ when the recipient is not covered under this
      health plan

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Subject:
      Attachment B-2 – Covered Services Version 1.8

    CHIP
      DME/SUPPLIES

    
      	
              SUPPLIES

            	
              COVERED

            	
              EXCLUDED

            	
              COMMENTS/MEMBER
                CONTRACT PROVISIONS

            
	
              Ace
                Bandages

            	 	
              X

            	
              Exception:
                If provided by and billed through the clinic or home care agency
                it is
                covered as an incidental supply.

            
	
              Alcohol,
                rubbing

            	 	
              X

            	
              Over-the-counter
                supply.

            
	
              Alcohol,
                swabs (diabetic)

            	
              X

            	 	
              Over-the-counter
                supply not covered, unless RX provided at time of
                dispensing.

            
	
              Alcohol,
                swabs

            	
              X

            	 	
              Covered
                only when received with IV therapy or central line
                kits/supplies.

            
	
              Ana
                Kit Epinephrine

            	
              X

            	 	
              A
                self-injection kit used by patients highly allergic to bee
                stings.

            
	
              Arm
                Sling

            	
              X

            	 	
              Dispensed
                as part of office visit.

            
	
              Attends
                (Diapers)

            	
              X

            	 	
              Coverage
                limited to children age 4 or over only when prescribed by a physician
                and
                used to provide care for a covered diagnosis as outlined in a treatment
                care plan

            
	
              Bandages

            	 	
              X

            	 
	
              Basal
                Thermometer

            	 	
              X

            	
              Over-the-counter
                supply.

            
	
              Batteries
                – initial

            	
              X

            	
              .

            	
              For
                covered DME items

            
	
              Batteries
                – replacement

            	
              X

            	 	
              For
                covered DME when replacement is necessary due to normal
                use.

            
	
              Betadine

            	 	
              X

            	
              See
                IV therapy supplies.

            
	
              Books

            	 	
              X

            	 
	
              Clinitest

            	
              X

            	 	
              For
                monitoring of diabetes.

            
	
              Colostomy
                Bags

            	 	 	
              See
                Ostomy Supplies.

            
	
              Communication
                Devices

            	 	
               X

            	 
	
              Contraceptive
                Jelly

            	 	
              X

            	
              Over-the-counter
                supply. Contraceptives are not covered under the plan.

            
	
              Cranial
                Head Mold

            	 	
              X

            	 
	
              Diabetic
                Supplies

            	
              X

            	 	
              Monitor
                calibrating solution, insulin syringes, needles, lancets, lancet
                device,
                and glucose strips.

            
	
              Diapers/Incontinent
                Briefs/Chux

            	
              X

            	 	
              Coverage
                limited to children age 4 or over only when prescribed by a physician
                and
                used to provide care for a covered diagnosis as outlined in a treatment
                care plan

            
	
              Diaphragm

            	 	
              X

            	
              Contraceptives
                are not covered under the plan.

            
	
              Diastix

            	
              X

            	 	
              For
                monitoring diabetes.

            
	
              Diet,
                Special

            	 	
              X

            	 
	
              Distilled
                Water

            	 	
              X

            	 
	
              Dressing
                Supplies/Central Line

            	
              X

            	 	
              Syringes,
                needles, Tegaderm, alcohol swabs, Betadine swabs or ointment,
                tape.  Many times these items are dispensed in a kit when
                includes all necessary items for one dressing site
                change.

            
	
              Dressing
                Supplies/Decubitus

            	
              X

            	 	
              Eligible
                for coverage only if receiving covered home care for wound
                care.

            
	
              Dressing
                Supplies/Peripheral IV Therapy

            	
              X

            	 	
              Eligible
                for coverage only if receiving home IV therapy.

            
	
              Dressing
                Supplies/Other

            	 	
               X

            	 
	
              Dust
                Mask

            	 	
              X

            	 
	
              Ear
                Molds

            	
              X

            	 	
              Custom
                made, post inner or middle ear surgery

            
	
              Electrodes

            	
              X

            	 	
              Eligible
                for coverage when used with a covered DME.

            
	
              Enema
                Supplies

            	 	
              X

            	
              Over-the-counter
                supply.

            
	
              Enteral
                Nutrition

            	
              X

            	 	
              Necessary
                supplies (e.g., bags, tubing, connectors, catheters, etc.)
                are

            

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Subject:
      Attachment B-2 – Covered Services Version 1.8

     

    
      	
              SUPPLIES

            	
              COVERED

            	
              EXCLUDED

            	
              COMMENTS/MEMBER
                CONTRACT PROVISIONS

            
	
              Supplies

            	 	 	
              eligible
                for coverage.  Enteral nutrition products are not covered except
                for those prescribed for hereditary metabolic disorders, a non-function
                or
                disease of the structures that normally permit food to reach the
                small
                bowel, or malabsorption due to disease

            
	
              Eye
                Patches

            	
              X

            	 	
              Covered
                for patients with amblyopia.

            
	
              Formula

            	 	
              X

            	
              Exception:
                Eligible for coverage only for chronic hereditary metabolic disorders
                a
                non-function or disease of the structures that normally permit food
                to
                reach the small bowel; or malabsorption due to disease (expected
                to last
                longer than 60 days when prescribed by the physician and authorized
                by
                plan.) Physician documentation to justify prescription of formula
                must
                include: • Identification of a metabolic disorder, dysphagia that results
                in a medical need for a liquid diet, presence of a gastrostomy, or
                disease
                resulting in malabsorption that requires a medically necessary nutritional
                product Does not include formula: • For members who could be sustained on
                an age-appropriate diet. • Traditionally used for infant feeding • In
                pudding form (except for clients with documented oropharyngeal motor
                dysfunction who receive greater than 50 percent of their daily caloric
                intake from this product) • For the primary diagnosis of failure to
                thrive, failure to gain weight, or lack of growth or for infants
                less than
                twelve months of age unless medical necessity is documented and other
                criteria, listed above, are met. Food thickeners, baby food, or other
                regular grocery products that can be blenderized and used with an
                enteral
                system that are not medically necessary, are not covered,
                regardless of whether these regular food products are taken orally
                or
                parenterally.

            
	
              Gloves

            	 	
              X

            	
              Exception:
                Central line dressings or wound care provided by home care
                agency.

            
	
              Hydrogen
                Peroxide

            	 	
              X

            	
              Over-the-counter
                supply.

            
	
              Hygiene
                Items

            	 	
              X

            	 
	
              Incontinent
                Pads

            	
              X

            	 	
              Coverage
                limited to children age 4 or over only when prescribed by a physician
                and
                used to provide care for a covered diagnosis as outlined in a treatment
                care plan

            
	
              Insulin
                Pump (External) Supplies

            	
              X

            	 	
              Supplies
                (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible
                for coverage if the pump is a covered item.

            
	
              Irrigation
                Sets, Wound Care

            	
              X

            	 	
              Eligible
                for coverage when used during covered home care for wound
                care.

            
	
              Irrigation
                Sets, Urinary

            	
              X

            	 	
              Eligible
                for coverage for individual with an indwelling urinary
                catheter.

            
	
              IV
                Therapy Supplies

            	
              X

            	 	
              Tubing,
                filter, cassettes, IV pole, alcohol swabs, needles, syringes and
                any other
                related supplies necessary for home IV therapy.

            
	
              K-Y
                Jelly

            	 	
              X

            	
              Over-the-counter
                supply.

            
	
              Lancet
                Device

            	
              X

            	 	
              Limited
                to one device only.

            
	
              Lancets

            	
              X

            	 	
              Eligible
                for individuals with diabetes.

            
	
              Med
                Ejector

            	
              X

            	 	 
	
              Needles
                and

            	 	 	
              See
                Diabetic Supplies

            

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

       

    

    Subject:
      Attachment B-2 – Covered Services Version 1.8

    
      	
              SUPPLIES

            	
              COVERED

            	
              EXCLUDED

            	
              COMMENTS/MEMBER
                CONTRACT PROVISIONS

            
	
              Syringes/Diabetic

            	 	 	 
	
              Needles
                and Syringes/IV and Central Line

            	 	 	
              See
                IV Therapy and Dressing Supplies/Central Line.

            
	
              Needles
                and Syringes/Other

            	
              X

            	 	
              Eligible
                for coverage if a covered IM or SubQ medication is being administered
                at
                home.

            
	
              Normal
                Saline

            	 	 	
              See
                Saline, Normal

            
	
              Novopen

            	
              X

            	 	 
	
              Ostomy
                Supplies

            	
              X

            	 	
              Items
                eligible for coverage include: belt, pouch, bags, wafer, face plate,
                insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape,
                skin
                prep, adhesives, drain sets, adhesive remover, and pouch deodorant.
                Items
                not eligible for coverage include:  scissors, room deodorants,
                cleaners, rubber gloves, gauze, pouch covers, soaps, and
                lotions.

            
	
              Parenteral
                Nutrition/Supplies

            	
              X

            	 	
              Necessary
                supplies (e.g., tubing, filters, connectors, etc.) are eligible for
                coverage when the Health Plan has authorized the parenteral
                nutrition.

            
	
              Saline,
                Normal

            	
              X

            	 	
              Eligible
                for coverage: a) when used to dilute medications for nebulizer treatments;
                b) as part of covered home care for wound care; c) for indwelling
                urinary
                catheter irrigation.

            
	
              Stump
                Sleeve

            	
              X

            	 	 
	
              Stump
                Socks

            	
              X

            	 	 
	
              Suction
                Catheters

            	
              X

            	 	 
	
              Syringes

            	 	 	
              See
                Needles/Syringes.

            
	
              Tape

            	 	 	
              See
                Dressing Supplies, Ostomy Supplies, IV Therapy
                Supplies.

            
	
              Tracheostomy
                Supplies

            	
              X

            	 	
              Cannulas,
                Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for
                coverage.

            
	
              Under
                Pads

            	 	 	
              See
                Diapers/Incontinent Briefs/Chux.

            
	
              Unna
                Boot

            	
              X

            	 	
              Eligible
                for coverage when part of wound care in the home setting. Incidental
                charge when applied during office visit.

            
	
              Urinary,
                External Catheter & Supplies

            	 	
              X

            	
              Exception:
                Covered when used by incontinent male where injury to the urethra
                prohibits use of an indwelling catheter ordered by the PCP and approved
                by
                the plan

            
	
              Urinary,
                Indwelling Catheter & Supplies

            	
              X

            	 	
              Cover
                catheter, drainage bag with tubing, insertion tray, irrigation set
                and
                normal saline if needed.

            
	
              Urinary,
                Intermittent

            	
              X

            	 	
              Cover
                supplies needed for intermittent or straight
                catherization.

            
	
              Urine
                Test Kit

            	
              X

            	 	
              When
                determined to be medically necessary.

            
	
              Urostomy
                supplies

            	 	 	
              See
                Ostomy Supplies.

            

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    Subject:
      Attachment B-2.1 – STAR+PLUS Covered Services Version 1.8

    DOCUMENT
      HISTORY LOG

    
      	
              STATUS1

            	
              DOCUMENT
                REVISION2

            	
              EFFECTIVE
                DATE

            	
              DESCRIPTION3

            
	
              Baseline

            	
              n/a

            	 	
              Initial
                version of Attachment B-2, Covered Services.

            
	
              Revision

            	
              1.1

            	
              June
                30, 2006

            	
              Revised
                Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS
                Covered Services. This is the initial version of Attachment B-2.1,
                STAR+PLUS Covered Services, which lists the Acute Care Services and
                the
                Community Based Long Term Care Services.

            
	
              Revision

            	
              1.2

            	
              September
                1, 2006

            	
              Contract
                Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
                Services.

            
	
              Revision

            	
              1.3

            	
              September
                1, 2006

            	
              Contract
                Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
                Services.

            
	
              Revision

            	
              1.4

            	
              September
                1, 2006

            	
              Contract
                Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
                Services.

            
	
              Revision

            	
              1.5

            	
              January
                1, 2007

            	
              Revised
                Attachment B-2.1, STAR+PLUS Covered Services, to include inpatient
                and
                outpatient mental health services for adults.

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

            	
              Revised
                Attachment B-2.1, STAR+PLUS Covered Services, to exclude inpatient
                mental
                health services for adults and children, and to establish monetary
                limits
                on Transition Assistance Services. Personal Attendant Services is
                clarified to include the three service delivery options described
                in
                Attachment B­1, Section 8.3.5.  Consumer Directed Personal
                Attendant Services is deleted from the list since it is one of the
                three
                service delivery options under Personal Attendant
                Services.

            
	
              Revision

            	
              1.7

            	
              June
                1, 2007

            	
              Revised
                Attachment B-2.1, STAR+PLUS Covered Services, to include inpatient
                mental
                health services for adults and children and to include effective
                dates by
                service area.

            
	
              Revision

            	
              1.8

            	
              September
                1, 2007

            	
              Contract
                Amendment did not revise Attachment B-2.1- STAR+PLUS Covered
                Services.

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

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

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

            

    

    
    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    STAR+PLUS
      Covered Services

    Acute
      Care Services

    The
      following is a non-exhaustive, high-level listing of Acute Care Covered Services
      included under the STAR+PLUS Medicaid managed care program.

    Medicaid
      HMO Contractors are responsible for providing a benefit package to Members
      that
      includes all medically necessary services covered under the traditional,
      fee-for-service Medicaid programs except for Non-capitated Services provided
      to
      Medicaid Members outside of the HMO capitation and listed in Attachment B-1,
      Section 8.2.2.8. In addition to the non-capitated services listed in Attachment
      B-1, Section 8.2.2.8, Hospital Inpatient Stays are excluded from the capitation
      payment to STAR+PLUS HMOs and are paid through HHSC’s Administrative Contractor
      responsible for payment of Traditional Medicaid fee-for-service claims. Medicaid
      HMO Contractors must coordinate care for Members for these Non-capitated
      Services so that Members have access to a full range of medically necessary
      Medicaid services, both capitated and non-capitated. A Contractor may elect
      to
      offer additional acute care Value-added Services.

    The
      STAR+PLUS Members are provided with two enhanced benefits compared to the
      traditional, fee-for­

    service
      Medicaid coverage:

    1)           waiver
      of the three-prescription per month limit, for members not covered by
      Medicare;

    2)           inclusion
      of an annual adult well check for patients 21 years of age and
      over.

    Medicaid
      HMO Contractors are responsible for providing a benefit package to Members
      that
      includes an annual adult well check for patients 21 years of age and
      over.  Prescription drug benefits to HMO Members are provided outside
      of the HMO capitation.

    STAR+PLUS
      HMO Contractors should refer to the current Texas Medicaid Provider
      Procedures Manual and the bi-monthly Texas Medicaid
      Bulletin for a more inclusive listing of limitations and
      exclusions that apply to each Medicaid benefit category. (These documents can
      be
      accessed online at: http://www.tmhp.com.)

    The
      services listed in this Attachment are subject to modification based on Federal
      and State laws and regulations and Programs policy updates.

    Services
      included under the HMO capitation payment

    •  Ambulance
      services

    •  Audiology
      services, including hearing aids for adults (hearing aids for children are
      provided through the PACT program and are a non-capitated service)

    •  

    •           Behavioral
      Health Services, including:

    •             Inpatient
      mental health services for Adults and Children (Effective 6/01/07 in the Harris
      Service Area; and effective 9/01/07 in the Bexar, Nueces and Travis Service
      Areas.)

    •             Outpatient
      mental health services for Adults and Children

    •             Outpatient
      chemical dependency services for children (under age 21)

    •             Detoxification
      services

    •             Psychiatry
      services

    •             Counseling
      services for adults (21 years of age and over)

    •  

    •           Birthing
      center services

    •           Chiropractic
      services

    •           Dialysis

    •           Durable
      medical equipment and supplies

    •           Emergency
      Services

    •           Family
      planning services

    •           Home
      health care services

    •           Hospital
      services, outpatient

    •           Laboratory

    •           Medical
      check-ups and Comprehensive Care Program (CCP) Services for children (under
      age
      21) through the Texas Health Steps Program

    •           Optometry,
      glasses, and contact lenses, if medically necessary

    •           Podiatry

    •           Prenatal
      care

    •           Primary
      care services

    •           Radiology,
      imaging, and X-rays

    •           Specialty
      physician services

    •           Therapies
      – physical, occupational and speech

    •           Transplantation
      of organs and tissues

    •           Vision

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    Community
      Based Long Term Care Services

    The
      following is a non-exhaustive, high-level listing of Community Based Long Term
      Care Covered Services included under the STAR+PLUS Medicaid managed care
      program.

    •
                Community Based Long
      Term Care Services for all Members

    •           Personal
      Attendant Services – All Members of a STAR+PLUS HMO may receive medically and
      functionally necessary personal attendant services (PAS).

    •           Day
      Activity and Health Services – All Members of a STAR+PLUS HMO may receive
      medically and functionally necessary Day Activity and Health Care Services
      (DAHS).

    •           1915
      (c) Nursing Facility Waiver Services for those Members who qualify for such
      services The state provides an enriched array of services to clients who
      would otherwise qualify for nursing facility care through a Home and Community
      Based Medicaid Waiver.  In traditional Medicaid, this is known as the
      Community Based Alternatives (CBA) waiver.  The STAR+PLUS HMO must
      also provide the services that are available to clients through the CBA waiver
      in traditional Medicaid to those clients that meet the functional and financial
      eligibility for the 1915 (c)
      Nursing Facility Waiver Services.

    •            Personal
      Attendant Services (including the three service delivery options: Self-Directed;
      Agency Model, Self-Directed; and Agency Model)

    •   
Nursing
      Services (in
      home)

    •   
Emergency
      Response Services (Emergency
      call button)

    •           Home
      Delivered Meals

    •          Minor
      Home Modifications

    •  
Adaptive
      Aids and Medical
      Equipment

    •   
Medical
      Supplies

    •   
Physical
      Therapy, Occupational
      Therapy, Speech Therapy

    •           Adult
      Foster Care

    •          
      Assisted Living

    •           Transition
      Assistance Services (These services are limited to a maximum of
      $2,500.00.  If the HMO determines that no other resources are
      available to pay for the basic services/items needed to assist a Member, who
      is
      leaving a nursing facility, with setting up a household, the HMO may authorize
      up to $2,500.00 for Transition Assistance Services (TAS).  The
      $2,500.00 TAS benefit is part of the expense ceiling when determining the Total
      Annual Individual Service Plan (ISP) Cost.)

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      Subject:
        Attachment B-2.2 – CHIP Perinatal Covered Services

    

    

    
      	
              DOCUMENT
                HISTORY LOG

            
	
              STATUS1

            	
              DOCUMENT

              REVISION2

            	
              EFFECTIVE

              DATE

            	
              DESCRIPTION3

            
	
               

              Baseline

               

            	
               

              n/a

               

            	 	
               

              Initial
                version of Attachment B-2, Covered Services

               

            
	
              Revision

            	
              1.1

            	
              June
                30, 2006

            	
              Revised
                Attachment B-2, Covered Services, by adding Attachment B-2.1, STAR+PLUS
                Covered Services.

               

            
	
              Revision

            	
              1.2

            	
              September
                1, 2006

            	
              Revised
                Attachment B-2, Covered Services, by updating provisions applicable
                to
                MCOs participating in the STAR and CHIP Programs.

               

            
	
              Revision

            	
              1.3

            	
              September
                1, 2006

            	
              Revised
                Attachment B-2, Covered Services, by adding Attachment B-2.2, CHIP
                Perinatal Covered Services.  This is the initial version of
                Attachment B-2.2, which lists the CHIP Perinatal Covered Services,
                exclusions and DME/Supplies.

               

            
	
              Revision

            	
              1.4

            	
              September
                1, 2006

            	
              Contract
                Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
                Services.

               

            
	
              Revision

            	
              1.5

            	
              January
                1, 2007

            	
              Contract
                Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
                Services.

               

            
	
              Revision

            	
              1.6

            	
              February
                1, 2007

            	
              Contract
                Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
                Services.

               

            
	
              Revision

            	
              1.7

            	
              July
                1, 2007

            	
              Contract
                Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
                Services.

               

            
	
              Revision

            	
              1.8

            	
              September
                1, 2007

            	
              Contract
                Amendment did not revise Attachment B-2.2- CHIP Perinatal Covered
                Services.

               

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

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

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

            

    

    
    

    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

    CHIP
      Perinatal Program Covered Services

    Covered
      CHIP Perinatal Program services must meet the definition of Medically Necessary
      Covered Services as defined in this Contract.  There
      is no lifetime maximum on benefits; however, 12-month enrollment period or
      lifetime limitations do apply to certain services, as specified in the following
      chart.   Co-pays do not apply to CHIP Perinatal Program
      Members.  CHIP Perinatal Program Members are eligible for 12-months
      continuous coverage following enrollment in the program.

    

    
      	
              Covered

               Benefit

            	
              CHIP
                Perinate Newborn

            	
              CHIP
                Perinate

            
	
              Inpatient
                General Acute and Inpatient Rehabilitation Hospital
                Services

               

            	
              For
                CHIP Perinate Newborns in families with incomes at or below 185%
                of the
                Federal Poverty Level, the facility charges are not a covered benefit
                for
                the initial Perinate Newborn admission; however, facility charges
                are a
                covered benefit after the initial Perinate Newborn admission. "Initial
                Perinate Newborn admission" means the hospitalization associated
                with the
                birth. 

               

              For
                CHIP Perinate Newborns in families with incomes at or below 185%
                of the
                Federal Poverty Level, professional service charges are a covered
                benefit
                for the initial Perinate Newborn admission and subsequent admissions.
                "Initial Perinate Newborn admission" means the hospitalization associated
                with the birth. 

               

              Services
                include, but are not limited to, the following:

               

               Hospital-provided
                Physician or Provider services

               

               Semi-private
                room and board (or private if medically necessary as certified by
                attending)

               

               General
                nursing care

               

               Special
                duty nursing when medically necessary

               

               ICU
                and services

               

               Patient
                meals and special diets

               

               Operating,
                recovery and other treatment rooms

               

               Anesthesia
                and administration (facility technical component)

               Surgical
                dressings, trays, casts, splints

               Drugs,
                medications and biologicals

               Blood
                or blood products that are not provided free-of-charge to the patient
                and
                their administration

               X-rays,
                imaging and other radiological tests (facility technical
                component)

               Laboratory
                and pathology services (facility technical component)

               Machine
                diagnostic tests (EEGs, EKGs, etc.)

               Oxygen
                services and inhalation therapy

               Radiation
                and chemotherapy

               Access
                to DSHS-designated Level III perinatal centers or Hospitals meeting
                equivalentlevels of care

               In-network
                or out-of-network facility and Physician services for a mother and
                her
                newborn(s) for a minimum of 48 hours following an uncomplicated vaginal
                delivery and 96 hours following an uncomplicated delivery by caesarian
                section.

               Hospital,
                physician and related medical services, such as anesthesia, associated
                with dental care

               Surgical
                implants

               Other
                artificial aids including surgical implants

               Implantable
                devices are covered under Inpatient and Outpatient services and do
                not
                count towards the DME 12-month period limit

               

               

            	
              For
                CHIP Perinates in families with incomes at or below 185% of the Federal
                Poverty Level, the facility charges are not a covered benefit; however,
                professional services charges associated with labor with delivery
                are a
                covered benefit.

               

              For
                CHIP Perinates in families with incomes between 186% and 200% of
                the
                Federal Poverty Level, benefits are limited to professional service
                charges and facility charges associated with labor with
                delivery.

               

              Covered
                medically necessary Hospital-provided services are limited to labor
                with
                delivery until birth.

               

              Services
                include:

               

               Operating,
                recovery and other treatment rooms

               

               Anesthesia
                and administration (facility technical component

               

               Medically
                necessary surgical services are limited to services that directly
                relate
                to the delivery of the unborn child.

               

            
	
              Skilled
                Nursing

              Facilities

              (Includes
                Rehabilitation

              Hospitals)

               

               

            	
              Services
                include, but are not limited to, the following:

               Semi-private
                room and board

               Regular
                nursing services

               Rehabilitation
                services

               Medical
                supplies and use of appliances and equipment furnished by the
                facility

               

            	
              Not
                a covered benefit.

            
	
              Outpatient
                Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic
                (Including Health Center) and Ambulatory Health Care
                Center

               

            	
              Services
                include, but are not limited to, the following services provided
                in a
                hospital clinic or emergency room, a clinic or health center,
                hospital-based emergency department or an ambulatory health care
                setting:

               

               X-ray,
                imaging, and radiological tests (technical component)

               

               Laboratory
                and pathology services (technical component)

               

               Machine
                diagnostic tests

               

               Ambulatory
                surgical facility services

               

               Drugs,
                medications and biologicals

               

               Casts,
                splints, dressings

               

               Preventive
                health services

               

               Physical,
                occupational and speech therapy

               

               Renal
                dialysis

               

               Respiratory
                services

               

               Radiation
                and chemotherapy

               

               Blood
                or blood products that are not provided free-of-charge to the patient
                and
                the administration of these products

               

               Facility
                and related medical services, such as anesthesia, associated with
                dental
                care, when provided in a licensed ambulatory surgical
                facility.

               

               Surgical
                implants

               

               Other
                artificial aids including surgical implants

               

               Implantable
                devices are covered under Inpatient and Outpatient services and do
                not
                count towards the DME 12-month period limit.

               

               

               

            	
              Services
                include, the following services provided in a hospital clinic or
                emergency
                room, a clinic or health center, hospital-based emergency department
                or an
                ambulatory health care setting:

               

               X-ray,
                imaging, and radiological tests (technical component)

               

               Laboratory
                and pathology services (technical component)

               

               Machine
                diagnostic tests

               

               Drugs,
                medications and biologicals that are medically necessary prescription
                and
                injection drugs.

               

               

              (1)
                Laboratory and radiological services are limited to services that
                directly
                relate to ante partum care and/or the delivery of the covered CHIP
                Perinate until birth.

               

              (2)
                Ultrasound of the pregnant uterus is a covered benefit when medically
                indicated.  Ultrasound may be indicated for suspected genetic
                defects, high-risk pregnancy, fetal growth retardation, or gestational
                age
                confirmation.

               

              (3)
                Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion (FIUT)
                and
                Ultrasonic Guidance for Cordocentesis, FIUT are covered benefits
                with an
                appropriate diagnosis.

               (4)
                Laboratory tests are limited to:  nonstress testing,
                contraction, stress testing, hemoglobin or hematocrit repeated once
                a
                trimester and at 32-36 weeks of pregnancy; or complete blood count
                (CBC),
                urinanalysis for protein and glucose every visit, blood type and
                RH
                antibody screen; repeat antibody screen for Rh negative women at
                28 weeks
                followed by RHO immune globulin

              administration
                if indicated; rubella antibody titer, serology for syphilis, hepatitis
                B
                surface antigen, cervical cytology, pregnancy test, gonorrhea test,
                urine
                culture, sickle cell test, tuberculosis (TB) test, human immunodeficiency
                virus (HIV) antibody screen, Chlamydia test, other laboratory tests
                not
                specified but deemed medically necessary, and multiple marker screens
                for
                neural tube defects (if the client initiates care between 16 and
                20
                weeks); screen for gestational diabetes at 24-28 weeks of pregnancy;
                other
                lab tests as indicated by medical condition of client.

            
	
              Physician/

              Physician

              Extender
                Professional Services

               

            	
              Services
                include, but are not limited to, the following:

               

               American
                Academy of Pediatrics recommended well-child exams and preventive
                health
                services (including, but not limited to, vision and hearing screening
                and
                immunizations)

               

               Physician
                office visits, in-patient and out-patient services

               

               Laboratory,
                x-rays, imaging and pathology services, including technical component
                and/or professional interpretation

               

               Medications,
                biologicals and materials administered in Physician’s office

               

               Allergy
                testing, serum and injections

               

               Professional
                component (in/outpatient) of surgical services, including:

              - Surgeons
                and assistant surgeons for surgical procedures including appropriate
                follow-up care

              - Administration
                of anesthesia by Physician (other than surgeon) or CRNA

              - Second
                surgical opinions

              - Same-day
                surgery performed in a Hospital without an over-night stay

              - Invasive
                diagnostic procedures such as endoscopic examinations

               Hospital-based
                Physician services (including Physician-performed technical and
                interpretive components)

               

               In-network
                and out-of-network Physician services for a mother and her newborn(s)
                for
                a minimum of 48 hours following an uncomplicated vaginal delivery
                and 96
                hours following an uncomplicated delivery by caesarian
                section.

               

               Physician
                services medically necessary to support a dentist providing dental
                services to a CHIP member such as general anesthesia or intravenous
                (IV)
                sedation.

               

               

               

            	
              Services
                include, but are not limited to the following:

               

               Medically
                necessary physician services are limited to prenatal and postpartum
                care
                and/or the delivery of the covered unborn child until birth

               

               Physician
                office visits, in-patient and out-patient services

               

               Laboratory,
                x-rays, imaging and pathology services including technical component
                and
                /or professional interpretation

               

               Medically
                necessary medications, biologicals and materials administered in
                Physician’s office

               

               Professional
                component (in/outpatient) of surgical services, including:

               

              o Surgeons
                and assistant surgeons for surgical procedures directly related to
                the
                labor with delivery of the covered unborn child until birth.

               

              o Administration
                of anesthesia by Physician (other than surgeon) or CRNA

               

              o Invasive
                diagnostic procedures directly related to the
                labor with delivery of the unborn
                child.

               

               Hospital-based
                Physician services (including Physician performed technical and
                interpretive components)

               

               Professional
                component of the ultrasound of the pregnant uterus when medically
                indicated for suspected genetic defects, high-risk pregnancy, fetal
                growth
                retardation, or gestational age confirmation.

               

               Professional
                component of Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion
                (FIUT) and Ultrasonic Guidance for Amniocentesis, Cordocentrsis,
                and
                FIUT.

               

            
	
              Prenatal
                Care and Pre-Pregnancy Family Services and Supplies

               

               

            	
              Not
                a covered benefit.

            	
              Services
                are limited to an initial visit and subsequent prenatal (ante partum)
                care
                visits that include:

               

              (1)
                One visit every four weeks for the first 28 weeks or
                pregnancy;

              (2)
                one visit every two to three weeks from 28 to 36 weeks of pregnancy;
                and

              (3)
                one visit per week from 36 weeks to delivery.

               

              More
                frequent visits are allowed as Medically Necessary. Benefits are
                limited
                to:

               

              Limit
                of 20 prenatal visits and 2 postpartum visits (maximum within 60
                days)
                without documentation of a complication of pregnancy.  More
                frequent visits may be necessary for high-risk
                pregnancies.  High-risk prenatal visits are not limited to 20
                visits per pregnancy.  Documentation supporting medical
                necessity must be maintained in the physician’s files and is subject to
                retrospective review.

               

              Visits
                after the initial visit must include:

               

               interim
                history (problems, marital status, fetal status);

               

               physical
                examination (weight, blood pressure, fundalheight, fetal position
                and
                size, fetal heart rate, extremities) and

               

               laboratory
                tests (urinanalysis for protein and glucose every visit; hematocrit
                or
                hemoglobin repeated once a trimester and at 32-36 weeks of pregnancy;
                multiple marker screen for fetal abnormalities offered at 16-20 weeks
                of
                pregnancy; repeat antibody screen for Rh negative women at 28 weeks
                followed by Rho immune globulin administration if indicated; screen
                for
                gestational diabetes at 24-28 weeks of pregnancy; and other lab tests
                as
                indicated by medical condition of client).

               

            
	
              Durable
                Medical Equipment (DME), Prosthetic Devices and

              Disposable
                Medical Supplies

               

               

            	
              $20,000
                12-month period limit for DME, prosthetics, devices and disposable
                medical
                supplies (diabetic supplies and equipment are not counted against
                this
                cap).   Services include DME (equipment which can withstand
                repeated use and is primarily and customarily used to serve a medical
                purpose, generally is not useful to a person in the absence of Illness,
                Injury, or Disability, and is appropriate for use in the home), including
                devices and supplies that are medically necessary and necessary for
                one or
                more activities of daily living and appropriate to assist in the
                treatment
                of a medical condition, including:

               Orthotic
                braces and orthotics

               Prosthetic
                devices such as artificial eyes, limbs, and braces

               Prosthetic
                eyeglasses and contact lenses for the management of severe ophthalmologic
                disease

               Hearing
                aids

               Diagnosis-specific
                disposable medical supplies, including diagnosis-specific prescribed
                specialty formula and dietary supplements.  (See Attachment
                A)

               

            	
              Not
                a covered benefit.

            
	
              Home
                and Community Health Services

               

               

               

            	
              Services
                that are provided in the home and community, including, but not limited
                to:

               

               Home
                infusion

               

               Respiratory
                therapy

               

               Visits
                for private duty nursing (R.N., L.V.N.)

               

               Skilled
                nursing visits as defined for home health purposes (may include R.N.
                or
                L.V.N.).

               

               Home
                health aide when included as part of a plan of care during a period
                that
                skilled visits have been approved.

               

               Speech,
                physical and occupational therapies.

               

               Services
                are not intended to replace the CHILD'S caretaker or to provide relief
                for
                the caretaker

               

               Skilled
                nursing visits are provided on intermittent level and not intended
                to
                provide 24-hour skilled nursing services

               

               Services
                are not intended to replace 24-hour inpatient or skilled nursing
                facility
                services

               

               

               

            	
              Not
                a covered benefit.

            
	
              Inpatient
                Mental Health Services

               

            	
              Mental
                health services, including for serious mental illness, furnished
                in a
                free-standing psychiatric hospital, psychiatric units of general
                acute
                care hospitals and state-operated facilities, including, but not
                limited
                to:

               Neuropsychological
                and psychological testing.

               Inpatient
                mental health services are limited to:

               45
                days 12-month inpatient limit

               Includes
                inpatient psychiatric services, up to 12-month period limit, ordered
                by a
                court of competent jurisdiction under the provisions of Chapters
                573 and
                574 of the Texas Health and Safety Code, relating to court ordered
                commitments to psychiatric facilities. Court order serves as binding
                determination of medical necessity. Any modification or termination
                of
                services must be presented to the court with jurisdiction over the
                matter
                for determination

               25
                days of the inpatient benefit can be converted to residential treatment,
                therapeutic foster care or other 24-hour therapeutically planned
                and
                structured services or sub-acute outpatient (partial hospitalization
                or
                rehabilitative day treatment) mental health services on the basis
                of
                financial equivalence against the inpatient per diem cost

               20
                of the inpatient days must be held in reserve for inpatient use
                only

               Does
                not require PCP referral

               

            	
              Not
                a covered benefit.

            
	
              Outpatient
                Mental Health Services

               

            	
              Mental
                health services, including for serious mental illness, provided on
                an
                outpatient basis, including, but not limited to:

               Medication
                management visits do not count against the outpatient visit
                limit.

               The
                visits can be furnished in a variety of community-based settings
                (including school and home-based) or in a state-operated
                facility

               Up
                to 60 days 12-month period limit for rehabilitative day
                treatment

               60
                outpatient visits 12-month period limit

               60
                rehabilitative day treatment days can be converted to outpatient
                visits on
                the basis of financial equivalence against the day treatment per
                diem
                cost

               60
                outpatient visits can be converted to skills training (psycho educational
                skills development) or rehabilitative day treatment on the basis
                of
                financial equivalence against the outpatient visit cost

               Includes
                outpatient psychiatric services, up to 12-month period limit, ordered
                by a
                court of competent jurisdiction under the provisions of Chapters
                573 and
                574 of the Texas Health and Safety Code, relating to court ordered
                commitments to psychiatric facilities. Court order serves as binding
                determination of medical necessity. Any modification or termination
                of
                services must be presented to the court with jurisdiction over the
                matter
                for determination

               Inpatient
                days converted to sub-acute outpatient services are in addition to
                the
                outpatient limits and do not count towards those limits

               A
                Qualified Mental Health Professional (QMHP), as defined by and
                credentialed through Texas Department of State Health Services (DSHS)
                standards (TAC Title 25, Part II, Chapter 412), is a Local Mental
                Health
                Authorities provider. A QMHP must be working under the authority
                of an
                DSHS entity and be supervised by a licensed mental health professional
                or
                physician. QMHPs are acceptable providers as long as the services
                would be
                within the scope of the services that are typically provided by QMHPs.
                Those services include individual and group skills training (which
                can be
                components of interventions such as day treatment and in-home services),
                patient and family education, and crisis services

               Does
                not require PCP referral

               

            	
              Not
                a covered benefit.

            
	
              Inpatient
                Substance Abuse Treatment Services

               

            	
              Services
                include, but are not limited to:

               

               Inpatient
                and residential substance abuse treatment services including
                detoxification and crisis stabilization, and 24-hour residential
                rehabilitation programs

               

               

               Does
                not require PCP referral

               

               Medically
                necessary   detoxification/stabilization services, limited
                to 14 days per 12-month period.

               

               24-hour
                residential rehabilitation programs, or the equivalent, up to 60
                days per
                12-month period

               

               30
                days may be converted to partial hospitalization or intensive outpatient
                rehabilitation, on the basis of financial equivalence against the
                inpatient per diem cost

               

               30
                days must be held in reserve for inpatient use only.

               

               

               

            	
              Not
                a covered benefit.

            
	
              Outpatient
                Substance Abuse Treatment Services

               

            	
               

               Services
                include, but are not limited to, the following:

               Prevention
                and intervention services that are provided by physician and non-physician
                providers, such as screening, assessment and referral for chemical
                dependency disorders.

               Intensive
                outpatient services is defined as an organized non-residential service
                providing structured group and individual therapy, educational services,
                and life skills training which consists of at least 10 hours per
                week for
                four to 12 weeks, but less than 24 hours per day

               Outpatient
                treatment service is defined as consisting of at least one to two
                hours
                per week providing structured group and individual therapy, educational
                services, and life skills training

               Outpatient
                treatment services up to a maximum of:

               Intensive
                outpatient program (up to 12 weeks per 12-month period)

               Outpatient
                services (up to six-months per 12-month period)

               Does
                not require PCP referral

               

            	
              Not
                a covered benefit.

            
	
              Rehabilitation
                Services

               

               

            	
              Services
                include, but are not limited to, the following:

               

               Habilitation
                (the process of supplying a child with the means to reach age-appropriate
                developmental milestones through therapy or treatment) and rehabilitation
                services include, but are not limited to the following:

               

               Physical,
                occupational and speech therapy

               

               Developmental
                assessment

               

               

               

            	
              Not
                a covered benefit.

            
	
              Hospice
                Care Services

               

            	
              Services
                include, but are not limited to:

               

               Palliative
                care, including medical and support services, for those children
                who have
                six months or less to live, to keep patients comfortable during the
                last
                weeks and months before death

               

               Treatment
                for unrelated conditions is unaffected

               

               Up
                to a maximum of 120 days with a 6 month life expectancy

               

               Patients
                electing hospice services waive their rights to treatment related
                to their
                terminal illnesses; however, they may cancel this election at
                anytime

               

               Services
                apply to the hospice diagnosis

               

               

               

            	
              Not
                a covered benefit.

            
	
              Emergency
                Services, including Emergency Hospitals, Physicians, and Ambulance
                Services

               

            	
              HMO
                cannot require authorization as a condition for payment for emergency
                conditions labor and

              delivery.

               

              Covered
                services include, but are not limited to, the following:

               

               Emergency
                services based on prudent lay person definition of emergency health
                condition

               

               Hospital
                emergency department room and ancillary services and physician services
                24
                hours a day, 7 days a week, both by in-network and out-of-network
                providers

               

               Medical
                screening examination 

               

               Stabilization
                services

               

               Access
                to DSHS designated Level 1 and Level II trauma centers or hospitals
                meeting equivalent levels of care for emergency services

               

               Emergency
                ground, air and water transportation

               

               Emergency
                dental services, limited to fractured or dislocated jaw, traumatic
                damage
                to teeth, and removal of cysts.

               

               

               

            	
              HMO
                cannot require authorization as a condition for payment for emergency
                conditions related to labor with delivery.

               

              Covered
                services are limited to those emergency services that are directly
                related
                to the delivery of the unborn child until birth.

               

               

               Emergency
                services based on prudent lay person definition of emergency health
                condition

               

               Medical
                screening examination to determine emergency when directly related
                to the
                delivery of the covered unborn child.

               

               Stabilization
                services related to the labor with delivery of the covered unborn
                child.

               

               Emergency
                ground, air and water transportation for labor and threatened labor
                is a
                covered benefit

               

               

              Benefit
                limits:  Post-delivery services or complications resulting in
                the need for emergency services for the mother of the CHIP Perinate
                are
                not a covered benefit.

            
	
              Transplants

               

            	
              Services
                include, but are not limited to, the following:

               

               Using
                up-to-date FDA guidelines, all non-experimental human organ and tissue
                transplants and all forms of non-experimental corneal, bone marrow
                and
                peripheral stem cell transplants, including donor medical
                expenses.

               

               

               

            	
              Not
                a covered benefit.

            
	
              Vision
                Benefit

               

               

               

               

            	
              The
                health plan may reasonably limit the cost of the
                frames/lenses.

              Services
                include:

               

               One
                examination of the eyes to determine the need for and prescription
                for
                corrective lenses per 12-month period, without authorization

               

               One
                pair of non-prosthetic eyewear per 12-month period

               

               

               

            	
              Not
                a covered benefit.

            
	
              Chiropractic
                Services

               

            	
               

               

               Services
                do not require physician prescription and are limited to spinal
                subluxation.

               

               

               

            	
              Not
                a covered benefit.

            
	
              Tobacco
                Cessation

              Program

               

            	
              Covered
                up to $100 for a 12- month period limit for a plan- approved
                program

               

               Health
                Plan defines plan-approved program.

               

               May
                be subject to formulary requirements.

               

               

               

            	
              Not
                a covered benefit.

            
	
              Case
                Management and Care Coordination Services

               

               

            	
              These
                services include outreach informing, case management, care coordination
                and community referral.

            	
              Covered
                benefit.

               

               

            
	
              Value-added
                services

            	
              See
                Attachment B-3.2

            	 

    

    
    

    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    

     CHIP
      PERINATAL PROGRAM EXCLUSIONS FROM COVERED SERVICES FOR CHIP
      PERINATES

    

    

    
      	
              •

            	
              For
                CHIP Perinates in families with incomes at or below 185% of the Federal
                Poverty Level, inpatient facility charges are not a covered benefit
                for
                the initial Perinatal Newborn admission. "Initial Perinatal Newborn
                admission" means the hospitalization associated with the birth. 

            

    

    
      	
              •

            	
               Inpatient
                and outpatient treatments other than prenatal care, labor with delivery,
                and postpartum care related to the covered unborn child until
                birth.

            

    

    
      	
              •

            	
               Inpatient
                mental health services.

            

    

    
      	
              •

            	
               Outpatient
                mental health services.

            

    

    
      	
              •

            	
               Durable
                medical equipment or other medically related remedial
                devices.

            

    

    
      	
              •

            	
               Disposable
                medical supplies.

            

    

    
      	
              •

            	
               Home
                and community-based health care
                services.

            

    

    
      	
              •

            	
               Nursing
                care services.

            

    

    
      	
              •

            	
               Dental
                services.

            

    

    
      	
              •

            	
               Inpatient
                substance abuse treatment services and residential substance abuse
                treatment services.

            

    

    
      	
              •

            	
               Outpatient
                substance abuse treatment services.

            

    

    
      	
              •

            	
               Physical
                therapy, occupational therapy, and services for individuals with
                speech,
                hearing, and language disorders.

            

    

    
      	
              •

            	
               Hospice
                care.

            

    

    
      	
              •

            	
               Skilled
                nursing facility and rehabilitation hospital
                services.

            

    

    
      	
              •

            	
               Emergency
                services other than those directly related to the labor with delivery
                of
                the covered unborn child.

            

    

    
      	
              •

            	
               Transplant
                services.

            

    

    
      	
              •

            	
               Tobacco
                Cessation Programs.

            

    

    
      	
              •

            	
               Chiropractic
                Services.

            

    

    
      	
              •

            	
               Medical
                transportation not directly related to the labor or threatened labor
                and/or delivery of the covered unborn
                child.

            

    

    
      	
              •

            	
               Personal
                comfort items including but not limited to personal care kits provided
                on
                inpatient admission, telephone, television, newborn infant photographs,
                meals for guests of patient, and other articles which are not required
                for
                the specific treatment related to labor with delivery or post partum
                care.

            

    

    
      	
              •

            	
               Experimental
                and/or investigational medical, surgical or other health care procedures
                or services which are not generally employed or recognized within
                the
                medical community

            

    

    
      	
              •

            	
               Treatment
                or evaluations required by third parties including, but not limited
                to,
                those for schools, employment, flight clearance, camps, insurance
                or
                court

            

    

    
      	
              •

            	
               Private
                duty nursing services when performed on an inpatient basis or in
                a skilled
                nursing facility.

            

    

    
      	
              •

            	
               Mechanical
                organ replacement devices including, but not limited to artificial
                heart

            

    

    
      	
              •

            	
               Hospital
                services and supplies when confinement is solely for diagnostic testing
                purposes and not a part of labor with
                delivery

            

    

    
      	
              •

            	
               Prostate
                and mammography screening

            

    

    
      	
              •

            	
               Elective
                surgery to correct vision

            

    

    
      	
              •

            	
               Gastric
                procedures for weight loss

            

    

    
      	
              •

            	
               Cosmetic
                surgery/services solely for cosmetic
                purposes

            

    

    
      	
              •

            	
               Out-of-network
                services not authorized by the Health Plan except for emergency care
                related to the labor with delivery of the covered unborn
                child.

            

    

    
      	
              •

            	
               Services,
                supplies, meal replacements or supplements provided for weight control
                or
                the treatment of obesity

            

    

    
      	
              •

            	
               Acupuncture
                services, naturopathy and
                hypnotherapy

            

    

    
      	
              •

            	
               Immunizations
                solely for foreign travel

            

    

    
      	
              •

            	
               Routine
                foot care such as hygienic care

            

    

    
      	
              •

            	
               Diagnosis
                and treatment of weak, strained, or flat feet and the cutting or
                removal
                of corns, calluses and toenails (this does not apply to the removal
                of
                nail roots or surgical treatment of conditions underlying corns,
                calluses
                or ingrown toenails) 

            

    

    
      	
              •

            	
               Corrective
                orthopedic shoes

            

    

    
      	
              •

            	
               Convenience
                items

            

    

    
      	
              •

            	
               Orthotics
                primarily used for athletic or recreational
                purposes

            

    

    
      	
              •

            	
               Custodial
                care (care that assists with the activities of daily living, such
                as
                assistance in walking, getting in and out of bed, bathing, dressing,
                feeding, toileting, special diet preparation, and medication supervision
                that is usually self-administered or provided by a caregiver. This
                care
                does not require the continuing attention of trained medical or
                paramedical personnel.)

            

    

    
      	
              •

            	
               Housekeeping

            

    

    
      	
              •

            	
               Public
                facility services and care for conditions that federal, state, or
                local
                law requires be provided in a public facility or care provided while
                in
                the custody of legal authorities

            

    

    
      	
              •

            	
               Services
                or supplies received from a nurse, which do not require the skill
                and
                training of a nurse

            

    

    
      	
              •

            	
               Vision
                training, vision therapy, or vision
                services

            

    

    
      	
              •

            	
               Reimbursement
                for school-based physical therapy, occupational therapy, or speech
                therapy
                services are not covered

            

    

    
      	
              •

            	
               Donor
                non-medical expenses

            

    

    
      	
              •

            	
               Charges
                incurred as a donor of an organ

            

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    CHIP
      PERINATAL PROGRAM EXCLUSIONS FROM
      COVERED SERVICES FOR CHIP PERINATE NEWBORNS

    

    With
      the
      exception of the first bullet, all the following exclusions match those found
      in
      the CHIP Program.

    

    
      	
              •

            	
               For
                CHIP Perinate Newborns in families with incomes at or below 185%
                of the
                Federal Poverty Level, inpatient facility charges are not a covered
                benefit for the initial Perinate Newborn admission.  "Initial
                Perinate Newborn admission" means the hospitalization associated
                with the
                birth.

            

    

    
      	
              •

            	
               Inpatient
                and outpatient infertility treatments or reproductive services other
                than
                prenatal care, labor and delivery, and care related to disease, illnesses,
                or abnormalities related to the reproductive
                system

            

    

    
      	
              •

            	
               Personal
                comfort items including but not limited to personal care kits provided
                on
                inpatient admission, telephone, television, newborn infant photographs,
                meals for guests of patient, and other articles which are not required
                for
                the specific treatment of sickness or
                injury

            

    

    
      	
              •

            	
               Experimental
                and/or investigational medical, surgical or other health care procedures
                or services which are not generally employed or recognized within
                the
                medical community

            

    

    
      	
              •

            	
               Treatment
                or evaluations required by third parties including, but not limited
                to,
                those for schools, employment, flight clearance, camps, insurance
                or
                court

            

    

    
      	
              •

            	
               Private
                duty nursing services when performed on an inpatient basis or in
                a skilled
                nursing facility.

            

    

    
      	
              •

            	
               Mechanical
                organ replacement devices including, but not limited to artificial
                heart

            

    

    
      	
              •

            	
               Hospital
                services and supplies when confinement is solely for diagnostic testing
                purposes, unless otherwise pre-authorized by Health
                Plan

            

    

    
      	
              •

            	
               Prostate
                and mammography screening

            

    

    
      	
              •

            	
               Elective
                surgery to correct vision

            

    

    
      	
              •

            	
               Gastric
                procedures for weight loss

            

    

    
      	
              •

            	
               Cosmetic
                surgery/services solely for cosmetic
                purposes

            

    

    
      	
              •

            	
               Out-of-network
                services not authorized by the Health Plan except for emergency care
                and
                physician services for a mother and her newborn(s) for a minimum
                of 48
                hours following an uncomplicated vaginal delivery and 96 hours following
                an uncomplicated delivery by caesarian
                section

            

    

    
      	
              •

            	
               Services,
                supplies, meal replacements or supplements provided for weight control
                or
                the treatment of obesity, except for the services associated with
                the
                treatment for morbid obesity as part of a treatment plan approved
                by the
                Health Plan

            

    

    
      	
              •

            	
               Acupuncture
                services, naturopathy and
                hypnotherapy

            

    

    
      	
              •

            	
               Immunizations
                solely for foreign travel

            

    

    
      	
              •

            	
               Routine
                foot care such as hygienic care

            

    

    
      	
              •

            	
               Diagnosis
                and treatment of weak, strained, or flat feet and the cutting or
                removal
                of corns, calluses and toenails (this does not apply to the removal
                of
                nail roots or surgical treatment of conditions underlying corns,
                calluses
                or ingrown toenails)

            

    

    
      	
              •

            	
               Replacement
                or repair of prosthetic devices and durable medical equipment due
                to
                misuse, abuse or loss when confirmed by the Member or the vendor
                

            

    

    
      	
              •

            	
               Corrective
                orthopedic shoes

            

    

    
      	
              •

            	
               Convenience
                items

            

    

    
      	
              •

            	
               Orthotics
                primarily used for athletic or recreational
                purposes

            

    

    
      	
              •

            	
               Custodial
                care (care that assists a child with the activities of daily living,
                such
                as assistance in walking, getting in and out of bed, bathing, dressing,
                feeding, toileting, special diet preparation, and medication supervision
                that is usually self-administered or provided by a parent. This care
                does
                not require the continuing attention of trained medical or paramedical
                personnel.)  This exclusion does not apply to hospice
                services.

            

    

    
      	
              •

            	
               Housekeeping

            

    

    
      	
              •

            	
               Public
                facility services and care for conditions that federal, state, or
                local
                law requires be provided in a public facility or care provided while
                in
                the custody of legal authorities

            

    

    
      	
              •

            	
               Services
                or supplies received from a nurse, which do not require the skill
                and
                training of a nurse

            

    

    
      	
              •

            	
               Vision
                training and vision therapy

            

    

    
      	
              •

            	
               Reimbursement
                for school-based physical therapy, occupational therapy, or speech
                therapy
                services are not covered except when ordered by a
                Physician/PCP

            

    

    
      	
              •

            	
               Donor
                non-medical expenses

            

    

    
      	
              •

            	
               Charges
                incurred as a donor of an organ when the recipient is not covered
                under
                this health plan

            

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    CHIP
&
CHIP
      PERINATAL PROGRAM
      DME/SUPPLIES

    Note:  DME/SUPPLIES
      are not a covered benefit for CHIP Perinate Members but are a benefit for CHIP
      Perinate Newborns.

    

    
      	
              SUPPLIES

            	
              COVERED

            	
              EXCLUDED

            	
              COMMENTS/MEMBER

              CONTRACT
                PROVISIONS

            
	
              Ace
                Bandages

            	 	
              X

            	
              Exception:
                If provided by and billed through the clinic or home care agency
                it is
                covered as an incidental supply.

            
	
              Alcohol,
                rubbing

            	 	
              X

            	
              Over-the-counter
                supply.

            
	
              Alcohol,
                swabs (diabetic)

            	
              X

            	 	
              Over-the-counter
                supply not covered, unless RX provided at time of
                dispensing.

            
	
              Alcohol,
                swabs

            	
              X

            	 	
              Covered
                only when received with IV therapy or central line
                kits/supplies.

            
	
              Ana
                Kit Epinephrine

            	
              X

            	 	
              A
                self-injection kit used by patients highly allergic to bee
                stings.

            
	
              Arm
                Sling

            	
              X

            	 	
              Dispensed
                as part of office visit.

            
	
              Attends
                (Diapers)

            	
              X

            	 	
              Coverage
                limited to children age 4 or over only when prescribed by a physician
                and
                used to provide care for a covered diagnosis as outlined in a treatment
                care plan.

            
	
              Bandages

            	 	
              X

            	 
	
              Basal
                Thermometer

            	 	
              X

            	
              Over-the-counter
                supply.

            
	
              Batteries
                – initial

            	
              X

            	
              .

            	
              For
                covered DME items

            
	
              Batteries
                – replacement

            	
              X

            	 	
              For
                covered DME when replacement is necessary due to normal
                use.

            
	
              Betadine

            	 	
              X

            	
              See
                IV therapy supplies.

            
	
              Books

            	 	
              X

            	 
	
              Clinitest

            	
              X

            	 	
              For
                monitoring of diabetes.

            
	
              Colostomy
                Bags

            	 	 	
              See
                Ostomy Supplies.

            
	
              Communication
                Devices

            	 	
              X

            	 
	
              Contraceptive
                Jelly

            	 	
              X

            	
              Over-the-counter
                supply. Contraceptives are not covered under the plan.

            
	
              Cranial
                Head Mold

            	 	
              X

            	 
	
              Diabetic
                Supplies

            	
              X

            	 	
              Monitor
                calibrating solution, insulin syringes, needles, lancets, lancet
                device,
                and glucose strips.

            
	
              Diapers/Incontinent
                Briefs/Chux

            	
              X

            	 	
              Coverage
                limited to children age 4 or over only when prescribed by a physician
                and
                used to provide care for a covered diagnosis as outlined in a treatment
                care plan

            
	
              Diaphragm

            	 	
              X

            	
              Contraceptives
                are not covered under the plan.

            
	
              Diastix

            	
              X

            	 	
              For
                monitoring diabetes.

            
	
              Diet,
                Special

            	 	
              X

            	 
	
              Distilled
                Water

            	 	
              X

            	 
	
              Dressing
                Supplies/Central Line

            	
              X

            	 	
              Syringes,
                needles, Tegaderm, alcohol swabs, Betadine swabs or ointment,
                tape.  Many times these items are dispensed in a kit when
                includes all necessary items for one dressing site
                change.

            
	
              Dressing
                Supplies/Decubitus

            	
              X

            	 	
              Eligible
                for coverage only if receiving covered home care for wound
                care.

            
	
              Dressing
                Supplies/Peripheral IV Therapy

            	
              X

            	 	
              Eligible
                for coverage only if receiving home IV therapy.

            
	
              Dressing
                Supplies/Other

            	 	
              X

            	 
	
              Dust
                Mask

            	 	
              X

            	 
	
              Ear
                Molds

            	
              X

            	 	
              Custom
                made, post inner or middle ear surgery

            
	
              Electrodes

            	
              X

            	 	
              Eligible
                for coverage when used with a covered DME.

            
	
              Enema
                Supplies

            	 	
              X

            	
              Over-the-counter
                supply.

            
	
              Enteral
                Nutrition Supplies

            	
              X

            	 	
              Necessary
                supplies (e.g., bags, tubing, connectors, catheters, etc.) are eligible
                for coverage.  Enteral nutrition products are not covered except
                for those prescribed for hereditary metabolic disorders, a non-function
                or
                disease of the structures that normally permit food to reach the
                small
                bowel, or malabsorption due to disease

            
	
              Eye
                Patches

            	
              X

            	 	
              Covered
                for patients with amblyopia.

            
	
              Formula

            	 	
              X

            	
              Exception:
                Eligible for coverage only for chronic hereditary metabolic disorders
                a
                non-function or disease of the structures that normally permit food
                to
                reach the small bowel; or malabsorption due to disease (expected
                to last
                longer than 60 days when prescribed by the physician and authorized
                by
                plan.)  Physician documentation to justify prescription of
                formula must include:

               

              • Identification
                of a metabolic disorder, dysphagia that results in a medical need
                for a
                liquid diet, presence of a gastrostomy, or disease resulting in
                malabsorption that requires a medically necessary nutritional
                product

               

              Does
                not include formula:

               

              • For
                members who could be sustained on an age-appropriate diet.

               

              • Traditionally
                used for infant feeding

               

              • In
                pudding form (except for clients with documented oropharyngeal motor
                dysfunction who receive greater than 50 percent of their daily caloric
                intake from this product)

               

              • For
                the primary diagnosis of failure to thrive, failure to gain weight,
                or
                lack of growth or for infants less than twelve months of age unless
                medical necessity is documented and other criteria, listed above,
                are
                met.

               

               

              Food
                thickeners, baby food, or other regular grocery products that can
                be
                blenderized and used with an enteral system that are not
                medically necessary, are not covered, regardless of whether these
                regular
                food products are taken orally or parenterally.

            
	
              Gloves

            	 	
              X

            	
              Exception:  Central
                line dressings or wound care provided by home care
                agency.

            
	
              Hydrogen
                Peroxide

            	 	
              X

            	
              Over-the-counter
                supply.

            
	
              Hygiene
                Items

            	 	
              X

            	 
	
              Incontinent
                Pads

            	
              X

            	 	
              Coverage
                limited to children age 4 or over only when prescribed by a physician
                and
                used to provide care for a covered diagnosis as outlined in a treatment
                care plan

            
	
              Insulin
                Pump (External) Supplies

            	
              X

            	 	
              Supplies
                (e.g., infusion sets, syringe reservoir and dressing, etc.) are eligible
                for coverage if the pump is a covered item.

            
	
              Irrigation
                Sets, Wound Care

            	
              X

            	 	
              Eligible
                for coverage when used during covered home care for wound
                care.

            
	
              Irrigation
                Sets, Urinary

            	
              X

            	 	
              Eligible
                for coverage for individual with an indwelling urinary
                catheter.

            
	
              IV
                Therapy Supplies

            	
              X

            	 	
              Tubing,
                filter, cassettes, IV pole, alcohol swabs, needles, syringes and
                any other
                related supplies necessary for home IV therapy.

            
	
              K-Y
                Jelly

            	 	
              X

            	
              Over-the-counter
                supply.

            
	
              Lancet
                Device

            	
              X

            	 	
              Limited
                to one device only.

            
	
              Lancets

            	
              X

            	 	
              Eligible
                for individuals with diabetes.

            
	
              Med
                Ejector

            	
              X

            	 	 
	
              Needles
                and Syringes/Diabetic

            	 	 	
              See
                Diabetic Supplies

            
	
              Needles
                and Syringes/IV and Central Line

            	 	 	
              See
                IV Therapy and Dressing Supplies/Central Line.

            
	
              Needles
                and Syringes/Other

            	
              X

            	 	
              Eligible
                for coverage if a covered IM or SubQ medication is being administered
                at
                home.

            
	
              Normal
                Saline

            	 	 	
              See
                Saline, Normal

            
	
              Novopen

            	
              X

            	 	 
	
              Ostomy
                Supplies

            	
              X

            	 	
              Items
                eligible for coverage include: belt, pouch, bags, wafer, face plate,
                insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape,
                skin
                prep, adhesives, drain sets, adhesive remover, and pouch
                deodorant.

              Items
                not eligible for coverage include:  scissors, room deodorants,
                cleaners, rubber gloves, gauze, pouch covers, soaps, and
                lotions.

            
	
              Parenteral
                Nutrition/Supplies

            	
              X

            	 	
              Necessary
                supplies (e.g., tubing, filters, connectors, etc.) are eligible for
                coverage when the Health Plan has authorized the parenteral
                nutrition.

            
	
              Saline,
                Normal

            	
              X

            	 	
              Eligible
                for coverage:

              a)
                when used to dilute medications for nebulizer treatments;

              b)
                as part of covered home care for wound care;

              c)
                for indwelling urinary catheter irrigation.

            
	
              Stump
                Sleeve

            	
              X

            	 	 
	
              Stump
                Socks

            	
              X

            	 	 
	
              Suction
                Catheters

            	
              X

            	 	 
	
              Syringes

            	 	 	
              See
                Needles/Syringes.

            
	
              Tape

            	 	 	
              See
                Dressing Supplies, Ostomy Supplies, IV Therapy
                Supplies.

            
	
              Tracheostomy
                Supplies

            	
              X

            	 	
              Cannulas,
                Tubes, Ties, Holders, Cleaning Kits, etc. are eligible for
                coverage.

            
	
              Under
                Pads

            	 	 	
              See
                Diapers/Incontinent Briefs/Chux.

            
	
              Unna
                Boot

            	
              X

            	 	
              Eligible
                for coverage when part of wound care in the home
                setting.  Incidental charge when applied during office
                visit.

            
	
              Urinary,
                External Catheter & Supplies

            	 	
              X

            	
              Exception:  Covered
                when used by incontinent male where injury to the urethra prohibits
                use of
                an indwelling catheter ordered by the PCP and approved by the
                plan

            
	
              Urinary,
                Indwelling Catheter & Supplies

            	
              X

            	 	
              Cover
                catheter, drainage bag with tubing, insertion tray, irrigation set
                and
                normal saline if needed.

            
	
              Urinary,
                Intermittent

            	
              X

            	 	
              Cover
                supplies needed for intermittent or straight
                catherization.

            
	
              Urine
                Test Kit

            	
              X

            	 	
              When
                determined to be medically necessary.

            
	
              Urostomy
                supplies

            	 	 	
              See
                Ostomy Supplies.

            

    

    
    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Contractual
      Document (CD) 

    Responsible
      Office: HHSC Office of General Counsel (OGC)

    
      Subject:
        Attachment B-3 – Value-added Services

      Version
        1.8

      

      DOCUMENT
        HISTORY LOG

      
        	
                STATUS1

              	
                DOCUMENT
                  REVISION2

              	
                EFFECTIVE
                  DATE

              	
                DESCRIPTION3

              
	
                Baseline

              	
                n/a

              	 	
                Initial
                  version of Attachment B-3, Value-added Services.

              
	
                Revision

              	
                1.1

              	
                June
                  30, 2006

              	
                Contract
                  amendment did not revise Attachment B-3, Value-added
                  Services.

              
	
                Revision

              	
                1.2

              	
                September
                  1. 2006

              	
                Revised
                  Physical Health Value-added Services to include Home Visits to
                  New
                  Mothers. Revised the certification provision by changing the start
                  date
                  for the 12-month provision of services.

              
	
                Revision

              	
                1.3

              	
                September
                  1, 2006

              	
                Contract
                  amendment did not revise Attachment B-3, Value-added
                  Services.

              
	
                Revision

              	
                1.4

              	
                September
                  1, 2006

              	
                Contract
                  amendment removed the separate signature requirement for Attachment
                  B-3,
                  Value-added Services. By signing the Contract and/or Contract Amendment,
                  the HMO certifies that it will provide the Value-added Services
                  from
                  September 1, 2006 through August 31, 2007.

              
	
                Revision

              	
                1.5

              	
                January
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-3, Value-added
                  Services.

              
	
                Revision

              	
                1.6

              	
                February
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-3, Value-added
                  Services.

              
	
                Revision

              	
                1.7

              	
                July
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-3, Value-added
                  Services.

              
	
                Revision

              	
                1.8

              	
                September
                  1, 2007

              	
                Revised
                  Attachment B-3, Value-added Services, to reflect newly negotiated
                  Value-added Services for FY 2008.

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

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

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

              

      

      
      

       

      
 

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

      Subject:
        Attachment B-3 – Value-added Services

      Version
        1.8

      

      ATTACHMENT
        B-3: VALUE-ADDED SERVICES 

      September
        1, 2007 – August 31, 2008

       

      HMO:
        Superior HealthPlan, Inc. HMO 

      PROGRAM:
        CHIP

      SERVICE
        AREA(S):Bexar, El Paso, Lubbock, Nueces, and Travis

      
        	 	
                Physical
                  Health Value-added Services

              	 
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	
                Vision

              	
                20%
                  discount off of Upgraded Hardware- The Member will receive a 20%
                  discount
                  on upgraded hardware.

              	
                There
                  is no limitation on the number of times the discount can be
                  utilized.

              	
                TVHP
                  contracted providers.

              
	
                Pharmacy

              	
                Provides
                  members with a $15.00 per household per quarter credit toward over
                  the
                  counter medications and supplies.

              	
                Services
                  must be sought from contracted pharmacies only. Items eligible
                  for
                  purchase under this benefit are over-the-counter, health related
                  items
                  only.

              	
                Pharmacy
                  Data Management contracted providers.

              
	 	 	 	 

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

      Subject:
        Attachment B-3 – Value-added Services

      Version
        1.8

      
        	
              	
                Physical
                  Health Value-added Services

              	 
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	
                Transportation

              	
                For
                  Members in need of transportation that cannot access transportation
                  in a
                  timely manner, Superior will provide bus tokens to ensure that
                  Members
                  have a means of accessing their provider appointment.

              	
                
                  Members
                    in the Nueces Service Area.
                    The transportation Authority
                    in this area will not agree
                    to allow the plan to purchase
                    bus vouchers or tokens.

                  The
                    bus tokens must be requested
                    in advance of a

                  provider
                    visit and authorized by Superior’s
                    Member Services Department.

                

              	
                Transit
                  Authorities in appliable Service Area.

              
	 
                
                NurseWise

              	 Twenty-four
                hour nurse advice line 	
                Available
                  to all members by calling the Member Services toll-free
                  number

              	 
                
                
                  NurseWise,
                    an affiliate
                    of Centene

                  Corporation

                

              
	
                Home
                  Visits to New Mothers

              	
                
                  Superior
                    Social Work and/or CONNECTIONS staff will make
                    home visits to any Member with a new baby. This visit
                    provides for resource and education coordination as identified
                    in the visit,[what does this mean?] and ensures Members
                    and the new babies are keeping all post natal

                  and
                    newborn doctor visits. This benefit is available to all

                  Superior
                    Members who have delivered a baby.

                

              	
                
                  Only
                    that a member consent to the home visit.

                

              	
                
                  Superior's
                    CONNECTIONS and Social Work staff provide this service.

                   

                

              
	 	 
                
                 

              

      

      

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

      Subject:
        Attachment B-3 – Value-added Services

      Version
        1.8

      
        	 	
                Behavioral
                  Health Value-added Services for Members Under 21

              	 
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	 	 	 	 
	 	 	 	 

      

      
      

      

      
        	 	
                Behavioral
                  Health Value-added Services for Members 21 and
                  Over

              	 
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	 	 	 	 
	 	 	 	 

      

      
      

      

      

      ADDITIONAL
        INFORMATION:

      1.
        Explain how and when Providers and Members will be notified about the
        availability of the value-added services to be provided.

      Value
        Added Services information will be included in the Superior Provider Manual
        and
        also during training sessions. Members will receive this information via
        the
        Plan Comparison Chart, in the Member Handbook, with New Member Packets and
        during orientations.  Periodically, Superior will also highlight Value
        Added Services in the Provider and Member Newsletters.

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

      Subject:
        Attachment B-3 – Value-added Services

      Version
        1.8

       

      2.
        Describe how a Member may obtain or access the value-added services to be
        provided.

       

      See
        explanations provided above for accessing services.

       

      A
        Member
        may access the Home Visits to New Mothers service by accepting a home visit
        appointment from a Superior Social Work or CONNECTIONS staff
        member.

       

      3.
        Describe how the HMO will identify the Value-added Service in administrative
        (encounter) data.

       

      Superior
        will track the value added services through our claims system for those
        value-adds that HIPAA-compliant procedural codes are available (vision,
        behavioral health, flu shots).  Superior will create a specific
        benefit category to track and report the value added services 'separately'
        from
        our 'capitated' service data.  In addition, Superior will have the
        ability to pass this information to the State utilizing the encounter submission
        process, as long as the State is able to segregate the value adds data from
        the
        capitated services data.

       

      For
        pharmacy services, Superior will receive a data file from the pharmacy vendor
        to
        capture all utilization of the pharmacy value-add benefit.

       

      For
        transportation services, Superior will maintain an electronic file of
        transportation services provided for Superior’s
        membership.

       

      Home
        visits to new mothers are tracked through Superior’s case management
        system.  Each staff member logs each member visit and the
        outcome/findings of the visit in Superior’s computer system.  Superior
        will work with HHSC to establish the most efficient transmission of the
        data.

       

      4.
         By signing the Contract and/or Contract Amendment HMO certifies that it
        will provide the approved Value-added Services described herein from September
        1, 2007 through August 31, 2008.

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

      Subject:
        Attachment B-3 – Value-added Services

      Version
        1.8

      

      DOCUMENT
        HISTORY LOG

      
        	
                STATUS1

              	
                DOCUMENT
                  REVISION2

              	
                EFFECTIVE
                  DATE

              	
                DESCRIPTION3

              
	
                Baseline

              	
                n/a

              	 	
                Initial
                  version of Attachment B-3, Value-added Services.

              
	
                Revision

              	
                1.1

              	
                June
                  30, 2006

              	
                Contract
                  amendment did not revise Attachment B-3, Value-added
                  Services.

              
	
                Revision

              	
                1.2

              	
                September
                  1, 2006

              	
                Revised
                  the Physical Health Value-added Services to include Home Visits
                  to New
                  Mothers. Revised the certification provision by changing the start
                  date
                  for the 12-month provision of services.

              
	
                Revision

              	
                1.3

              	
                September
                  1, 2006

              	
                Contract
                  amendment did not revise Attachment B-3, Value-added
                  Services.

              
	
                Revision

              	
                1.4

              	
                September
                  1, 2006

              	
                Contract
                  amendment removed the separate signature requirement for Attachment
                  B-3,
                  Value-added Services. By signing the Contract and/or Contract Amendment,
                  the HMO certifies that it will provide the Value-added Services
                  from
                  September 1, 2006 through August 31, 2007.

              
	
                Revision

              	
                1.5

              	
                January
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-3, Value-added
                  Services.

              
	
                Revision

              	
                1.6

              	
                February
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-3, Value-added
                  Services.

              
	
                Revision

              	
                1.7

              	
                July
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-3, Value-added
                  Services.

              
	
                Revision

              	
                1.8

              	
                September
                  1, 2007

              	
                Revised
                  Attachment B-3, Value-added Services, to reflect newly negotiated
                  Value-added Services for FY 2008.

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

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

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

              

      

      
      

      

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

      Subject:
        Attachment B-3 – Value-added Services

      Version
        1.8

      

      ATTACHMENT
        B-3: VALUE-ADDED SERVICES September 1, 2007 – August 31,
        2008

      HMO:
        Superior HealthPlan, Inc.

      HMO
        PROGRAM: Medicaid

      SERVICE
        AREA(S):Bexar, El Paso, Lubbock, Nueces, and Travis

      
        	 	
                Physical
                  Health Value-added Services

              	 
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	
                Vision

              	
                Members
                  are allowed to purchase any prescription eyewear and apply a $100
                  allowance toward the purchase of that eyewear.

              	
                Members
                  are responsible for any charges that exceed the $100 allowance.
                  Disposable
                  contact lenses are excluded from this $100 allowance. This Value-Added
                  benefit is only allowed one time per benefit period (i.e.
                  24-months).

              	
                TVHP
                  contracted providers.

              
	
                Pharmacy

              	
                Provides
                  members with a $15.00 per household per quarter credit toward over
                  the
                  counter medications and supplies.

              	
                Services
                  must be sought from contracted pharmacies only. Items eligible
                  for
                  purchase under this benefit are over-the-counter, health related
                  items
                  only.

              	
                Pharmacy
                  Data Management contracted
                  providers.

              

      

      
      

      

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Subject:
        Attachment B-3 – Value-added Services

      Version
        1.8

       

      
        
          	
                	
                  Physical
                    Health Value-added Services

                	 
	
                  Value-added
                    Service

                	
                  Description
                    of Value-added Services and Members Eligible to Receive the
                    Services

                	
                  Limitations
                    or Restrictions

                	
                  Provider(s)
                    responsible for providing this service

                
	
                  Transportation

                	
                  
                    HMO
                      will offer tokens or vouchers for bus services

                    to
                      HMO members that have trouble accessing the

                    State's
                      Medical Transportation Program in a

                    timely
                      manner to ensure access to their provider

                    appointments.
                      In addition, HMO will provide

                    transportation
                      to non-medical services such as

                    health
                      education programs, nutrition classes, and

                    birth
                      preparation classes. HMO's member service

                    staff
                      will approve and coordinate the

                    transportation
                      service".

                  

                	
                  
                    Members
                      in the Nueces Service Area.
                      The transportation Authority
                      in this area will not agree
                      to allow the plan to purchase
                      bus vouchers or tokens.

                    The
                      bus tokens must be requested
                      in advance of a

                    provider
                      visit and authorized by Superior’s
                      Member Services Department.

                  

                	
                  Transit
                    Authorities in appliable Service Area.

                
	 NurseWise	 Twenty-four
                  hour nurse advice line 	 Available
                  to all members by calling the Member Services toll-free
                  number	 NurseWise,
                  an affiliate
                  of Centene
                  
                    Corporation

                  

                
	
                  Home
                    Visits to New Mothers

                	
                  
                    Superior
                      Social Work and/or CONNECTIONS staff will make
                      home visits to any Member with a new baby. This visit
                      provides for resource and education coordination as identified
                      in the visit, and ensures Members
                      and the new babies are keeping all post natal

                    and
                      newborn doctor visits. This benefit is available to all

                    Superior
                      Members who have delivered a baby.

                  

                	
                  
                    Only
                      that a member consent to the home visit.

                  

                	
                  
                    Superior's
                      CONNECTIONS and Social Work staff provide this service.

                     

                  

                
	 	 
                  
                   

                

        

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

      Subject:
        Attachment B-3 – Value-added Services

      Version
        1.8

      
        	 	
                Behavioral
                  Health Value-added Services for Members Under 21

              	 
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	
                Behavioral
                  Health

              	
                Rehabilitation/skills
                  training. These are services provided to pregnant and parenting
                  substance
                  abusers at MHMR centers or in other treatment settings, focusing
                  both on
                  substance abuse and parenting issues. An augmentation of standard
                  substance abuse treatment to focus on the special needs of this
                  population. Authorized in increments of 15 minutes, with amount,
                  duration,
                  and scope based on medical necessity. This benefit is available
                  to all
                  Members. It is geared to pregnant women and parenting
                  Members.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                  In addition, the service will be authorized for15­minute increments.
                  The amount, duration, and scope are based on medical
                  necessity.

              	
                It
                  is anticipated that Superior’s contracted MHMR providers specializing in
                  Rehabilitation/Skills training in each Service Area will render
                  this
                  service.

              
	
                Behavioral
                  Health

              	
                Superior’s
                  Behavioral Health Subcontractor will authorize Behavioral Health
                  practitioners in medical settings to provide health psychology
                  interventions focused on the effective management of chronic medical
                  conditions. These might include psycho-educational groups for chronic
                  conditions, individual coaching for patients with chronic disease
                  states,
                  or skills training activities.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                  The authorization will be tied to medical necessity.

              	
                It
                  is anticipated that these services will be rendered by Superior’s
                  behavioral health practitioners located in Superior’s contracted Federally
                  Qualified Health Centers.

              
	
                Behavioral
                  Health

              	
                Partial
                  Hospitalization/Extended Day Treatment-An alternative to, or a
                  step down
                  from, inpatient care.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                  Services are authorized for a minimum of five hours, but for less
                  than
                  24-hours per day. The amount, duration, and scope will be based
                  on medical
                  necessity.

              	
                It
                  is anticipated that Superior’s contracted Behavioral Health Providers such
                  as its’ MHMR facilities and other contracted facilities in each Service
                  Area will render this service.

              

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

      Subject:
        Attachment B-3 – Value-added Services

      Version
        1.8

      
        	 	
                Behavioral
                  Health Value-added Services for Members Under 21

              	 
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	
                Behavioral
                  Health

              	
                Intensive
                  Outpatient Treatment/Day Treatment (IOP)- Used as an alternative
                  to or
                  step down from more restrictive levels of care.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Material
                  Subcontractor. In addition, the service will be authorized for
                  greater
                  than one and one half hours, but less than five hours per day.
                  Amount,
                  duration, and scope are based on medical necessity.

              	
                It
                  is anticipated that Superior’s contracted Behavioral Health Providers such
                  as the MHMR or other facilities in each Service Area will render
                  this
                  service.

              

      

      
      

      

      
        	 	
                Behavioral
                  Health Value-added Services for Members 21 and
                  Over

              	 
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	
                Behavioral
                  Health

              	
                Rehabilitation/skills
                  training. These are services provided to pregnant and parenting
                  substance
                  abusers at MHMR centers or in other treatment settings, focusing
                  both on
                  substance abuse and parenting issues. An augmentation of standard
                  substance abuse treatment to focus on the special needs of this
                  population. This benefit is available to all Members. It is geared
                  to
                  pregnant women and parenting Members.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                  In addition, the service will be authorized for15­minute increments.
                  The amount, duration, and scope are based on medical
                  necessity.

              	
                It
                  is anticipated that Superior’s contracted MHMR providers specializing in
                  Rehabilitation/Skills training in each Service Area will render
                  this
                  service.

              

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

      Subject:
        Attachment B-3 – Value-added Services

      Version
        1.8

      
        	 	
                Behavioral
                  Health Value-added Services for Members 21 and
                  Over

              	 
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	
                Behavioral
                  Health

              	
                Partial
                  Hospitalization/Extended Day Treatment-An alternative to, or a
                  step down
                  from, inpatient care.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                  Services are authorized for a minimum of five hours, but for less
                  than
                  24-hours per day. The amount, duration, and scope will be based
                  on medical
                  necessity.

              	
                It
                  is anticipated that Superior’s contracted Behavioral Health Providers such
                  as its’ MHMR facilities and other contracted facilities in each Service
                  Area will render this service.

              
	
                Behavioral
                  Health

              	
                Superior’s
                  Behavioral Health Subcontractor, will authorize Behavioral Health
                  practitioners in medical settings to provide health psychology
                  interventions focused on the effective management of chronic medical
                  conditions. These might include psycho-educational groups for chronic
                  conditions, individual coaching for patients with chronic disease
                  states,
                  or skills training activities.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                  The authorization will be tied to medical necessity.

              	
                It
                  is anticipated that these services will be rendered by Superior’s
                  behavioral health practitioners located in Superior’s contracted Federally
                  Qualified Health Centers.

              
	
                Behavioral
                  Health

              	
                Intensive
                  Outpatient Treatment/Day Treatment (IOP)- Used as an alternative
                  to or
                  step down from more restrictive levels of care.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                  In addition, the service will be authorized for greater than one
                  and one
                  half hours, but less than five hours per day. Amount, duration,
                  and scope
                  are based on medical necessity.

              	
                It
                  is anticipated that Superior’s contracted Behavioral Health Providers such
                  as the MHMR or other facilities in each Service Area will render
                  this
                  service.

              

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

      Subject:
        Attachment B-3 – Value-added Services

      Version
        1.8

      
        	 	
                Behavioral
                  Health Value-added Services for Members 21 and
                  Over

              	 
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	
                Behavioral
                  Health

              	
                Off-site
                  Services such as home-based services, , mobile crisis, intensive
                  case
                  management. It should be noted that staff must go off-site to provide
                  such
                  services. These services are provided to Members to help reduce
                  or avoid
                  inpatient admissions by a community based, mobile, multi-disciplinary
                  team
                  of licensed clinicians and trained, unlicensed workers working
                  under the
                  direction of a licensed professional.

              	
                These
                  services must be authorized by Superior’s Behavioral Health Subcontractor.
                  The amount, duration and scope are based on medical
                  necessity.

              	
                It
                  is anticipated that Superior’s contracted Behavioral Health Providers such
                  as the MHMR in each Service Area will render this
                  service.

              

      

      
      

      

      

      ADDITIONAL
        INFORMATION:

      1.
        Explain how and when Providers and Members will be notified about the
        availability of the value-added services to be provided.

       

      Value
        Added Services information will be included in the Superior Provider Manual
        and
        also during training sessions. Members will receive this information via
        the
        Plan Comparison Chart, in the Member Handbook, with New Member Packets and
        during orientations.  Periodically, Superior will also highlight Value
        Added Services in the Provider and Member Newsletters.

       

      2.
        Describe how a Member may obtain or access the value-added services to be
        provided.

       

      See
        explanations provided above for accessing services.

      A
        Member
        may access the Home Visits to New Mothers service by accepting a home visit
        appointment from a Superior Social Work or CONNECTIONS staff
        member.

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

      Subject:
        Attachment B-3 – Value-added Services

      Version
        1.8

      3.
        Describe how the HMO will identify the Value-added Service in administrative
        (encounter) data.

       

      Superior
        will track the value added services through our claims system for those
        value-adds that HIPAA-compliant procedural codes are available (vision,
        behavioral health). Superior will create a specific benefit category to track
        and report the value added services 'separately' from our 'capitated' service
        data. In addition, Superior will have the ability to pass this information
        to
        the State utilizing the encounter submission process, as long as the State
        is
        able to segregate the value adds data from the capitated services data. For
        pharmacy services, Superior will receive a data file from the pharmacy vendor
        to
        capture all utilization of the pharmacy value-add benefit.

      For
        transportation services, Superior will maintain an electronic file of
        transportation services provided for Superior’s membership.

      Home
        visits to new mothers are tracked through Superior’s case management
        system.  Each staff member logs each member visit and the
        outcome/findings of the visit in Superior’s computer system.  Superior
        will work with HHSC to establish the most efficient transmission of the
        data.

       

      4.
        By
        signing the Contract and/or Contract Amendment HMO certifies that it will
        provide the approved Value-added Services described herein from September
        1,
        2007 through August 31, 2008.

    

    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    
      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

      Subject:
        Attachment B-3.1 – STAR+PLUS Value-added Services

      Version
        1.8

      

      DOCUMENT
        HISTORY LOG

      
        	
                STATUS1

              	
                DOCUMENT
                  REVISION2

              	
                EFFECTIVE
                  DATE

              	
                DESCRIPTION3

              
	
                Baseline

              	
                1.0

              	 	
                Initial
                  version of Attachment B-3, Value-added Services

              
	
                Revision

              	
                1.1

              	
                June
                  30, 2006

              	
                Revised
                  Attachment B-3, Value Added Services, by adding Attachment B-3.1,
                  STAR+PLUS Value Added Services. This is the initial version of
                  Attachment
                  B-3.1, STAR+PLUS Value Added Services.

              
	
                Revision

              	
                1.2

              	
                September
                  1, 2006

              	
                Contract
                  amendment did not revise Attachment B-3.1, STAR+PLUS Value Added
                  Services

              
	
                Revision

              	
                1.3

              	
                September
                  1, 2006

              	
                Contract
                  amendment did not revise Attachment B-3.1, STAR+PLUS Value Added
                  Services

              
	
                Revision

              	
                1.4

              	
                September
                  1, 2006

              	
                Contract
                  amendment removed the separate signature requirement for Attachment
                  B-3.1,
                  STAR+PLUS Value-added Services. By signing the Contract and/or
                  Contract
                  Amendment, the HMO certifies that it will provide the Value-added
                  Services
                  from January 1, 2007 through August 31, 2007.

              
	
                Revision

              	
                1.5

              	
                January
                  1, 2007

              	
                Revised
                  Attachment B-3.1, STAR+PLUS Value Added Services to state that
                  only
                  non-dual members are eligible for dental benefits and to clarify
                  description of Out-of-Home Respite.

              
	
                Revision

              	
                1.6

              	
                February
                  1, 2007

              	
                Revised
                  Attachment B-3.1, STAR+PLUS Value Added Services, to clarify the
                  coverage
                  period for the VAS.

              
	
                Revision

              	
                1.7

              	
                July
                  1, 2007

              	
                Revised
                  Attachment B-3.1, STAR+PLUS Value Added Services, to clarify the
                  coverage
                  period for the VAS.

              
	
                Revision

              	
                1.8

              	
                September
                  1, 2007

              	
                Revised
                  Attachment B-3-1, STAR+PLUS Value-added Services, to reflect newly
                  negotiated Value-added Services for FY 2008.

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

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

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

              

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

      Subject:
        Attachment B-3.1 – STAR+PLUS Value-added Services

      Version
        1.8

      ATTACHMENT
        B-3.1: STAR+PLUS VALUE-ADDED SERVICES 

      September
        1, 2007 – August 31, 2008 

      HMO:
        Superior HealthPlan, Inc. 

      SERVICE
        AREA(S): Bexar & Nueces

       

      
         

        
          
            	
                  	
                    Physical
                      Health Value-added Services

                  	 
	
                    Value-added
                      Service

                  	
                    Description
                      of Value-added Services and Members Eligible to Receive the
                      Services

                  	
                    Limitations
                      or Restrictions

                  	
                    Provider(s)
                      responsible for providing this service

                  
	
                    Pharmacy

                  	
                    
                      
                        Provides
                          members with a $15.00 per household

                        quarter
                          credit toward over the counter

                        medications
                          and supplies.

                      

                    

                  	
                    
                      
                        Services
                          must be sought from

                        contracted
                          pharmacies only. Items

                        eligible
                          for purchase under this

                        benefit
                          are over-the-counter health

                        related
                          items only.

                      

                    

                  	
                    
                      Pharmacy
                        Data

                      Management
                        contracted

                      providers.

                    

                  
	Dental	
                    Basic
                      dental coverage, which includes the

                    following
                      CPT codes: 0140- Emergency

                    Evaluation;
                      0120- Periodic Oral Evaluation;

                    0220-
                      Intra-oral Periapaical First Film; 0230-

                    Intraoral
                      Periapical- Each Additional; 0240- Intraoral

                    Occlusal
                      Film; 0270- Bitewings- single film;

                    0272-
                      Bitewings- two films; 07110- Extraction-

                    Single
                      Tooth/Routine to Difficult; and 07120

                    Extraction-
                      Each Additional.

                  	
                    If
                      a Member receives services that

                    are
                      outside of the scope of the CPT

                    Codes
                      listed, the Member will be

                    subject
                      to a co-payment of 75% of

                    the
                      dentists’ usual and customary

                    charges
                      for those services.

                    Only
                      non-dual members are eligible

                    for
                      dental benefits.

                  	
                    
                      
                        OraQuest
                          Dental Network

                      

                    

                  
	Nursewise	 
                    
                    Twenty-four
                      hour nurse advice line

                  	Available
                    to all members by calling
                    the
                      Member Services toll-free

                    numberTwenty-four
                      hour nurse advice line

                  	NurseWise,
                    an affiliate of
                    Centene
                      Corporation

                  
	 	 	 	 

          

          

          

          
            	
                  	
                    Community
                      Based Long Term Care Value-added Services

                  	 
	
                    Value-added
                      Service

                  	
                    Description
                      of Value-added Services and Members Eligible to Receive the
                      Services

                  	
                    Limitations
                      or Restrictions

                  	
                    Provider(s)
                      responsible for providing this
                      service

                  

          

          
            	
                    Out-of-Home
                      Respit

                  	
                    
                      
                        Respite
                          services for a caretaker who needs relief

                        from
                          their care-giving responsibilities because of

                        severe
                          physical or mental stress or who is

                        temporarily
                          unable to provide care because of

                        illness,
                          hospitalization, family emergency or other

                        obligation.
                          Services will be provided in the setting

                        most
                          appropriate to the Member's needs

                        including
                          assisted living facilities, adult foster

                        care
                          homes, or adult day activity centers.

                      

                    

                  	
                    
                      
                        This
                          benefit is limited to non-dual

                        Adult
                          non-Waiver Members age 21

                        and
                          over. Must be prior authorized.

                        Limited
                          to up to ten hours per

                        month
                          of in home respite services.

                      

                    

                  	
                    
                      Network
                        providers.

                    

                  
	 	 
                    
                     

                  

          

          
 

        

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

       

      Subject:
        Attachment B-3.1 – STAR+PLUS Value-added Services

      Version
        1.8

       

       

      
        	 	
                Behavioral
                  Health Value-added Services for Members 21 and
                  Over

              
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              	 
	
                Behavioral
                  Health

              	
                Health
                  Psychology Interventions provided by a behavioral health practitioner
                  in a
                  medical setting that focuses on the effective management of chronic
                  medical conditions. This might include psycho-educational groups
                  for
                  chronic conditions, individual coaching for patients with chronic
                  disease
                  states, or skills training activities.

              	
                Limited
                  to non-dual Members only. Services must be authorized and is based
                  on
                  medical necessity.

              	
                Network
                  Federally Qualified Health Centers (FQHCs)

              	 
	
                Behavioral
                  Health

              	
                Intensive
                  Outpatient Treatment/Day Treatment (IOP)- Used as an alternative
                  to step
                  down from more restrictive levels of care.

              	
                Limited
                  to non-dual Members only. Services must be authorized and is based
                  on
                  medical necessity. Services will be authorized for greater than
                  one and
                  one half hours, but less than five hours per day.

              	
                It
                  is anticipated that behavioral health providers such as the MHMR
                  or other
                  facilities within the Service Area will render this
                  service.

              	 

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

      Subject:
        Attachment B-3.1 – STAR+PLUS Value-added Services

      Version
        1.8

      
        	 	
                Behavioral
                  Health Value-added Services for Members 21 and
                  Over

              
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              	 
	
                Behavioral
                  Health

              	
                Partial
                  Hospitalization/Extended Day Treatment-An alternative to, or a
                  step down
                  from, inpatient care.

              	
                Limited
                  to non-dual Members only. Services must be authorized and is based
                  on
                  medical necessity. Services will be authorized for a minimum of
                  five
                  hours, but for less than 24-hours per day.

              	
                It
                  is anticipated that behavioral health providers such as the MHMR
                  or other
                  facilities within the Service Area will render this
                  service.

              	 
	
                Behavioral
                  Health

              	
                Off-site
                  services such as intensive case management. It should be noted
                  that staff
                  must go off-site to provide such services. These services are provided
                  to
                  Members to help reduce or avoid inpatient admissions by a community
                  based,
                  mobile, multi-disciplinary team of licensed clinicians and trained,
                  unlicensed workers working under the direction of a licensed
                  professional.

              	
                Limited
                  to non-dual Members only. Services must be authorized and is based
                  on
                  medical necessity.

              	
                It
                  is anticipated that behavioral health providers such as the MHMR
                  or other
                  facilities within the Service Area will render this
                  service.

              	 

      

      
      

      

      

      ADDITIONAL
        INFORMATION:

      1.
        Explain how and when Providers and Members will be notified about the
        availability of the value-added services to be provided.

       

      Value
        added services information will be included in the Superior Provider Manual
        and
        also during training sessions.  Members will receive this information
        via the Plan Comparison Chart, in the Member Handbook, with New Member Packets
        and during orientations.  Periodically, Superior will also highlight
        Value Added Services in the Provider and member Newsletters.

       

      2.
        Describe how a Member may obtain or access the value-added services to be
        provided.

       

      See
        explanations provided above for accessing services.

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Contractual
        Document (CD) Responsible Office: HHSC Office of General Counsel
        (OGC)

      Subject:
        Attachment B-3.1 – STAR+PLUS Value-added Services

      Version
        1.8

      3.
        Describe how the HMO will identify the Value-added Service in administrative
        (encounter) data.

       

      Superior
        will track value added services through our claims system for those value
–adds
        that are IIPAA-compliant procedural codes are available (podiatry,
        etc.).  Superior will create specific benefit categories to track and
        report the value added services “separately” from our “capitated” service data.
        In addition, Superior will have the ability to pass this information to the
        State utilizing the encounter submission process, as long as the Sate is
        able to
        segregate the value adds data from the capitated services
        data.   For pharmacy services, Superior will receive a data file
        from the pharmacy vendor to capture all utilization of pharmacy value added
        benefits. The same is true for dental services.

       

      4.
        By
        signing the Contract and/or Contract Amendment HMO certifies that it will
        provide the approved Value-added Services
        described herein from September 1, 2007 – August 31,
        2008.

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      Subject:
        Attachment B-3.2 – CHIP Perinatal Program Value-added
        Services

    
      

      DOCUMENT
        HISTORY LOG

      
        	
                STATUS1

              	
                DOCUMENT
                  REVISION2

              	
                EFFECTIVE
                  DATE

              	
                DESCRIPTION3

              
	
                Baseline

              	
                1.0

              	 	
                Initial
                  version of Attachment B-3, Value-added Services

              
	
                Revision

              	
                1.1

              	
                June
                  30, 2006

              	
                Revised
                  Attachment B-3, Value Added Services, by adding Attachment B-3.1,
                  STAR+PLUS Value Added Services.

              
	
                Revision

              	
                1.2

              	
                September
                  1, 2006

              	
                Contract
                  amendment did not revise Attachment B-3, Value Added
                  Services

              
	
                Revision

              	
                1.3

              	
                September
                  1, 2006

              	
                Revised
                  Attachment B-3, Value Added Services, by adding Attachment B-3.2,
                  CHIP
                  Perinatal Program Value Added Services. This is the initial version
                  of
                  Attachment B-3.2, CHIP Perinatal Program Value Added
                  Services.

              
	
                Revision

              	
                1.4

              	
                September
                  1, 2006

              	
                Contract
                  amendment removed the separate signature requirement for Attachment
                  B-3.2,
                  CHIP Perinatal Program Value-added Services. By signing the Contract
                  and/or Contract Amendment, the HMO certifies that it will provide
                  the
                  Value-added Services from January 1, 2007 through August 31,
                  2007.

              
	
                Revision

              	
                1.5

              	
                January
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-3.2, CHIP Perinatal Program
                  Value
                  Added Services.

              
	
                Revision

              	
                1.6

              	
                February
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-3.2, CHIP Perinatal Program
                  Value
                  Added Services.

              
	
                Revision

              	
                1.7

              	
                July
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-3.2, CHIP Perinatal Program
                  Value
                  Added Services.

              
	
                Revision

              	
                1.8

              	
                September
                  1, 2007

              	
                Revised
                  Attachment B-3.2, CHIP Perinatal Program Value-added Services,
                  to reflect
                  newly negotiated Value-added Services for FY 2008.

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

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

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

              

      

      
      

      

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      ATTACHMENT
        B-3.2: CHIP PERINATAL PROGRAM VALUE-ADDED SERVICES September 1, 2007 – August
        31, 2008

      HMO:
        _________________________________________________________________________________
        

      SERVICE
        AREA(S):
        ______________________________________________________________________

       

       

      
        	 	
                Physical
                  Health Value-added Services

              	 
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	 	 	 	 
	 	 	 	 
	 	 	 	 

      

      
      

       

      
 

      
        	 	
                Behavioral
                  Health Value-added Services for Members Under 21

              	 
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	 	 	 	 
	 	 	 	 
	 	 	 	 

      

      
      

      

      

      
        	 	
                Behavioral
                  Health Value-added Services for Members 21 and
                  Over

              	 
	
                Value-added
                  Service

              	
                Description
                  of Value-added Services and Members Eligible to Receive the
                  Services

              	
                Limitations
                  or Restrictions

              	
                Provider(s)
                  responsible for providing this service

              
	 	 	 	 
	 	 	 	 
	 	 	 	 

      

      
      

      

      ADDITIONAL
        INFORMATION:

      

      1.
        Explain how and when Providers and Members will be notified about the
        availability of the value-added services to be provided.

       

      2.
        Describe how a Member may obtain or access the value-added services to be
        provided.

       

      3.
        Describe how the HMO will identify the Value-added Service in administrative
        (encounter) data.

       

      4.
        By
        signing the Contract and/or Contract Amendment HMO certifies that it will
        provide the approved Value-added Services described herein from September
        1,
        2007 through August 31, 2008.

       

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

Subject:
      Attachment B-4 – Performance Improvement Goals Version 1.8

    
      
        	
                STATUS1

              	
                DOCUMENT
                  REVISION2

              	
                EFFECTIVE
                  DATE

              	
                DESCRIPTION3

              
	
                Baseline

              	
                n/a

              	 	
                Initial
                  version Attachment B-4, Performance Improvement Goals.

              
	
                Revision

              	
                1.1

              	
                June
                  30, 2006

              	
                Contract
                  amendment to include STAR+PLUS Program. Revised Attachment B-4,
                  Performance Improvement Goals Template, by adding Attachment B-4.1,
                  FY2008
                  Performance Improvement Goals Template. No change to this
                  Section.

              
	
                Revision

              	
                1.2

              	
                September
                  1, 2006

              	
                Revised
                  version of Attachment B-4 that includes provisions applicable to
                  MCOs
                  participating in the STAR and CHIP Programs. Updates the attachment
                  to
                  reflect the changes made in Attachment B-1, Section
                  8.1.1.1.

              
	
                Revision

              	
                1.3

              	
                September
                  1, 2006

              	
                Contract
                  amendment did not revise Attachment B-4, Performance Improvement
                  Goals.

              
	
                Revision

              	
                1.4

              	
                September
                  1, 2006

              	
                Contract
                  amended to include Attachment B-4 Performance Improvement Goals
                  for
                  SFY2007 and format change

              
	
                Revision

              	
                1.5

              	
                January
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-4, Performance Improvement
                  Goals.

              
	
                Revision

              	
                1.6

              	
                February
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-4, Performance Improvement
                  Goals.

              
	
                Revision

              	
                1.7

              	
                July
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-4, Performance Improvement
                  Goals.

              
	
                Revision

              	
                1.8

              	
                September
                  1, 2007

              	
                Revised
                  Attachment B-4, to replace FY2007 Performance Improvement Goals
                  with newly
                  negotiated FY2008 Performance Improvement Goals by Program and
                  by Service
                  Area.  Attachment B-4.1, FY2008 Performance Improvement Goals
                  Template, is deleted as duplicative.

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

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

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

              

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Subject:
        Attachment B-4 – Performance Improvement Goals Version 1.8

      Texas
        Health and Human Services
        Commission

      HMO
        Performance Improvement Goal
        Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
        2008)

      
        	
                A.
                  Health Plan Information 

                Plan
                  Name: Superior HealthPlan 

                HMO
                  Program:
                  CHIP 

                HMO
                  Service
                  Delivery Area: Bexar SDA

              	
                 

              	 
	
                B.
                  Overarching Goal

              	 	 	
                C.
                  Sub Goals:

              
	
                Goal
                  1:

              	 	
                 

              	
                 

              
	
                Improve
                  Access to Primary Care 
                  Services
                    for Members

                

              	 	 	
                
                  90%
                    of initial credentialing of PCPs will be finalized within
                    75 days of receipt of application.

                

              
	
                 

              	 	
                 

              	
                The
                  percentage of Family Practitioners with open panels will increase
                  by 10
                  percentage points over baseline.

              
	
                Goal
                  2: Improve Access to Behavioral Health Services for
                  Members

              	 	
                 

              	
                Increase
                  Behavioral Health Urgent Care Appointment Availability by 5 percentage
                  points over the baseline. Increase
                  Behavioral Health Routine Care Appointment Availability by 5 percentage
                  points over the baseline.

              
	
                Goal
                  3:

              	 	
                 

              	
                 

              
	
                Increase
                  Utilization of New Member Medical Check-Ups 
                  within
                    90 days of Enrollment

                

              	 	 	
                
                  90%
                    of new members will receive a reminder/insert in the new member
                    packets to remind members to schedule a new patient
                    check-up.

                

              
	
                 

              	 	
                 

              	
                100%
                  of new members with working phone numbers and with default or no
                  PCP will
                  have a new PCP assignment within 60 days of
                  enrollment.

              

      

      
      

       

      Additional information related to the Performance Improvement Goals can
        be
        found in Attachment B-1, Section 8.1.1.1, to the Contract.

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Subject:
        Attachment B-4 – Performance Improvement Goals Version 1.8

       

      HMO
        Performance Improvement Goal
        Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
        2008)

      
        	
                A.
                  Health Plan Information 

                Plan
                  Name: Superior HealthPlan 

                HMO
                  Program: CHIP 

                HMO
                  Service
                  Delivery Area: El Paso SDA

              
	
                B.
                  Overarching Goal

              	
                C.
                  Sub Goals:

              
	
                Goal
                  1:

              	
                 

              
	
                Improve
                  Access to Primary Care

              	
                90%
                  of initial credentialing of PCPs will be finalized within 75 days
                  of
                  receipt of application.

              
	
                Services
                  for Members

              	
                The
                  percentage of Family Practitioners with open panels will increase
                  by four
                  percentage points over baseline.

              
	
                Goal
                  2: Improve Access to Behavioral Health Services for
                  Members

              	
                Increase
                  Behavioral Health Urgent Care Appointment Availability by 5 percentage
                  points over the baseline. 

                Increase
                  Behavioral Health Routine Care Appointment Availability by 5 percentage
                  points over the baseline.

              
	
                Goal
                  3:

              	
                 

              
	
                Increase
                  Utilization of New Member Medical Check-Ups

              	
                90%
                  of initial credentialing of PCPs will be finalized new member packets
                  to
                  remind members to schedule a new patient check-up.

              
	
                within
                  90 days of Enrollment

              	
                100%
                  of new members with working phone numbers and with default or no
                  PCP will
                  have a new PCP assignment within 60 days of
                  enrollment.

              

      

      
      

       

      
 

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Subject:
        Attachment B-4 – Performance Improvement Goals Version 1.8

       

      HMO
        Performance Improvement Goal
        Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
        2008)

      
        	
                A.
                  Health Plan Information 

                Plan
                  Name: Superior HealthPlan 

                HMO
                  Program: CHIP 

                HMO
                  Service
                  Delivery Area: Lubbock SDA

              
	
                B.
                  Overarching Goal

              	
                C.
                  Sub Goals:

              
	
                Goal
                  1:

              	
                 

              
	
                Improve
                  Access to Primary Care

              	
                90%
                  of initial credentialing of PCPs will be finalized within 75 days
                  of
                  receipt of application.

              
	
                Services
                  for Members

              	
                The
                  percentage of Family Practitioners with open panels will increase
                  by four
                  percentage points over baseline.

              
	
                Goal
                  2: Improve Access to Behavioral Health Services for
                  Members

              	
                Increase
                  Behavioral Health Urgent Care Appointment Availability by 5 percentage
                  points over the baseline. 

                Increase
                  Behavioral Health Routine Care Appointment Availability by 5 percentage
                  points over the baseline.

              
	
                Goal
                  3:

              	
                 

              
	
                Increase
                  Utilization of New Member Medical Check-Ups

              	
                90%
                  of initial credentialing of PCPs will be finalized new member packets
                  to
                  remind members to schedule a new patient check-up.

              
	
                within
                  90 days of Enrollment

              	
                100%
                  of new members with working phone numbers and with default or no
                  PCP will
                  have a new PCP assignment within 60 days of
                  enrollment.

              

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Subject:
        Attachment B-4 – Performance Improvement Goals Version 1.8

       

      HMO
        Performance Improvement Goal
        Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
        2008)

      
        	
                A.
                  Health Plan Information 

                Plan
                  Name: Superior HealthPlan 

                HMO
                  Program: CHIP 

                HMO
                  Service Delivery Area: Nueces SDA

              
	
                B.
                  Overarching Goal

              	
                C.
                  Sub Goals:

              
	
                Goal
                  1:

              	
              
	
                Improve
                  Access to Primary Care

              	
                
                  90%
                    of initial credentialing of PCPs will be finalized within 75
                    days of receipt of application.

                

              
	
                Services
                  for Members

              	
                The
                  percentage of Family Practitioners with open panels will increase
                  by four
                  percentage points over baseline.

              
	
                Goal
                  2: Improve Access to Behavioral Health Services for
                  Members

              	
                Increase
                  Behavioral Health Urgent Care Appointment Availability by 5 percentage
                  points over the baseline. 

                Increase
                  Behavioral Health Routine Care Appointment Availability by 5 percentage
                  points over the baseline.

              
	
                Goal
                  3:

              	
                 

              
	
                Increase
                  Utilization of New Member Medical Check-Ups

              	
                
                  90%
                    of initial credentialing of PCPs will be finalized new member
                    packets to remind members to schedule a new patient
                    check-up.

                

              
	
                within
                  90 days of Enrollment

              	
                100%
                  of new members with working phone numbers and with default or no
                  PCP will
                  have a new PCP assignment within 60 days of
                  enrollment.

              

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Subject:
        Attachment B-4 – Performance Improvement Goals Version 1.8

       

      HMO
        Performance Improvement Goal
        Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
        2008)

      
        	
                A.
                  Health Plan Information 

                Plan
                  Name: Superior HealthPlan 

                HMO
                  Program: CHIP 

                HMO
                  Service
                  Delivery Area: Travis SDA

              	
                 

              	 
	
                B.
                  Overarching Goal

              	 	 	
                C.
                  Sub Goals:

              
	
                Goal
                  1:

              	 	
                 

              	
                 

              
	
                Improve
                  Access to Primary Care

              	 	 	
                
                  90%
                    of initial credentialing of PCPs will be finalized within 75 days
                    of receipt of application.

                

              
	
                Services
                  for Members

              	 	
                 

              	
                The
                  percentage of Family Practitioners with open panels will increase
                  by 10
                  percentage points over baseline.

              
	
                Goal
                  2: Improve Access to Behavioral Health Services for
                  Members

              	 	
                 

              	
                Increase
                  Behavioral Health Urgent Care Appointment Availability by 5 percentage
                  points over the baseline. 

                Increase
                  Behavioral Health Routine Care Appointment Availability by 5 percentage
                  points over the baseline.

              
	
                Goal
                  3:

              	 	
                 

              	
                 

              
	
                Increase
                  Utilization of New Member Medical Check-Ups

              	 	 	
                
                  90%
                    of new members will receive a reminder/insert in the new member
                    packets to remind members to schedule a new patient
                    check-up.

                

              
	
                within
                  90 days of Enrollment

              	 	
                 

              	
                100%
                  of new members with working phone numbers and with default or no
                  PCP will
                  have a new PCP assignment within 60 days of
                  enrollment.

              

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Subject:
        Attachment B-4 – Performance Improvement Goals Version 1.8

       

      HMO
        Performance Improvement Goal
        Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
        2008)

      
        	
                A.
                  Health Plan Information 

                Plan
                  Name: Superior HealthPlan 

                HMO
                  Program: STAR 

                HMO
                  Service
                  Delivery Area: Bexar SDA

              	
                 

              	 
	
                B.
                  Overarching Goal

              	 	 	
                C.
                  Sub Goals:

              
	
                Goal
                  1:

              	 	
                 

              	
                90%
                  of initial credentialing of PCPs will be finalized

              
	
                Improve
                  Access to Primary Care

              	 	 	
                within
                  75 days of receipt of application.

              
	
                Services
                  for Members

              	 	
                 

              	
                The
                  percentage of Family Practitioners with open panels will increase
                  by 10
                  percentage points over baseline.

              
	
                Goal
                  2: Improve Access to Behavioral Health Services for
                  Members

              	 	
                 

              	
                Increase
                  Behavioral Health Urgent Care Appointment Availability by 5 percentage
                  points over the baseline. Increase Behavioral Health Routine Care
                  Appointment Availability by 5 percentage points over the
                  baseline.

              
	
                Goal
                  3:

              	 	
                 

              	
                90%
                  of new members will receive a reminder/insert in the

              
	
                Increase
                  Utilization of New Member Medical Check-Ups

              	 	 	
                new
                  member packets to remind members to schedule a new patient
                  check-up.

              
	
                within
                  90 days of Enrollment

              	 	
                 

              	
                100%
                  of new members with working phone numbers and with default or no
                  PCP will
                  have a new PCP assignment within 60 days of
                  enrollment.

              

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Subject:
        Attachment B-4 – Performance Improvement Goals Version 1.8

       

      HMO
        Performance Improvement Goal
        Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
        2008)

      
        	
                A.
                  Health Plan Information 

                Plan
                  Name: Superior HealthPlan 

                HMO
                  Program: STAR 

                HMO
                  Service
                  Delivery Area: El Paso SDA

              
	
                B.
                  Overarching Goal

              	
                C.
                  Sub Goals:

              
	
                Goal
                  1:

              	
                 

              
	
                Improve
                  Access to Primary Care

              	
                90%
                  of initial credentialing of PCPs will be finalizedwithin 75 days
                  of
                  receipt of application.

              
	
                Services
                  for Members

              	
                The
                  percentage of Family Practitioners with open panels will increase
                  by four
                  percentage points over baseline.

              
	
                Goal
                  2: Improve Access to Behavioral Health Services for
                  Members

              	
                Increase
                  Behavioral Health Urgent Care Appointment Availability by 5 percentage
                  points over the baseline. 

                Increase
                  Behavioral Health Routine Care Appointment Availability by 5 percentage
                  points over the baseline.

              
	
                Goal
                  3:

              	
              
	
                Increase
                  Utilization of New Member Medical Check-Ups

              	
                
                  90%
                    of new members will receive a reminder/insert in the new member
                    packets to remind members to schedule a new patient
                    check-up.

                

              
	
                within
                  90 days of Enrollment

              	
                100%
                  of new members with working phone numbers and with default or no
                  PCP will
                  have a new PCP assignment within 60 days of
                  enrollment.

              

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Subject:
        Attachment B-4 – Performance Improvement Goals Version 1.8

       

      HMO
        Performance Improvement Goal
        Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
        2008)

      
        	
                A.
                  Health Plan Information 

                Plan
                  Name: Superior HealthPlan 

                HMO
                  Program: STAR 

                HMO
                  Service Delivery Area: Lubbock SDA

              
	
                B.
                  Overarching Goal

              	
                C.
                  Sub Goals:

              
	
                Goal
                  1:

              	
                 

              
	
                Improve
                  Access to Primary Care

              	
                
                  90%
                    of new members will receive a reminder/insert in the within 75 days
                    of receipt of application.

                

              
	
                Services
                  for Members

              	
                The
                  percentage of Family Practitioners with open panels will increase
                  by 1.4
                  percentage points over baseline.

              
	
                Goal
                  2: Improve Access to Behavioral Health Services for
                  Members

              	
                Increase
                  Behavioral Health Urgent Care Appointment Availability by 5 percentage
                  points over the baseline. 

                Increase
                  Behavioral Health Routine Care Appointment Availability by 5 percentage
                  points over the baseline.

              
	
                Goal
                  3:

              	
              
	
                Increase
                  Utilization of New Member Medical Check-Ups

              	
                
                  90%
                    of new members will receive a reminder/insert in the new member
                    packets to remind members to schedule a new patient
                    check-up.

                

              
	
                within
                  90 days of Enrollment

              	
                100%
                  of new members with working phone numbers and with default or no
                  PCP will
                  have a new PCP assignment within 60 days of
                  enrollment.

              

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Subject:
        Attachment B-4 – Performance Improvement Goals Version 1.8

       

      HMO
        Performance Improvement Goal
        Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
        2008)

      
        	
                A.
                  Health Plan Information 

                Plan
                  Name: Superior HealthPlan
                  

                HMO
                  Program: STAR 

                HMO
                  Service Delivery Area: Nueces SDA

              
	
                B.
                  Overarching Goal

              	
                C.
                  Sub Goals:

              
	
                Goal
                  1:

              	
                 

              
	
                Improve
                  Access to Primary Care

              	
                
                  90%
                    of new members will receive a reminder/insert in the within 75 days
                    of receipt of application.

                

              
	
                Services
                  for Members

              	
                The
                  percentage of Family Practitioners with open panels will increase
                  by 10
                  percentage points over baseline.

              
	
                Goal
                  2: Improve Access to Behavioral Health Services for
                  Members

              	
                Increase
                  Behavioral Health Urgent Care Appointment Availability by 5 percentage
                  points over the baseline. 

                Increase
                  Behavioral Health Routine Care Appointment Availability by 5 percentage
                  points over the baseline.

              
	
                Goal
                  3:

              	
                 

              
	
                Increase
                  Utilization of New Member Medical Check-Ups

              	
                
                  90%
                    of new members will receive a reminder/insert in the new member
                    packets to remind members to schedule a new patient
                    check-up.

                

              
	
                within
                  90 days of Enrollment

              	
                100%
                  of new members with working phone numbers and with default or no
                  PCP will
                  have a new PCP assignment within 60 days of
                  enrollment.

              

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Subject:
        Attachment B-4 – Performance Improvement Goals Version 1.8

       

      HMO
        Performance Improvement Goal
        Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
        2008)

      
        	
                A.
                  Health Plan Information 

                Plan
                  Name: Superior HealthPlan 

                HMO
                  Program: STAR 

                HMO
                  Service Delivery Area: Travis

              	
                 

              	 
	
                B.
                  Overarching Goal

              	 	 	
                C.
                  Sub Goals:

              
	
                Goal
                  1:

              	 	
                 

              	
                 

              
	
                Improve
                  Access to Primary Care

              	 	 	
                
                  90%
                    of initial credentialing of PCPs will be finalized within 75 days
                    of receipt of application.

                

              
	
                Services
                  for Members

              	 	
                 

              	
                The
                  percentage of Family Practitioners with open panels will increase
                  by 10
                  percentage points over baseline.

              
	
                Goal
                  2: Improve Access to Behavioral Health Services for
                  Members

              	 	
                 

              	
                Increase
                  Behavioral Health Urgent Care Appointment Availability by 5 percentage
                  points over the baseline. 

                Increase
                  Behavioral Health Routine Care Appointment Availability by 5 percentage
                  points over the baseline.

              
	
                Goal
                  3:

              	 	
                 

              	
                 

              
	
                Increase
                  Utilization of New Member Medical Check-Ups

              	 	 	
                
                  90%
                    of new members will receive a reminder/insert in the new member
                    packets to remind members to schedule a new patient
                    check-up.

                

              
	
                within
                  90 days of Enrollment

              	 	
                 

              	
                100%
                  of new members with working phone numbers and with default or no
                  PCP will
                  have a new PCP assignment within 60 days of
                  enrollment.

              

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Subject:
        Attachment B-4 – Performance Improvement Goals Version 1.8

       

      HMO
        Performance Improvement Goal
        Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
        2008)

      
        	
                A.
                  Health Plan Information 

                Plan
                  Name: Superior HealthPlan 

                HMO
                  Program: STAR+PLUS 

                HMO
                  Service Delivery Area: Bexar SDA

              	
                 

              	 
	
                B.
                  Overarching Goal

              	 	 	
                C.
                  Sub Goals:

              
	
                Goal
                  1:

              	 	
                 

              	
                 

              
	
                Improve
                  Access to Primary Care

              	 	 	
                
                  90%
                    of initial credentialing of PCPs will be finalized within 75 days
                    of receipt of application.

                

              
	
                Services
                  for Members

              	 	
                 

              	
                The
                  percentage of Family Practitioners with open panels will increase
                  by 10
                  percentage points over baseline.

              
	
                Goal
                  2: Improve Access to Behavioral Health Services for
                  Members

              	 	
                 

              	
                Increase
                  Behavioral Health Urgent Care Appointment Availability by 5 percentage
                  points over the baseline. 

                Increase
                  Behavioral Health Routine Care Appointment Availability by 5 percentage
                  points over the baseline.

              
	
                Goal
                  3:

              	 	
                 

              	
                 

              
	
                Improve
                  Member Understanding of Service Coordination

              	 	
                 

              	
                
                  100%
                    of new members with a Face to Face assessment  occurring
                    between 9-1-07 and 7-31-08 will receive a newly developed Service
                    Coordination information/pamphlet. 

                  100%
                    of all members NOT receiving Service Coordination are
                    mailed an informational pamphlet about service coordination availability
                    each quarter.

                

              

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Subject:
        Attachment B-4 – Performance Improvement Goals Version 1.8

       

      HMO
        Performance Improvement Goal
        Template for State Fiscal Year 2008 (September 1, 2007 – August 31,
        2008)

      
        	
                A.
                  Health Plan Information 

                Plan
                  Name: Superior HealthPlan 

                HMO
                  Program: STAR+PLUS 

                HMO
                  Service Delivery Area: Nueces

              	 	 
	
                B.
                  Overarching Goal

              	 	 	
                C.
                  Sub Goals:

              
	
                Goal
                  1:

              	 	
                 

              	
                 

              
	
                Improve
                  Access to Primary Care

              	 	 	
                
                  90%
                    of initial credentialing of PCPs will be finalized within 75
                    days of receipt of application.

                

              
	
                Services
                  for Members

              	 	
                 

              	
                The
                  percentage of Family Practitioners with open panels will increase
                  by 10
                  percentage points over baseline.

              
	
                Goal
                  2: Improve Access to Behavioral Health Services for
                  Members

              	 	
                 

              	
                Increase
                  Behavioral Health Urgent Care Appointment Availability by 5 percentage
                  points over the baseline. 

                Increase
                  Behavioral Health Routine Care Appointment Availability by 5 percentage
                  points over the baseline.

              
	
                Goal
                  3:

              	 	
                 

              	
                 

              
	
                Improve
                  Member Understanding of Service Coordination

              	 	
                 

              	
                
                  100%
                    of new members with a Face to Face assessment occurring between
                    9-1-07 and 7-31-08 will receive a newly developed Service Coordination
                    information/pamphlet. 

                  100%
                    of all members NOT receiving Service Coordination are
                    mailed an informational pamphlet about service coordination availability
                    each quarter.

                

              

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      

      
        Subject:
          Attachment B-4.1 – FY2008 Performance Improvement
          Goals

      
        	
                DOCUMENT
                  HISTORY LOG

              
	
                STATUS1

              	
                DOCUMENT

                REVISION2

              	
                EFFECTIVE

                DATE

              	
                DESCRIPTION3

              	 
	
                Baseline

              	
                1.0

              	 	
                Initial
                  version of Attachment B-4, Performance Improvement Goals.

              	 
	
                Revision

              	
                1.1

              	
                June
                  30, 2006

              	
                Revised
                  Attachment B-4, Performance Improvement Goals Template, by adding
                  Attachment B-4.1, FY2008 Performance Improvement Goals Template.
                  This is
                  the initial version of Attachment B-4.1, FY2008 Performance Improvement
                  Goals.

              	 
	
                Revision

              	
                1.2

              	
                September
                  1, 2006

              	
                Contract
                  amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
                  Goals.

              	 
	
                Revision

              	
                1.3

              	
                September
                  1, 2006

              	
                Contract
                  amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
                  Goals.

              	 
	
                Revision

              	
                1.4

              	
                September
                  1, 2006

              	
                Contract
                  amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
                  Goals, but did change format.

              	 
	
                Revision

              	
                1.5

              	
                January
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
                  Goals.

              	 
	
                Revision

              	
                1.6

              	
                February
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
                  Goals.

              	 
	
                Revision

              	
                1.7

              	
                July
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-4.1, FY2008 Performance Improvement
                  Goals.

              	 
	
                Cancellation

              	
                1.8

              	
                September
                  1, 2007

              	
                Attachment
                  B-4.1 is cancelled as duplicative.  Attachment B-4 will be
                  updated with FY2008 Performance Improvement Goals by Program and
                  by
                  Service Area.

              	 
	
                 

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

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

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

              

      

      
      

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Texas
        Health and Human Services Commission

      HMO
        Performance Improvement Goal Template

      for
        State Fiscal Year 2008

      (September
        1, 2007 – August 31, 2008)

      

      

      
        	
              
	
                A.  Health
                  Plan Information

                 

                Plan
                  Name:

                HMO
                  Program:   

                HMO
                  Service Delivery Area:

                 

              
	
                B.  Overarching
                  Goal

              	
                C.  Sub
                  Goals:

              	 
	
                Goal
                  1-5:

                 

                Three
                  to five Goals for all applicable HMO Programs to be determined
                  and
                  negotiated prior to FY2008.

                 

              	
                 

                To
                  be determined for FY2008.

                 

              	 
	
                Goal
                  6:

                 

                (STAR+PLUS
                  HMOs)
                  Increase the use of the Consumer Directed Services (CDS)
                  Program

                 

              	
                 

                Increase
                  the percentage of enrollees receiving Personal Assistance Services
                  (PAS)
                  through the Consumer Directed Services (CDS) Program by 15% as
                  compared to
                  the baseline rate of ____

                 

              	 

      

      
      

      	
              A.  Health
                Plan Information

               

              Plan
                Name:

              HMO
                Program:   

              HMO
                Service Delivery Area:

               

            
	
              B.  Overarching
                Goal

            	
              C.  Sub
                Goals:

            	 
	
              Goal
                1-5:

               

              Three
                to five Goals for all applicable HMO Programs to be determined and
                negotiated prior to FY2008.

               

            	
               

              To
                be determined for FY2008.

               

            	 
	
              Goal
                6:

               

              (STAR+PLUS
                HMOs)
                Increase the use of the Consumer Directed Services (CDS)
                Program

               

            	
               

              Increase
                the percentage of enrollees receiving Personal Assistance Services
                (PAS)
                through the Consumer Directed Services (CDS) Program by 15% as compared
                to
                the baseline rate of ____

               

            	 

    

    
    

     

    Specific
      percentages for Sub-Goals will be negotiated by HHSC and the HMO before the
      beginning of FY2008.

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      Responsible
        Office: HHSC Office of General Counsel (OGC)

      Subject:
        Attachment B-5 –Deliverables/Liquidated Damages
        Matrix

    

    
      DOCUMENT
        HISTORY LOG

       

      
        	
                DOCUMENT
                  HISTORY LOG

              
	
                STATUS1

              	
                DOCUMENT

                REVISION2

              	
                EFFECTIVE

                DATE

              	
                DESCRIPTION3

              	 
	
                Baseline

              	
                n/a

              	 	
                Initial
                  version of Attachment B-5, Deiverables/Liquidated Damage
                  Matrix.

              	 
	
                Revision

              	
                1.1

              	
                June
                  30, 2006

              	
                Contract
                  amendment did not revise Attachment B-5, Deliverables/Liquidated

                  Damage
                    Matrix.

                

              	 
	
                Revision

              	
                1.2

              	
                September
                  1, 2006

              	
                
                  Amended
                    Attachment B-5, Deliverables/Liquidated Damages Matrix, to add
                    a
                    footnote
                    clarifying the deliverable due dates. Also amended the provisions
                    regarding Claims
                    Processing Requirements and the Reporting Requirements for the
                    Claims
                    Summary
                    Report.

                

              	 
	
                Revision

              	
                1.3

              	
                September
                  1, 2006

              	
                Amended
                  Attachment B-5, Deliverables/Liquidated Damages Matrix, performance
standard
                  for Provider Directories for the CHIP Perinatal
                  Program.

              	 
	
                Revision

              	
                1.4

              	
                September
                  1, 2006

              	
                Contract
                  amendment did not revise Attachment B-5, Deliverables/Liquidated

                  Damage
                    Matrix.

                

              	 
	
                Revision

              	
                1.5

              	
                January
                  1, 2007

              	Contract
                amendment did not revise Attachment B-5,
                Deliverables/Liquidated
                Damage
                  Matrix.

              	 
	
                Revision

              	
                1.6

              	
                February
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-5,
                  Deliverables/Liquidated
                  Damage
                    Matrix.

                

              	 
	
                Revision

              	
                1.7

              	
                July
                  1, 2007

              	
                
                  Amended
                    Attachment B-5, Deliverables/Liquidated Damages Matrix, to
                    add

                  clarifications
                    to the provisions addressing Claims Processing Requirements and
                    the

                  Reporting
                    Requirements for the Claims Summary Report.

                

              	 
	
                Cancellation

              	
                1.8

              	
                September
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-5, Deliverables/Liquidated
                  Damage
                  Matrix.

              	 
	
                 

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

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

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

              

      

       

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

    
      Deliverables/Liquidated
        Damages Matrix

       

      
        
          	
                   
                    Service/
                    Component1

                	
                   Performance
                    Standard2

                	
                   
                    Measurement
                    Period3

                	
                   
                    Measurement
                    Assessment4

                	
                   Liquidated
                    Damages

                
	 
                  
                  Contract

                  Attachment
                    B-1,

                  RFP
                    §7.3 --

                  Transition
                    Phase

                  Schedule

                   

                  Contract

                  Attachment
                    B-1,

                  RFP
                    §7.3.1 --

                  Transition
                    Phase

                  Tasks

                  Contract

                  Attachment
                    B-1,

                  RFP
                    §8.1 --

                  General
                    Scope

                	
                  The
                    HMO must be operational no

                  later
                    than the agreed upon

                  Operations
                    Start Date. HHSC, or

                  its
                    agent, will determine when the

                  HMO
                    is considered to be

                  operational
                    based on the

                  requirements
                    in Section 7 and 8 of

                  Attachment
                    B-1.

                	 
                  
                  
                    Operations
                      Start

                  

                  Date

                	 
                  
                   

                  
                    Each
                      calendar day of

                  

                  non-compliance,
                    per

                  HMO
                    Program, per

                  Service
                    Area (SA).

                	 
                  
                  HHSC
                    may assess up to $10,000 per

                  calendar
                    day for each day beyond the

                  Operations
                    Start date that the HMO is

                  not
                    operational until the day that the

                  HMO
                    is operational, including all

                  systems.

                
	 
                  
                  Contract

                  Attachment
                    B-1

                  RFP
                    §7.3.1.5 --

                  Systems

                  Readiness

                  Review

                	 
                  
                   

                  The
                    HMO must submit to HHSC or

                  to
                    the designated Readiness

                  Review
                    Contractor the following

                  plans
                    for review, by December 14,

                  2005
                    for STAR and CHIP, and by

                  July
                    31, 2006 for STAR+PLUS:

                  •
Joint
                    Interface
                    Plan;

                  •
Disaster
                    Recovery
                    Plan;

                	 Transition
                  Period 	 
                  
                  
                    Each
                      calendar day of

                  

                  non-compliance,
                    per

                  report,
                    per HMO

                  Program,
                    and per SA.

                	 
                  
                  
                    HHSC
                      may assess up to $1,000 per

                  

                  calendar
                    day for each day a

                  deliverable
                    is late, inaccurate or

                  incomplete.

                

        

      

      
        
        

      

      
        1
          Derived from the Contract or HHSC’s Uniform Managed Care Manual.

        2Standard
          specified in the Contract. Note: Where the due date states 30 days, the
          HMO is
          to provide the deliverable by the last day of the month following
          the end of the reporting period. Where the due date states 45 days, the
          HMO is
          to provide the deliverable by the 15th day of the second month
          following the end of the reporting period.

        3
          Period during which HHSC will evaluate service for purposes of tailored
          remedies.

        4
          Measure against which HHSC will apply remedies

      

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
       

      
        
          	
                   
                    Service/
                    Component1

                	
                   Performance
                    Standard2

                	
                   
                    Measurement
                    Period3

                	
                   
                    Measurement
                    Assessment4

                	
                   Liquidated
                    Damages

                
	 
                  
                   

                	
                  
                    
                      •
Business
                        Continuity Plan;

                      •
Risk
                        Management
                        Plan;

                      and

                      •
Systems
                        Quality
                        Assurance

                      Plan.

                    

                  

                   

                	 
                  
                  
                     

                  

                	 
                  
                   

                   

                	 
                  
                  
                  

                   

                
	 
                  
                   

                  Contract

                  Attachment
                    B-1

                  RFP
                    §7.3.1.7 –

                  Operations

                  Readiness

                   

                	 
                  
                  Contract
                    Attachment
                    B-1 RFP
                    §7.3.1.7 –

                  Operations
                    Readiness
                    Final
                    versions of the Provider Directory
                    must be submitted to the

                  Administrative
                    Services Contractor no
                    later than 95 days prior to the Operational
                    Start Date for the CHIP, STAR,
                    and STAR+PLUS HMOs, and
                    no later than 30 days prior to

                  the
                    Operational Start Date for the CHIP
                    Perinatal HMOs.

                   

                  
                  

                   

                	 Transition
                  Period	 
                  
                  
                    
                      Each
                        calendar day of

                      non-compliance,
                        per

                      directory,
                        per HMO

                      Program
                        and per SA.

                    

                  

                	 
                  
                  
                    
                    

                  

                  
                    HHSC
                      may assess up to $1,000 per

                    calendar
                      day for each day the

                    directory
                      is late, inaccurate or

                    incomplete.

                  

                
	 
                  
                  Contract

                  Attachment
                    B-1

                  RFP
                    §§ 6, 7, 8

                  and
                    9

                  Uniform

                  Managed
                    Care

                  Manual

                	 
                  
                  All
                    reports and deliverables as

                  specified
                    in Sections 6, 7, 8 and 9

                  of
                    Attachment B-1 must be

                  submitted
                    according to the

                  timeframes
                    and requirements stated

                  in
                    the Contract (including all

                  attachments)
                    and HHSC’s Uniform

                  Managed
                    Care Manual. (Specific

                  Reports
                    or deliverables listed

                  separately
                    in this matrix are subject

                  to
                    the specified liquidated

                  damages.)

                	 
                  
                  Transition
                    Period,

                  Quarterly
                    during

                  Operations
                    Period

                	 
                  
                  Each
                    calendar day of

                  non-compliance,
                    per

                  HMO
                    Program, per SA.

                	 
                  
                  HHSC
                    may assess up to $250 per

                  calendar
                    day if the report/deliverable

                  is
                    late, inaccurate, or incomplete.

                
	 Contract	 The
                  HMO may not engage in 	 Transition,
                  	 Per
                  incident of non- 	 HHSC
                  may assess up to $1,000 per.

        

      

      
        
        

      

      
        1
          Derived from the Contract or HHSC’s Uniform Managed Care Manual.

        2Standard
          specified in the Contract. Note: Where the due date states 30 days, the
          HMO is
          to provide the deliverable by the last day of the month following
          the end of the reporting period. Where the due date states 45 days, the
          HMO is
          to provide the deliverable by the 15th day of the second month
          following the end of the reporting period.

        3
          Period during which HHSC will evaluate service for purposes of tailored
          remedies.

        4
          Measure against which HHSC will apply remedies

      

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      
        
          
             

            
              
                	
                         
                          Service/
                          Component1

                      	
                         Performance
                          Standard2

                      	
                         
                          Measurement
                          Period3

                      	
                         
                          Measurement
                          Assessment4

                      	
                         Liquidated
                          Damages

                      
	 
                        
                        Attachment
                          B-1

                        RFP
                          §8.1.6 --

                        Marketing
                          &

                        Prohibited

                        Practices

                        Uniform

                        Managed
                          Care

                        Manual

                         

                      	
                        
                          
                            
                            

                            prohibited
                              marketing practices.

                          

                        

                         

                      	 
                        
                        
                          
                            Measured

                            Quarterly
                              during

                            the
                              Operations

                            Period

                          

                        

                      	 
                        
                         

                        compliance.

                      	 
                        
                        
                        

                         incident
                          of non-compliance.

                      
	 
                        
                         

                        
                          Contract

                        

                        Attachment
                          B-1

                        RFP
                          §8.1.17.2 --

                        Financial

                        Reporting

                        Requirements

                        Uniform

                        Managed
                          Care

                        Manual
                          –

                        Chapter
                          5

                         

                      	 
                        
                        
                        

                        
                        

                        
                          
                            Financial
                              Statistical Reports (FSR):

                          

                          For
                            each SA, the HMO must file

                          quarterly
                            and annual FSRs.

                          Quarterly
                            reports are due no later

                          than
                            30 days after the conclusion of

                          each
                            State Fiscal Quarter (SFQ).

                          The
                            first annual report is due no

                          later
                            than 120 days after the end of

                          each
                            Contract Year and the second

                          annual
                            report is due no later than

                          365
                            days after the end of each

                          Contract
                            Year.

                        

                      	 
                        
                        Quarterly
                          during

                        the
                          Operations

                        Period

                      	 
                        
                        
                          
                            
                            

                            
                              Per
                                calendar day of

                              non-compliance,
                                per

                              HMO
                                Program, per SA.

                            

                          

                        

                      	 
                        
                        
                          
                          

                        

                        
                          
                            HHSC
                              may assess up to $1,000 per

                            calendar
                              day a quarterly or annual

                            report
                              is late, inaccurate or

                            incomplete.

                          

                        

                      
	 
                        
                        Contract

                        Attachment
                          B-1

                        RFP
                          §8.1.17.2 --

                        Financial

                        Reporting

                        Requirements:

                        
                        

                         

                      	 
                        
                        Medicaid
                          Disproportionate Share

                        Hospital
                          (DSH) Reports: The

                        Medicaid
                          HMO must submit, on an

                        annual
                          basis, preliminary and final

                        DSH
                          Reports. The Preliminary

                        report
                          is due no later than June
                          1st

                        after
                          each reporting year, and the

                         

                      	 
                        
                        
                        

                        
                          Measured
                            during

                          4th
Quarter
                            of
                            the

                          Operations
                            Period

                          (6/1–8/31)

                        

                      	 
                        
                        
                          Per
                            calendar day of

                          non-compliance,
                            per

                          HMO
                            Program, per SA.

                        

                      	 
                        
                        HHSC
                          may assess up to $1,000 per

                        calendar
                          day, per program, per

                        service
                          area, for each day the report

                        is
                          late, incorrect, inaccurate or

                        incomplete.

                      

              

            

            
              
              

            

            
              1
                Derived from the Contract or HHSC’s Uniform Managed Care Manual.

              2Standard
                specified in the Contract. Note: Where the due date states 30 days,
                the HMO is
                to provide the deliverable by the last day of the month following
                the end of the reporting period. Where the due date states 45 days,
                the HMO is
                to provide the deliverable by the 15th day of the second month
                following the end of the reporting period.

              3
                Period during which HHSC will evaluate service for purposes of tailored
                remedies.

              4
                Measure against which HHSC will apply
                remedies

            

          

        

      

       

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        
          
             

            
              
                	
                         
                          Service/
                          Component1

                      	
                         Performance
                          Standard2

                      	
                         
                          Measurement
                          Period3

                      	
                         
                          Measurement
                          Assessment4

                      	
                         Liquidated
                          Damages

                      
	 
                        
                        Uniform

                        Managed
                          Care

                        Manual
                          –

                        Chapter
                          5

                         

                      	
                        
                          
                            
                               

                            

                             

                          

                        

                        
                          final
                            report is due no later than July

                          15th
after
                            each reporting
                            year. This

                          standard
                            does not apply to CHIP

                          HMOs.

                        

                      	 
                        
                        
                           

                        

                      	 
                        
                         

                         

                      	 
                        
                        
                           

                        

                         

                      
	 
                        
                        
                           
Contract

                        Attachment
                          B-1

                        RFP
                          §8.1.18 –

                        Management

                        Information

                        System
                          (MIS)

                        Requirements

                         

                         

                      	 
                        
                        The
                          HMO’s MIS must be able to

                        resume
                          operations within 72 hours

                        of
                          employing its Disaster Recovery

                        Plan.

                        
                           

                        

                        
                           

                        

                         

                      	 
                        
                        
                           
Measured

                        Quarterly
                          during

                        the
                          Operations

                        Period

                      	 
                        
                        Per
                          calendar day of

                        non-compliance,
                          per

                        HMO
                          Program, per SA.

                        
                          
                            
                               

                            

                             

                          

                        

                      	 
                        
                        
                          
                             

                          

                        

                        
                          
                            
                              HHSC
                                may assess up to $5,000 per

                            

                            calendar
                              day of non-compliance

                          

                        

                      
	 
                        
                        
                          Contract

                        

                        Attachment
                          B-1

                        RFP
                          §8.1.18.3 –

                        Management

                        Information

                        System
                          (MIS)

                        Requirements:

                        
                          
                            
                               
System-Wide

                          

                          Functions

                        

                        
                           

                        

                         

                      	 
                        
                        
                          The
                            HMO’s MIS system must meet

                          all
                            requirements in Section 8.1.18.3

                          of
                            Attachment B-1.

                        

                      	 
                        
                        
                           

                        

                        
                          
                             
Measured

                          Quarterly
                            during

                          the
                            Operations

                          Period

                        

                      	 
                        
                        Per
                          calendar day of

                        non-compliance,
                          per

                        HMO
                          Program, per SA.

                         

                      	 
                        
                        
                           
HHSC
                          may assess up to $5,000 per

                        calendar
                          day of non-compliance.

                      
	 
                        
                        Contract

                        Attachment
                          B-1

                        RFP
                          §8.1.18.5 --

                        Claims

                        Processing

                        Requirements

                      	 
                        
                        
                          
                            The
                              HMO must adjudicate all

                          

                        

                        provider
                          Clean Claims within 30

                        days
                          of receipt by the HMO. The

                        HMO
                          must pay providers interest at

                        an
                          18% per annum, calculated daily

                        for
                          the full period in which the Clean

                      	 
                        
                        
                          
                            Measured

                          

                        

                        Quarterly
                          during

                        the
                          Operations

                        Period

                      	 Per
                        incident of noncompliance.	 
                        
                        HHSC
                          may assess up to $1,000 per

                        claim
                          if the HMO fails to timely pay

                        interest.

                      

              

            

            
              
                 

              

            

            
              1
                Derived from the Contract or HHSC’s Uniform Managed Care Manual.

              2Standard
                specified in the Contract. Note: Where the due date states 30 days,
                the HMO is
                to provide the deliverable by the last day of the month following
                the end of the reporting period. Where the due date states 45 days,
                the HMO is
                to provide the deliverable by the 15th day of the second month
                following the end of the reporting period.

              3
                Period during which HHSC will evaluate service for purposes of tailored
                remedies.

              4
                Measure against which HHSC will apply
                remedies

            

          

        

        
           

           

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        
           

          
            
              	
                       
                        Service/
                        Component1

                    	
                       Performance
                        Standard2

                    	
                       
                        Measurement
                        Period3

                    	
                       
                        Measurement
                        Assessment4

                    	
                       Liquidated
                        Damages

                    
	 
                      
                      
                        Uniform

                        Managed
                          Care

                        Manual
                          Chapter

                        2

                      

                    	
                      
                        
                          
                             

                          

                           

                        

                      

                      
                        
                           
Claim
                          remains unadjudicated

                        beyond
                          the 30-day claims

                        processing
                          deadline. Interest owed

                        the
                          provider must be paid on the

                        same
                          date that the claim is

                        adjudicated.

                      

                    	 
                      
                      
                         

                      

                    	 
                      
                       

                       

                    	 
                      
                      
                         

                      

                       

                    
	 
                      
                      Contract

                      Attachment
                        B-1

                      RFP
                        §8.1.18.5 --

                      Claims

                      Processing

                      Requirements

                      Uniform

                      Managed
                        Care

                      Manual
                        –

                      Chapter
                        2

                       

                       

                    	 
                      
                      The
                        HMO must comply with the

                      claims
                        processing requirements and

                      standards
                        as described in Section

                      8.1.18.5
                        of Attachment B-1 and in

                      Chapter
                        2 of the Uniform Managed

                      Care
                        Manual.

                      
                         

                      

                      
                         

                      

                       

                    	 
                      
                      Measured

                      Quarterly
                        during

                      the
                        Operations

                      Period

                    	 
                      
                      
                         
Per
                        quarterly reporting

                      period,
                        per HMO

                      Program,
                        per Service

                      Area,
                        per claim type.

                      
                        
                          
                             

                          

                           

                        

                      

                    	 
                      
                      
                        
                           

                        

                      

                      
                        
                          HHSC
                            may assess liquidated

                          damages
                            of up to $5,000 for the first

                          quarter
                            that an HMO’s Claims

                          Performance
                            percentages by claim

                          type,
                            by Program, and by service

                          area,
                            fall below the performance

                          standards.
                            HHSC may assess up to

                          $25,000
                            per quarter for each

                          additional
                            quarter that the Claims

                          Performance
                            percentages by claim

                          type,
                            by Program, and by service

                          area,
                            fall below the performance

                          standards.

                        

                      

                    
	 
                      
                      
                         
Contract

                      Attachment
                        B-1

                      RFP
                        §8.1.20.2--

                      Reporting

                      Requirements

                      Uniform

                      Managed
                        Care

                      
                         

                      

                       

                    	 
                      
                      
                        Claims
                          Summary Report:

                        The
                          HMO must submit quarterly,

                        Claims
                          Summary Reports to HHSC

                        by
                          HMO Program, by Service Area,

                        and
                          by claim type, by the 30th
                          day

                        following
                          the reporting period unless

                        otherwise
                          specified.

                      

                    	 
                      
                      
                         

                      

                      
                        Measured

                        Quarterly
                          during

                        the
                          Operations

                        Period

                      

                    	 
                      
                      Per
                        calendar day of

                      non-compliance,
                        per

                      HMO
                        Program, per

                      Service
                        Area, per claim

                      type.

                       

                    	 
                      
                      
                         
HHSC
                        may assess up to $1,000 per

                      calendar
                        day the report is late,

                      inaccurate,
                        or incomplete.

                    

            

          

          
            
               

            

          

          
            1
              Derived from the Contract or HHSC’s Uniform Managed Care Manual.

            2Standard
              specified in the Contract. Note: Where the due date states 30 days,
              the HMO is
              to provide the deliverable by the last day of the month following
              the end of the reporting period. Where the due date states 45 days,
              the HMO is
              to provide the deliverable by the 15th day of the second month
              following the end of the reporting period.

            3
              Period during which HHSC will evaluate service for purposes of tailored
              remedies.

            4
              Measure against which HHSC will apply remedies

            
              
                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

                
                   

                  
                    
                      	
                               
                                Service/
                                Component1

                            	
                               Performance
                                Standard2

                            	
                               
                                Measurement
                                Period3

                            	
                               
                                Measurement
                                Assessment4

                            	
                               Liquidated
                                Damages

                            
	 
                              
                              Manual

                              Chapters
                                2 and

                              5

                               

                            	
                              
                                
                                  
                                     

                                  

                                   

                                

                              

                               

                            	 
                              
                              
                                 

                              

                            	 
                              
                               

                               

                            	 
                              
                              
                                 

                              

                               

                            
	 
                              
                              
                                 
Contract

                              Attachment
                                B-1

                              RFP
                                §8.1.5.9--

                              Member

                              Complaint
                                and

                              Appeal
                                Process

                              Contract

                              Attachment
                                B-1

                              RFP
                                §8.2.7.1 --

                              Member

                              Complaint

                              Process

                              Contract

                              Attachment
                                B-1

                              RFP
                                §8.4.3 –

                              CHIP
                                Member

                              Complaint
                                and

                              Appeal
                                Process

                               

                               

                            	 
                              
                              
                                 

                              

                              
                                 

                              

                              
                                The
                                  HMO must resolve at least

                                98%
                                  of Member Complaints within

                                30
                                  calendar days from the date the

                                Complaint
                                  is received by the HMO.

                              

                            	 
                              
                              Measured

                              Quarterly
                                during

                              the
                                Operations

                              Period

                            	 
                              
                              
                                 
Per
                                reporting period,

                              per
                                HMO Program, per

                              SA.

                              
                                
                                  
                                     

                                  

                                   

                                

                              

                            	 
                              
                              
                                
                                   

                                

                              

                              
                                
                                   

                                  
                                    
                                      
                                         
HHSC
                                        may assess up to $250 per

                                    

                                    reporting
                                      period if the HMO fails to

                                    meet
                                      the performance standard.

                                  

                                

                              

                            
	 
                              
                              
                                 

                              

                              
                                
                                   
Contract

                                
                                  Attachment
                                    B-1

                                  RFP
                                    §8.3.3 –

                                  STAR+PLUS

                                  Assessment

                                  Instruments

                                  Uniform

                                

                              

                            	 
                              
                              
                                The
                                  MDS-HC instrument must be

                                completed
                                  and electronically

                                submitted
                                  to HHSC in the specified

                                format
                                  within 30 days of enrollment

                                for
                                  every Member receiving

                                Community-based
                                  Long-term Care

                                Services,
                                  and then each year by the

                              

                            	 
                              
                              Operations,

                              Turnover

                              
                                 

                              

                               

                            	 
                              
                              
                                Per
                                  calendar day of

                                non-compliance,
                                  per

                                Service
                                  Area.

                              

                            	 
                              
                              
                                 
HHSC
                                may assess up to $500 per

                              calendar
                                day per Service Area, for

                              each
                                day a report is late, inaccurate

                              or
                                incomplete.

                            

                    

                  

                  
                    
                       

                    

                  

                  
                    1
                      Derived from the Contract or HHSC’s Uniform Managed Care Manual.

                    2Standard
                      specified in the Contract. Note: Where the due date states
                      30 days, the HMO is
                      to provide the deliverable by the last day of the month following
                      the end of the reporting period. Where the due date states
                      45 days, the HMO is
                      to provide the deliverable by the 15th day of the second month
                      following the end of the reporting period.

                    3
                      Period during which HHSC will evaluate service for purposes
                      of tailored
                      remedies.

                    4
                      Measure against which HHSC will apply remedies

                    
                       

                    

                    
                       

                      
                        
                          
                            
                            

                          

                          
                            
                            

                            
                              

                            

                          

                          
                            
                            

                          

                        

                        
                           

                          
                            
                              	
                                       
                                        Service/
                                        Component1

                                    	
                                       Performance
                                        Standard2

                                    	
                                       
                                        Measurement
                                        Period3

                                    	
                                       
                                        Measurement
                                        Assessment4

                                    	
                                       Liquidated
                                        Damages

                                    
	 
                                      
                                      Managed
                                        Care

                                      Manual

                                       

                                    	
                                      
                                        
                                          
                                             

                                          

                                          
                                            
                                               
anniversary
                                              of the Member’s date of

                                            enrollment.

                                          

                                        

                                      

                                       

                                    	 
                                      
                                      
                                         

                                      

                                    	 
                                      
                                       

                                       

                                    	 
                                      
                                      
                                         

                                      

                                       

                                    
	 
                                      
                                       

                                      
                                        Contract

                                        Attachment
                                          B-1

                                        RFP
                                          §8.1.5.9—

                                        Member

                                        Complaint
                                          and

                                        Appeal
                                          Process

                                        Contract

                                        Attachment
                                          B-1

                                        RFP
                                          §8.2.7.2 --

                                        Medicaid

                                        Standard

                                        Member
                                          Appeal

                                        Process

                                        Contract

                                        Attachment
                                          B-1

                                        RFP
                                          § 8.4.3

                                        CHIP
                                          Member

                                        Complaint
                                          and

                                        Appeal
                                          Process

                                      

                                    	 
                                      
                                      The
                                        HMO must resolve at least

                                      98%
                                        of Member Appeals within 30

                                      calendar
                                        days from the date the

                                      Appeal
                                        is filed with the HMO.

                                      
                                         

                                      

                                      
                                         

                                      

                                       

                                    	 
                                      
                                      Measured

                                      Quarterly
                                        during

                                      the
                                        Operations

                                      Period

                                    	 
                                      
                                      
                                        
                                          
                                             

                                          

                                          
                                            Per
                                              reporting period,

                                            per
                                              HMO Program, per

                                            SA.

                                          

                                        

                                      

                                    	 
                                      
                                      
                                        
                                           

                                        

                                      

                                      
                                        
                                          
                                             
HHSC
                                            may assess up to $500 per

                                          reporting
                                            period if the HMO fails to

                                          meet
                                            the performance standard.

                                        

                                      

                                    
	 
                                      
                                      Contract

                                      Attachment
                                        B-1

                                      RFP
                                        §9.2 --

                                      Transfer
                                        of Data

                                      
                                         

                                      

                                       

                                    	 
                                      
                                      
                                        
                                           
The
                                          HMO must transfer all data

                                        regarding
                                          the provision of Covered

                                        Services
                                          to Members to HHSC or a

                                        new
                                          HMO, at the sole discretion of

                                        HHSC
                                          and as directed by HHSC.

                                        All
                                          transferred data must comply

                                        with
                                          the Contract requirements,

                                      

                                    	 
                                      
                                      Measured
                                        at Time

                                      of
                                        Transfer of Data

                                      and
                                        ongoing after

                                      the
                                        Transfer of

                                      Data
                                        until

                                      satisfactorily

                                      completed

                                      
                                         

                                      

                                       

                                    	 
                                      
                                      
                                        Per
                                          incident of noncompliance

                                        (failure
                                          to

                                        provide
                                          data and/or

                                        failure
                                          to provide data

                                        in
                                          required format), per

                                        HMO
                                          Program, per SA.

                                      

                                    	 
                                      
                                      HHSC
                                        may assess up to $10,000 per

                                      calendar
                                        day the data is late,

                                      inaccurate
                                        or incomplete.

                                    

                            

                          

                          
                            
                               

                            

                          

                          
                            1
                              Derived from the Contract or HHSC’s Uniform Managed Care Manual.

                            2Standard
                              specified in the Contract. Note: Where the due date
                              states 30 days, the HMO is
                              to provide the deliverable by the last day of the month
following
                              the end of the reporting period. Where the due date
                              states 45 days, the HMO is
                              to provide the deliverable by the 15th day of the second
month
                              following the end of the reporting period.

                            3
                              Period during which HHSC will evaluate service for
                              purposes of tailored
                              remedies.

                            4
                              Measure against which HHSC will apply
                              remedies

                          

                        

                      

                    

                    
                      
                        
                           

                        

                      

                    

                    
                      
                        
                          
                            
                            

                          

                          
                            
                            

                            
                              

                            

                          

                          
                            
                            

                          

                        

                        
                           

                          
                            
                              	
                                       
                                        Service/
                                        Component1

                                    	
                                       Performance
                                        Standard2

                                    	
                                       
                                        Measurement
                                        Period3

                                    	
                                       
                                        Measurement
                                        Assessment4

                                    	
                                       Liquidated
                                        Damages

                                    
	 
                                      
                                       

                                    	
                                      
                                        
                                          
                                             

                                          

                                           

                                        

                                      

                                      including
                                        HIPAA.

                                    	 
                                      
                                      
                                         

                                      

                                    	 
                                      
                                       

                                       

                                    	 
                                      
                                      
                                         

                                      

                                       

                                    
	 
                                      
                                      Contract

                                      Attachment
                                        B-1

                                      RFP
                                        §9.3 --

                                      Turnover

                                      Services

                                       

                                       

                                    	 
                                      
                                      
                                         

                                      

                                      
                                         

                                      

                                      
                                        Six
                                          months prior to the end of the

                                        contract
                                          period or any extension

                                        thereof,
                                          the HMO must propose a

                                        Turnover
                                          Plan covering the possible

                                        turnover
                                          of the records and

                                        information
                                          maintained to either the

                                        State
                                          (HHSC) or a successor HMO.

                                      

                                    	 
                                      
                                      Measured
                                        at Six

                                      Months
                                        prior to the

                                      end
                                        of the contract

                                      period
                                        or any

                                      extension
                                        thereof

                                      and
                                        ongoing until

                                      satisfactorily

                                      completed

                                    	 
                                      
                                      
                                        
                                          
                                             

                                          

                                          
                                            Each
                                              calendar day of

                                            non-compliance,
                                              per

                                            HMO
                                              Program, per SA.

                                          

                                        

                                      

                                    	 
                                      
                                      
                                        
                                           

                                        

                                      

                                      
                                        
                                          HHSC
                                            may assess up to $1,000 per

                                          calendar
                                            day the Plan is late,

                                          inaccurate,
                                            or incomplete.

                                        

                                      

                                    
	 
                                      
                                      Contract

                                      Attachment
                                        B-1

                                      RFP
                                        §9.4 --

                                      Post-Turnover

                                      Services

                                      
                                         

                                      

                                       

                                    	 
                                      
                                      
                                        The
                                          HMO must provide the State

                                        (HHSC)
                                          with a Turnover Results

                                        report
                                          documenting the completion

                                        and
                                          results of each step of the

                                        Turnover
                                          Plan 30 days after the

                                        Turnover
                                          of Operations.

                                      

                                    	 
                                      
                                      Measured
                                        30 days

                                      after
                                        the Turnover

                                      of
                                        Operations

                                      
                                         

                                        
                                           

                                        

                                      

                                    	 
                                      
                                      Each
                                        calendar day of

                                      non-compliance,
                                        per

                                      HMO
                                        program, per SA.

                                       

                                    	 
                                      
                                      HHSC
                                        may assess up to $250 per

                                      calendar
                                        day the report is late,

                                      inaccurate
                                        or incomplete.

                                    
	 
                                      
                                      
                                         
Contract

                                      Attachment
                                        A

                                      HHSC
                                        Uniform

                                      Managed
                                        Care

                                      Contract
                                        Terms

                                      and
                                        Conditions,

                                      Section
                                        4.08

                                      Subcontractors

                                    	 
                                      
                                      The
                                        HMO must notify HHSC in

                                      writing
                                        immediately upon making a

                                      decision
                                        to terminate a subcontract

                                      with
                                        a Material Subcontractor or

                                      upon
                                        receiving notification from the

                                      Material
                                        Subcontractor of its intent

                                      to
                                        terminate such subcontract.

                                    	 
                                      
                                      Transition,

                                      Measured

                                      Quarterly
                                        during

                                      the
                                        Operations

                                      Period

                                    	 
                                      
                                      Each
                                        calendar day of

                                      non-compliance,
                                        per

                                      HMO
                                        Program, per SA.

                                    	 
                                      
                                      HHSC
                                        may assess up to $5,000 per

                                      calendar
                                        day of non-compliance.

                                    

                            

                          

                          
                            
                               

                            

                          

                          
                            1
                              Derived from the Contract or HHSC’s Uniform Managed Care Manual.

                            2Standard
                              specified in the Contract. Note: Where the due date
                              states 30 days, the HMO is
                              to provide the deliverable by the last day of the month
following
                              the end of the reporting period. Where the due date
                              states 45 days, the HMO is
                              to provide the deliverable by the 15th day of the second
month
                              following the end of the reporting period.

                            3
                              Period during which HHSC will evaluate service for
                              purposes of tailored
                              remedies.

                            4
                              Measure against which HHSC will apply
                              remedies

                          

                        

                      

                    

                  

                

              

            

          

        

      

    

     

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    Subject:
      Attachment B-7 – STAR+PLUS Attendant Care Enhanced Payments
      Methodology

    
      DOCUMENT
        HISTORY LOG

      
        	
                STATUS1

              	
                DOCUMENT
                  REVISION2

              	
                EFFECTIVE
                  DATE

              	
                DESCRIPTION3

              
	
                Baseline

              	
                n/a

              	
                January
                  1, 2007

              	
                Initial
                  version of Attachment B-7, STAR+PLUS Attendant Care Enhanced Payments
                  Methodology, was incorporated into Version 1.5 of the
                  Contract.

              
	
                Revision

              	
                1.6

              	
                February
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-7, STAR+PLUS Attendant Care
                  Enhanced
                  Payments Methodology.

              
	
                Revision

              	
                1.7

              	
                July
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-7, STAR+PLUS Attendant Care
                  Enhanced
                  Payments Methodology.

              
	
                Revision

              	
                1.8

              	
                September
                  1, 2007

              	
                Contract
                  amendment did not revise Attachment B-7, STAR+PLUS Attendant Care
                  Enhanced
                  Payments Methodology.

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

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

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

              

      

      
      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      ATTACHMENT
        B-7: STAR+PLUS ATTENDANT CARE ENHANCED PAYMENTS
        METHODOLOGY

      HMO:
        Superior Health Plan

      SERVICE
        AREA(S): Bexar & Nueces

      
        	
                I.
                  Provider Contracting

              	
                (a)
                  Description of criteria the HMO will use to allow participation
                  in the
                  STAR+PLUS Attendant Care Enhanced Payments.  Will the HMO have a
                  enrollment period that corresponds to the DADS enrollment period
                  to allow
                  new providers to participate in the HMO's Attendant Care Enhanced
                  Payments, or will the HMO have it's own enrollment period that
                  is separate
                  and not tied to the DADS enrollment? (b) Description of any limitations
                  or
                  restrictions.

              
	 	
                Superior
                  HealthPlan will only allow those providers that are currently
                  participating in the DADS Attendant Compensation Rate Enhancements
                  to
                  participate in the STAR+PLUS Attendant Care Enhanced Payments.
                  SHP will
                  have an enrollment period corresponding to the DADS enrollment
                  period to
                  allow new providers to participate in the SHP Attendant Care Enhanced
                  Payments.

              

      

      
      

      

      

      
        	
                II.
                  Payment for STAR+PLUS Attendant Care Enhanced
                  Payments

              	
                Description
                  of methodology the HMO will use to pay for the Attendant Care Enhanced
                  Payments.  Provide sufficient detail to fully explain the
                  planned methodology.

              
	 	
                Superior
                  will not use the DADS rates. SHP will establish an additional amount
                  to be
                  added on to the unit rate by type of service.

              
	
                III.
                  Timing of the Attendant Care Enhanced Payments

              	
                Description
                  of when the payments will be made to the Providers and the frequency
                  of
                  payments.  Also include timeframes for Providers complaints and
                  appeals regarding enhanced payments.

              
	 	
                The
                  enhanced rate payment amount will be paid at the time of claims
                  payment so
                  the frequency will depend on the frequency with which providers
                  file their
                  claims. Provider complaints and appeals will be handled through
                  the normal
                  complaint and appeal process and finalized within 30 days from
                  receipt.

              

      

      
      

      

      

      Additional
        information related to the Attendant Care Enhanced Payments can be found
        in
        Attachment B-1, Section 8.3.7.3 of the Contract.

      
        	
                IV.
                  Assurances from Participating Providers

              	
                Description
                  of how the HMO will ensure that the participating Providers are
                  using the
                  enhancement funds to compensate direct care workers as intended
                  by the
                  2000-01 General Appropriations Act (Rider 27, House Bill 1, 76th Legislature,
                  Regular
                  Session, 1999) and by T.A.C. Title 1, Part 15, Chapter
                  355.

              
	 	
                Participating
                  Providers will be required by contract to complete and submit an
                  affidavit
                  annually stating they applied the enhancement funds to the compensation
                  for direct care staff. Compensation may include increased hourly
                  rates,
                  bonuses, paid holidays or additional benefits such as employer
                  paid
                  insurance.

              
	
                V.
                  Monitoring of Attendant Care Enhanced Payments

              	
                Explanation
                  of the Monitoring Process that the HMO will use to monitor whether
                  the
                  Attendant Care Enhanced Payments are used for the purposes intended
                  by the
                  Texas Legislature.

              
	 	
                Each
                  Provider’s compliance with the attendant compensation spending requirement
                  for the reporting period will be monitored on an annual basis via
                  the
                  submission of the affidavit stating they applied the enhancement
                  funds to
                  the compensation for direct care staff. Compensation may include
                  increased
                  hourly rates, bonuses, paid holidays or additional benefits such
                  as
                  employer paid insurance. In addition, providers may be audited
                  on as
                  as-needed basis to ensure financial records support the pass through
                  of
                  the enhanced funds. Enhanced payments could potentially be recouped
                  for
                  those Providers who fail to pass the funds to their direct care
                  staff.

              

      

      
      

      

      By
        signing the Contract and/or Contract Amendment, HMO certifies that the approved
        STAR+PLUS Attendant Care Enhanced Payments Methodology described herein is
        the
        methodology the HMO will use to make the legislatively mandated payments
        to its
        Long Term Services and Support (LTSS) Providers participating in the Attendant
        Care Enhanced Payments.

       

      Additional
        informationrelated to the Attendant
        Care Enhanced Payments can be found in Attachment B-1, Section 8.3.7.3 of
        the
        Contract.

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