Document:

Exhibit 10.1

            AMENDMENT TO EMPLOYMENT AGREEMENT DATED NOVEMBER 8, 2004
                 BETWEEN STEVE CURD AND VANTAGEMED CORPORATION

         1. Paragraph 6 of the Employment Agreement dated November 8, 2004
between Steve Curd and VantageMed Corporation (the "Employment Agreement") is
hereby amended to read as follows:

         6. Acceleration of Option on a Change of Control. The Option shall
         provide that all of the unvested portion of the Option will vest upon a
         Change of Control (as defined in the Stock Option Plan). If the
         Employee is terminated or Resigns pursuant to Paragraph 4(d) or 4(e)
         hereunder within ninety (90) days prior to a Change in Control, the
         Option will accelerate upon the Change in Control as set forth in this
         Paragraph 6.

         2. Except as otherwise described herein, the terms and conditions of
the Employment Agreement remain in full force and effect.

        IN WITNESS WHEREOF, the parties have executed this Agreement as of the
date and year written below.

                                             VantageMed Corporation

                                             By:
                                                  ------------------------------
                                                  Liesel Loesch
Date:   May 9, 2006                          Its: Chief Financial Officer

                                                  ------------------------------
Date:   May 9, 2006                               Steve CurdExhibit 10.4

     

    
      
        Back
          to Form 10-Q

      

      
         

        
          

        

      

      
         

      

    

     

    Exhibit
      10.4

     

    

      NOTICE
        OF AWARD

      

      State
        Of Missouri

      Office
        Of Administration

      Division
        of Purchasing and Materials Management

      PO
        Box 809

      Jefferson
        City, MO 65102

      http://www.oa.mo.gov/purch

      

      
        	
                CONTRACT
                  NUMBER

                C306118005

              	
                CONTRACT
                  TITLE

                Medicaid
                  Managed Care- Eastern Region

              
	
                AMENDMENT
                  NUMBER

                N/A

              	
                CONTRACT
                  PERIOD

                July
                  1, 2006 through June 30, 2007

              
	
                REQUISITION
                  NUMBER

                NR
                  886 25756004320

              	
                VENDOR
                  NUMBER

                36405049501

              
	
                CONTRACTOR
                  NAME AND ADDRESS

                Harmony
                  Health Plan, Inc.

                23
                  Public Sqaure, Suite 400

                Belleville,
                  IL 62220

              	
                STATE
                  AGENCY’S NAME AND ADDRESS

                Department
                  of Social Services

                Division
                  of Medical Services

                Post
                  Office Box 6500

                Jefferson
                  City, MO 65102-6500

              
	
                 

                ACCEPTED
                  BY THE STATE OF MISSOURI AS FOLLOWS:

                 

                The
                  proposal submitted by Harmony Health Plan of Illinois, Inc. dba
                  Harmony
                  Health Plan of Missouri in response to B3Z06118 is accepted in
                  its
                  entirety with the inclusion of the e-mail dated March 27,
                  2008.

                 

              
	
                BUYER:

                Julie
                  Kleffner

              	
                BUYER
                  CONTACT INFORMATION

                Phone:
                  573-751-7656    Fax 573-526-9817

                E-mail:
                  Julie.Kleffner@oa.mo.gov

              
	
                SIGNATURE
                  OF BUYER:

                 /s/  
Julie
                  Kleffner             
                  

                Julie
                  Kleffner

              	
                DATE:

                April
                  6, 2006

              
	
                DIRECTOR
                  OF PURCHASING AND MATERIALS MANAGEMENT

                /s/   James
                  Miluski            
                  

                James
                  Miluski

              

      

      

    

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

     

    STATE
      OF MISSOURI

    OFFICE
      OF ADMINISTRATION

    DIVISION
      OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)

    REQUEST
      FOR PROPOSAL (RFP)

    

    

    

    
      	
              RFP
                NO.: B3Z06118

            	
              REQ
                NO.: NR 886 25756004320

            
	
              TITLE:
                Medicaid Managed Care - Central, Eastern, & Western
                Regions

            	
              BUYER:
                Julie Kleffner

            
	
              ISSUE
                DATE: 01/10/06

            	
              PHONE
                NO.: (573) 751-7656

            
	 	
              E-MAIL:
                Julie.Kleffner@oa.mo.gov

            

    

    

    

    RETURN
      PROPOSAL NO LATER THAN: 02/10/06 AT 2:00 PM CENTRAL TIME

    

    

    
      	
              MAILING
                INSTRUCTIONS:

            	
              Print
                or type RFP
                Number
                and Return
                Due Date
                on
                the lower left hand corner of the envelope or package. Delivered
                sealed
                proposals must be in DPMM office (301 W High Street, Room 630) by
                the
                return date and time.

            
	
              RETURN
                PROPOSAL TO:

            	
              (U.S.
                Mail) 

              DPMM
                

              PO
                BOX 809

              JEFFERSON
                CITY MO 65102-0809

            	
              (Courier
                Service) 

              DPMM

              301
                WEST HIGH STREET, RM 630 JEFFERSON CITY MO
                65101

            
	
              CONTRACT
                PERIOD:

            	
              July
                1, 2006 through June 30, 2007

              (with
                two additional one-year renewal periods at the State’s sole
                option)

            

    

    DELIVER
      SUPPLIES/SERVICES FOB (Free on Board) DESTINATION TO THE FOLLOWING
      ADDRESS:

    

    Department
      of Social Services

    Division
      of Medical Services

    P.O.
      Box 6500

    Jefferson
      City, MO 65102-6500

    

    The
      offeror hereby declares understanding, agreement and certification of compliance
      to provide the items and/or services, at the prices quoted, in accordance with
      all requirements and specifications contained herein and the Terms and
      Conditions Request for Proposal (Revised 01/03/06). The offeror further agrees
      that the language of this RFP shall govern in the event of a conflict with
      his/her proposal. The offeror further agrees that upon receipt of an authorized
      purchase order from the Division of Purchasing and Materials Management or
      when
      a Notice of Award is signed and issued by an authorized official of the State
      of
      Missouri, a binding contract shall exist between the offeror and the State
      of
      Missouri.

    

    SIGNATURE
      REQUIRED

    

      
        	
                LEGAL
                  NAME OF ENTITY/INDIVIDUAL

                     

              
	
                MAILING
                  ADDRESS

                     

              
	
                CITY,
                  STATE, ZIP CODE

                 

              
	
                CONTACT
                  PERSON

                     

              	
                EMAIL
                  ADDRESS

                     

              
	
                PHONE
                  NUMBER

                     

              	
                FAX
                  NUMBER

                     

              
	
                TAXPAYER
                  ID NUMBER (TIN)

                     

              	
                TAXPAYER
                  ID (TIN) TYPE (CHECK ONE)

                ___ FEIN
                  ___ SSN

              	
                VENDOR
                  NUMBER (IF KNOWN)

                     

              
	
                VENDOR
                  TYPE (CHECK ONE)

                 

                ___
                  Corporation ___ Individual ___ State/Local
                  Government ___ Partnership
                  ___ Sole Proprietor ___Other ________________

              
	
                AUTHORIZED
                  SIGNATURE

              	
                DATE

                     

              
	
                PRINTED
                  NAME

                     

              	
                TITLE

                     

              

      

    

     

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      	1.  	
              INTRODUCTION
                AND GENERAL INFORMATION

            

    

    

    
      	1.1  	
              Introduction:

            

    

    

    
      	1.1.1  	
              This
                document constitutes a request for competitive, sealed proposals
                from the
                health plan provider community for becoming providers in the Missouri
                managed care program, hereinafter referred to as "MC+ managed care"
                in the
                following regions of the State of
                Missouri:

            

    

    

    
      	a.  	
              Central
                Region: Audrain, Boone, Callaway, Camden, Chariton, Cole, Cooper,
                Gasconade, Howard, Miller, Moniteau, Monroe, Montgomery, Morgan,
                Osage,
                Pettis, Randolph, and Saline
                counties.

            

    

    

    
      	b.  	
              Eastern
                Region: Franklin, Jefferson, Lincoln, St. Charles, St. Francois,
                Ste.
                Genevieve, St. Louis, Warren, and Washington counties and St. Louis
                City.

            

    

    

    
      	c.  	
              Western
                Region: Cass, Clay, Henry, Jackson, Johnson, Lafayette, Platte, Ray,
                and
                St. Clair counties.

            

    

    

    
      	1.1.2  	
              Organization
                - This document, referred to as a Request for Proposal (RFP), is
                divided
                into the following parts:

            

    

    

    
      	1)  	
              Introduction
                and General Information

            

    

    
      	2)  	
              Performance
                Requirements

            

    

    
      	3)  	
              General
                Contractual Requirements

            

    

    
      	4)  	
              Proposal
                Submission Information

            

    

    
      	5)  	
              Pricing
                Pages: The Pricing Pages are a separate link that must be downloaded
                from
                the Division of Purchasing and Materials Management’s Internet web site
                at: .
                It shall be the sole responsibility of the offeror to obtain the
                Pricing
                Pages. If the pricing page(s) are not downloaded and included with
                the
                response, the response could be determined to be non-responsive and
                eliminated from consideration for
                award.

            

    

    
      	6)  	
              Exhibits
                A - B

            

    

    
      	7)  	
              Terms
                and Conditions

            

    

    
      	8)  	
              Attachments
                1 - 14: The offeror is advised that attachments exist to this document
                which provide additional information and instruction. These attachments
                are separate links that must be downloaded from the Division of Purchasing
                and Materials Management’s Internet web site at: .
                It shall be the sole responsibility of the offeror to obtain each
                of the
                attachments. The offeror shall not be relieved of any responsibility
                for
                performance under the contract due to the failure of the offeror
                to obtain
                a copy of the attachments.

            

    

    

    
      	1.2  	
              Pre-Proposal
                Conference and MC+ Managed Care Quality Assessment and Improvement
                Advisory Groups Meeting:

            

    

    

    
      	1.2.1  	
              A
                pre-proposal conference regarding this Request for Proposal will
                be held
                on January 24, 2006, at 10:00 a.m. in the Interpretive Center of
                the James
                C. Kirkpatrick State Information Center, 600 West Main Street, Jefferson
                City, Missouri. 

            

    

    

    
      	1.2.2  	
              The
                MC+ Managed Care Quality Assessment and Improvement Advisory Groups
                quarterly meeting is scheduled for January 25, 2006 at 10:30 a.m.
                in room
                202 of the Howerton Court Building, 615 Howerton Court, Jefferson
                City,
                Missouri. During the meeting, portions of the RFP will be discussed;
                specifically section 2.28.2 Adjustments for Performance Based on
                HEDIS
                Performance Ratings and the Quality Strategy, Attachment 6.
                

            

    

    

    
      	1.2.3  	
              All
                potential offerors are encouraged to attend this conference and the
                MC+
                Managed Care Quality Assessment and Improvement Advisory Groups quarterly
                meeting in order to ask questions and provide comments on the RFP.
                Attendance is not required in order to submit a response; however,
                offerors are encouraged to attend since information relating to this
                RFP
                will be discussed in detail. The offeror should bring a copy of the
                RFP to
                the pre-proposal conference since it will be used as the agenda for
                the
                pre-proposal conference . The offeror should also bring a copy of
                the RFP
                to the MC+ Managed Care Quality Assessment and Improvement Advisory
                Groups
                quarterly meeting.

            

    

    

    
      	1.2.4  	
              Offerors
                may submit questions regarding the RFP prior to the Pre-Proposal
                Conference to allow time for the State of Missouri to prepare answers.
                However, the offeror should restate each question for verbal response
                during the Pre-Proposal Conference and/or MC+ Managed Care Quality
                Assessment and Improvement Advisory Groups quarterly meeting. Only
                those
                questions/answers which necessitate changes to the RFP will be included
                in
                an amendment, if any.

            

    

    

    
      	1.2.5  	
              Offerors
                are strongly encouraged to advise the Division of Purchasing and
                Materials
                Management within five (5) working days of the scheduled pre-proposal
                conference and/or MC+ Managed Care Quality Assessment and Improvement
                Advisory Groups quarterly meeting of any special accommodations needed
                for
                disabled personnel who will be attending the conference and/or meeting
                so
                that these accommodations can be
                made.

            

    

    

    
      	1.3  	
              Available
                Documentation and Offeror's
                Contact:

            

    

    

    
      	1.3.1  	
              The
                offeror may request a copy of any of the following documents by contacting
                Julie Kleffner at the Division of Purchasing and Materials Management.
                Requests for copies may be sent to Ms. Kleffner via fax at 573-526-9817,
                or emailed to Julie.Kleffner@oa.mo.gov, or mailed to
                the Division of Purchasing and Materials Management, P.O. Box 809,
                Jefferson City, MO 65102.

            

    

    

    
      	a.  	
              Overview
                - Division of Medical Services. Available via the Internet at the
                Division
                of Medical Services’ website: (Look
                under Missouri Medicaid Description and Missouri Medicaid
                History).

            

    

    Paragraph
      1.3.1 b .revised by Amendment #002

    
      	b.  	
              Quality
                Improvement System for Managed Care (QISMC)

            

    

    Paragraph
      1.3.1 c .revised by Amendment #001

    
      	c.  	
              Health
                Plan Record Layout Manual - available electronically at website
                www.emomed.com (Look
                under Provider, Electronic Billing Layout, System Manuals, Health
                Plan
                Layout Manual)

            

    

    

    
      	d.  	
              Medicaid
                Fee-for-Service Pricing File available electronically at the Division
                of
                Medical Service’ website:
                

            

    

    

    
      	e.  	
              Division
                of Medical Services MC+ Managed Care Policy
                Statements

            

    

    

    
      	f.  	
              Missouri’s
                1115 Waiver Amendment

            

    

    

    
      	g.  	
              EPSDT
                Screening Codes and Reporting
                Methodology

            

    

    

    
      	h.  	
              Historical
                Enrollment Data

            

    

    Paragraph
      1.3.1 i(MRDD Waiver Services) deleted by Amendment #001 and all other paragraphs
      renumbered accordingly

    
      	i.  	
              Description
                of Member Satisfaction Survey Data
                Reporting

            

    

    

    
      	j.  	
              Hospital
                Per Diem Rates

            

    

    

    
      	k.  	
              Federal
                regulations regarding home health agencies are available via the
                Internet
                at http://www.gpoaccess.gov/cfr/retrieve.html (42 CFR 484, Subpart
                A, B, C
                and 42 CFR 441.15).

            

    

    

    Paragraph
      1.3.1 l. revised by Amendment #001

    
      	l.  	
              Guidelines
                for Addressing Fraud and Abuse in managed Care", is available via
                the
                internet at 

            

    

    

    
      	m.  	
              Jackson
                County Consent Decree and Operational
                Guide

            

    

    Paragraphs1.3.1
      n. and o. inserted by Amendment #001

    
      	n.  	
              Mercer
                presentation from the January 24, 2006 Pre-proposal
                Conference

            

    

    

    
      	o.  	
              Criteria
                for Post-Payment Review of Specialty Pediatric Hospital
                Discharges.

            

    

    

    
      	1.3.2  	
              All
                possible efforts have been made to ensure that the information provided
                in
                these relevant documents is complete and current. However, the offeror
                shall not assume that such information is indeed complete or
                current.

            

    

    

    
      	1.4  	
              Questions:

            

    

    

    
      	1.4.1  	
              All
                questions regarding this Request for Proposal and/or the competitive
                procurement process must be directed to Julie Kleffner at the Division
                of
                Purchasing and Materials Management. Questions may be faxed to Julie
                Kleffner at 573-526-9817, or emailed to Julie.Kleffner@oa.mo.gov,
                or
                mailed to
                the Division of Purchasing and Materials Management, P.O. Box 809,
                Jefferson City, MO 65102. All questions should be submitted three
                weeks
                prior to the proposal receipt date specified on Page
                1.

            

    

    

    
      	1.5  	
              Description
                of Missouri MC+ Managed Care
                Program:

            

    

    

    
      	1.5.1  	
              Effective
                July 1, 2006, the State of Missouri will continue a health care delivery
                program in Audrain, Boone, Callaway, Camden, Cass, Chariton, Clay,
                Cole,
                Cooper, Franklin, Gasconade, Henry, Howard, Jackson, Jefferson, Johnson,
                Lafayette, Lincoln, Miller, Moniteau, Monroe, Montgomery, Morgan,
                Osage,
                Pettis, Platte, Randolph, Ray, Saline, St. Charles, St. Clair, St.
                Francois, Ste. Genevieve, St. Louis, Warren, and Washington counties
                and
                St. Louis City to serve MC+ managed care eligibles meeting specified
                eligibility criteria. The goal is to improve the accessibility and
                quality
                of health care services for Missouri's MC+ managed care and State
                aid
                eligible populations, while controlling the program's rate of cost
                increase.

            

    

    

    
      	a.  	
              The
                Missouri Department of Social Services, Division of Medical Services
                intends to achieve this goal by enrolling MC+ managed care eligibles
                in
                comprehensive, qualified health plans that contract with the State
                of
                Missouri to provide a specified scope of benefits to each enrolled
                member
                in return for a capitated payment made on a per member, per month
                basis.

            

    

    

    
      	1.5.2  	
              The
                health care delivery program was designed through a collaborative
                process
                that included feedback from providers, consumers, health plans,
                communities, the State of Missouri government agencies, and the Centers
                for Medicare and Medicaid Services (CMS) (formerly the Health Care
                Financing Administration).

            

    

    

    
      	1.5.3  	
              The
                Missouri Department of Social Services, Division of Medical Services
                has
                identified eight (8) guiding principles for Missouri’s Medicaid Program as
                follows: 

            

    

    

    
      	1)  	
              All
                recipients must have a medical home.

            

    

    
      	2)  	
              Attention
                to wellness of the individual (i.e. education).

            

    

    
      	3)  	
              Chronic
                care management. 

            

    

    
      	4)  	
              Care
                management - (resources focused towards people receiving the services
                they
                need, not necessarily because the service is available).
                

            

    

    
      	5)  	
              Appropriate
                setting at the right cost.

            

    

    
      	6)  	
              Emphasis
                on the individual person.

            

    

    
      	7)  	
              Evidenced
                based guidelines for improved quality care and use of
                resources.

            

    

    
      	8)  	
              Encourage
                responsibility and investment on the part of the recipient to ensure
                wellness.

            

    

    

    
      	1.6  	
              Program
                Management and Oversight:

            

    

    

    
      	1.6.1  	
              In
                the State of Missouri, the Department of Social Services, Division
                of
                Medical Services is officially designated with administration of
                the
                medical assistance and federal Medicaid (Title XIX and Title XXI)
                programs. In addition to Division of Medical Services’ oversight, CMS also
                monitors MC+ managed care activities through its Regional Office
                in Kansas
                City, Missouri and its Center for Medicaid and State Operations,
                Division
                of Integrated Health Systems in Baltimore,
                Maryland.

            

    

    

    
      	1.7  	
              Missouri
                MC+ Managed Care Program Eligibility
                Groups:

            

    

    

    
      	1.7.1  	
              For
                purposes of this Request for Proposal, the MC+ managed care population
                consists of different eligibility groups which have been combined
                for the
                purpose of rate setting. The qualifications for the program are based
                on a
                combination of factors, including family composition, income level,
                insurance status, or pregnancy status depending on the eligibility
                group
                in question. The eligibility groups and their current estimated sizes
                are
                described below and summarized in Attachment
                1.

            

    

    

    
      	a.  	
              Eligibility
                of Parents/Caretakers, Children, Pregnant Women, and
                Refugees:
                Individuals covered under MC+ managed care within this group are
                as
                follows:

            

    

    

    
      	1)  	
              Parents/Caretakers
                and Children eligible under Medical Assistance for Families, and
                Transitional Medical Assistance.

            

    

    

    
      	2)  	
              Children
                eligible under MC+ for Poverty Level
                Children.

            

    

    

    
      	3)  	
              Women
                eligible under Medical Assistance for Pregnant Women and 60 days
                post-partum.

            

    

    

    
      	4)  	
              Individuals
                eligible under Recipients of Refugee Medical
                Assistance.

            

    

    

    
      	5)  	
              Individuals
                eligible under the above groups and are MRDD Waiver
                participants.

            

    

    

    
      	6)  	
              Those
                that are eligible are defined by their MC+ Medical Eligibility (ME)
                Codes
                as Specified in Attachment 1.

            

    

    

    
      	b.  	
              Eligibility
                of Other MC+ Children In the Care and Custody of the State and Receiving
                Adoption Subsidy Assistance:
                All children in the care and custody of the Department of Social
                Services;
                all children placed in a not-for-profit residential group home by
                a
                juvenile court; all children receiving adoption subsidy assistance;
                and
                all children receiving non-medical assistance (i.e., living expenses)
                that
                are in the legal custody of the Department of Social Services shall
                remain
                the responsibility of the Department of Social Services. Those that
                are
                eligible are defined by their MC+ Medical Eligibility code as specified
                in
                Attachment 1.

            

    

    

    
      	c.  	
              1115
                Demonstration Waiver: Missouri
                submitted an amendment to its pending 1115 demonstration waiver on
                August
                26, 1997. The amendment is to Missouri’s 1115 demonstration waiver that
                was submitted on June 30, 1994. The 1115 demonstration waiver as
                amended
                was approved April 28, 1998. The waiver amendment continues Missouri’s
                commitment to improving medical care to low income children and supports
                families moving from welfare into
                jobs.

            

    

    

    
      	1)  	
              Uninsured
                Children Below 200 Percent Under Title XIX, Coordinated with Title
                XXI
                Funding:
                Uninsured children with net family income up to 200 percent of the
                federal
                poverty level (300 percent gross income) are covered under an MC+
                expansion. The MC+ expansion will occur under a Title XIX 1115 waiver.
                Children will include individuals birth through age 18. No new eligibles
                will be excluded because of pre-existing illness or condition. "Uninsured
                Children" are persons up to nineteen years of age who have not had
                access
                to employer-subsidized health care insurance or other health care
                coverage
                for six (6) months prior to application, are residents of the State
                of
                Missouri, and have parents or guardians who meet the following
                requirements:

            

    

    

    
      	·  	
              Furnish
                to the Department of Social Services the uninsured child’s social security
                number or numbers, if the uninsured child has more than one such
                number;

            

    

    

    
      	·  	
              Cooperate
                with the Department of Social Services in identifying and providing
                information to assist the Division of Medical Services in pursuing
                any
                third-party health insurance carrier who may be liable to pay for
                health
                care;

            

    

    

    
      	·  	
              Cooperate
                with the Department of Social Services, Family Support Division in
                establishing paternity and in obtaining support payments, including
                medical support;

            

    

    

    
      	·  	
              Demonstrate,
                upon request, their child’s participation in wellness programs including
                immunizations and a periodic physical examination. (This shall not
                apply
                to any child whose parent or legal guardian objects in writing to
                such
                wellness programs including immunizations and an annual physical
                examination because of religious beliefs or medical
                contraindications);

            

    

    

    
      	·  	
              Demonstrate
                annually that their total net worth does not exceed two hundred fifty
                thousand dollars in total value;
                and

            

    

    

    
      	·  	
              There
                will be protections against dropping or foregoing private coverage,
                including a six (6) month waiting period and insurance availability
                screens through the Division of Medical Services’ Health Insurance Premium
                Payment (HIPP) program.

            

    

    

    
      	Ø  	
              Any
                child identified as having special health care needs defined as a
                condition which left untreated would result in the death or serious
                physical injury of a child, that does not have access to affordable
                employer-subsidized health care insurance will be exempt from the
                requirement to be without health care coverage for six months in
                order to
                be eligible for services. 

            

    

    

    
      	Ø  	
              A
                child shall not be subject to the 30-day waiting period as long as
                the
                child meets all other qualifications for eligibility.
                

            

    

    

    
      	d.  	
              MC+
                managed care eligibles in the above specified eligibility groups
                may
                voluntarily disenroll from the MC+ Managed Care Program or choose
                not to
                enroll in the MC+ Managed Care Program if
                they:

            

    

    

    
      	1)  	
              Are
                eligible for Supplemental Security Income (SSI) under Title XVI of
                the
                Social Security Act;

            

    

    

    
      	2)  	
              Are
                described in Section 501(a)(1)(D) of the Social Security
                Act;

            

    

    

    
      	3)  	
              Are
                described in Section 1902(e)(3) of the Social Security
                Act;

            

    

    

    
      	4)  	
              Are
                receiving foster care or adoption assistance under part E of Title
                IV of
                the Social Security Act;

            

    

    

    
      	5)  	
              Are
                in foster care or otherwise in out-of-home placement;
                or

            

    

    

    
      	6)  	
              Meet
                the SSI disability definition as determined by the Department of
                Social
                Services.

            

    

    

    
      	1.7.2  	
              Not
                Covered Under the MC+ Managed Care Program:
                The following individuals are not covered under the MC+ Managed Care
                Program and receive their services through the Medicaid/MC+
                fee-for-service program:

            

    

    

    
      	a.  	
              Permanently
                and Totally Disabled individuals eligible under ME Codes 04 (Permanently
                and Totally Disabled), 13 (Medical Assistance-PTD), 16 (Nursing Care-PTD),
                and 11 (Medical Assistance (MA) Spenddown and Non-Spenddown, Old
                Age
                Assistance (OAA)).

            

    

    

    
      	b.  	
              Individuals
                eligible under ME Code 14 (Nursing Care-OAA) residing in a nursing
                home
                and receiving cash to apply toward their nursing home costs or a
                vendor
                payment directly to a nursing home for their care through the Medicaid
                program.

            

    

    

    
      	c.  	
              Individuals
                eligible under ME Codes 23 and 41 (MA ICF-MR Poverty) residing in
                a State
                Mental Institution or an Intermediate Care Facility for the Mentally
                Retarded (ICF/MR).

            

    

    

    
      	d.  	
              Individuals
                eligible under ME Codes 28, 49, and 67 (Children placed in foster
                homes or
                residential care by the Department of Mental Health).
                

            

    

    

    
      	e.  	
              Pregnant
                women eligible under ME Code 58 and 59, the Presumptive Eligibility
                Program for ambulatory prenatal care
                only.

            

    

    

    
      	f.  	
              Individuals
                eligible under ME Codes 2, 3, 12, and 15 (Aid to the Blind and Blind
                Pension).

            

    

    

    
      	g.  	
              AIDS
                Waiver participants (individuals twenty-one (21) years of age and
                over).

            

    

    

    
      	h.  	
              Any
                individual eligible and receiving either or both Medicare Part A
                and Part
                B benefits.

            

    

    

    
      	i.  	
              Individuals
                eligible under ME Codes 33 and 34 (MO Children with Developmental
                Disabilities Waiver).

            

    

    

    
      	j.  	
              Individuals
                eligible under ME Code 55 (Qualified Medicare Beneficiary -
                QMB).

            

    

    

    
      	k.  	
              Children
                eligible under ME Code 65, placed in residential care by their parents,
                if
                eligible for MC+/Medicaid on the date of placement.
                

            

    

    

    
      	l.  	
              Uninsured
                women losing their MC+ eligibility 60 days after the birth of their
                child
                would be eligible under ME Code 80 for women’s health services for one
                year plus 60 days, regardless of income level. This population will
                obtain
                their services through the MC+ fee-for-service
                program.

            

    

    

    
      	m.  	
              Individuals
                with ME code 81 (Temporary Assignment
                Category).

            

    

    

    
      	n.  	
              Women
                eligible under ME codes 83 and 84 (Breast and Cervical Cancer Treatment).
                

            

    

    

    
      	o.  	
              Individuals
                eligible under ME code 87 (Presumptive Eligibility for
                Children).

            

    

    

    
      	p.  	
              Individuals
                eligible under ME code 88 (Voluntary Placement).
                

            

    

    

    Paragraph1.7.2
      q. inserted by Amendment #001

    
      	q.  	
              Individuals
                eligible under ME code 82 (MoRx)

            

    

    

    
      	1.7.3  	
              Where
                economically cost effective, the Division of Medical Services will
                use the
                Division of Medical Services’ HIPP program to obtain available coverage
                through available commercial insurance. Those services included in
                the
                comprehensive benefit packages described herein, but not included
                in the
                commercial insurance service package, may be obtained through MC+
                managed
                care or fee-for-service as
                appropriate.

            

    

    

    
      	1.8  	
              Information:

            

    

    

    
      	1.8.1  	
              Although
                an attempt has been made to provide accurate and up-to-date information,
                the State of Missouri does not warrant or represent that the background
                information provided herein reflects all relationships or existing
                conditions related to this Request for
                Proposal.

            

    

    

    
      	1.8.2  	
              The
                State of Missouri has previously contracted for these services through
                C302226001 through C302226004 for the Eastern and Central Regions
                and
                through C303182001 through C303182004 for the Western Region. These
                contracts expire on June 30, 2006. A copy of the contracts can be
                viewed
                and printed from the Division of Purchasing and Materials Management’s
                Public
                Record Search and Retrieval System located
                on the Internet at: .
                In addition, all proposal and evaluation documentation leading to
                the
                award of the expiring contracts may also be viewed and printed from
                the
                Division of Purchasing and Materials Management’s Public
                Record Search and Retrieval System. Please
                reference the Bid number B3Z02226 and B3Z03182 or any of the contract
                numbers when searching for these
                documents.

            

    

    

    Harmony
      Health Plan has read and understands the information and requirements set forth
      in RFP B3Z06118 Section 1.0 and all paragraphs and subparagraphs contained
      in
      1.0 through 1.8.2. 

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          B3Z06118  Page
            

        

      

    

    

    

    
      	2.  	
              CONTRACTUAL
                REQUIREMENTS

            

    

    

    
      	2.1.1  	
              The
                contractor (hereinafter referred to as the "health plan") shall provide
                a
                managed care medical service delivery system for the Department of
                Social
                Services, Division of Medical Services (hereinafter referred to as
                the
                "state agency"), located in the State of Missouri pursuant to the
                requirements contained herein. 

            

    

    

    Harmony
      Health Plan of Illinois, Inc. d/b/a Harmony Health Plan of Missouri ("Harmony")
      is a wholly owned subsidiary of WellCare Health Plans, Inc. (“WHP”), a holding
      company serving the needs of over 950,000 members who participate in
      government-sponsored health programs in Florida, Illinois, Indiana, New York,
      Connecticut, Louisiana, and Georgia (effective April 2006).  Harmony, is
      the Missouri company in the WellCare family of companies, having submitted
      its
      application for H.M.O licensure to the Missouri Department of Insurance on
      January 17, 2006.  

     

    Harmony
      currently manages over 174,000 Medicaid and Medicare members in Illinois and
      Indiana.  Harmony began providing Medicaid managed care services in
      1997.  WellCare also manages over 690,000 Medicaid managed care members in
      Florida, New York, and Connecticut.  The Company began providing Medicaid
      managed care service in 1993. 

    

    In
      addition, WellCare manages nearly 100,000 State Child Health Insurance Program
      (“SCHIP”) members in Florida, New York, and Connecticut.  These programs
      began in 2000. In general, the Company has extensive experience managing health
      service delivery to Medicaid managed care enrollees as well as to Medicare
      +
      Choice enrollees. Between its Medicaid and Medicare programs, WellCare’s full
      risk revenues are over one billion dollars annually. 

     

    WellCare
      is an integrated provider of managed care services targeted exclusively to
      government-sponsored healthcare programs, including Medicare, Medicaid and
      State
      Children’s Health Programs, or SCHIP. We have centralized core functions, such
      as claims processing and medical management, combined with marketing and
      provider outreach tailored to the local markets we serve. This integrated
      strategy allows us to provide high quality, affordable healthcare services
      to
      our members while maintaining effective partnerships with our providers and
      our
      regulators. We believe that our integrated approach to the delivery of managed
      care services will allow us to effectively grow our business. Because our
      organization is an integrated provider of managed care services, the
      organization will from this point be referred in the narrative as Harmony and
      separated only where there is a clear distinction needed between both
      entities.

     

    Harmony’s
      key administrative functions are located in it’s Southern Illinois offices in
      Belleville, Illinois.  These functions include: Provider Relations,
      Provider Contracting, Community Outreach and Marketing. Harmony is headed
      locally by Tina Gallagher, Executive Director - Missouri. Ms. Gallagher reports
      directly to Harmony’s President, Keith Kudla, who reports to WellCare's CEO,
      Todd Farha.

     

    Other
      key operational functions including: Finance, IT, Legal, Corporate Compliance,
      Enrollment, Member Services, Grievance and Appeals, Regulatory Affairs and
      Claims Adjudication are provided out of WellCare (Tampa, Florida). Medical
      Direction, Health Care Services and Customer Service will be handled by
      Harmony’s regional headquarters in Chicago, Illinois. Each of these functions
      has gone through successful CMS and State review. Upon contract award, Harmony
      will explore the opportunity to open an office in
      Missouri.

    

    Our
      management team has extensive experience operating managed care plans. Our
      senior executives have many years of combined experience in the healthcare
      industry, including healthcare plans such as Aetna, Cigna, Humana and Oxford,
      among others. Our management team is focused on process and data analytics,
      which has enabled us to create a culture that emphasizes effective execution
      of
      our business plans and analysis of results. Members of our medical management
      team are board certified in a variety of healthcare disciplines, allowing us
      to
      effectively manage a broad range of healthcare issues. We believe that our
      management’s experience brings a professional, disciplined approach to the
      operation of government-sponsored healthcare plans, resulting in increased
      operational efficiencies. 

     

    
      	2.1.2  	
              Prior
                to performing services in each of the counties, the health plan
                shall:

            

    

    

    
      	a.  	
              Have
                and maintain a certificate of authority from the Department of Insurance
                to establish and operate a health maintenance organization in all
                the
                counties specified herein;

            

    

    

    
      	b.  	
              Understand
                that federal approval is required prior to commitment of the federal
                financing share of funds under the contract;

            

    

    

    
      	c.  	
              Participate
                in readiness reviews. If the health plan is new to the MC+ managed
                care
                program, the state agency shall conduct on-site readiness reviews
                of the
                health plan in order to document the status of the health plan with
                respect to meeting the program requirements outlined herein. If the
                health
                plan has an established relationship with the state agency, the state
                agency shall conduct off-site reviews of the health plan in order
                to
                document the status of the health plan with respect to meeting any
                new
                program requirements; and

            

    

    

    
      	d.  	
              Submit
                to the state agency all policies and procedures that require prior
                approval listed in Attachment 12. The health plan must submit all
                modifications, additions, or deletions to such policies and procedures
                to
                the state agency at least thirty (30) days prior to implementation.
                The
                health plan must operate in accordance with such policies and procedures.
                The health plan must incorporate and implement any revisions identified
                by
                the state agency to the health plan’s policies and procedures within the
                time frame specified by the state agency. All other policies and
                procedures required herein shall be submitted to the state agency
                on
                request.

            

    

    

    Harmony
      Health Plan understands and acknowledges the requirements set forth in RFP
      B3Z06118 paragraph 2.1.2 and subparagraph a-d. Harmony has filed all
      documentation for licensure with the Missouri Department of Insurance as of
      January 17, 2006 (see Proof of Filing document in Appendix Binder, Tab
      2).

    

    
      	2.1.3  	
              The
                health plan awarded a contract for the Eastern region shall provide
                services to individuals determined eligible by the state agency for
                the
                Missouri MC+ Managed Care Program in all of the following ten areas
                in the
                State of Missouri: 

            

    

    

    
      	a.  	
              Franklin
                County

            

    

    
      	b.  	
              Jefferson
                County 

            

    

    
      	c.  	
              Lincoln
                County 

            

    

    
      	d.  	
              St.
                Charles County 

            

    

    
      	e.  	
              St.
                Francois County 

            

    

    
      	f.  	
              Ste.
                Genevieve County 

            

    

    
      	g.  	
              St.
                Louis County 

            

    

    
      	h.  	
              Warren
                County

            

    

    
      	i.  	
              Washington
                County 

            

    

    
      	j.  	
              St.
                Louis City 

            

    

    

    Harmony
      Health Plan understands and acknowledges the requirements set forth in RFP
      B3Z06118 paragraph 2.1.3 and subparagraph a-j.

    

    
      	2.1.4  	
              The
                health plan awarded a contract for the Central region shall provide
                services to individuals determined eligible by the state agency for
                the
                Missouri MC+ Managed Care Program in all of the following eighteen
                areas
                in the State of Missouri:

            

    

    

    
      	a.  	
              Audrain
                County 

            

    

    
      	b.  	
              Boone
                County 

            

    

    
      	c.  	
              Callaway
                County 

            

    

    
      	d.  	
              Camden
                County 

            

    

    
      	e.  	
              Chariton
                County 

            

    

    
      	f.  	
              Cole
                County 

            

    

    
      	g.  	
              Cooper
                County 

            

    

    
      	h.  	
              Gasconade
                County 

            

    

    
      	i.  	
              Howard
                County 

            

    

    
      	j.  	
              Miller
                County 

            

    

    
      	k.  	
              Moniteau
                County 

            

    

    
      	l.  	
              Monroe
                County 

            

    

    
      	m.  	
              Montgomery
                County 

            

    

    
      	n.  	
              Morgan
                County 

            

    

    
      	o.  	
              Osage
                County 

            

    

    
      	p.  	
              Pettis
                County 

            

    

    
      	q.  	
              Randolph
                County

            

    

    
      	r.  	
              Saline
                County 

            

    

    

    Harmony
      Health Plan is not applying for contract award in the Central
      region.

    

    
      	2.1.5  	
              The
                health plan awarded a contract for the Western region shall provide
                services to individuals determined eligible by the state agency for
                the
                Missouri MC+ Managed Care Program in all of the following nine areas
                in
                the State of Missouri: 

            

    

    

    
      	a.  	
              Cass
                County 

            

    

    
      	b.  	
              Clay
                County 

            

    

    
      	c.  	
              Henry
                County

            

    

    
      	d.  	
              Jackson
                County

            

    

    
      	e.  	
              Johnson
                County 

            

    

    
      	f.  	
              Lafayette
                County 

            

    

    
      	g.  	
              Platte
                County 

            

    

    
      	h.  	
              Ray
                County 

            

    

    
      	i.  	
              St.
                Clair County 

            

    

    

    Harmony
      Health Plan is not applying for contract award in the Western
      region.

    

    

    
      	2.2  	
              Health
                Plan Administration:

            

    

    

    
      	2.2.1  	
              The
                health plan shall have in place sufficient administrative staff and
                organizational structure to comply with all requirements described
                herein.
                The health plan must be staffed by qualified persons in numbers
                appropriate to the health plan's size of enrollment. At a minimum,
                the
                health plan must provide the following staff to perform the
                responsibilities listed. Unless otherwise specified, the health plan
                may
                combine or split the listed responsibilities among the health plan’s staff
                as long as the health plan demonstrates that the responsibilities
                are
                being met. Similarly, the health plan may contract with a third party
                (subcontractor) to perform one or more of these
                responsibilities.

            

    

    

    
      	a.  	
              A
                full time Medicaid Plan Administrator with clear authority over the
                general administration and implementation of the requirements set
                forth
                herein.

            

    

    

    
      	b.  	
              Clerical
                and support staff to ensure appropriate functioning of the health
                plan's
                operation.

            

    

    

    
      	c.  	
              A
                Medical Director who shall be a Missouri-licensed physician. The
                Medical
                Director shall be actively involved in all major clinical and quality
                program components of the health plan. The Medical Director shall
                devote
                sufficient time to the health plan to ensure timely medical decisions,
                including after hours consultation as needed. The Medical Director
                shall
                be responsible for the sufficiency and supervision of the health
                plan
                provider network. The Medical Director shall ensure compliance with
                State
                and local reporting laws on communicable diseases, child abuse, neglect,
                etc.

            

    

    

    
      	d.  	
              A
                Dental Consultant who shall be a Missouri-licensed dentist. The Dental
                Consultant shall devote sufficient time to the health plan to ensure
                timely dental decisions and claim
                review.

            

    

    

    
      	e.  	
              A
                full-time Chief Financial Officer to oversee the budget and accounting
                systems implemented by the health
                plan.

            

    

    

    
      	f.  	
              A
                Quality Assessment and Improvement and Utilization Management Coordinator
                who shall be a Missouri-licensed registered nurse, nurse practitioner,
                or
                physician.

            

    

     

    
      	g.  	
              A
                Special Programs Coordinator who shall be a Missouri-licensed social
                worker, registered nurse including advanced practice nurse, physician,
                or
                physician's assistant; or have a Master's degree in health services,
                public health, or health care administration. In addition, the Special
                Programs Coordinator should be familiar with the variety of services
                available through the Missouri human services agencies that interface
                with
                health care. The duties of the Special Programs Coordinator shall
                include
                care coordination with all stakeholders and providers involved in
                the care
                of members. These stakeholders and providers may include, but not
                be
                limited to, the state agency, the Department of Health and Senior
                Services, local public health agencies, the Department of Mental
                Health,
                the Department of Elementary and Secondary Education, the Family
                Support
                Division, Children’s Division, hospitals, the judicial system, schools,
                and Community Mental Health Centers. The Special Programs Coordinator
                shall provide timely and comprehensive facilitation of the identification
                of medically necessary services and implementation of such when included
                in a member's Individualized Education Program/Individual Family
                Service
                Plan. The Special Programs Coordinator is the point of contact for
                members, their representatives, providers, the state agencies, and
                local
                public health agencies.

            

    

    

    
      	h.  	
              A
                Mental Health Coordinator shall be a qualified mental health professional
                as specified herein and possess, at a minimum, a master’s
                degree.

            

    

    

    
      	i.  	
              Prior
                authorization staff shall be available to authorize services twenty-four
                (24) hours per day, seven (7) days per week. This staff shall be
                directly
                supervised by a Missouri-licensed registered nurse, physician, or
                physician's assistant. Prior approval functions for mental health
                services
                shall be performed by a qualified mental health
                professional.

            

    

    

    
      	j.  	
              Inpatient
                certification review staff shall conduct inpatient initial, concurrent,
                and retrospective reviews. The review staff shall consist of registered
                nurses, physicians, physician's assistants, or licensed practical
                nurses
                experienced in inpatient reviews and under the direct supervision
                of a
                registered nurse, physician, or physician's
                assistant.

            

    

    

    
      	k.  	
              Member
                services staff shall coordinate communications with members and act
                as
                member advocates. The health plan shall provide sufficient member
                services
                staff to enable members to receive prompt resolution to their problems
                or
                inquiries.

            

    

    

    
      	l.  	
              Provider
                services staff shall coordinate communications between the health
                plan and
                providers. The health plan shall provide sufficient provider services
                staff to enable providers to receive prompt resolution to their problems
                or inquiries.

            

    

    

    
      	m.  	
              A
                Complaint, Grievance, and Appeal Coordinator shall manage and adjudicate
                member and provider complaints, grievances, and appeals in a timely
                manner.

            

    

    

    
      	n.  	
              Claims
                Administrator/Management Information System (MIS)
                Director.

            

    

    

    
      	o.  	
              Compliance
                Officer.

            

    

    

    Harmony
      Health Plan understands and will comply with the requirements set forth in
      RFP
      B3Z06118 paragraph 2.2.1 and subparagraphs a - o. Please refer to Harmony’s Key
      Management Staffing Table, Position Descriptions and Resumes located in Appendix
      Binder, Tab 3. 

    

    
      	2.2.2  	
              The
                health plan shall inform the state agency in writing within seven
                (7)
                calendar days of staffing changes in the following key positions.
                The
                health plan shall fill vacancies in any of these key positions with
                permanent qualified replacements within ninety (90) calendar days
                of the
                departure of the former staff
                member.

            

    

    

    
      	a.  	
              Medicaid
                Plan Administrator

            

    

    

    
      	b.  	
              Medical
                Director

            

    

    

    
      	c.  	
              Quality
                Assessment and Improvement and Utilization Management Coordinator
                

            

    

    

    
      	d.  	
              Special
                Programs Coordinator

            

    

    

    
      	e.  	
              Mental
                Health Coordinator

            

    

    

    
      	f.  	
              Chief
                Financial Officer

            

    

    

    Harmony
      Health Plan understands and will comply with the requirements set forth in
      RFP
      B3Z06118 paragraph 2.2.2. 

    

    
      	2.2.3  	
              The
                health plan shall ensure that all staff have appropriate training,
                education, experience, liability coverage, and orientation to fulfill
                the
                requirements of the positions and have met all appropriate licensure
                requirements.

            

    

    

    Harmony
      Health Plan understands and will comply with the requirements set forth in
      RFP
      B3Z06118 paragraph 2.2.3. In addition Harmony ensures that personnel are
      currently licensed to perform the services they provide, Harmony conducts
      background checks on candidates. The company’s intention to review background
      data is clearly communicated to candidates. Human Resources contracts with
      and
      forwards the application data to a third party vendor that verifies the accuracy
      of certain elements of the candidate’s background. 

    

    WellCare
      provides associates with access to value-added learning through WellCare
      University.  Curriculum is divided into three categories: 
core/fundamental skills (i.e. leadership, regulatory, technology), company
      and
      area-specific skills, and corporate citizenship (i.e. values, culture). 
Most program facilitation is by certified faculty in a classroom format with
      the
      incorporation of computer-based self-study programs an interactive online
      workshops. 

    

    WellCare
      associates also have access to an online associate resource center (ARC). 
ARC is located on the associates' computers and features benefit information
      for
      all lines of business, policies and procedures, directories, important phone
      numbers, authorization and referral guides, workflows, template letters and
      faxes, and alerts.

    
      	2.2.4  	
              The
                health plan may not knowingly employ as a director, officer, partner,
                or
                person with beneficial ownership of more than 5 percent of the health
                plan’s equity, a person who is debarred, suspended, or otherwise excluded
                from participating in procurement activities under the Federal Acquisition
                Regulation or from participating in non-procurement activities under
                regulations issued pursuant to Executive Order No. 12549 or under
                guidelines implementing such order; or is an affiliate (as defined
                in such
                Act) of such a person. In addition, the health plan may not have
                an
                employment, consulting, or other agreement with such a person described
                above for the provision of items and services that are significant
                and
                material to the health plan’s obligations required
                herein.

            

    

    

    Harmony
      Health Plan understands and acknowledges the requirements set forth in RFP
      B3Z06118 paragraph 2.2.4. Please refer to the Disclosure Statement located
      in
      Appendix Binder, Tab 4.

    

    
      	2.2.5  	
              The
                health plan shall require each physician providing services to members
                to
                have a unique identifier in accordance with the system established
                under
                section 1173(b) of the Health Insurance Portability and Accountability
                Act
                of 1996.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.2.5. Harmony employs the Diamond 950 system as the core
      transaction processing system for the maintenance of provider, member, benefit,
      and contract information. This top-tier commercial system supports our core
      transaction processing functions. Operating on Sun hardware and an Oracle
      database, Diamond is designed to be scalable to accommodate internal growth
      and
      growth from acquisitions.

    

    

    
      	2.2.6  	
              Non-Discrimination
                in Hiring and Provision of Services:
                The health plan shall ensure that all federal and state laws, as
                amended,
                and policies of non-discrimination in hiring and the provision of
                services
                are strictly enforced. The health plan shall comply with Title VI
                of the
                Civil Rights Act of 1964, as amended; the Rehabilitation Act of 1973,
                as
                amended; Title IX of the Education Amendments of 1972, as amended;
                the Age
                Discrimination Act of 1975, as amended; and the American Disabilities
                Act
                of 1990, as amended.

            

    

    

    
      	a.  	
              The
                health plan shall incorporate in its policies, administration, and
                delivery of services the values of:

            

    

    

    
      	1)  	
              Honoring
                member's beliefs;

            

    

    

    
      	2)  	
              Being
                sensitive to cultural diversity;
                and

            

    

    

    
      	3)  	
              Fostering
                in staff and providers attitudes and interpersonal communication
                styles
                which respect the member’s cultural
                backgrounds.

            

    

    

    

    
      	b.  	
              The
                health plan shall have specific policy statements on minority inclusion
                and non-discrimination and procedures to communicate the policy statements
                and procedures to subcontractors.

            

    

    

    
      	c.  	
              The
                health plan shall not discriminate in regard to the participation,
                reimbursement, or indemnification of any provider who is acting within
                the
                scope of his or her license or certification under applicable State
                law,
                solely on the basis of that license or certification. If a health
                plan
                declines to include individual or groups of providers in its network,
                it
                must give the affected providers written notice of the reason for
                its
                decision. The health plan’s provider selection policies and procedures
                cannot discriminate against particular providers that serve high
                risk
                populations or specialize in conditions that require costly treatment.
                This section may not be construed
                to:

            

    

    

    
      	1)  	
              Require
                the health plan to contract with providers beyond the number necessary
                to
                meet the needs of its members;

            

    

    

    
      	2)  	
              Preclude
                the health plan from using different reimbursement amounts for different
                specialties or for different practitioners in the same specialty;
                or

            

    

    

    
      	3)  	
              Preclude
                the health plan from establishing measures that are designed to maintain
                quality of services, control costs, and are consistent with its
                responsibilities to members.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.2.6 and subparagraphs a-c.

    

    

    
      	2.3  	
              Health
                Plan Provider Networks:
                

            

    

    

    
      	2.3.1  	
              The
                health plan shall establish and maintain health plan provider networks
                in
                geographically accessible locations, in accordance with the travel
                distance standards specified herein, comprised of hospitals, physicians,
                advanced practice nurses, mental health providers, substance abuse
                providers, pharmacies, dentists, emergent and non-emergent transportation
                services, etc., with sufficient capacity to make available all services
                in
                accordance with the service accessibility standards specified herein.
                In
                order to maintain geographically accessible locations, the health
                plan
                should look to providers in contiguous and other counties for full
                development of the network.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.3.1. Harmony has established contractual relationships
      with
      providers in each of the nine eastern region counties and St. Louis City.
Though
      the network is sufficient by all requirements put forth by state of MO, Division
      of Insurance, regarding primary care providers and hospitals, Harmony will
      continue to identify areas for continued growth based upon the Plan’s review of
      the network under the following metrics: 

    

    a. Eligibles
      to specialist ratio vs. our target membership to specialist
 ratio
      

    b. Distance/drive
      time showing all-sufficient

    c. Referral
      patterns of the PCPs 

    

    Harmony
      has included it’s provider network for review (see Provider Network Table
      document in Appendix Binder, Tab 5).

    

    Harmony
      has processes to support monitoring of provider access to members for
      availability 24 hours a day, 7 days a week. Harmony actively recruits nurse
      practioners for inclusion in the provider network. Mental health and substance
      abuse providers, as well as dental, pharmacies, emergent and non-emergent
      transportation providers meet the standards as put forth by the state of MO,
      Division of Insurance.

    

    
      	2.3.2  	
              Primary
                Care Provider Responsibilities:
                The health plan shall have written policies and procedures for linking
                every member to a primary care provider. The primary care provider
                must
                serve as the member's initial and most important contact. As such,
                primary
                care provider responsibilities must include at a
                minimum:

            

    

    

    
      	a.  	
              Maintaining
                continuity of each member's health
                care.

            

    

    

    
      	b.  	
              Making
                referrals for specialty care and other medically necessary services
                to
                both in-network and out-of-network
                providers.

            

    

    

    
      	c.  	
              Maintaining
                a comprehensive current medical record for the member, including
                documentation of all services provided to the member by the primary
                care
                provider, as well as any specialty or referral services, diagnostic
                reports, physical and mental health screens,
                etc.

            

    

    

    
      	d.  	
              Although
                primary care providers are responsible for the above activities,
                the
                health plan must monitor the primary care providers’ actions for
                compliance with health plan and MC+ Managed Care Program
                policies.

            

    

    

    
      	e.  	
              Primary
                care providers may have formalized relationships with other primary
                care
                providers to see their members for after hours care, during certain
                days,
                for certain services, or other reasons to extend their practice.
                However,
                the primary care provider shall be ultimately responsible for the
                above
                listed activities.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements for Primary Care
      Providers set forth in RFP B3Z06118 paragraph 2.3.2 and subparagraphs a - e.
      Harmony has policies and procedures to ensure compliance with the aforementioned
      Performance Requirements.  Please refer to the Appendix Binder, Tab 1, Item
      1 for Mandatory
      Assignment Process
      Policy and Procedure.  This policy and procedure may be updated from time
      to time, but shall remain compliant with DSS standards.

    

    

    
      	2.3.3  	
              Eligible
                Specialties:
                The health plan shall limit its primary care providers to licensed
                residents specializing in family and general practice, pediatrics,
                obstetrics and gynecology (OB/GYN), and internal medicine; registered
                nurses who are advanced practice nurses with specialties in family
                practice, pediatric practice, and OB/GYN practice; and licensed physicians
                in the following specialties: family and general practitioners,
                pediatricians, OB/GYN, and
                internists.

            

    

    

    
      	a.  	
              To
                the maximum extent possible, the health plan should include all of
                these
                specialties in its health plan provider
                network.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements for eligible
      specialties set forth in RFP B3Z06118 paragraph 2.3.3. and subparagraph
      a.

    

    
      	2.3.4  	
              Primary
                Care Provider Teams and Primary Care Clinics: The
                responsibilities of a primary care provider team and a primary care
                clinic
                shall be the same as the responsibilities listed herein for primary
                care
                providers.

            

    

    

    
      	a.  	
              If
                the health plan provider network includes institutions with teaching
                programs, primary care provider teams, comprised of residents and
                a
                supervising faculty physician, may serve as a primary care provider. In
                addition, the health plan should establish primary care provider
                teams
                that include advanced practice nurses or physician assistants as
                recognized by the Board of Healing Arts who, at the member's discretion,
                may serve as the point of first contact for the member. In both instances,
                the health plan shall organize its primary care provider teams so
                as to
                ensure continuity of care to members and identify a "lead physician"
                within the team for each member. The "lead physician" must be an
                attending
                physician and not a resident.

            

    

    

    
      	b.  	
              The
                health plan may also elect to make available clinics to serve as
                primary
                care providers. The primary care clinic must provide the range of
                services
                required of all primary care providers. A centralized medical record
                shall
                be maintained on each member enrolled with the primary care
                clinic.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.3.4. Harmony supports this requirement by allowing members
      to choose primary care provider teams and primary care clinics as their initial
      point of entry into the system.  Primary care provider teams and primary
      care clinics are held to the same standards as any participating primary care
      provider within Harmony’s network of providers.

    

    
      	2.3.5  	
              The
                health plan shall offer its members freedom of choice in selecting
                a
                primary care provider. The number of members assigned to a primary
                care
                provider shall be decreased by the health plan if necessary to maintain
                the appointment availability standards. To the degree possible, these
                shifts should occur prospectively (before care has been initiated)
                and the
                health plan should take steps to minimize the need for such
                shifts.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.3.5. Members have the right to choose their Primary Care
      Provider and may contact Customer Service to do so. 

    

    Contracted
      Providers are encouraged to be available and accessible to Members in accordance
      with federal, state and accrediting body guidelines. Harmony’s Provider
      Operations department coordinates an annual audit of accessibility and
      availability standards and the identification of corrective actions for areas
      where improvement is needed. Telephone audits are performed on an annual basis
      to monitor timeliness of appointment scheduling and wait times. GEO Access
      reports are reviewed and reported on a semi-annual basis to monitor network
      adequacy.

    

    Results
      and Corrective Actions related to these audits are presented and reviewed by
      the
      Medical Advisory Committee which then reports into the Quality Improvement
      Committee. Harmony has policies and procedures to ensure compliance with the
      aforementioned Performance Requirements.  Please refer to the Appendix
      Binder, Tab 1, Item 2 for Availability
      of Service
      Policy and Procedure.  This policy and procedure may be updated from time
      to time, but shall remain compliant with DSS.

    

    
      	2.3.6  	
              The
                health plan shall include a mix of mental health and substance abuse
                providers with experience in treating children, adolescents, and
                adults in
                the health plan provider network to ensure a broad range of treatment
                options are available.

            

    

    

    
      	a.  	
              To
                the maximum extent possible, the health plan should include Community
                Mental Health Centers (CMHC) in the health plan provider network.
                A
                listing of CMHC is provided in Attachment
                5.

            

    

    

    
      	b.  	
              The
                mental health provider network may include licensed psychiatrists,
                licensed psychologists, licensed psychiatric advance practice nurses,
                provisional licensed professional counselors, licensed professional
                counselors, provisional licensed clinical social workers, licensed
                clinical social workers, licensed clinical nurse specialists, licensed
                home health, licensed psychiatric nurse, and state certified mental
                health
                or substance abuse program. To be considered adequate, the mental
                health
                provider network must, at a minimum, include Qualified Mental Health
                Professionals (QMHP), Qualified Substance Abuse Professionals (QSAP),
                licensed psychiatrists, licensed psychologists, licensed psychiatric
                nurses, licensed professional counselors, licensed clinical social
                workers, and licensed clinical nurse
                specialists.

            

    

    

    
      	1)  	
              A
                QMHP shall be one of the following and provide services within their
                defined scope of practice:

            

    

    

    
      	·  	
              A
                physician, licensed under Missouri state law to practice medicine
                or
                osteopathy who has either specialized training in mental health services
                or one (1) year of experience, under supervision, in treating problems
                related to mental illness;

            

    

    

    
      	·  	
              A
                psychiatrist, a physician licensed under Missouri state law, who
                has
                successfully completed a training program in psychiatry approved
                by the
                American Medical Association, the American Osteopathic Association,
                or
                other training program identified as equivalent by the state
                agency;

            

    

    

    
      	·  	
              A
                psychologist licensed under Missouri state law to practice psychology
                with
                specialized training in mental health
                services;

            

    

    

    
      	·  	
              A
                professional counselor licensed under Missouri state law to practice
                counseling who has specialized training in mental health
                services;

            

    

    

    
      	·  	
              A
                licensed clinical social worker or a clinical social worker with
                a
                Master's Degree in social work from an accredited program who has
                specialized training in mental health
                services;

            

    

    

    
      	·  	
              A
                psychiatric nurse, a registered professional nurse, licensed under
                Missouri state law who has at least two (2) years of experience in
                a
                psychiatric setting or a Master's Degree in psychiatric nursing;
                or

            

    

    

    
      	·  	
              An
                individual possessing a Master's Degree or Doctorate Degree in counseling
                and guidance, rehabilitation counseling, vocational counseling,
                psychology, pastoral counseling, family therapy, social work, or
                a related
                field, who has successfully completed a practicum or has one (1)
                year of
                experience under the supervision of a mental health
                professional.

            

    

    

    
      	2)  	
              A
                QSAP shall be one of the following and provide services within their
                defined scope of practice:

            

    

    

    
      	·  	
              A
                counselor, psychologist, clinical social worker, or physician licensed
                in
                Missouri who has at least one (1) year of full-time experience in
                the
                treatment or rehabilitation of substance
                abuse;

            

    

    

    
      	·  	
              A
                graduate of an accredited college or university with a Master's Degree
                in
                social work, counseling, psychology, psychiatric nursing, or closely
                related field who has at least two (2) years of full-time experience
                in
                the treatment or rehabilitation of substance
                abuse;

            

    

    

    
      	·  	
              A
                graduate of an accredited college or university with a Bachelor's
                Degree
                in social work, counseling, psychology, or closely related field
                who has
                at least three (3) years of full-time experience in the treatment
                or
                rehabilitation of substance abuse;
                or

            

    

    

    
      	·  	
              An
                alcohol, drug, or substance abuse counselor certified by the Missouri
                Substance Abuse Counselors Certification Board,
                Inc.

            

    

    

    Harmony
      Behavioral understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.3.6.
      Harmony understands the obligation to include the Missouri Community Mental
      Health Centers (CMHC) within the managed behavioral health network. Harmony
      Behavioral Health strives to participate with inpatient and outpatient
      behavioral health facilities, psychiatric units in medical and surgical
      facilities, Community Mental Health Centers, and behavioral health providers
      who
      display effective and efficient use of members’ benefits and resources. All of
      the identified Missouri CMHCs will be offered an opportunity to join the Harmony
      Behavioral Health provider network.

    

    Harmony
      Behavioral Health’s current behavioral health network includes licensed
      independent professionals, Community Mental Health Centers, large and small
      not-for-profit agencies and specialty providers. 

    

    Harmony
      Behavioral Health conducts ongoing network development activities to comply
      with
      the contract requirements of the Centers for Medicare and Medicaid Services,
      the
      State of Missouri and to meet the changing requirements of the member
      population. A GeoAccess report is generated quarterly to assess the
      participating network for Harmony and identify areas requiring attention.

    

    The
      initial credentialing process for providers joining the Harmony Behavioral
      Health network ensures a mix of licensed professionals with experience treating
      various specialty populations, such as children and adolescents and members
      with
      co-occurring mental health and substance abuse treatment needs. The Harmony
      Behavioral Health Quality Improvement program conducts an annual audit of the
      provider network to ensure that the providers continue to meet the licensing
      and
      credentialing standards to participate in the network.

    

    
      	2.3.7  	
              Mental
                Health and Substance Abuse In-Network Self Referrals:
                The
                health plan shall have written policies and procedures that permit
                members
                to seek in-network mental health services and substance abuse services
                without a referral or authorization from the primary care provider.
                The
                policies and procedures shall permit members to contact an in-network
                mental health and substance abuse provider directly and shall provide
                for
                the authorization of at least four (4) visits annually without prior
                authorization requirements. Health plan mental health and substance
                abuse
                providers shall complete a health status screen, at the initial point
                of
                contact and as part of the re-assessment process for members in treatment.
                Members with physical health conditions as indicated by the screen
                shall
                be referred to their primary care provider for evaluation and treatment
                of
                the physical health condition.

            

    

    

    Harmony
      Behavioral understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.3.7. 

    

    
      	2.3.8  	
              Physician
                Specialists:
                Because of the large number of physician specialties that exist,
                the
                health plan is not required to maintain specific member-to-specialist
                provider ratios. However, the health plan must provide adequate access
                to
                physician specialists for primary care provider referrals and employ
                or
                contract with physician specialists in sufficient numbers to ensure
                specialty services can be made available in a timely manner. The
                health
                plan shall have protocols for coordinating care between primary care
                providers and specialists which include the expected response time
                for
                consults between primary care providers and
                specialists.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.3.8. Harmony Health Plans informs specialists during
      orientation and again in the Provider Manual that expected consultation reports
      are to be sent to PCP within one day in emergent/urgent situations and within
      one week for routine consults.

    

    
      	2.3.9  	
              Any
                Willing Pharmacy Provider:
                Any pharmacy, licensed without restriction under chapter 338, Revised
                Statutes of the State of Missouri (RSMo), as amended, and participating
                as
                an approved provider in the Missouri Medicaid program, which is qualified
                under the terms of the health plan and willing to accept the health
                plan's
                operating terms including, but not limited to, its schedule of fees,
                covered expenses, and quality standards, shall be allowed to participate
                in the health plan. Nothing shall prevent a health plan from instituting
                reasonable credentialing criteria, requiring fee discounts, or
                establishing any other reasonable measure designed to maintain quality
                or
                control costs.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.3.9.

    

    

    
      	2.3.10  	
              Federally
                Qualified Health Centers and Rural Health Clinics:
                The health plan shall include Federally Qualified Health Centers
                (FQHCs)
                and Rural Health Clinics (RHCs) in the health plan provider network,
                unless the health plan can demonstrate that it has both adequate
                capacity
                and an appropriate range of services to provide care for the expected
                enrollment in the region without contracting with FQHCs or RHCs.
                (A
                description of FQHC/RHC services is included in Attachment 2. A listing
                of
                FQHCs and RHCs are provided in Attachment 5.) If the health plan
                is
                competing against an FQHC or RHC owned health plan, the health plan
                shall
                not be required to comply with the previous requirement, although
                the
                health plan still must provide the FQHC/RHC services that are within
                the
                covered benefits of the MC+ managed care program. The health plan
                shall
                have protocols for coordinating care between the primary care provider
                and
                the FQHC and RHC provider and indicate the expected response time
                for
                consults between the FQHC and RHC and the primary care
                provider.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.3.10. Harmony has and will continue to establish
      contractual relationships with FQHC/RHCs in the region.

    

    
      	2.3.11  	
              Family
                Planning and Sexually Transmitted Disease (STD) Treatment Providers:
                The
                health plan should include Title X and sexually transmitted disease
                treatment providers in the health plan provider network to serve
                members
                covered under the comprehensive and extended family planning, women's
                reproductive health, and sexually transmitted diseases benefit packages.
                The health plan shall allow for full freedom of choice for the provisions
                of these services. A listing of Family Planning and STD treatment
                providers is provided in Attachment
                5.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.3.11. Harmony members may seek treatment of family planning
      services and sexually transmitted disease at these providers without
      authorization from Harmony, regardless of participation status with
      Harmony.

    

    

    
      	2.3.12  	
              Local
                Public Health Agencies:
                The health plan should include local public health agencies in the
                health
                plan provider network for the public health services described herein
                or
                for other services. (A listing of local public health agencies is
                provided
                in Attachment 5.) However, in order to ensure care coordination of
                members
                seeking services at a local public health agency, the health plan
                should
                establish an agreement with local public health agencies describing,
                at a
                minimum, care coordination, medical record management, and billing
                procedures. Requirements for reimbursement for certain services are
                specified in the Performance Requirements segment regarding public
                health
                programs and mandated health plan reimbursements. Attachment 4 lists
                a
                number of conditions for which the health plan shall report to or
                cooperate with local public health agencies. In addition, the health
                plan
                may wish to contract with local public health agencies, as defined
                above,
                to provide other health plan covered
                services.

            

    

    

    
      	a.  	
              All
                statutorily mandated disease or condition reporting requirements
                remain,
                regardless of the site of the service. The health plan shall provide
                a
                list of their contracted laboratories to the Missouri Department
                of Health
                and Senior Services by July 1 each
                year.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.3.12 and subparagraph a. Harmony members may utilize
      services at a local public health agency regardless of that agency’s
      participation status with Harmony.

    

    

    
      	2.3.13  	
              Network
                Changes:
                The health plan shall notify the state agency within five (5) business
                days of first awareness/notification of change to the composition
                of the
                health plan provider network or the health care service subcontractors’
                provider network that materially affect the health plan’s ability to make
                available all covered services in a timely manner. The health plan
                shall
                have procedures to address changes in the health plan provider network
                that negatively affect the ability of members to access services,
                including access to a culturally diverse provider network. Material
                changes in network composition that negatively affect member access
                to
                services may be grounds for contract cancellation or State determined
                sanctions.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.3.13.

    

    

    
      	2.3.14  	
              Mainstreaming:
                The state agency considers mainstreaming of MC+ managed care members
                into
                the broader health delivery system to be important. The health plan
                therefore must ensure that all of the in-network providers accept
                members
                for treatment. The health plan also must accept responsibility for
                ensuring that in-network providers do not intentionally segregate
                members
                in any way from other persons receiving
                services.

            

    

    

    
      	a.  	
              To
                ensure mainstreaming of members, the health plan shall take affirmative
                action so that members are provided covered services without regard
                to
                race, color, creed, sex, religion, age, national origin, ancestry,
                marital
                status, sexual preference, health status, income status, program
                membership, or physical or mental disability, except where medically
                indicated. Examples of prohibited practices include, but are not
                limited
                to, the following:

            

    

    

    
      	1)  	
              Denying
                or not providing to a member any covered service or availability
                of a
                facility.

            

    

    

    
      	2)  	
              Providing
                to a member any covered service which is different, or is provided
                in a
                different manner, or at a different time from that provided to other
                members, other public or private patients, or the public at
                large.

            

    

    

    
      	3)  	
              Subjecting
                a member to segregation or separate treatment in any manner related
                to the
                receipt of any covered service.

            

    

    

    
      	b.  	
              If
                the health plan knowingly executes a subcontract with a provider
                with the
                intent of allowing or permitting the subcontractor to implement barriers
                to care (i.e., the terms of the subcontract are more restrictive
                than the
                contract), the State shall consider the health plan to have breached
                the
                provisions and requirements of the contract. In addition, if the
                health
                plan becomes aware of any of its existing subcontractors' failure
                to
                comply with this section and does not take action to correct this
                within
                thirty (30) calendar days, the State shall consider the health plan
                to
                have breached the provisions and requirements of the
                contract.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.3.14. subsections a-b. Harmony monitors this provision
      of
      the contract during on-site visits with participating provider offices by
      Harmony’s provider relations staff. Harmony’s provider network is contractually
      bound by inclusion of the following contract language:
 “Nondiscrimination.
      Provider shall render services to Members in the same manner, in accordance
      with
      the same standards, and within the same time availability, as to its other
      patients. Provider shall not refuse to render services to a Member based on
      the
      Member’s race, sex, sexual orientation, national origin, religion, health
      status, benefit plan or source of payment of such
      Members.” 
      In addition all Harmony providers agree to provide Covered Services to Enrollees
      and non-enrollees on an equal basis and not to discriminate between Enrollees
      and Medicaid Enrollees.

    

    
      	2.3.15  	
              The
                health plan shall comply with any applicable federal requirements
                with
                respect to home health agencies, as
                amended.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.3.15.

    

     

    
      	2.3.16  	
              School
                Based Dental Services:
                The state agency has reimbursed dental providers for the provision
                of
                preventive dental services provided to children in a school setting.
                These
                preventive services have included dental exams, prophylaxis, and
                sealants.
                The state agency is committed to the continuation of such programs
                for
                members enrolled with a health plan. The health plan shall contract
                and
                reimburse any licensed dental providers who provide such services
                in a
                school setting. The dental providers must be qualified under the
                terms of
                the health plan and willing to accept the health plan’s operating terms,
                including but not limited to, its fee schedule, covered expenses,
                and
                quality standards, to be allowed to participate in the health plan
                provider network. Nothing shall prevent a health plan from instituting
                reasonable credentialing criteria for school-based dental services
                or
                establishing other reasonable measures designed to maintain quality
                of
                care or control costs.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.3.16. Harmony has developed a relationship with Bridgeport
      Dental Services to support all dental requirements of the contract. This
      includes partnering with all of the school based dental services in the
      region.

    

    
      	2.3.17  	
              Tertiary
                Care:
                Tertiary care is defined as health services provided by highly-specialized
                providers, such as medical sub-specialists. These services frequently
                require complex technological and support facilities. The health
                plan
                shall provide tertiary care services including trauma centers, burn
                centers, level III (high risk) nurseries, rehabilitation facilities,
                and
                medical sub-specialists available twenty-four (24) hours per day
                in the
                region. If the health plan does not have a full range of tertiary
                care
                services, the health plan must have a process for providing such
                services
                including transfer protocols and arrangements with out-of-network
                providers.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.3.17.

    

    Harmony
      will provide tertiary care for Harmony members at Cardinal Glennon Hospital.
      Harmony has had a contractual relationship with Cardinal Glennon and its
      specialty care providers since 2000. All services, including the trauma center,
      burn center, all nursery levels up to Level IV nursery, rehabilitation
      facilities and medical sub-specialties are available in region and are available
      24 hours a day/7 days a week. Additionally, Harmony has a contractual
      relationship with St. Mary’s Health Center in Richmond Heights for tertiary care
      OB services. Harmony has transfer protocols and arrangements when required
      to
      support members who choose to use an out-of-network provider. Harmony has
      policies and procedures to ensure compliance with the aforementioned Performance
      Requirements.  Please refer to the Appendix Binder, Tab 1, Item 3 for
Authorization
      and Availability Policy
      and Procedure.  This policy and procedure may be updated from time to time,
      but shall remain compliant with DSS standards 

    

    
      	2.3.18  	
              Specialty
                Pediatric Hospitals: The
                health plan shall include specialty pediatric hospitals as defined
                in 13
                CSR 70-15.010 (2) (P), as amended, in the health plan provider
                network.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.3.18. Please refer to Harmony’s Provider Network Table
      included in Appendix Binder, Tab 5.

    
      	2.4  	
              Payments
                to Providers: 

            

    

    

    The
      state
      agency believes that one of the advantages of a managed care system is that
      it
      permits the health plan and providers to enter into creative payment
      arrangements intended to encourage and reward effective utilization management
      and quality of care. The state agency therefore shall give the health plan
      and
      providers as much freedom as possible to negotiate mutually acceptable payment
      rates and payment time frames. All subcontracts shall contain the time frames
      for paying in-network providers for covered services. However, regardless of
      the
      specific arrangements the health plan makes with providers, the health plan
      shall make timely payments to both in-network and out-of-network providers,
      subject to the conditions described below. All disputes between the health
      plan
      and in-network and out-of-network providers shall be solely between such
      providers and the health plan. In the case of any disputes regarding payment
      for
      covered services between the health plan and providers, the member shall not
      be
      charged for any of the disputed costs. This agreement shall only be overcome
      by
      written evidence of an agreement between the provider and the member indicating
      that the member accepts the status and liabilities of a private pay patient.
      The
      health plan shall make it clear to members that all covered services are
      available to the member at no cost subject to any applicable co-pays. The
      private pay agreement shall only be for services not included in the
      comprehensive benefit package.

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.4.

    

    Harmony’s
      Provider Agreements outline the terms by which Harmony will reimburse providers.
      Harmony shall meet timely payment requirements to both in-network and
      out-of-network providers. Harmony shall clearly state in various member
      communications (to include the Member Handbook) that all covered services are
      available to the member at no cost subject to any applicable
      co-pays.

    

    
      	2.4.1  	
              Retroactive
                Eligibility Period:
                Except for newborns, the health plan shall not be responsible for
                any
                payments owed to providers for services rendered prior to a member's
                enrollment even if they fell within the established period of retroactive
                eligibility.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.4.1.

    

    

    
      	2.4.2  	
              Claims
                Processing Requirements: The
                claim processing requirements are set forth by RSMo 376.383 and RSMo
                376.384, as amended. 

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.4.2.

    

    WellCare
      will pay 95% of “clean” claims from unaffiliated providers within thirty (30)
      days of receipt of the claim. Reports are generated by the claim processing
      unit
      to ensure timeliness of the processing of claims (on a first in/first out
      basis). In addition, Claim Management reports are generated weekly to monitor
      claims turn around time. If a “clean” claim from an unaffiliated provider is not
      paid within thirty (30) days of receipt, WellCare will pay interest and
      penalties in accordance with the rate that is established under
      any State regulations or statutes.

    

    Interest
      payments are generated using a proprietary application that accesses WellCare’s
      core claim payment system. Interest payments are calculated monthly using a
      3-step process which includes entering the line of business, claim type, and
      the
      time period for which interest is being generated. This application then
      calculates interest on any claim finalized within the selected time period
      based
      on the parameters set forth in the program and creates a batch of checks. The
      batch of checks and remittance advices are printed and mailed to the provider
      within 1 business day.

    

    
      	2.4.3  	
              Clean
                Claims:
                Clean claim means a claim that can be processed without obtaining
                additional information from the provider of the service or from a
                third
                party.

            

    

    

    Harmony
      Health Plan agrees with the definition of Clean Claims as set forth in RFP
      B3Z06118 paragraph 2.4.3.

    

    
      	2.4.4  	
              Inappropriate
                Payment Denials:
                If
                the health plan has a pattern of inappropriately denying or delaying
                payments for services, the health plan may be subject to suspension
                of new
                enrollments, withholding in full or in part of capitation payments,
                contract cancellation, or refusal to contract in a future time period.
                This applies not only to cases where the state agency has ordered
                payment
                after appeal but to cases where no appeal has been made (i.e., the
                state
                agency is knowledgeable about the documented abuse from other
                sources).

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.4.4.

    

    
      	2.4.5  	
              Copayment
                Requirements and Member Participation in Pharmacy Professional Dispensing
                Fee:

            

    

    

    
      	a.  	
              Copayment
                requirements do not apply to MC+ Managed Care members.
                

            

    

    

    
      	b.  	
              Member
                Participation in Pharmacy Professional Dispensing
                Fee

            

    

    

    
      	1)  	
              Unlike
                traditional copayment requirements, the current Missouri Medicaid
                Recipient Pharmacy fee requirement is considered a portion of the
                professional dispensing fee and is not deducted from the reimbursement
                to
                providers. Therefore, the member portion of the pharmacy dispensing
                fee is
                required to be collected, according to current Medicaid policy, for
                pharmacy services provided by the health plan. The provider must
                charge
                and collect dispensing fees as specified in accordance with section
                208.152 RSMo, as amended. Providers shall not deny or reduce services
                to
                members solely on the basis of the member’s inability to pay the fee when
                charged. A member’s inability to pay a required amount as due and charged
                when a service is delivered, shall in no way extinguish the member’s
                liability to pay the amount due. Fee responsibility and amounts
                collectible shall be as follows:

            

    

    

    
      	
              Ingredient
                Cost for Each Item of Service

            	
              Member
                Participation in Pharmacy Professional Dispensing
                Fee

            
	
              $10.00
                or Less:

            	
              $0.50

            
	
               $10.01
                to $25.00:

            	
              $1.00

            
	
              $25.01
                or More:

            	
              $2.00

            

    

    

    
      	2)  	
              Under
                current pharmacy dispensing fee policy, all Missouri eligible recipients
                are subject to the fee requirement when provided covered pharmacy
                services, with the exception of the
                following:

            

    

    

    
      	·  	
              Beneficiaries
                under age 19.

            

    

    

    
      	·  	
              Services
                related to Early Periodic Screening, Diagnosis and Treatment (EPSDT):
                Those drugs which are prescribed and identified as relating to an
                EPSDT
                program screening or referral services must be confirmed as such
                to the
                dispensing provider through one of the following
                methods:

            

    

    

    
      	Ø  	
              The
                prescribing provider identifies on the prescription that it relates
                to an
                EPSDT examination and treatment; or

            

    

    

    
      	Ø  	
              The
                prescribing provider verbally states that the prescription relates
                to an
                EPSDT examination and treatment in cases of telephone prescribing.
                This
                verbal assertion must be included in the dispensing provider’s reduction
                into writing of the prescription.

            

    

    

    
      	·  	
              Institutionalized
                members residing in a skilled nursing facility, psychiatric hospital,
                residential care facility, or adult boarding
                home.

            

    

    

    
      	·  	
              Foster
                Care children. 

            

    

    

    
      	·  	
              All
                Medicare/Medicaid crossover claims as primary coverage as afforded
                by the
                Medicare program.

            

    

    

    
      	·  	
              Those
                services specifically identified as related to Family Planning
                services.

            

    

    

    
      	·  	
              Emergency
                services.

            

    

    

    
      	·  	
              Services
                provided to pregnant women which are directly related to the pregnancy
                or
                a complication of the pregnancy.

            

    

    

    
      	3)  	
              Participation
                in the health plan provider network shall be limited to providers
                who
                accept, as payment in full, the amounts paid by the health plan plus
                any
                fee amount required of the member and collected by the
                provider.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.4.5 and subparagraphs a and b.

    

    Harmony
      has contracted with Pharmacy Benefits Manager (PBM), Walgreens Health
      Initiatives, Inc. (WHI) to serve the Missouri MC+ managed care population.
      Harmony has delegated administrative services through the WHI contract to (1)
      manage Harmony’s prescription benefit through a network of retails pharmacies
      contracted by WHI, (2) arrange for prescription benefit management and (3)
      manage pharmacy claims processing services. 

    

    WHI
      has successfully provided delegated PBM services for over 700,000
      WellCare/Harmony members for over three years.

    

    
      	2.4.6  	
              Pharmacy
                Dispensing Fee:
                The health plan shall pay a pharmacy dispensing fee of $4.09 to each
                qualifying pharmacy for the first 1,000 prescriptions filled in any
                calendar quarter. The reimbursement of a pharmacy dispensing fee
                shall be
                available only to corporations, partnerships, or individual
                proprietorships with less than 25 employees who operate pharmacies
                or
                pharmacy franchises and to public health entities owned and operated
                by a
                state, county, or local government agency and where the entity is
                a
                hospital which qualifies as a first-tier 10% add-on disproportionate
                share
                hospital in accordance with 13 CSR 70-15.010. The health plan shall
                identify its pharmacies that qualify. The health plan shall supply
                the
                state agency with a list of those pharmacies identified to qualify
                for a
                pharmacy dispensing fee reimbursement upon
                request.

            

    

    

    Harmony
      Health Plan and it’s delegated entity understands and will adhere to the
      requirements set forth in RFP B3Z06118 paragraph 2.4.6.

    

    

    
      	2.4.7  	
              Federally
                Qualified Health Centers (FQHCs) and Rural Health Clinics
                (RHCs):
                If
                the health plan includes subcontracted FQHCs or RHCs in the health
                plan
                provider network, the FQHC or RHC is entitled to reimbursement of
                reasonable costs from the state agency and any differential payment
                paid
                by the state agency.

            

    

    

    
      	a.  	
              The
                health plan shall reimburse the FQHC/RHC at the same reimbursement
                level
                as other providers for the same services. The state agency shall
                perform
                reconciliation between the health plan reimbursement and the FQHC/RHC's
                reasonable costs for the covered services provided under the contract.
                The
                FQHC/RHC must fully comply with the state agency's payment and billing
                systems, and provide the state agency with all cost reporting information
                required by the state agency to verify reasonable costs and apply
                applicable reasonable cost reimbursement principles. The health plan
                shall
                submit a list of its contracted FQHCs and RHCs to the state agency
                annually at the start of each contract
                period.

            

    

    

    
      	b.  	
              If
                the health plan contracts with FQHCs or RHCs, the health plan shall
                fulfill the following:

            

    

    

    
      	1)  	
              Billing
                for Services Provided by an FQHC or RHC: The FQHC/RHC must bill using
                a
                valid FQHC/RHC's Medicaid Provider
                Number. The health plan shall include this Medicaid Provider Number
                on
                FQHC/RHC claims as follows:

            

    

    

    
      	·  	
              FQHC
                Medical and Dental Claims:
                The health plan shall submit the FQHC's Missouri Medicaid Provider
                Number on the NSF layout, record 'FAO', within field number 23. This
                field
                is referenced as the Rendering Provider
                Number.

            

    

    

    
      	·  	
              FQHC
                Home Health Claims:
                The health plan shall submit the FQHC's Missouri Medicaid Provider
                Number
                on the UB92 layout, record '80', within field number 11. This field
                is
                referenced as the Other Provider.

            

    

    

    
      	·  	
              FQHC
                Pharmacy Claims:
                The health plan shall submit the FQHC's Missouri Medicaid Provider
                Number
                on the NCPDP 3C layout, field number 411. This field is referenced
                as the
                Prescriber ID.

            

    

    

    
      	·  	
              RHC
                Claims:
                The health plan shall submit the RHC's Missouri Medicaid Provider
                Number
                on the UB92 layout, record 80', within field number 11. This field
                is
                referenced as the Other Provider.

            

    

    

    
      	2)  	
              The
                FQHC/RHC must bill its usual and customary amount for all payor classes.
                The health plan shall include the billed amount when the health plan
                submits the encounter claims to the state
                agency.

            

    

    

    
      	3)  	
              Reporting
                Requirements for Services Provided by an FQHC or
                RHC

            

    

    

    
      	·  	
              The
                health plan shall submit Schedule M-1 included with Attachment 7
                documenting the accepted charges, denied charges, and payments for
                each
                contracted RHC/FQHC. The health plan shall submit Schedule M-1 thirty
                (30)
                calendar days after the month end for services provided by the contracted
                FQHC/RHC. Attachment 7 also provides the instructions for completing
                Schedule M-1.

            

    

    

    
      	·  	
              The
                health plan shall submit Schedule M-2 included with Attachment 7
                documenting the accepted charges, denied charges, and payments for
                each
                contracted RHC/FQHC for the FQHC's/RHC's entire fiscal year. The
                health
                plan shall submit Schedule M-2 within 14 business days of request
                by the
                state agency for MC+ managed care services provided by contracted
                FQHC/RHC
                during the reporting period requested. Attachment 7 also provides
                the
                instructions for completing Schedule
                M-2.

            

    

    

    
      	·  	
              Health
                plan records applicable to a FQHC/RHC are subject to audit by the
                state
                agency or its contracted agent.

            

    

    

    Harmony
      attests that the contents and provisions of the contractual agreements with
      FQHCs/RHCs promote full compliance with the requirements set forth in RFP
      B3Z06118 paragraph 2.4.7 and subparagraphs a and b. 

    

    

    
      	2.4.8  	
              Payment
                for Emergency Services and Post-stabilization Care
                Services:

            

    

    

    
      	a.  	
              The
                health plan shall cover and pay for emergency services regardless
                of
                whether the provider that furnishes the services has a contract with
                the
                health plan.

            

    

    

    
      	1)  	
              The
                state agency encourages the health plan and providers to reach agreement
                on payment for services.

            

    

    

    
      	2)  	
              The
                health plan shall pay out-of-network providers for emergency services
                at
                the current Missouri Medicaid program rates in effect at the time
                of
                service unless the health plan and provider have negotiated a mutually
                acceptable rate.

            

    

    

    
      	b.  	
              The
                health plan may not deny payment for treatment obtained under either
                of
                the following circumstances:

            

    

    

    
      	1)  	
              A
                member had an emergency medical condition, including cases in which
                the
                absence of immediate medical attention would not have had the outcomes
                specified in the definition of emergency medical condition specified
                herein.

            

    

    

    
      	2)  	
              A
                representative of the health plan instructs the member to seek emergency
                services.

            

    

    

    
      	c.  	
              The
                health plan shall not limit what constitutes an emergency medical
                condition as defined herein on the basis of lists of diagnoses or
                symptoms.

            

    

    

    
      	d.  	
              The
                health plan shall not refuse to cover emergency services based on
                the
                emergency room provider, hospital, or fiscal agent not notifying
                the
                member’s primary care provider or the health plan of the member’s
                screening and treatment within ten (10) calendar days of presentation
                for
                emergency services.

            

    

    

    
      	e.  	
              A
                member who has an emergency medical condition may not be held liable
                for
                payment of subsequent screening and treatment needed to diagnose
                the
                specific condition or stabilize the
                patient.

            

    

    

    
      	f.  	
              The
                attending emergency physician, or the provider actually treating
                the
                member, is responsible for determining when the member is sufficiently
                stabilized for transfer or discharge, and that determination is binding
                on
                the health plan.

            

    

    

    
      	g.  	
              The
                health plan must be financially responsible for post-stabilization
                care
                services obtained within or outside the health plan that are pre-approved
                by a health plan provider or other health plan
                representative.

            

    

    

    
      	h.  	
              The
                health plan must be financially responsible for post-stabilization
                care
                services obtained within or outside the health plan that are not
                pre-approved by a health plan provider or other health plan organization
                representative, but administered to maintain the enrollee’s stabilized
                condition within thirty (30) minutes of a request to the health plan
                for
                pre-approval of further post-stabilization care
                services.

            

    

    

    
      	i.  	
              The
                health plan must be financially responsible for post-stabilization
                care
                services obtained within or outside the health plan that are not
                pre-approved by a health plan provider or other health plan
                representative, but administered to maintain, improve, or resolve
                the
                enrollee’s stabilized condition if:

            

    

    

    
      	1)  	
              The
                health plan does not respond to a request for pre-approval within
                thirty
                (30) minutes;

            

    

    
      	2)  	
              The
                health plan cannot be contacted; or

            

    

    
      	3)  	
              The
                health plan representative and the treating physician cannot reach
                an
                agreement concerning the member’s care and a health plan physician is not
                available for consultation. In this situation, the health plan must
                give
                the treating physician the opportunity to consult with a health plan
                physician and the treating physician may continue with care of the
                patient
                until a health plan physician is reached or one of the criteria in
                subparagraph l below is met.

            

    

    

    
      	j.  	
              The
                health plan must limit charges to members for post-stabilization
                care
                services to an amount no greater than what the health plan would
                charge
                the member if he or she had obtained the services through the health
                plan.

            

    

    

    
      	k.  	
              The
                health plan shall negotiate mutually acceptable payment rates with
                out-of-network providers for post-stabilization services for which
                the
                health plan has financial
                responsibility.

            

    

    

    
      	l.  	
              The
                health plan’s financial responsibility for post-stabilization care
                services it has not pre-approved ends
                when:

            

    

    

    
      	1)  	
              A
                health plan physician with privileges at the treating hospital assumes
                responsibility for the member’s
                care;

            

    

    
      	2)  	
              A
                health plan physician assumes responsibility for the member’s care through
                transfer;

            

    

    
      	3)  	
              A
                health plan representative and the treating physician reach an agreement
                concerning the enrollee’s care; or

            

    

    
      	4)  	
              The
                member is transferred.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.4.8 and subparagraphs a - l. 

    

    Harmony
      covers emergency services including ambulance services both in and out of the
      geographic area without authorization for both contracted and non-contracted
      providers. Harmony will also pay for care related to an unexpected illness
      or
      injury and renal dialysis services (when diagnosed with end-stage renal disease)
      when a member is temporarily (less than 12 consecutive months) outside the
      Plan’s service area without prior authorization.

    

    
      	2.4.9  	
              The
                health plan shall maintain the fee schedule for dental services located
                in
                Attachment 14 at no lower than the Medicaid fee-for-service fee schedule
                in effect at the time of service.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.4.9. Harmony has contracted with Bridgeport Dental to
      provide delegated Dental services to Harmony’s Missouri MC+ managed care
      enrollees. 

    

    
      	2.4.10  	
              Specialty
                Pediatric Hospitals. The
                health plan shall reimburse specialty pediatric hospitals as defined
                in 13
                CSR 70-15.010 (2) (P) at no lower than the Medicaid fee-for-service
                fee
                schedule in effect at the time of service unless otherwise negotiated
                with
                the provider.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.4.10. 

    

    
      	2.4.11  	
              A
                health plan shall pay for services furnished outside their service
                area to
                the same extent that it would pay for services furnished within their
                service area if the services are furnished to a member and any of
                the
                following conditions are met: 

            

    

    

    
      	a.  	
              Medical
                services are needed because of a medical
                emergency;

            

    

    
      	b.  	
              Medical
                services are needed and the member’s health would be endangered if he were
                required to travel to member’s residence:

            

    

    
      	c.  	
              The
                health plan determines, on the basis of medical advice, that the
                needed
                medical services, or necessary supplementary resources, are more
                readily
                available outside the service area. These services are subject to
                the
                health plan’s prior authorization and concurrent review
                process.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.4.11. subparagraphs a-c. Harmony has policies and
      procedures to ensure compliance with the aforementioned Performance
      Requirements.  Please refer to the Appendix Binder, Tab 1, Item 4 and 5
      respectively for Service
      Authorization Decisions and
      Inpatient
      Concurrent Review Policies
      and Procedures.  These policies and procedures may be updated from time to
      time, but shall remain compliant with DSS standards 

    

    
      	2.5  	
              Eligibility
                Determinations:

            

    

    

    The
      Missouri Department of Social Services, the Family Support Division performs
      eligibility determinations. Trained staff are stationed full-time at field
      offices located throughout the State and on a periodic basis at health care
      provider sites that serve large numbers of MC+ members.

    

    
      	2.5.1  	
              Health
                Plan Lock-In:
                All members will have a twelve (12) month lock-in to provide a solid
                continuum of care. Once a member chooses a health plan or is assigned
                to a
                health plan, the member will have ninety (90) calendar days from
                the
                effective date of coverage with the health plan in which to change
                health
                plans for any reason. This applies to the member’s initial enrollment and
                to any subsequent enrollment periods where the member changed health
                plans. All transfers between health plans that members request during
                the
                first ninety (90) calendar days following initial enrollment shall
                be
                granted without review by the state agency. Both the 90-day and the
                12-month enrollment period begin on the same day. Children in COA
                4 shall
                be allowed automatic and unlimited changes in health plan choice
                as often
                as circumstances necessitate.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.5.1. 

    

    
      	2.5.2  	
              Open
                Enrollment:
                The state agency may conduct an open enrollment for the contract
                period.
                The state agency may at its sole option adjust enrollment during
                the
                transition between contract
                periods.

            

    

    

    
      	a.  	
              Annual
                Open Enrollment: The state agency shall give members an annual open
                enrollment period prior to their 12-month enrollment anniversary
                date with
                the health plan. The state agency shall provide an open enrollment
                notice
                to members at least sixty (60) calendar days before each annual enrollment
                opportunity.

            

    

    

    Harmony
      Health Plan understands the Open Enrollment provision as set forth in RFP
      B3Z06118 paragraph 2.5.2.

    

    
      	2.5.3  	
              Enrollment
                Counseling:
                The state agency shall make available helpline operators to all program
                MC+ managed care eligibles to provide assistance in selecting and
                enrolling into a health plan through the operation of a toll-free
                telephone line. Helpline operators also shall be available by telephone
                to
                assist MC+ managed care eligibles who would like to change health
                plans
                (e.g., during open enrollment). MC+ managed care eligibles shall
                be
                offered the assistance of a helpline operator when needed. The helpline
                operator responsibilities shall include the
                following:

            

    

    

    
      	a.  	
              Educating
                the family about managed care in general, including the requirement
                to
                enroll in a health plan, the way services typically are accessed
                under
                managed care, the role of the primary care provider, the health plan
                member’s right to choose a primary care provider subject to the capacity
                of the provider, the responsibilities of the health plan member,
                and the
                member’s rights to file grievances and appeals and to request a State Fair
                Hearing.

            

    

    

    
      	b.  	
              Educating
                the family about benefits available through the health plan, both
                in-network and out-of-network.

            

    

    

    
      	c.  	
              Informing
                the family of available health plans and outlining criteria that
                might be
                important when making a choice (e.g., presence or absence of the
                family's
                existing provider in the health plan provider
                network).

            

    

    

    
      	d.  	
              Identifying
                any sources of Third Party Liability that were not identified by
                the FSD
                eligibility technician.

            

    

    

    
      	e.  	
              Administering
                a health plan screen when possible, as designated by the state agency,
                that collects baseline health status data to be used as part of the
                health
                plan program evaluation. Any baseline health status data shall be
                made
                available to the health plan. (See Attachment 8 for the most current
                version.)

            

    

    

    
      	f.  	
              Explaining
                options for obtaining services outside the health plan
                network.

            

    

    

    
      	g.  	
              Providing
                a listing of the health plan primary care providers generated from
                the
                provider demographic electronic file submitted by the health plan
                to the
                state agency.

            

    

    

    Harmony
      Health Plan understands the responsibilities of the Enrollment Counselor as
      set
      forth in RFP B3Z06118 paragraph 2.5.3 and subparagraphs
      a-g.

    

    
      	2.5.4  	
              Voluntary
                Selection of Health Plan:
                Missouri MC+ managed care eligibles shall be given fifteen (15) calendar
                days from the time of their eligibility for managed care to select
                a
                health plan. All members of a family shall be encouraged to select
                the
                same health plan. If a family does not select a health plan within
                the
                fifteen (15) day window, the state agency shall automatically assign
                the
                family to a health plan.

            

    

    

    Harmony
      Health Plan understands the Voluntary Selection of Health Plan provision set
      forth in RFP B3Z06118 paragraph 2.5.4. 

    

    
      	2.5.5  	
              Automatic
                Assignment Into Health
                Plans:

            

    

    

    
      	a.  	
              The
                state agency shall employ an algorithm to assign to the health plan,
                on a
                prorated basis, any MC+ managed care eligibles who do not make a
                voluntary
                selection of a health plan during open enrollment. The algorithm
                shall be
                based on the following:

            

    

    

    
      	1)  	
              If
                the MC+ managed care eligible’s case head is enrolled with a health plan,
                the MC+ managed care eligible shall be assigned to that health plan.
                If
                not, the next step in the algorithm shall be
                followed.

            

    

    

    
      	2)  	
              If
                the MC+ managed care eligible is included in a case where another
                member
                is enrolled with a health plan, the MC+ managed care eligible shall
                be
                assigned to that health plan. If not, the MC+ managed care eligible
                shall
                be assigned randomly.

            

    

    

    Paragraph
      2.5.5 b. revised by Amendment #001

     

    
      	b.  	
              Eastern/Western
                Regions:
                The random auto assignment shall be based on the total evaluation
                determined by the State of Missouri (see Proposal Submission Information
                section). 

            

    

     

    Paragraph
      2.5.5 c. inserted by Amendment #001

     

    
      	c.  	
              Central
                Region: The
                random auto assignment shall be based on the inclusion of health
                plan
                signed contracts with acute care safety net hospitals, as defined
                in 13
                CSR 70-15.010 of the Code of State Regulations, as amended. (A listing
                of
                safety net hospitals is provided in Attachment 5.) The acute care
                safety
                net hospital must be located in the Central region
                counties.

            

    

    

    
      	1)  	
              The
                health plan including such acute care safety net hospitals in its
                network
                shall equally divide seventy percent (70%) of the random auto assignments,
                while the remaining health plans shall equally share the remaining
                thirty
                percent (30%) of the algorithm
                assignments.

            

    

    

    
      	2)  	
              In
                the event all health plans have such acute care safety net hospitals
                in
                their networks, all contracted health plans shall equally share one
                hundred percent (100%) of the random auto
                assignments.

            

    

    

    Harmony
      Health Plan understands the Automatic Assignment process set forth in RFP
      B3Z06118 paragraph 2.5.5 and subparagraphs a -c. 

    

    
      	2.5.6  	
              Automatic
                Re-Assignment Following Resumption of Eligibility:
                Members who are disenrolled from a health plan due to loss of eligibility,
                shall automatically be re-enrolled, or assigned, into the same health
                plan
                and to the same primary care provider should they regain eligibility
                within sixty (60) calendar days. The member will have ninety (90)
                calendar
                days from the effective date of coverage with the health plan in
                which to
                change health plans for any reason. If more than sixty (60) calendar
                days
                have elapsed, the member shall be permitted to select a health plan
                and
                primary care provider through the enrollment
                process.

            

    

    

    Harmony
      Health Plan understands the Automatic Re-Assignment Following Resumption of
      Eligibility process set forth in RFP B3Z06118 paragraph 2.5.6.

    

    
      	2.6  	
              Member
                Enrollment and
                Disenrollment:

            

    

    

    
      	2.6.1  	
              MC+
                Managed Care Marketing
                Guidelines:
                The health plan may educate and conduct marketing campaigns for MC+
                managed care members, subject to the restrictions and definitions
                outlined
                herein. Education activities are efforts directed to current members
                to
                provide knowledge or skills. Marketing campaigns are efforts directed
                to
                an audience of members and potential health plan members to retain
                or
                increase health plan membership. The health plan and subcontractors
                shall
                not influence member enrollment.

            

    

    

    
      	a.  	
              Marketing
                Guidelines:
                The health plan shall:

            

    

    

    
      	1)  	
              Submit
                its proposed marketing plan, all marketing materials, and member
                education
                materials to the state agency for written approval prior to use.
                The state
                agency shall only consider the marketing plan and materials submitted
                by
                the health plan, (not subcontractors). The health plan should submit
                all
                materials in mock camera-ready form. When submitting marketing and
                education materials for approval, the health plan shall indicate
                how and
                when the material will be used, the time frames for the use, and
                the media
                to be used for distribution if approved. All written materials must
                be at
                a 6th
                grade reading level or less. The state agency shall approve, disapprove,
                or require modifications of education and marketing materials. The
                state
                agency shall review and respond as soon as possible, but within thirty
                (30) calendar days of receipt by the state agency. Marketing and
                education
                materials are deemed approved if a response from the state agency
                is not
                returned within thirty (30) calendar days following receipt of the
                materials by the state agency. The health plan shall engage in only
                those
                marketing activities which are prior approved in
                writing.

            

    

    

    
      	2)  	
              The
                health plan’s marketing material shall include a listing of their
                in-network providers identified by specialty and location, as appropriate
                for the document submitted for
                approval.

            

    

    

    
      	3)  	
              The
                health plan’s marketing and education materials shall include the member’s
                rights and responsibilities to assistance in obtaining all covered
                services.

            

    

    

    
      	4)  	
              Correct
                problems and errors with the marketing plan and/or materials as identified
                by the state agency. The health plan shall submit to the state agency
                a
                written corrected marketing plan or revised material within ten (10)
                business days following receipt date of the written notice from the
                state
                agency.

            

    

    

    
      	5)  	
              Not
                display or distribute any marketing materials in any manner at Family
                Support Division (FSD) offices, or health plan provider sites, unless
                the
                health plan has received prior written permission to do so from the
                state
                agency. Only approved member handbooks and provider network listing
                may be
                distributed to local FSD offices. The health plan shall supply current
                materials and remove their out-dated materials in public areas at
                the FSD
                offices.

            

    

    

    
      	6)  	
              Review
                all education and marketing materials at least once a year. The health
                plan shall provide the state agency with copies of materials and
                documentation verifying the health plan reviewed their education
                and
                marketing material.

            

    

    

    
      	7)  	
              Submit
                to the state agency, for prior written approval, all materials used
                by
                in-network providers to advise members of the health plans with which
                they
                have contracts. The health plan shall provide the following listing
                of
                what constitutes approved material to in-network
                providers.

            

    

    

    
      	·  	
              A
                list of all
                health plans with which they have
                contracts;

            

    

    
      	·  	
              A
                letter to previous fee-for-service recipients who may be eligible
                for MC+
                managed care, informing them of all
                health plan(s) with which the provider has
                contracted;

            

    

    
      	·  	
              A
                display of all
                contracted health plan logos in an equal
                fashion;

            

    

    
      	·  	
              A
                listing of all
                contracted health plan phone
                numbers;

            

    

    
      	·  	
              Access
                to all
                contracted health plan directories and member handbooks as a member
                resource but not for distribution; and

            

    

    
      	·  	
              Displaying
                enrollment helpline phone number.

            

    

    

    The
      in-network provider shall provide equal representation of all
      contracted health plans and shall not favor one health plan over another in
      displayed information.

    

    
      	8)  	
              Show
                the date the state agency approved the material in the lower right-hand
                corner of all materials.

            

    

    

    
      	9)  	
              Use
                mandatory education, marketing, and member notice language provided
                by the
                state agency. The state agency shall provide such language as it
                deems
                necessary. Any publicity given to the MC+ Managed Care Program or
                the MC+
                managed care benefits, including but not limited to: notices, pamphlets,
                press releases, research, reports, signs, and public notices prepared
                by
                or for the health plan shall be released only with prior written
                approval
                by the state agency.

            

    

    

    
      	10)  	
              Not
                use the state agency’s or the Department of Social Services’ name, logo,
                or other identifying marks on any of the materials produced or issued
                without the prior written approval of the state
                agency.

            

    

    

    
      	11)  	
              Not
                use any report, graph, chart, picture, or other document produced
                and
                included in whole or in part under the MC+ managed care contract
                which is
                subject to copyright or the subject of any application for copyright
                by or
                on behalf of the health plan.

            

    

    

    
      	12)  	
              Develop
                MC+ managed care marketing plans and materials that are accurate
                and shall
                not mislead, confuse, defraud, or deceive MC+ managed care eligibles,
                or
                otherwise violate Federal or State consumer protection laws or
                regulations. MC+ managed care benefits must be listed according to
                the
                current MC+ managed care contracts. The health plan may not verbally
                or in
                writing identify or portray covered benefits as enhanced, additional,
                or
                free.

            

    

    

    
      	13)  	
              Not
                practice door-to-door, face-to-face, telephonic, or other "cold call"
                marketing. The offerings of cash, prizes, other items for material
                gain,
                or other insurance products as an award for enrollment are prohibited.
                However, the health plan may offer additional health benefits to
                their
                members. If the health plan offers additional health benefits, the
                health
                plan must notify the state agency of these benefits no later than
                ten (10)
                calendar days prior to their offering and must notify the state agency
                no
                less than thirty (30) calendar days prior to discontinuing such
                benefits.

            

    

    

    Cold
      Call
      Marketing means any unsolicited personal contact by the health plan with a
      potential member for the purpose of marketing as defined in this paragraph.
      

    

    As
      a part of its commitment to member services and member satisfaction, Harmony
      provides additional benefits to its members. Harmony’s additional benefits were
      specifically designed for the Medicaid population. These services promote
      positive health choices, foster communication between members, providers, and
      the health plan, and improve member access to health information. Harmony
      features these services in new member packets, welcome calls, member
      newsletters, orientation with PCPs, and the provider newsletter. Harmony’s key
      additional services for members are as follows:

    

    Member
      Voice Mail

    

    Harmony
      provides free voice mail as an enhanced service for each family participating
      in
      the health plan. The voice mail program strives to reduce or eliminate the
      communication barrier that exists for many Medicaid members. Medicaid members
      frequently change addresses or have disconnected phone lines, which makes it
      difficult for plan outreach. Harmony’s free voice mail system provides a
      consistent telephone number for each Harmony member at which the Plan,
      physicians, pharmacists, and/or friends and family can leave messages for the
      family. The toll-free voice mail system number is accessible from any phone
      in
      the state, including pay phones, and is available 24 hours a day, seven days
      a
      week, 365 days a year. One of the primary benefits of the voice mail system
      is
      that it provides access to a number of important messages regarding a member’s
      health. Harmony uses the voice mail system for health education and outreach
      leaving targeted messages for different populations regarding appointments,
      reminders to get preventive care and general health information. In addition,
      messages from providers and case managers can be left in the voice mailbox
      for
      members. 

    

    Health
      Information Library

    

    Harmony
      provides members with access to a telephonic Health Information Library. Harmony
      members can call the toll-free member hotline at any time to access information
      on over 500 health-related topics, many of which are also available in Spanish.
      Harmony contracts with Primary Care Network to provide this service.

    

    Transportation

     

    Harmony
      provides free member-initiated transportation services to and from all medically
      necessary services, such as appointments, pharmacies and health education
      classes, with
      no prior authorization required.
      The transportation service supports member access to the health care delivery
      system and preventive care. Harmony contracts with Medical Transportation
      Management, Inc. to provide this valuable service to its
      members.

    

     

    Harmony
      NurseLink

    

    Harmony
      NurseLink provides a 24-hour service for members who are unsuccessful reaching
      their provider and who need assistance in seeking medical care after normal
      business hours. When a member calls Harmony after normal business hours, the
      member has the option to speak with someone immediately. These calls are
      forwarded to the NurseLink program operated by Primary Care Network. Members
      contacting this service speak with a registered nurse (a physician is available
      if needed) who is trained to handle urgent health-related calls, including
      emergency situations. This service provides members with 24-hour telephone-based
      information, clinical assessments, triage, health counseling, and referral
      services. Primary Care Network also serves members who require medical care
      when
      they are outside the service area by identifying an area provider who can render
      care until the member returns to the Plan service area. In addition, Primary
      Care Network provides physicians, pharmacies and Harmony members with a number
      to call after hours when there are questions concerning health services delivery
      that cannot wait until the next business day. Harmony’s NurseLink has
      translation services and TTY capability. 

    

    Harmony
      Hugs

    

    “Harmony
      Hugs”, a maternity (prenatal and postnatal) care program, was implemented in
      order to encourage members to seek prenatal care as early in their pregnancy
      as
      possible. Maternity risk screening and case management are initiated upon
      identification of a pregnant member.

    

    Enrollment
      in “Harmony Hugs” is voluntary. Upon enrollment in the Harmony Hugs program,
      members receive tee shirts and educational materials related to pregnancy,
      childbirth, and parenting skills. A Harmony case manager monitors and remains
      in
      contact with the member during pregnancy. The level of risk and the individual
      needs of the member determine the frequency of contact. Each telephone contact
      made by the case manager includes assessment and education information.
      Educational materials are distributed throughout the
      pregnancy.

    

    After
      delivery, the mother is sent a new baby welcome packet. The mother is urged
      to
      schedule post-partum and newborn well-baby exams. There are incentives, which
      include newborn care kits and gift certificates that are offered to members
      who
      remain compliant with prenatal care after enrolling in the Harmony Hugs
      program.

     

    Community
      Outreach Coordinator

    

    The
      community outreach coordinator provides customer assistance primarily in the
      area of outreach with a focus on improving the health status of Harmony members.
      This position was created to establish and maintain visibility and respond
      to
      needs within the community as it relates to Harmony Health Plan in each region.
      The coordinator provides early intervention with positive resolution of member
      treatment compliance issues through home visits with members identified by
      the
      health services department as candidates for outreach. The activities of the
      outreach coordinator address the social needs that impact a member’s ability to
      be compliant with a clinical plan of care. The coordinator facilitates referral
      to appropriate community-based agencies. 

    

    The
      coordinator is also instrumental in the coordination of the quarterly “Kids
      Club” birthday parties for Harmony’s young members. The birthday parties provide
      a comfortable atmosphere for health education as well as a celebration for
      members and their parents/guardians.

     

    Periodicity
      Letters

    

    Effective
      members are notified by mail of upcoming health screenings and preventive
      services that they should be receiving. Notices may include, but are not limited
      to, initial screening upon enrollment, ongoing age-specific health screenings,
      immunizations, mammograms, Pap smears, cholesterol screening (when values are
      abnormal), follow-up on acute cardiovascular events, diabetes management,
      hypertension management, and asthma management. 

    

    Member
      Newsletters

    

    The
      member newsletter is distributed quarterly and routinely includes articles
      that
      promote healthy lifestyles, define member benefits, and encourage appropriate
      use of the emergency room and visits to the PCP.

    

    Breathe-EZ
      - A Smoking Cessation Program

    

    The
      Breathe-EZ program utilizes techniques and guidelines developed by the American
      Lung Association to provide members with the encouragement and support needed
      to
      break the smoking habit. The Plan covers fees associated with a recognized
      smoking cessation program (i.e. Smoke Stoppers) or accredited hospital-based
      smoking cessation programs.

    

    
      	14)  	
              Provide
                notice to the state agency or have prior written approval from the
                state
                agency in certain situations to sponsor or participate in community
                activities, programs, or events.

            

    

    

    
      	·  	
              Community
                activities are defined for the purpose of this document as: An activity
                where people come together to learn about or question health care
                benefits, responsibilities, and procedures. These community activities
                require no
                notice to the state agency, except when held at provider sites. At
                community activities, the health plan shall only use materials approved
                by
                the state agency and must adhere to the ban on engaging in enrollment
                activities required herein.

            

    

    

    
      	·  	
              Community
                activities at provider sites require a seven (7) calendar day notice
                to
                the state agency prior to sponsoring or participating in an activity.
                Provider sites may include, but are not limited to pharmacies in
                discount
                or grocery stores if the pharmacies are in an MC+ managed care network,
                local public health agency, provider clinics, hospitals
                etc.

            

    

    

    
      	·  	
              The
                health plan may offer the availability of gifts no greater than $10
                in
                value, and only if such gifts are offered during any community activity
                (i.e. health fair). The nominal items must be offered to all individuals
                attending the community activity. The gifts must be directly and
                obviously
                health related or limited to printed materials, T-shirts, pens or
                pencils,
                caps, mugs, key chains, etc. All items must have prior written approval
                by
                the state agency and written proof of cost per unit must be provided
                by
                the health plan to the state agency prior to approval. Once an item
                is
                approved, it does not have to be re-approved for additional community
                activities. Advertising the availability of such gifts through mailings,
                TV or radio, posters, and other promotions or publicity is
                prohibited.

            

    

    

    
      	15)  	
              Not
                offer raffles or
                conduct lotteries. Door prizes may be offered within the parameters
                and
                limits specified for participation in community activities, programs,
                or
                events.

            

    

    

    
      	16)  	
              Request
                state agency prepared mandatory MC+ managed care materials from the
                state
                agency. The health plan and its subcontractors should make the general
                public aware of the MC+ program by providing any of the
                following:

            

    

    

    
      	·  	
              General
                MC+ eligibility information; or

            

    

    
      	·  	
              MC+
                applications to complete and mail. 

            

    

    

    
      	17)  	
              Not
                conduct or participate in health plan enrollment, disenrollment,
                transfer,
                or opt out activities. The health plan and the providers shall not
                influence a member’s enrollment. Prohibited activities
                include:

            

    

    

    
      	·  	
              Requiring
                or encouraging the member to apply for an assistance category not
                included
                in MC+ managed care;

            

    

    

    
      	·  	
              Requiring
                or encouraging the member and/or guardian to use the opt out as an
                option
                in lieu of delivering health plan
                benefits;

            

    

    

    
      	·  	
              Mailing
                or faxing health plan enrollment
                forms;

            

    

    

    
      	·  	
              Aiding
                the member in filling out health plan enrollment
                forms;

            

    

    

    
      	·  	
              Photocopying
                blank health plan enrollment forms for potential
                members;

            

    

    

    
      	·  	
              Distributing
                blank health plan enrollment forms;

            

    

    

    
      	·  	
              Participating
                in three way calls to the MC+ managed care enrollment
                helpline;

            

    

    

    
      	·  	
              Suggesting a
                member transfer to another health plan;
                or

            

    

    

    
      	·  	
              Other
                activities in which the health plan, its representatives, or in-network
                providers are engaged in activities to enroll a member in a particular
                health plan or in any way assisting a member to enroll in a health
                plan
                (their own or another).

            

    

    

    
      	18)  	
              Advise
                the health plan’s subcontractors of these marketing guidelines and ensure
                that subcontractors adhere to them. No subcontract shall operate
                to
                relieve the health plan of its obligations. The health plan shall
                have
                written procedures to ensure subcontractor notification and compliance
                with these marketing guidelines.

            

    

    

    
      	19)  	
              Use
                pre-approved MC+ managed care information and materials for presentations
                or interviews with print and electronic
                media.

            

    

    

    
      	20)  	
              Not
                use testimonial materials and/or
                celebrity endorsements.

            

    

    

    
      	21)  	
              Insert
                new language in the educational and marketing materials and substitute
                in
                a timely manner, as outlined by the state agency, any changes in
                Federal
                or State law or regulation, as amended, as the need
                arises.

            

    

    

    
      	22)  	
              Make
                an effort to ensure that presentations shall be available to maximize
                consumer access to information, including presentation after normal
                work
                hours, and at sites other than the Family Support Division offices,
                such
                as WIC sites, Head Start centers, health fairs,
                etc.

            

    

    

    
      	23)  	
              Make
                member education available on an ongoing basis to provide guidance
                on how
                to use a health plan, and how to assert certain rights with their
                health
                plan, if necessary.

            

    

    

    
      	24)  	
              Market
                to the entire service area

            

    

    

    
      	25)  	
              All
                marketing and educational material shall maintain a member’s right to
                confidentiality. In particular, post cards must be folded to protect
                the
                confidentiality of the member.

            

    

    

    
      	26)  	
              Not
                develop marketing materials that contain any assertion or statement
                (whether written or oral) that:

            

    

    

    
      	·  	
              The
                recipient must enroll with the health plan in order to obtain benefits
                or
                in order not to lose benefits.

            

    

    
      	·  	
              The
                health plan is endorsed by CMS, the Federal or State government or
                similar
                entity.

            

    

    

    Harmony
      Health Plan understands and will adhere to the MC+ Managed Care Marketing
      Guideline requirements set forth in RFP B3Z06118 paragraph 2.6.1 and
      subparagraph a. Harmony has added the marketing guidelines to the Provider
      Manual. These guidelines will be part of the ongoing education of providers
      and
      their staff. 

    

    
      	2.6.2  	
              Health
                Plan Enrollment
                Procedures:

            

    

    

    
      	a.  	
              The
                state agency reserves the right to suspend or limit enrollment into
                a
                health plan. In the event the health plan’s enrollment reaches sixty-five
                (65) percent of the total MC+ managed care enrollment in the region,
                the
                health plan shall not be offered as a choice for enrollment nor shall
                the
                health plan receive members through the automatic assignment algorithm.
                However, the health plan may receive new members as a result of newborn
                enrollments, reassignments when a member loses and regains MC+ managed
                care eligibility within a sixty (60) day period, other family or
                case
                members are members of the health plan, for the member’s continuity of
                care, or for just cause determined by the state agency. The state
                agency’s
                evaluation of a health plan’s enrollment market share shall take place on
                a calendar quarter.

            

    

    

    
      	b.  	
              The
                state agency shall conduct enrollment activities for MC+ managed
                care
                eligibles. The health plan or its subcontractors shall not conduct
                or
                participate in eligibility or enrollment
                activities.

            

    

    

    
      	c.  	
              The
                health plan shall have written policies and procedures for enrolling
                these
                members within five (5) business days after receiving notification
                of the
                member's anticipated enrollment date from the state agency (e.g.,
                if the
                health plan is informed of a new member on a Wednesday, it must contact
                the member by the following
                Tuesday).

            

    

    

    
      	d.  	
              The
                health plan shall enroll any MC+ managed care eligible who selects
                the
                health plan or is assigned with the health plan. The only exceptions
                shall
                be if:

            

    

    

    
      	1)  	
              The
                health plan's specified enrollment limit has been
                reached.

            

    

    

    
      	2)  	
              The
                member was previously disenrolled from the health plan as the result
                of a
                request for disenrollment by the health plan, as allowed
                herein.

            

    

    

    
      	e.  	
              Enrollment
                of Program Newborns:
                The health plan shall have written policies and procedures for enrolling
                the newborn children of members effective to the date of birth. Newborns
                of members enrolled at the time of the child's birth shall be
                automatically enrolled with the mother's health plan. The health
                plan
                shall have a procedure in place to refer newborns to the Family Support
                Division to initiate eligibility determinations. A mother of a newborn
                may
                choose a different health plan for her child; unless a different
                health
                plan is requested, the child shall remain with the mother's health
                plan.

            

    

    

    
      	1)  	
              The
                mother's health plan shall be responsible for all medically necessary
                services provided under the comprehensive benefit package to the
                newborn
                child of an enrolled mother. The child's date of birth shall be counted
                as
                day one (1). The health plan shall provide services to the child
                until the
                child is disenrolled from the health plan. When the newborn is assigned
                a
                departmental client number (DCN), the health plan shall receive capitation
                payment for the month of birth and for all subsequent months the
                child
                remains enrolled with the health
                plan.

            

    

    

    
      	2)  	
              In
                the case of an administrative lag in enrolling the newborn and costs
                are
                incurred during that period, the health plan shall hold the member
                harmless for those costs. The health plan shall be responsible for
                the
                cost of the newborn including medical services provided prior to
                completion of the State enrollment
                process.

            

    

    

    
      	f.  	
              Changes
                in Status:
                The health plan shall encourage its membership to report to the Family
                Support Division any changes in the status of families or members,
                including changes in family size, income, insurance coverage, and
                residence.

            

    

    

    
      	g.  	
              Enrollment
                and Disenrollment Updates: Every
                business day, the state agency shall make available, via electronic
                media,
                updates on members newly enrolled into the health plan, or newly
                disenrolled. The health plan shall have written policies and procedures
                for receiving these updates and incorporating them into the health
                plan
                and health care service subcontractors’ management information system each
                day.

            

    

    

    
      	h.  	
              Weekly
                Reconciliation:
                On
                a weekly basis, the state agency shall make available, via electronic
                media, a listing of current members. The health plan shall reconcile
                this
                membership list against the health plan internal records within thirty
                (30) business days of receipt and shall notify the state agency of
                any
                discrepancies.

            

    

    

    
      	i.  	
              Services
                for New Members:
                The health plan shall make available the full scope of benefits to
                which a
                member is entitled immediately upon his or her
                enrollment.

            

    

    

    
      	j.  	
              New
                Member Orientation:
                The health plan shall have written policies and procedures for orienting
                new members to their benefits; the role of the primary care provider;
                how
                to utilize services; what to do in an emergent or urgent medical
                situation; how to file a grievance or appeal; and how to report suspected
                fraud and abuse.

            

    

    

    
      	1)  	
              Member
                Responsibilities:
                The health plan shall have written policies that address the members'
                responsibilities for cooperating with providers. These member
                responsibility policies must be supplied in writing to all providers
                and
                members. These written policies should address the members'
                responsibilities for:

            

    

    

    
      	·  	
              Providing,
                to the extent possible, information needed by providers in caring
                for the
                member.

            

    

    

    
      	·  	
              Contacting
                their primary care provider as their first point of contact when
                needing
                medical care.

            

    

    

    
      	·  	
              Following
                appointment scheduling processes.

            

    

    

    
      	·  	
              Following
                instructions and guidelines given by
                providers.

            

    

    

    
      	2)  	
              Member
                Rights: The
                health plan shall have written policies regarding member rights as
                specified below:

            

    

    

    
      	·  	
              General
                Rule. Each
                health plan must comply with any applicable Federal and State laws that
                pertain to member rights and ensure that its staff and affiliated
                providers take those rights into account when furnishing services
                to
                members.

            

    

    

    
      	·  	
              Dignity
                and privacy.
                Each member is guaranteed the right to be treated with respect and
                with
                due consideration for his or her dignity and
                privacy.

            

    

    

    
      	·  	
              Receive
                information on available treatment options.
                Each member is guaranteed the right to receive information on available
                treatment options and alternatives, presented in a manner appropriate
                to
                the member’s condition and ability to
                understand.

            

    

    

    
      	·  	
              Participate
                in decisions.
                Each member is guaranteed the right to participate in decisions regarding
                his or her health care, including the right to refuse
                treatment.

            

    

    

    
      	·  	
              Free
                from restraint or seclusion.
                Each member is guaranteed the right to be free from any form of restraint
                or seclusion used as a means of coercion, discipline, convenience,
                or
                retaliation.

            

    

    

    
      	·  	
              Copy
                of medical records.
                Each member is guaranteed the right to request and receive a copy
                of his
                or her medical records, and to request that they be amended or corrected,
                as specified in 45 CFR part 164.

            

    

    

    
      	·  	
              Free
                exercise of rights.
                Each member is free to exercise his or her rights, and that the exercise
                of those rights does not adversely affect the way the health plan
                and its
                providers or the state agency treat the
                member.

            

    

    

    
      	k.  	
              Assignment
                of Primary Care Providers:
                The health plan shall have written policies and procedures for assigning
                each of the health plan’s members to a primary care provider. The process
                must include at least the following
                features:

            

    

    

    
      	1)  	
              The
                health plan shall contact the member within five (5) business days
                from
                the date of the state agency's notification to the health plan of
                the
                member's anticipated enrollment date. To the extent provider capacity
                exists, the health plan shall offer freedom of choice to members
                in making
                a primary care provider selection.

            

    

    

    At
      the
      time of the state agency’s notification to the health plan, the health plan may
      assign a primary care provider taking into consideration factors such as current
      provider relationships, language needs, (to the extent they are known), and
      area
      of residence. When contacting the member, the health plan shall provide the
      member with the primary care provider's name, location, and telephone number.
      When contacting the member, the health plan shall provide options for selecting
      a primary care provider other than the primary care provider assigned to the
      member. The health plan shall inform the member he/she has fifteen (15) calendar
      days to choose another primary care provider if they do not approve of the
      primary care provider assigned to them, and if they have not notified the health
      plan of their preferred primary care provider within that time frame, the member
      will remain with the primary care provider previously assigned to the
      member.

    

    
      	2)  	
              Prior
                to becoming effective with the health plan, if a member does not
                select a
                primary care provider or the health plan has not already assigned
                a
                primary care provider to the member at the time of notification from
                the
                state agency of the member's anticipated enrollment date, the health
                plan
                shall make an automatic assignment, taking into consideration such
                known
                factors as current provider relationships, language needs (to the
                extent
                they are known), and area of residence. The health plan shall then
                notify
                the member in writing of his or her primary care provider's name,
                location, and office telephone number. The member must have a primary
                care
                provider assigned by the time the member is effective with the health
                plan. If circumstances are such that the member does not have a primary
                care provider assigned on the effective date with the health plan,
                the
                health plan shall not deny services or payment of any service. The
                health
                plan shall submit to the state agency the methodology utilized by
                the
                health plan to assign primary care providers to
                members.

            

    

    

    
      	3)  	
              Members
                with disabling conditions or chronic illnesses may request that their
                primary care providers be specialists, such as a psychiatrist, oncologist,
                obstetrician, gynecologist, or other such specialist. The health
                plan must
                have procedures for ensuring access to needed services for those
                members
                or the request shall be granted. The specialist must accept the member
                as
                a primary care patient and accept the responsibility of a primary
                care
                provider as specified herein. The health plan must communicate its
                decision to the member within ten (10) calendar days of request.
                The
                adequacy of these policies shall be reviewed by the state
                agency.

            

    

    

    
      	4)  	
              The
                health plan shall have written policies and procedures for notifying
                primary care providers of their assigned member prior to the member's
                effective date with the primary care
                provider.

            

    

    

    
      	l.  	
              Changing
                Primary Care Providers:
                The health plan shall have written policies and procedures for allowing
                members to select or be assigned to a new primary care provider within
                the
                health plan when such a change is mutually agreed to by the health
                plan
                and member. The health plan shall allow members at least two such
                changes
                per year, and shall inform members of the process for initiating
                these
                changes. However, children in COA 4 may change primary care providers
                at
                will. Possible reasons for a member to change primary care providers
                include, but are not limited to:

            

    

    

    
      	1)  	
              Accessibility
                - transportation problems, provider office hours, does not return
                phone
                calls, waiting times.

            

    

    

    
      	2)  	
              Acceptability
                - sees too many doctors, uncomfortable with surroundings or location,
                provider or staff attitudes, lack of courtesy, following a member’s
                initial visit to the primary care
                provider.

            

    

    

    
      	3)  	
              Quality
                - treatment (medical), referral related, does not explain treatment
                plan/diagnosis. If provider problem, may request primary care provider
                changes and second opinion.

            

    

    

    
      	4)  	
              Enrollment
                - primary care provider with whom the member has an established
                patient/provider relationship no longer participates in the health
                plan.
                In cases where the primary care provider no longer participates,
                the
                health plan shall allow members to select another primary care provider
                or
                make a re-assignment within fifteen (15) calendar days of the termination
                effective date.

            

    

    

    
      	5)  	
              An
                act of cultural insensitivity that negatively impacts the member's
                ability
                to obtain care.

            

    

    

    
      	6)  	
              A
                primary care provider change is ordered as part of the resolution
                to the
                grievance and appeal process. A member’s right to request a change in a
                primary care provider through the grievance and appeal process or
                other
                means shall not be restricted.

            

    

    

    
      	m.  	
              Identification
                Cards:
                The state agency shall issue a plastic, magnetic strip identification
                card
                to all Missouri MC+ eligibles. This card is not proof of eligibility,
                but
                to be used as a key for accessing the State's electronic eligibility
                verification systems by Medicaid enrolled providers. These systems
                shall
                contain the most current information available to the state agency,
                including specific information regarding health plan enrollment.
                There
                will be no health plan specific information printed on the card.
                In
                addition to the state agency issued card, the health plan should
                issue a
                membership card that contains information more specific to the health
                plan. The health plan issued membership card must be issued to the
                member
                prior to the member's effective date of coverage with the health
                plan.
                Upon selection or assignment of a health plan, the member’s effective date
                shall be 15 calendar days in the future, thereby allowing the health
                plan
                to send the appropriate enrollment materials, such as the identification
                card, to the member prior to the effective date. Exceptions apply
                to this
                policy for newborns and emergency enrollments. The state agency recognizes
                those exceptions and such enrollment materials may be produced as
                expeditiously as possible, but no later than 15 calendar days from
                the
                notification of the enrollment. At a minimum, the health plan issued
                membership card must contain the member’s name, identification number,
                primary care provider name and telephone number, instructions for
                emergencies, and other relevant toll free lines for access such as
                mental
                health, dental, pharmacy, and nurse advice
                lines.

            

    

    

    
      	n.  	
              Member
                Handbook: The
                health plan shall mail a member handbook, or other written materials
                with
                information on how to access services, to all members within ten
                (10)
                business days of being notified of their future enrollment with the
                health
                plan. When there are program changes, the health plan shall notify
                the
                affected members at least thirty (30) calendar days before implementation
                of such change. On an annual basis, the health plan shall review
                the
                member handbook and shall document that such review
                occurred.

            

    

    

    
      	1)  	
              The
                member handbook must be written at no higher than a sixth grade level.
                Suggested reference material to determine whether this requirement
                is
                being met are:

            

    

    

    
      	·  	
              Fry
                Readability Index

            

    

    

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

            

    

    

    
      	·  	
              Gunning
                FOG Index

            

    

    

    
      	·  	
              McLaughlin
                SMOG Index

            

    

    

    
      	·  	
              The
                Flesch-Kincaid Index or other word processing software approved by
                the
                state agency.

            

    

    

    
      	2)  	
              At
                a minimum, the member handbook shall include the information and
                items
                listed below. The health plan may include some of the following
                information as inserts to the member handbook. The health plan shall
                include certain passages and language provided by the state agency
                in the
                member handbook. The health plan shall comply with all changes regarding
                member handbook content specified by the state agency in a timely
                manner
                as defined by the state agency.

            

    

    

    
      	·  	
              Table
                of contents.

            

    

    

    
      	·  	
              Information
                about choosing and changing primary care providers, including notice
                of
                how to determine whether a participating provider is accepting new
                patients.

            

    

    

    
      	·  	
              Information
                about what to do when family size
                changes.

            

    

    

    
      	·  	
              Appointment
                procedures.

            

    

    

    
      	·  	
              A
                description of all available health plan services and an explanation
                of
                any service limitations or exclusions from coverage and a notice
                stating
                that the health plan shall be liable only for those services authorized
                by
                the health plan.

            

    

    

    
      	·  	
              A
                description of all available services outside the comprehensive benefit
                package. Such information shall include information on where and
                how
                members may access benefits not available under the comprehensive
                benefit
                package.

            

    

    

    
      	·  	
              The
                definition of medical necessity used in determining whether benefits
                will
                be covered.

            

    

    

    
      	·  	
              A
                description of all prior authorization or other requirements for
                treatments and services.

            

    

    

    
      	·  	
              A
                description of utilization review policies and procedures used by
                the
                health plan.

            

    

    

    
      	·  	
              An
                explanation of a member's financial responsibility for payment when
                services are provided by an out-of-network provider or by any provider
                without required authorization or when a procedure, treatment, or
                service
                is not covered by MC+ managed care.

            

    

    

    
      	·  	
              Notice
                that a member may obtain an out-of network provider when the health
                plan
                does not have an in-network provider with appropriate training and
                experience to meet the particular health care needs of the member
                and the
                procedure by which the member can obtain such
                referral.

            

    

    

    
      	·  	
              Notice
                that a member with a condition which requires ongoing care from a
                specialist may request a standing referral to such a specialist and
                the
                procedure for requesting and obtaining such a standing
                referral.

            

    

    

    
      	·  	
              Notice
                that a member with a life-threatening condition or disease or a
                degenerative and disabling condition or disease, either of which
                requires
                specialized medical care over a prolonged period of time, may request
                a
                specialist responsible for providing or coordinating the member's
                medical
                care and the procedure for requesting and obtaining such a
                specialist.

            

    

    

    
      	·  	
              Notice
                that a member with a life-threatening condition or disease or a
                degenerative and disabling condition or disease, either of which
                requires
                specialized medical care over a prolonged period of time, may request
                access to a specialty care center and the procedure by which such
                access
                may be obtained.

            

    

    

    
      	·  	
              A
                description of the mechanisms by which members may participate in
                the
                development of the policies of the health
                plan.

            

    

    

    
      	·  	
              Notice
                of all appropriate mailing addresses and telephone numbers to be
                utilized
                by members seeking information or
                authorization.

            

    

    

    
      	·  	
              Procedures
                for disenrollment, including an explanation of the member's right
                to
                disenroll with and without cause.

            

    

    

    
      	·  	
              How
                to contact member services and a description of its
                function.

            

    

    

    
      	·  	
              Information
                on grievance, appeal, and fair hearing procedures and timeframes.
                Such
                information includes:

            

    

    

    
      	a)  	
              The
                right to file grievances and
                appeals.

            

    

    
      	b)  	
              The
                requirement and timeframes for filing a grievance or
                appeal.

            

    

    
      	c)  	
              The
                availability of assistance in the filing
                process.

            

    

    
      	d)  	
              The
                toll-free numbers that the member can use to file a grievance or
                an appeal
                by phone.

            

    

    
      	e)  	
              The
                procedures for exercising the rights to appeal or request a State
                fair
                hearing.

            

    

    
      	f)  	
              That
                the member may represent himself or use legal counsel, a relative,
                a
                friend, or other spokesperson.

            

    

    
      	g)  	
              Must
                explain the specific regulations that support, or the change in Federal
                or
                State law that requires the action.

            

    

    
      	h)  	
              The
                fact that, when requested by the member
                -

            

    

    
      	·  	
              Benefits
                will continue if the member files an appeal or a request for State
                fair
                hearing within the timeframes specified for filing;
                and

            

    

    
      	·  	
              The
                member may be required to pay the cost of services furnished while
                the
                appeal is pending, if the final decision is adverse to the
                member.

            

    

    
      	i)  	
              The
                member’s right to request a State fair hearing, or in cases of an action
                based on change in law, the circumstances under which a hearing will
                be
                granted.

            

    

    
      	·  	
              A
                member may request a State fair hearing within 90 calendar days from
                the
                health plan’s notice of action.

            

    

    
      	·  	
              The
                state agency must reach its decisions within the specified
                timeframes:

            

    

    

    
      	1)  	
              Standard
                resolution: within 90 calendar days of the date the member filed
                the
                appeal with the health plan if the member filed initially with the
                health
                plan (excluding the days the enrollee took to subsequently file for
                a
                State fair hearing) or the date the member filed for direct access
                to a
                State fair hearing.

            

    

    
      	2)  	
              Expedited
                resolution (if the appeal was heard first through the health plan
                appeal
                process): within 3 working days from the state agency’s receipt of a
                hearing request for a denial of a service
                that:

            

    

    

    
      	·  	
              Meets
                the criteria for an expedited appeal process but was not resolved
                using
                the health plan’s expedited appeal timeframes,
                or

            

    

    
      	·  	
              Was
                resolved wholly or partially adversely to the member using the health
                plan’s expedited appeal timeframes.

            

    

    

    
      	3)  	
              Expedited
                resolution (if the appeal was made directly to the State Fair Hearing
                process without accessing the health plan appeal process): within
                3
                working days from the state agency’s receipt of a hearing request for a
                denial of a service that meets the criteria for an expedited appeal
                process.

            

    

    

    
      	j.  	
              Any
                appeal rights that the state chooses to make available to providers
                to
                challenge the failure of the organization to cover a
                service.

            

    

    

    
      	·  	
              How
                to report suspected fraud and abuse
                activities.

            

    

    

    
      	·  	
              Pharmacy
                dispensing fee requirements (if applicable): The health plan must
                include
                a statement that care shall not be denied due to lack of payment
                of
                pharmacy dispensing fee
                requirements.

            

    

    

    
      	·  	
              Provider
                network listing including a list of the names, specialty, telephone
                numbers, service site address of all providers available for selection,
                and in the case of physicians, board certification. The provider
                network
                listing can be a separate document apart from the member
                handbook.

            

    

    

    
      	·  	
              The
                extent to which, and how, after-hours and emergency coverage are
                provided,
                including the following: (a) What constitutes an emergency medical
                condition, emergency services, and post-stabilization services; (b)
                The
                fact that prior authorization is not required for emergency services;
                (c)
                The process and procedures for obtaining emergency services, including
                use
                of the 911-telephone system or its local equivalent; (d) The locations
                of
                any emergency settings and other locations at which providers and
                hospitals furnish emergency services and post-stabilization services
                covered herein; (e) The fact that the member has a right to use any
                hospital or other setting for emergency care; and (f) The
                post-stabilization care services rules specified
                herein.

            

    

    

    
      	·  	
              How
                to obtain emergency transportation and non-emergency medically necessary
                transportation.

            

    

    

    
      	·  	
              EPSDT
                services including immunization and lead guidelines designated by
                the
                state agency.

            

    

    

    
      	·  	
              Maternity,
                family planning, and sexually transmitted diseases
                services.

            

    

    

    
      	·  	
              Mental
                health and substance abuse services, including information on how
                to
                obtain such services, the rights the member has to request such services,
                and how to access services when in crisis, including the toll free
                number
                to be used to access such services.

            

    

    

    
      	·  	
              How
                to obtain services when out of the member’s geographic region and for
                after-hours coverage.

            

    

    

    
      	·  	
              Out-of-county
                and out-of-state moves.

            

    

    

    
      	·  	
              Statement
                that the health plan shall protect its members in the event of insolvency.
                The health plan shall not hold its members liable for any of the
                following: 

            

    

    

    
      	Ø  	
              The
                debts of the health plan in the case of health plan
                insolvency;

            

    

    

    
      	Ø  	
              Services
                provided to a member in the event the health plan failed to receive
                payment from the state agency for such
                service;

            

    

    

    
      	Ø  	
              Services
                provided to a member in the event a health care provider with a
                contractual referral or other type arrangement with the health plan
                fails
                to receive payment from the state agency or the health plan for such
                services; or

            

    

    

    
      	Ø  	
              Payments
                to a provider that furnishes covered services under a contractual
                referral
                or other type arrangement with the health plan in excess of the amount
                that would be owed by the member if the health plan had directly
                provided
                the services.

            

    

    

    
      	·  	
              Inform
                the member that if he or she has a worker's compensation claim, or
                a
                pending personal injury or medical malpractice law suit, or has been
                involved in an auto accident, to immediately contact the health
                plan.

            

    

    

    
      	·  	
              Inform
                the member that if he or she has another health insurance policy,
                all
                prepayment requirements must be met as specified by the other health
                insurance plan. The member must notify the health plan of any changes
                to
                their other health insurance policy. The member can contact the health
                plan with any questions.

            

    

    

    
      	·  	
              Inform
                the member of the Health Insurance Premium Payment program which
                pays for
                health insurance for members when it is determined cost
                effective.

            

    

    

    
      	·  	
              Contributions
                the member can make towards his or her own health, appropriate and
                inappropriate behavior, and any other information deemed essential
                by the
                health plan or the state agency including the member’s rights and
                responsibilities.

            

    

    

    
      	·  	
              Inform
                members that multilingual interpreters will be offered when needed
                and
                written information is available in prevalent languages and how to
                access
                those services.

            

    

    

    
      	·  	
              Inform
                the member of the procedures that will be utilized to notify members
                affected by termination or change in benefits, services, or service
                delivery office/site.

            

    

    

    
      	·  	
              Inform
                the member that the health plan shall provide information on the
                health
                plan’s physician incentive plan to any member upon request. Enrollment
                materials/member handbooks should annually disclose to members their
                right
                to adequate and timely information related to physician
                incentives.

            

    

    

    
      	·  	
              With
                respect to advance directives, inform the member of the
                following:

            

    

    

    
      	a)  	
              Their
                rights under the law of the state.

            

    

    
      	b)  	
              The
                health plan’s policies respecting the implementation of those rights,
                including a statement of any limitation regarding the implementation
                of
                advance directives as a matter of
                conscience.

            

    

    
      	c)  	
              The
                health plan must inform members that complaints concerning noncompliance
                with the advance directive requirements may be filed with the State
                survey
                and certification agency.

            

    

    

    
      	·  	
              Additional
                information that is available upon request, including the
                following:

            

    

    

    
      	a)  	
              Information
                on the structure and operation of the MC+ health
                plan.

            

    

    

    
      	·  	
              Inform
                the member how to obtain one free copy of his or her medical records
                annually.

            

    

    

    
      	·  	
              Inform
                the member how to request and obtain an Explanation of Benefits (EOB).
                 

            

    

    

    
      	o.  	
              The
                health plan shall submit the member handbook to the state agency
                for
                approval prior to distribution to members. The health plan shall
                make
                modifications in member handbook language if ordered by the state
                agency
                so as to comply with the member handbook
                requirements.

            

    

    

    
      	p.  	
              The
                member must receive written notification of changes in health plan
                operations that affect them at least thirty (30) calendar days before
                the
                intended effective date of the change unless otherwise noted. Examples
                of
                such changes are as follows:

            

    

    

    
      	1)  	
              Network
                changes such as a new Pharmacy Benefit Manager, mental health
                subcontractor, or other major subcontractor. Notification is required
                to
                all members.

            

    

    
      	2)  	
              Primary
                care provider or other provider seen on a regular basis leaves the
                network. The health plan shall provide written notice to the affected
                members within 15 calendar days after receipt or issuance of the
                termination notice.

            

    

    
      	3)  	
              Comprehensive
                Benefit Package changes from what is explained in the member handbook.
                Notification is required to all
                members.

            

    

    
      	4)  	
              Utilization
                Management Procedure changes from what is explained in the member
                handbook. Notification is required to all
                members.

            

    

    
      	5)  	
              Prior
                Authorization Procedure changes from what is explained in the member
                handbook. Notification is required to all
                members.

            

    

    
      	6)  	
              Advance
                directive policy changes as a result of changes in State
                law.

            

    

    

    
      	q.  	
              All
                written member notifications must be prior approved by the state
                agency
                and written at no higher than a sixth grade level. The health plan
                shall
                include certain passages and language provided to the health plan
                by the
                state agency in the member notification. The health plan shall comply
                with
                all changes regarding member notification content specified by the
                state
                agency in a timely manner as defined by the state
                agency.

            

    

    

    
      	r.  	
              Transferring
                Members Between Health Plans:
                It may be necessary to transfer a member between health plans for
                a
                variety of reasons. The health plan shall have written policies and
                procedures for transferring relevant member information, including
                medical
                records and other pertinent materials, to or from another health
                plan.
                Upon request, a copy of the member's medical records and supporting
                documentation must accompany disenrollment and transfer requests
                from the
                health plan. The state agency shall monitor, and approve or disapprove
                all
                transfer requests for just cause, within sixty (60) calendar days
                subject
                to medical record review. Possible reasons for a member to request
                a
                transfer include, but are not limited
                to:

            

    

    

    
      	·  	
              Member
                requests health plan transfer during open
                enrollment.

            

    

    

    
      	·  	
              Member
                request health plan transfer during the first 90 days enrolled in
                the
                health plan.

            

    

    

    
      	·  	
              Transfer
                is the resolution to a grievance or
                appeal.

            

    

    

    
      	·  	
              Enrollment
                - primary care provider or specialist with whom the member has an
                established patient/provider relationship does not participate in
                the
                health plan but does participate in another health
                plan.

            

    

    

    
      	·  	
              The
                member is pregnant and her primary care provider or obstetrician
                does not
                participate in the health plan but does participate in another health
                plan.

            

    

    

    
      	·  	
              The
                member is a newborn and the primary care provider or pediatrician
                selected
                by the mother does not participate in the health plan but does in
                another
                health plan.

            

    

    

    
      	·  	
              Transfer
                to another health plan is necessary to ensure continuity of
                care.

            

    

    

    
      	·  	
              An
                act of cultural insensitivity that negatively impacts the member's
                ability
                to obtain care and cannot be resolved by health
                plan.

            

    

    

    
      	·  	
              Other
                reasons, including but not limited to, poor quality of care, lack
                of
                access to services covered under the contract, or lack of access
                to
                providers experienced in dealing with the member’s health care
                needs.

            

    

    

    
      	1)  	
              Children
                in COA 4 shall be allowed automatic and unlimited changes in health
                plan
                choice as often as circumstances necessitate. Foster parents will
                normally
                have the decision making responsibility for which health plan shall
                serve
                the foster child residing with them; however, there will be situations
                where the Social Service worker or the courts shall select the health
                plan
                for a child in State custody or foster care
                placement.

            

    

    

    
      	s.  	
              Member
                Disenrollment:

            

    

    

    
      	1)  	
              The
                state agency has sole authority for disenrolling members from the
                health
                plan. The health plan may request disenrollment of members from health
                plan providers, subject to the conditions described
                below:

            

    

    

    
      	·  	
              A
                persistent refusal of the member to follow prescribed treatments
                or comply
                with health plan requirements that are consistent with federal and
                state
                laws and regulations, as amended.

            

    

    

    
      	·  	
              Consistently
                missed appointments without prior notification to the
                provider.

            

    

    

    
      	·  	
              Fraudulent
                misuse of the MC+ managed care program, or abusive or threatening
                conduct.

            

    

    

    
      	·  	
              Request
                of a home birth service.

            

    

    

    
      	2)  	
              The
                health plan must not initiate disenrollment because of a medical
                diagnosis
                or the health status of a member. The health plan shall not request
                disenrollment because of the member’s attempt to exercise his or her
                rights under the grievance system. The health plan shall not request
                disenrollment because of pre-existing medical conditions or high
                cost
                medical bills or an anticipated need for health care. The health
                plan
                shall not request a disenrollment due to behaviors resulting from
                a
                medical or mental illness/disorder.

            

    

    

    
      	3)  	
              Prior
                to requesting a disenrollment or transfer of a member, the health
                plan
                shall document at least three interventions over a period of 90 calendar
                days which occurred through treatment, case management, and care
                coordination to resolve any difficulty leading to the request, unless
                the
                member has demonstrated abusive or threatening behavior in which
                case only
                one attempt is required. The health plan shall cite at least one
                of the
                above examples of good cause before requesting that the state agency
                disenroll that member. If the health plan intends to proceed with
                disenrollment during the ninety (90) calendar day period, the health
                plan
                must give a notice citing the appropriate reason to both the member
                and
                the state agency at least 30 calendar days before the end of the
                ninety
                (90) calendar day period. The health plan must document all notifications
                regarding requests for
                disenrollment.

            

    

    

    
      	·  	
              Members
                shall have the right to challenge a health plan initiated disenrollment
                to
                both the state agency and the health plan through the appeal process
                within ninety (90) calendar days of the health plan's request to
                the state
                agency for disenrollment of the member. When a member files an appeal,
                the
                process must be completed prior to the health plan and the state
                agency
                continuing disenrollment
                procedures.

            

    

    

    
      	·  	
              Within
                fifteen (15) working days of the final notification (after no appeal
                or a
                final hearing decision), members shall be enrolled in another health
                plan
                or transferred to another provider.

            

    

    

    
      	4)  	
              If
                the health plan recommends disenrollment or transfers for reasons
                other
                than those stated above, the State shall consider the health plan
                to have
                breached the provisions and requirements of the
                contract.

            

    

    

    
      	t.  	
              Reasons
                for Disenrollment:
                The state agency may disenroll members from a health plan for any
                of the
                following reasons:

            

    

    

    
      	1)  	
              Selection
                of another health plan during open enrollment, the first 90 calendar
                days
                of enrollment, or for just cause.

            

    

    

    
      	2)  	
              Change
                of residence that places the member outside of the health plan's
                service
                area.

            

    

    

    
      	3)  	
              To
                implement the decision of a hearing officer in a grievance proceeding
                by
                the member against the health plan, or by the health plan against
                the
                member.

            

    

    

    
      	4)  	
              Loss
                of eligibility for either Medicaid or MC+ managed
                care.

            

    

     

    Paragraph
      2.6.2 t. 5. inserted by Amendment #001

     

    
      	
              5)  

            	
              Member
                exercises choice to voluntarily disenroll as specified herein under
                Missouri MC+ Managed Care Program eligibility groups. This choice
                can be
                referred to as opt out. 

            

    

    

    
      	u.  	
              Disenrollment
                Effective Dates:
                Member disenrollments outside of the open enrollment process shall
                become
                effective on the date specified by the state agency. The health plan
                shall
                have written policies and procedures for complying with state agency
                disenrollment orders.

            

    

     

    Paragraph
      2.6.2 v. revised by Amendment #001

     

    
      	v.  	
              Hospitalization
                at the Time of Enrollment or Disenrollment:
                With the exception of newborns, the health plan shall not assume
                financial
                responsibility for members who are hospitalized in an acute setting
                on the
                effective date of coverage until an appropriate acute inpatient hospital
                discharge. If the member is in the Medicaid fee-for-service program
                at the
                time of acute inpatient hospitalization on the effective date of
                coverage,
                the member shall remain in the fee-for-service program until an
                appropriate acute inpatient hospital discharge. Members, including
                newborn
                members, who are in another health plan at the time of acute inpatient
                hospitalization on the effective date of coverage, shall remain with
                that
                health plan until an appropriate acute inpatient hospital discharge.
                Members, including newborn members, who are hospitalized in an acute
                setting shall not be disenrolled from a health plan until an appropriate
                acute inpatient hospital discharge, unless the member is no longer
                Medicaid or MC+ managed care eligible or opts out.
                

            

    

    

    For
      the
      purpose of a member moving from one health plan to another health plan, in
      addition to acute inpatient hospitalizations, admissions to facilities that
      provide a lower level of care in lieu of an acute inpatient admission may be
      considered as an acute inpatient hospitalization for purposes of this section.
      The state agency reserves the right to determine if such an admission qualifies
      as an acute inpatient hospitalization. Only acute inpatient hospitalization
      shall apply when a new member moves from the Medicaid fee-for-service program
      to
      MC+ managed care. The health plan shall provide timely notification to the
      state
      agency of a member's acute inpatient hospitalization on the effective date
      of
      coverage to effect a retroactive/prospective adjustment in the coverage dates
      for MC+ managed care.

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.6.2 and subparagraph a -v. Harmony has policies and
      procedures to ensure compliance with the aforementioned Performance
      Requirements. 

    

    
      	2.7  	
              Comprehensive
                Benefit Package:

            

    

    

    Description
      of Comprehensive Benefit Package:
      The
      health plan shall assume the responsibility for all covered medical conditions
      of each MC+ managed care member as of the effective date of coverage. The health
      plan shall make the comprehensive benefit package available to members. Services
      outside the United States, District of Columbia, and the following territories:
      Northern Mariana Islands, American Samoa, Guam, Puerto Rico, and the Virgin
      Islands are not covered. Services must be provided according to the medical
      needs of the member. The health plan may manage specific services as long as
      the
      health plan provides services that are medically appropriate. The health plan
      shall have a process for allowing exceptions that is in accordance with 13
      CSR
      70-2.100. The health plan may develop criteria by which the health plan shall
      review future treatment options, set prior authorization criteria, or exercise
      other administrative options for the health plan’s administration of medical
      care benefits. The health plan may place appropriate limits on a service on
      the
      basis of criteria such as medical necessity; or for utilization control,
      provided the services furnished can reasonably be expected to achieve their
      purpose. The health plan may not arbitrarily deny or reduce the amount,
      duration, or scope of a required service solely because of the diagnosis, type
      of illness, or condition. Attachment 3 outlines the comprehensive benefit
      package for all members and the services they will receive.

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.7. 

    

    
      	2.7.1  	
              The
                health plan shall include the following services within the comprehensive
                benefit package:

            

    

    

    
      	a.  	
              Inpatient
                hospital services;

            

    

    

    
      	b.  	
              Outpatient
                hospital services;

            

    

    

    
      	c.  	
              Emergency
                room services;

            

    

    

    
      	d.  	
              Ambulatory
                surgical center, birthing center;

            

    

    

    
      	e.  	
              Physician,
                advanced practice nurse, and certified nurse midwife
                services;

            

    

    

    
      	1)  	
              The
                health plan shall provide certified nurse midwife services that are
                medically appropriate either through the health plan provider network
                or
                by other means outside the health plan provider network at the health
                plan’s expense. If the member elects a home birth, the member shall be
                disenrolled from MC+ managed care according to the MC+ managed care
                home
                birth policy statement. The disenrolled member shall then receive
                services
                through the MC+ fee-for-service
                program.

            

    

    

    
      	f.  	
              Maternity
                benefits for inpatient hospital and certified nurse midwife. The
                health
                plan shall provide coverage for a minimum of forty-eight (48) hours
                of
                inpatient hospital services following a vaginal delivery and a minimum
                of
                ninety-six (96) hours of inpatient hospital services following a
                cesarean
                section for a mother and her newly born child in a hospital or any
                other
                health care facility licensed to provide obstetrical care under the
                provision of Chapter 197, RSMo, as
                amended.

            

    

    

    The
      health plan may authorize a shorter length of hospital stay for services related
      to maternity and newborn care if a shorter inpatient hospital stay meets with
      the approval of the attending physician after consulting with the mother and
      is
      in keeping with federal and state law, as amended. The physician's approval
      to
      discharge shall be made in accordance with the most current version of the
      "Guidelines for Perinatal Care" prepared by the American Academy of Pediatrics
      and the American College of Obstetricians and Gynecologists, or similar
      guidelines prepared by another nationally recognized medical organization and
      be
      documented in the member’s medical record.

    

    The
      health plan shall provide coverage for post-discharge care to the mother and
      her
      newborn. The first post-discharge visit shall occur within twenty-four (24)
      to
      forty-eight (48) hours. Post-discharge care shall consist of a minimum of two
      visits at least one of which shall be in the home, in accordance with accepted
      maternal and neonatal physical assessments, by a registered professional nurse
      with experience in maternal and child health nursing or a physician. The
      location and schedule of the post-discharge visits shall be determined by the
      attending physician. Services provided by the registered professional nurse
      or
      physician shall include, but not be limited to, physical assessment of the
      newborn and mother, parent education, assistance and training in breast or
      bottle feeding, education and services for complete childhood immunizations,
      the
      performance of any necessary and appropriate clinical tests, and submission
      of a
      metabolic specimen satisfactory to the State laboratory. Such services shall
      be
      in accordance with the medical criteria outlined in the most current version
      of
      the "Guidelines for Perinatal Care", or similar guidelines prepared by another
      nationally recognized medical organization. If the health plan intends to use
      another nationally recognized medical organization's guidelines, the state
      agency must approve prior to implementation of its use.

    

    
      	g.  	
              Family
                Planning Services - If family planning services are sought out-of-network
                by a member, the health plan shall be financially liable for payment
                of
                those services in accordance with federal freedom of choice
                provisions.

            

    

    

    
      	h.  	
              Pharmacy
                benefits excluding protease inhibitors - pharmacy benefits are included
                in
                the comprehensive benefit package if the health plan included pharmacy
                benefits in its awarded proposal;

            

    

    

    
      	1)  	
              The
                health plan shall submit the information regarding its pharmacy program
                to
                the state agency for prior approval in accordance with the MC+ Managed
                Care Policy Statements, as amended.

            

    

    

    
      	i.  	
              Dental
                services related to trauma to the mouth, jaw, teeth or other contiguous
                sites as a result of injury. Adults age 21 and over receive treatment
                of a
                disease/medical condition without which the health of the recipient
                would
                be adversely affected through the Fee For Service program.
                

            

    

    

    
      	j.  	
              Laboratory,
                radiology, and other diagnostic
                services;

            

    

    

    
      	k.  	
              Prenatal
                case management;

            

    

    

    
      	l.  	
              One
                eye examination every 2 years;

            

    

    

    
      	m.  	
              Home
                health services;

            

    

    

    
      	n.  	
              Adult
                day health care services;

            

    

    

    
      	o.  	
              Personal
                care services;

            

    

    

    
      	p.  	
              Transportation
                services;

            

    

    

    
      	1)  	
              The
                health plan shall provide emergency transportation (ground and air)
                for
                its members. The health plan shall provide non-emergency medical
                transportation to members who do not have the ability to provide
                their own
                transportation (such as their own vehicle, friends, or relatives)
                to and
                from services required herein as well as Medicaid/MC+ Fee-For-Service
                covered services not included in the comprehensive benefit
                package.

            

    

    

    
      	q.  	
              Hospice
                services;

            

    

    

    
      	r.  	
              Durable
                medical equipment limited to: prosthetic devices (with the exception
                of
                artificial larynx), respiratory equipment and oxygen (with the exception
                of CPAP, BiPAP, and nebulizers), wheelchairs, diabetic supplies and
                equipment, and ostomy supplies. Members with a Home Health Plan of
                Care
                receive all medically necessary durable medical equipment services
                during
                the plan of care coverage period.

            

    

    

    
      	s.  	
              Podiatry
                services with the exception of trimming of nondystrophic nails, any
                number; debridement of nail(s) by any method(s), one to five; debridement
                of nail(s) by any method(s), six or more; excision of nail and nail
                matrix, partial or complete; and strapping of ankle and/or foot.
                

            

    

    

    
      	t.  	
              Services
                provided by local public health agencies - The Department of Health
                and
                Senior Services and local public health agencies administer certain
                public
                health programs which are critical to the protection of the public's
                health and, therefore, must be made available to members at local
                public
                health agencies whether in-network or out-of-network. The health
                plan
                shall reimburse the local public health agency according to the most
                current Medicaid program fee schedule in effect at the time of service,
                unless otherwise negotiated. Such services shall
                include:

            

    

    

    
      	1)  	
              All
                sexually transmitted disease (STD) services including screening,
                diagnosis, and treatment. In-network providers shall follow current
                Center
                for Disease Control (CDC) Sexually Transmitted Diseases Treatment
                Guidelines and the United States Department of Health and Human Services
                Chlamydia Control Project Screening Criteria, or their equivalent.
                The STD
                guidelines may be found on the Internet at:
                http://www.dhss.mo.gov/STDSurveillance/. STD screening, diagnosis,
                and
                treatment services shall include:

            

    

    

    
      	·  	
              STD
                screening exam.

            

    

    

    
      	·  	
              Screening,
                diagnosis, and treatment for the following STDs: gonorrhea, syphilis,
                chancroid, granuloma inguinale, lymphogranuloma venereum, genital
                herpes,
                genital warts, trichomoniasis, chlamydia (cervicitis), chlamydia
                (urethritis), hepatitis B, and others as may be designated by the
                state
                agency.

            

    

    

    
      	·  	
              Screening,
                diagnosis, and treatment of vaginal or urethral discharge including
                non-gonococcal urethritis and mucopurulent
                cervicitis.

            

    

    

    
      	·  	
              Evaluation
                and initiation of treatment of pelvic inflammatory disease
                (PID).

            

    

    

    
      	·  	
              Diagnosis
                and preventive treatment of members who are reported as contacts/sex
                partners of any person and diagnosed with a STD. The member shall
                be given
                the option of seeing an in-network provider
                first.

            

    

    

    
      	·  	
              The
                local public health agency shall encourage members to follow-up with
                their
                primary care provider; however, if the member chooses follow-up care
                at
                the local public health agency for confidentiality reasons, the health
                plan shall reimburse the local public health agency for follow-up
                office
                visits (not to exceed three visits per
                episode).

            

    

    

    
      	2)  	
              Human
                immunodeficiency virus (HIV) services relating to screening and diagnostic
                studies. In-network providers shall use current CDC HIV Counseling,
                Testing, Referral Standards, and Guidelines or their equivalent.
                The HIV
                guidelines may be found on the internet at: .

            

    

    

    
      	3)  	
              Tuberculosis
                services including screening, diagnosis, and treatment. In-network
                providers shall follow current CDC/American Thoracic Society Guidelines:
                Treatment of Tuberculosis and Tuberculosis Infection in Adults and
                Children, or their equivalent, including the use of Mantoux PPD skin
                test
                to screen for tuberculosis. The Tuberculosis guidelines may be found
                on
                the Internet
                at: .

            

    

    

    
      	·  	
              All
                members diagnosed with tuberculosis infection or tuberculosis disease
                shall be reported to the local public health
                agency.

            

    

    

    
      	·  	
              All
                members receiving treatment for tuberculosis disease shall be referred
                to
                the local public health agency’s tuberculosis contact person for directly
                observed therapy (DOT). The health plan shall communicate with the
                local
                public health agency’s tuberculosis contact person to obtain information
                regarding the member’s health status. The health plan shall communicate
                this information to the in-network provider. The health plan shall
                be
                responsible for care coordination and medically necessary follow-up
                treatment.

            

    

    

    
      	·  	
              All
                laboratory tests for tuberculosis shall meet the standards established
                by
                the CDC/Missouri Department of Health and Senior Services. Sensitivity
                tests shall be performed on all initial specimens positive for M.
                Tuberculosis. Department of Health and Senior Services encourages
                all
                sputum specimens to be submitted to the Department of Health and
                Senior
                Services’ Tuberculosis Reference Laboratory at the Missouri Rehabilitation
                Center. Positive cultures for M Tuberculosis isolated at private
                laboratories must be sent to the TB Reference Laboratory (Required
                by
                Missouri Rule 19 CSR 20-20.080).

            

    

    

    
      	4)  	
              Childhood
                Immunizations: In-network
                providers shall fully immunize their members following the most recent
                immunization recommendations designated by the state agency. The
                state
                agency shall provide the health plan's Medical Director with copies
                of the
                most recent recommendations upon contract award and upon request
                and when
                the recommendations change.

            

    

    

    
      	·  	
              The
                health plan and its in-network providers must enroll and must obtain
                vaccines through the Missouri Department of Health and Senior Services
                Vaccines for Children (VFC) Program or any such vaccine supply program
                as
                designated by the state agency. Any time a member receives immunizations
                from a local public health agency, or at a Special Supplemental Nutrition
                Program for Women, Infants, and Children (WIC) site, the health plan
                shall
                reimburse only the cost for administration at the current Medicaid
                program
                rates in effect at the time of the service, unless otherwise
                negotiated.

            

    

    

    
      	·  	
              The
                health plan shall reimburse governmental public health agencies for
                the
                cost of both administration and vaccines not available through the
                VFC
                program or vaccine supply program as designated by the state agency
                when
                the vaccine is deemed medically
                necessary.

            

    

    

    
      	·  	
              The
                health plan shall collaborate with the state agency and the Missouri
                Department of Health and Senior Services to determine the health
                plan's
                aggregate immunization level. The Missouri Department of Health and
                Senior
                Services, Immunization Program will offer consultation to the health
                plan
                to foster the exchange of immunization information, and to in-network
                providers for purposes of assessment, reminder/recall, and
                reporting.

            

    

    

    
      	·  	
              The
                health plan shall establish, as a quality assessment and improvement
                measure, a target rate of 90% for the number of two (2) year olds
                immunized.

            

    

    

    
      	5)  	
              Childhood
                lead poisoning prevention services shall include screening, diagnosis,
                treatment, and follow-up as indicated. In-network providers shall
                follow
                the Centers for Medicare and Medicaid Services (CMS) (formerly the
                Health
                Care Financing Administration) guidelines in effect for the specific
                time
                period and CDC guidelines: Screening Young Children for Lead Poisoning
                and
                Managing Elevated Blood Lead Levels Among Young Children. The Department
                of Health and Senior Services shall provide the health plan's Medical
                Director with copies of current protocols and guidelines upon contract
                award or at any time upon request. If there is a discrepancy between
                guidelines, the state agency requires use of the HCY/EPSDT Lead Risk
                Assessment Guide developed in accordance with CMS guidelines. The
                HCY/EPSDT Lead Risk Assessment Guide may be used separately or in
                conjunction with the HCY Screening
                form.

            

    

    

    
      	u.  	
              Emergency
                Medical/Mental Health Services.
                Emergency medical/mental health services means covered inpatient
                and
                outpatient services that are furnished by a provider that is qualified
                to
                furnish these services and are needed to evaluate or stabilize an
                emergency medical condition.

            

    

    

    
      	1)  	
              An
                emergency medical condition means a medical or mental health condition
                manifesting itself by acute symptoms of sufficient severity (including
                severe pain) that a prudent layperson, who possesses an average knowledge
                of health and medicine, could reasonably expect the absence of immediate
                medical attention to result in the
                following:

            

    

    

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

            

    

    
      	·  	
              Serious
                impairment to bodily functions;

            

    

    
      	·  	
              Serious
                dysfunction of any bodily organ or
                part;

            

    

    
      	·  	
              Serious
                harm to self or others due to an alcohol or drug abuse
                emergency;

            

    

    
      	·  	
              Injury
                to self or bodily harm to others;
                or

            

    

    
      	·  	
              With
                respect to a pregnant woman having contractions: (1) that there is
                inadequate time to effect a safe transfer to another hospital before
                delivery, or (2) that transfer may pose a threat to the health or
                safety
                of the woman or the unborn.

            

    

    

    
      	2)  	
              Post-stabilization
                care services means covered services, related to an emergency medical
                condition that are provided after a member is stabilized in order
                to
                maintain the stabilized conditions or to improve or resolve the member’s
                condition.

            

    

    

    
      	v.  	
              Early
                Periodic Screening, Diagnosis, and Treatment
                Services:
                The Omnibus Budget Reconciliation Act of 1989 (OBRA-89) mandated
                that
                Medicaid cover all medically necessary services listed in Section
                1905 (a)
                of the Social Security Act to children from birth through age 20.
                In
                Missouri, this program is known as the Healthy Children and Youth
                (HCY)
                Program. In accordance with the health plan’s written policies and
                procedures, the health plan shall conduct outreach and education
                of
                children eligible for the HCY/EPSDT program, provide the full HCY/EPSDT
                services to all eligible children and young adults under the age
                of 21,
                and conduct and document well child visits (screenings) using the
                State
                HCY/EPSDT screening form as amended. (The HCY screening form may
                be found
                on the Internet at: http://manuals.momed.com/ Look under Missouri
                Medicaid
                Provider Manuals, Forms, List of Forms, Healthy Children and Youth
                Screening [HCY Screening].) The health plan shall provide the full
                scope
                of HCY/EPSDT services in accordance with the
                following:

            

    

    

    
      	1)  	
              The
                health plan shall conduct HCY/EPSDT well child visits on all eligible
                members under age twenty-one (21) to identify health and developmental
                problems. The state agency recognizes that the decision to not have
                a
                child screened is the right of the parent or guardian of the child.
                For
                those children that have not had well child visits in accordance
                with the
                periodicity schedule established by the state agency, the health
                plan
                shall document its outreach and educational efforts to the parent
                or
                guardian informing them of the importance of well child visits, that
                a
                well child visits is due, that appointment scheduling assistance
                is
                available, and that transportation (except to those children with
                ME Codes
                71-75) is available. (The current periodicity schedule is contained
                in
                Attachment 3.) The health plan shall follow the MC+ fee-for-service
                policies for recognition of completion of all components of a full
                medical
                HCY/EPSDT well child visit service. A full HCY/EPSDT well child visits
                includes all of the components listed below. A partial well child
                visit
                includes the first six (6) components listed below. The last three
                (3)
                components are individual screens. An interperiodic screen is defined
                as
                any encounter with a health care professional acting within his or
                her
                scope of practice. 

            

    

    

    
      	·  	
              A
                comprehensive health and developmental history including assessment
                of
                both physical and mental health
                developments;

            

    

    

    
      	·  	
              A
                comprehensive unclothed physical
                exam;

            

    

    

    
      	·  	
              Health
                education (including anticipatory
                guidance);

            

    

    

    
      	·  	
              Laboratory
                tests as indicated (appropriate according to age and health history
                unless
                medically contraindicated);

            

    

    

    
      	·  	
              Appropriate
                immunizations according to age;

            

    

    

    
      	·  	
              Verbal
                lead assessment beginning at age six (6) months and continuing through
                age
                seventy-two (72) months. Blood level testing is mandatory at twelve
                (12)
                and twenty-four (24) months or annually if residing in a high-risk
                area of
                Missouri as defined by Department of Health and Senior Services regulation
                19 CSR 20-8.030;

            

    

    

    
      	·  	
              Vision
                screening;

            

    

    

    
      	·  	
              Hearing
                screening; 

            

    

    

    
      	·  	
              Dental
                screening (oral exam by primary care provider as part of comprehensive
                exam). Recommended that preventive dental services begin at age six
                (6)
                through twelve (12) months and be repeated every six (6)
                months.

            

    

    

    
      	2)  	
              If
                a suspected problem is detected during a well child visit, the child
                must
                be evaluated as necessary, using the required assessment protocol,
                for
                further diagnosis. This diagnosis is used to determine treatment
                needs.

            

    

    

    
      	3)  	
              HCY/EPSDT
                requires coverage for all follow-up diagnostic and treatment services
                deemed medically necessary to ameliorate or correct a problem discovered
                during an HCY/EPSDT well child visits. Such medically necessary diagnosis
                and treatment services must be provided as long as they are Medicaid
                covered services as defined in the Social Security
                Act.

            

    

    

    
      	4)  	
              The
                health plan shall establish a tracking system that provides information
                on
                compliance with HCY/EPSDT service provision requirements in the following
                areas:

            

    

    

    
      	·  	
              Initial
                visit for newborns. The initial HCY/EPSDT well child visits shall
                be the
                newborn physical exam in the
                hospital.

            

    

    

    
      	·  	
              Preventive
                pediatric visits according to the periodicity schedule inclusive
                of a
                verbal lead assessment and blood lead
                tests.

            

    

    

    
      	·  	
              Diagnosis
                and/or treatment, or other referrals in accordance with HCY/EPSDT
                well
                child visit results.

            

    

    

    
      	·  	
              The
                health plan shall ensure that the tracking system generates information
                consistent with the requirements regarding encounter data as specified
                elsewhere herein.

            

    

    

    
      	5)  	
              The
                health plan shall have an established process for reminders, follow-ups,
                and outreach to members. This process shall include, but not be limited
                to, notifying the parent(s) or guardian(s) of children of the needs
                and
                scheduling of periodic well child visits according to the periodicity
                schedule. The health plan shall provide assistance to new members
                in
                accessing HCY/EPSDT well child visit services within ninety (90)
                calendar
                days of health plan enrollment. The health plan shall provide assistance
                to members in accessing subsequent HCY/EPSDT well child visits in
                accordance with the periodicity schedule. At the time of notification,
                the
                health plan shall offer transportation and scheduling assistance
                if
                necessary. For members with ME Codes 71 through 75, non-emergency
                medical
                transportation is not a covered
                benefit.

            

    

    

    
      	6)  	
              The
                health plan should seek innovative, cooperative ways to enhance
                care coordination
                and delivery of HCY/EPSDT. This may include the use of a standardized
                data
                base system among health plans.

            

    

    

    
      	7)  	
              The
                health plan shall report HCY/EPSDT well child visits through encounter
                data submissions in accordance with the requirements regarding encounter
                data as specified elsewhere herein. The state agency shall use such
                encounter data submissions and other data sources to determine health
                plan
                compliance with CMS requirements that 80 percent of eligible members
                under
                the age of twenty-one are receiving HCY/EPSDT well child visits in
                accordance with the periodicity schedule. The state agency shall
                use the
                participant ratio as calculated using the CMS 416 methodology for
                measuring the health plan’s
                performance.

            

    

    

    
      	·  	
              The
                health plan shall report HCY/EPSDT well child visits in accordance
                with
                the appropriate well child visits codes established by the state
                agency.
                HCY/EPSDT screening codes are identified in MC+ Managed Care Policy
                Statements. Services not reported as HCY/EPSDT well child visits
                in
                accordance with the appropriate codes will not be counted toward
                the
                health plan's participant ratio.

            

    

    

    
      	·  	
              In
                the event the state agency uses other data sources submitted by the
                health
                plan, the health plan shall certify the data
                provided.

            

    

    

    
      	a.  	
              The
                data must be certified by one of the
                following:

            

    

    

    
      	1)  	
              The
                health plan’s Chief Executive
                Officer.

            

    

    
      	2)  	
              The
                health plan’s Chief Financial
                Officer.

            

    

    
      	3)  	
              An
                individual who has delegated authority to sign for, and who reports
                directly to, the health plan’s Chief Executive Officer or Chief Financial
                Officer.

            

    

    

    
      	b.  	
              The
                certification must attest, based on best knowledge, information,
                and
                belief, as to the accuracy, completeness, and truthfulness of the
                data.

            

    

    

    
      	c.  	
              The
                health plan must submit the certification concurrently with the
                data.

            

    

    

    
      	w.  	
              Mental
                health and substance abuse
                services:

            

    

    

    
      	1)  	
              For
                children covered under MC+ managed care within Category of Aid 4,
                mental
                health and substance abuse services, if medically necessary, shall
                not be
                the financial responsibility of the health plan and shall be provided
                in
                accordance with the requirements regarding coordination with services
                not
                included in the comprehensive benefit package as specified elsewhere
                herein.

            

    

    

    
      	·  	
              For
                inpatients with dual diagnoses (physical
                and mental), the health plan shall be financially responsible for
                all
                inpatient hospital days if the primary, secondary, or tertiary diagnosis
                is a combination of physical and mental health. These admissions
                are
                subject to the prior authorization and concurrent review process
                identified by the health plan.

            

    

    

    
      	2)  	
              All
                other members shall receive all medically necessary mental health
                and
                substance abuse services included in the comprehensive benefit package.
                The state agency, in conjunction with the Department of Mental Health,
                has
                developed community-based services with an emphasis on the least
                restrictive setting. The health plan shall consider, when appropriate,
                using such services in lieu of using an out-of-home placement setting
                for
                members.

            

    

    

    
      	3)  	
              With
                the member’s or the member’s parent/guardian’s consent, the health plan
                shall notify the member's primary care provider when a member is
                admitted
                for mental health or substance abuse
                services.

            

    

    

    
      	4)  	
              The
                health plan shall have protocols for coordinating the diagnosis,
                treatment, and care between primary care providers and mental health
                and
                substance abuse providers which include the expected response time
                for
                consults between primary care providers and mental health and substance
                abuse providers.

            

    

    

    
      	5)  	
              Services
                shall include, but not be limited
                to:

            

    

    

    
      	·  	
              Inpatient
                hospitalization, when provided by acute hospital, private or state
                psychiatric hospital.

            

    

    

    
      	·  	
              Outpatient
                services when provided by a licensed psychiatrist, licensed psychologist,
                licensed clinical social worker, provisional licensed clinical social
                worker, licensed counselor, provisional licensed professional counselor,
                licensed psychiatric advanced practice nurse, licensed home health
                psychiatric nurse, or state certified mental health or substance
                abuse
                program. These services must include outreach efforts on an as needed
                basis that recognize the unique mental health challenges of some
                members.
                These efforts may include phone contacts and home
                visits.

            

    

    

    
      	·  	
              Crisis
                intervention/access services, which may include the provision of
                a 24-hour
                hotline staffed by qualified mental health professionals and qualified
                substance abuse counselors providing intake, evaluation and referral
                services, including services that are alternatives to out of the
                home
                placements and mobile crisis teams for on-site
                interventions.

            

    

    

    
      	·  	
              Alternative
                services which are reasonable, cost effective, and related to the
                member's
                treatment plan.

            

    

    

    
      	6)  	
              The
                health plan is responsible for payment of mental health and substance
                abuse services defined herein that are court ordered, 96 hour detentions,
                and for involuntary commitments.

            

    

    

    
      	7)  	
              Mental
                Health and Substance Abuse Services: To ensure the continuity of
                care and
                the transition of members who have received mental health and substance
                abuse services from an out-of-network provider prior to enrollment
                with
                the health plan, the state agency encourages the out-of network provider
                to contact the health plan to make transition arrangements with the
                health
                plan. Upon enrollment, the health plan shall transition the member
                and
                provide the immediate continuation of mental health and substance
                abuse
                services. The health plan shall authorize out-of-network providers
                to
                continue ongoing mental health and substance abuse treatment, services,
                items, and prescriptions for new members until such time as the new
                member
                has been transferred appropriately to the care of an in-network
                provider.

            

    

    

    
      	·  	
              If
                the member transferred from an out-of-network provider to an in-network
                provider, the health plan shall secure the member's mental health
                and
                substance abuse medical records from the out-of-network provider.
                The
                health plan shall pay rates comparable to Medicaid, unless otherwise
                negotiated, to obtain these
                records.

            

    

    

    
      	·  	
              Mental
                Health Out-of-Network Referrals: If the health plan believes that
                a child
                or youth may require residential services in order to receive appropriate
                care and treatment for a serious emotional disorder, the health plan
                may
                apply to the Missouri Division of Comprehensive Psychiatric Services
                (CPS)
                for placement in accordance with the MC+ managed care policy statement
                titled, Mental Health and Substance Abuse Fee-For-Service
                Coordination.

            

    

    

    
      	·  	
              Services
                provided by a Community Psychiatric Rehabilitation provider shall
                be
                reimbursed by the state agency on a fee-for-service basis according
                to the
                terms and conditions of the Medicaid
                program.

            

    

    

    
      	·  	
              Targeted
                case management services for mental health services shall be reimbursed
                by
                the state agency on a fee-for-service basis according to the terms
                and
                conditions of the Medicaid program.

            

    

    

    Harmony
      Behavioral understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.7.1.
      It is the policy of Harmony Behavioral Health, Inc. to ensure minimal or no
      disruption of treatment for enrollees requiring transition of care and services
      from the current fee for service to HMO-based managed behavioral health care
      under the management of Harmony Behavioral Health and its provider network.
      Harmony Behavioral Health shall adhere to the state of Missouri requirements
      for
      transitioning members from out-of-network providers. Harmony Behavioral Health
      will assist in coordination and transition of care and services to Harmony
      network providers according to the policy. 

    

    
      	x.  	
              Transplant
                Related Services:
                The health plan shall permit and authorize and shall be financially
                responsible for any inpatient, outpatient, physician, and related
                support
                services including presurgery assessment/evaluation prior to the
                date of
                the actual bone marrow/stem cell or solid organ transplant surgery.
                The
                bone marrow/stem cell or solid organ transplant will be prior authorized
                by the state agency and must be performed at a state agency’s approved
                transplant facility in accordance with the MC+ members’ freedom of choice.
                The health plan shall be responsible for pre-transplant and
                post-transplant follow-up care and immuno-suppressive pharmacy products
                prescribed after the inpatient transplant discharge. To ensure continuity
                of care, the health plan must permit and authorize follow-up services
                and
                the health plan shall be responsible for the reimbursement of such
                services. The primary care provider must be allowed to refer a transplant
                patient to the performing transplant facility for follow-up transplant
                care. Reimbursement to out-of-network providers of transplant support
                services must be no less than the current Medicaid program rates
                in effect
                at the time of the services.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.7.1 and subparagraphs a-x. 

    

    
      	2.7.2  	
              The
                health plan shall include all the services specified in the comprehensive
                benefit package with the exception of non-emergency medical transportation
                (NEMT), for uninsured children in ME Codes 71 through 75 (Refer to
                Attachment 1, COA 5).

            

    

    

    Harmony
      Health Plan understands and will provide all covered services specified in
      the
      comprehensive benefit package as set forth in RFP B3Z06118 Attachment 1, COA
      5.

    

    
      	2.7.3  	
              In
                addition to the services listed in the Comprehensive Benefit Package,
                herein, the health plan shall include the following additional services
                for children under 21 years of age and pregnant women with ME codes
                18,
                43, 44, 45, and 61.

            

    

    

    
      	a.  	
              Dental
                Services (Dental services for pregnant women age 21 and over with
                ME codes
                18, 43, 44, 45, and 61 shall be limited to dentures and services
                related to trauma to the mouth, jaw, teeth or other contiguous
                sites as a result of injury. Services to prepare the mouth for dentures,
                such as examinations, X-rays, or extractions will not be covered
                by the
                health plan. Ancillary denture services such as relining, rebasing,
                and
                repairs will not be covered by the health plan. All other Medicaid
                State
                Plan dental services for these pregnant women are covered through
                the Fee
                For Service Program);

            

    

    

    
      	b.  	
              Hearing
                aids and related services; 

            

    

    

    
      	c.  	
              Optical
                services (Pregnant women age 21 and over with ME codes 18, 43, 44,
                45, and
                61 do not receive eyeglasses except for one pair following cataract
                surgery. Eye glasses for these pregnant women are covered through
                the
                Fee-For-Service program);

            

    

    

    
      	d.  	
              Comprehensive
                Day Rehabilitation (for certain persons with disabling impairments
                as the
                result of a traumatic head injury);

            

    

    

    
      	e.  	
              Durable
                medical equipment (including but not limited to: orthotic devices,
                artificial larynx, enteral and parenteral nutrition, walkers, wheelchair
                accessories and batteries, CPAP, BiPAP, and
                nebulizers);

            

    

    

    
      	f.  	
              Diabetes
                self management training for persons with gestational, Type I or
                Type II
                diabetes;

            

    

    

    
      	g.  	
              Podiatry
                services. 

            

    

    

    Harmony
      Health Plan understands and will provide those services set forth in RFP
      B3Z06118 paragraph 2.7.3 and subparagraphs a-g. 

    

    
      	2.7.4  	
              Medically
                Necessary:
                The health plan shall determine whether or not a service(s) furnished
                or
                proposed to be furnished is (are) reasonable and medically necessary
                for
                the prevention, diagnosis or treatment of a physical or mental illness
                or
                injury; to achieve age appropriate growth and development; to minimize
                the
                progression of disability; or to attain, maintain or regain functional
                capacity; in accordance with accepted standards of practice in the
                medical
                community of the area in which the physical or mental health services
                are
                rendered; and service(s) could not have been omitted without adversely
                affecting the member's condition or the quality of medical care rendered;
                and service(s) is (are) furnished in the most appropriate setting.
                Services must be sufficient in amount, duration, and scope to reasonably
                achieve their purpose and may only be limited by medical
                necessity.

            

    

    

    
      	a.  	
              In
                reference to medically necessary care, mental health services shall
                be
                provided in accordance with a process of mental health assessment
                that
                accurately determines the clinical condition of the member and the
                acceptable standards of practice for such clinical conditions. The
                process
                of mental health assessment shall include distinct criteria for children
                and adolescents.

            

    

    

    
      	b.  	
              The
                Omnibus Budget Reconciliation Act of 1989 (OBRA-89) mandated that
                Medicaid
                provide medically necessary services to children from birth through
                age
                20, which are necessary to treat or ameliorate defects, physical
                or mental
                illness, or conditions identified by an HCY/EPSDT screen. Services
                must be
                sufficient in amount, duration, and scope to reasonably achieve their
                purpose and may only be limited by medical
                necessity.

            

    

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.7. 4 and subparagraphs a and b. 

    

    
      	2.8  	
              Multilingual
                Services:

            

    

    

    
      	2.8.1  	
              During
                the enrollment process, members shall be asked if English is their
                main
                language. If English is not the member’s main language, the member shall
                be asked to identify that language. The information gathered by the
                state
                agency shall be shared with the health
                plan.

            

    

    

    Harmony
      Health Plan understands process set forth in RFP B3Z06118 paragraph
      2.8.1.

    

    
      	2.8.2  	
              The
                health plan shall make interpreter services available as necessary
                to
                ensure that members are able to communicate with the health plan
                and
                providers and receive covered benefits. The health plan shall use
                certified interpreters. The health plan shall inform members of the
                availability of interpreter services. If the health plan has more
                than two
                hundred (200) members or five (5) percent of its program membership
                (whichever is less) who speak a single language other than English
                as a
                primary language, the health plan shall make available general services
                and materials, such as the health plan’s member handbook in that
                language.

            

    

    

    Harmony
      Health Plan understands requirements set forth in RFP B3Z06118 paragraph 2.8.2.
      Harmony provides interpretive services for its members with limited
      English-proficiency or sensory of speech impairments. Harmony’s criteria for
      obtaining services include assertions that the interpreter has a familiarity
      with medical or other specialized terminology and the ethic of interpreting.
      Harmony seeks interpreters through hospitals and other organizations that
      require certification. 

    

    Additionally,
      Harmony’s member services help line offers a dedicated phone queue for Spanish
      speaking members. The phone queue is accessed through an automated routing
      system with phone scripts recorded in Spanish. The Customer Service help line
      utilizes AT&T’s Language line to communicate with other non-English or
      limited English proficient members. 

    

    Harmony
      shall make available all member communications and materials, such as the member
      handbook and member newsletters, in the prevalent language as determined by
      the
      requirements within this section.

    

    

    
      	2.8.3  	
              In
                addition, the health plan shall develop appropriate methods for
                communicating with visual and hearing impaired members and accommodating
                the physically disabled. The health plan shall offer members standard
                materials, such as the member handbook and enrollment materials in
                alternative formats (i.e., large print, Braille, cassette, and diskette)
                immediately upon request from members with sensory
                impairments.

            

    

    

    Harmony
      Health Plan understands requirements set forth in RFP B3Z06118 paragraph 2.8.3.
      Harmony’s Customer Service department utilizes Telecommunications Device for the
      Deaf (TDD) to communicate with hearing impaired members. Harmony shall make
      available all member communications and materials, such as the member handbook
      and member newsletters, in alternate language formats as determined by the
      requirements within this section.

    

    
      	2.9  	
              Member
                Services:

            

    

    

    
      	2.9.1  	
              Member
                Services Staff: The
                health plan shall provide adequately trained member services staff
                to
                operate at least nine (9) consecutive hours during the hours of 7:00
                a.m.
                through 7:00 p.m. (i.e., 8:00 a.m. through 5:00 p.m.), Monday through
                Friday. The health plan may observe State designated holidays or
                the
                holidays designated in its awarded proposal for its operation of
                member
                services. The health plan’s member services staff shall be responsible for
                the following:

            

    

    

    
      	a.  	
              Explaining
                the operation of the health plan and assisting members in the selection
                of
                a primary care provider. Educating the family about managed care
                including
                the way services typically are accessed under managed care and the
                role of
                the primary care provider.

            

    

    

    
      	b.  	
              Specifying
                member’s rights and
                responsibilities.

            

    

    

    
      	c.  	
              Explaining
                covered benefits.

            

    

    

    
      	d.  	
              Assisting
                members to make appointments and obtain
                services.

            

    

    

    
      	e.  	
              Arranging
                medically necessary transportation for
                members.

            

    

    

    
      	f.  	
              Handling,
                recording, and tracking member inquiries promptly and
                timely.

            

    

    

    
      	g.  	
              The
                health plan’s member services staff must have available a complete and
                up-to-date list of the in-network providers in the health plan provider
                network. The health plan shall have a policy and procedure for regularly
                updating the provider listing. Member services staff must provide
                the
                following information to members requesting the names of
                providers:

            

    

    

    
      	1)  	
              Whether
                the provider currently participates in the health
                plan;

            

    

    

    
      	2)  	
              Whether
                the provider is currently accepting new patients;
                and

            

    

    

    
      	3)  	
              Any
                restrictions on services, including any referral or prior authorization
                requirements the member must meet to obtain services from the
                provider.

            

    

    

    
      	h.  	
              The
                health plan’s member services staff shall be trained on fraud and abuse
                policies and procedures.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.9.1 and subparagraphs a-h. 

    

    Harmony’s
      member help line is an integral component of the Customer Service Department
      because it is the foundation of Harmony’s relationship with its customers in the
      community and is the first-line contact between the plan and its customers.
      Harmony encourages its customers to contact the helpline as a first resource
      in
      seeking answers to questions or concerns about the plan.

    

    Harmony
      help line provides a live voice 24 hours a day, seven days a week. The member
      help line is staffed by Customer Service Representatives on business days from
      8:00 a.m. to 5:00 pm CST. Primary Care Net provides Harmony’s after hour
      coverage, through the 24 hour NurseLink service. Harmony recognizes the
      following holidays for 2006; New Year’s Day, Memorial Day, Independence Day,
      Labor Day, Thanksgiving Day, Day after Thanksgiving and Christmas
      Day.

    

    Upon
      enrollment new member materials are mailed out to new members containing
      Harmony’s Member Services help line number. In addition to the mailing, welcome
      calls are also made to new members of the plan. Once Harmony sends out new
      member materials to the new members on the membership rosters, Member Services
      staff will attempt to follow up with each new member. The purpose of the call
      is
      to welcome the new member to the plan, make sure the member received his/her
      new
      member materials packet, verify member’s personal information including phone
      number and address, describe the basic components of the plan and answer any
      questions the member may have.

    

    Harmony
      will also issue a quarterly newsletter to its members that provide updates
      related to covered services, access to providers and updated policies and
      procedures. Also included in the newsletters will be health education materials.
      Harmony’s Disease Management program will periodically send information to
      members as warranted by their condition.

    

    Harmony’s
      also has a Health Information Library that provides members with free access
      to
      information on many health related topics. The service is confidential which
      makes patients more comfortable accessing the service.

    

    Prior
      to accepting calls associated with Missouri Medicaid program, all
      representatives will go through a formal training program detailing the
      benefits, covered services, and policy and procedures associated with the
      product. Representatives will also have at their disposal training material
      to
      reference while speaking with members or providers. New representatives hired
      after the formal training program will receive training in the following manner.
      Each Customer Service Representative is provided with training prior to
      answering member calls. The representatives also receives training materials
      with written documentation for handling incoming calls. The training program
      includes education on member or provider policies and procedures, Harmony plan
      and benefit information and training on the MIS system for call
      tracking.

    

    Policy
      and procedures will be updated as necessary to respond to the specific
      requirements of the Medicaid program. During training, each representative
      also
      has side-by-side training with multiple representatives to gain exposure to
      the
      types of calls and typical responses to calls. Representatives are trained
      to
      respond to the following situations; (1) questions about covered services;
      (2)
      PCP change requests; (3) identification of patient conditions that could benefit
      from case management; (4) access to care issue; (5) member complaints and
      grievances; (6) disenrollment requests; (7) potential fraud and abuse, (8)
      claim
      inquiries and (9) member eligibility questions.

    

    
      	2.9.2  	
              Toll-Free
                Telephone Number:
                The health plan shall maintain a toll-free member services telephone
                number. The toll-free member services telephone or other toll-free
                voice
                and telecommunications device for the deaf members must be staffed
                twenty-four (24) hours per day to provide needed authorization of
                services
                during evenings and weekends and
                holidays.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.9.2. Harmony maintains a toll-free Customer Service
      telephone number. The phone system directly connects its members to Primary
      Care
      Network’s 24-hour NurseLink service for live after hours phone coverage. Harmony
      contracts with Primary Care Network (PCN) to provide 24-hour service for members
      who are unsuccessful reaching their provider and who need assistance in seeking
      medical care after normal business hours. Members contacting this service speak
      with a registered nurse (a physician is available if needed) who is trained
      to
      handle urgent health-related calls, including emergency situations. This service
      provides members with 24-hour telephone-based information, clinical assessments,
      triage, health counseling, and referral services. PCN also services members
      who
      require medical care when they are outside the service area by identifying
      an
      area provider who can render care until the member returns to the Plan service
      area. In addition, PCN provides physicians, pharmacies and Harmony members
      with
      a number to call after hours when there are questions concerning health services
      delivery that cannot wait until the next business day. Harmony’s NurseLink has
      translation services and TTY capability.

    

    
      	2.10  	
              Provider
                Services:

            

    

    

    
      	2.10.1  	
              Provider
                Services Staff: The
                health plan shall provide adequately trained provider services staff
                to
                operate at least nine (9) consecutive hours during the hours of 7:00
                a.m.
                through 7:00 p.m. (i.e., 8:00 a.m. through 5:00 p.m.) Monday through
                Friday. The health plan may observe State designated holidays or
                the
                holidays designated in its awarded proposal for its operation of
                provider
                services. If the health plan observes holidays different than the
                State’s,
                the health plan must obtain the prior written approval of the state
                agency.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.10.1. 

    

    Harmony’s
      provider help lines are integral components of the Customer Service Department.
      Harmony encourages its providers to contact the helpline as a first resource
      in
      seeking answers to questions or concerns about the plan.

    

    The
      provider help lines are staffed by Provider Service Representatives on business
      days from 8:00 a.m. to 5:00 pm CST. Primary Care Net provides Harmony’s after
      hour coverage, through the 24 hour NurseLink service. Harmony recognizes the
      following holidays for 2006; New Year’s Day, Memorial Day, Independence Day,
      Labor Day, Thanksgiving Day, Day after Thanksgiving and Christmas
      Day.

    

    

    
      	2.10.2  	
              The
                health plan’s provider services staff shall be responsible for the
                following:

            

    

    

    
      	a.  	
              Establishing
                a mechanism by which providers may determine in a timely manner whether
                a
                member is covered by the health plan and the member’s primary care
                provider assignment;

            

    

    

    
      	b.  	
              Educating
                providers on the above mechanism’s
                use;

            

    

    

    
      	c.  	
              Educating
                and assisting providers with the health plan service accessibility
                standards including but not limited to prior authorization, denial,
                and
                referral procedures;

            

    

    

    
      	d.  	
              Educating
                and assisting providers with claims submission and payment
                procedures;

            

    

    

    
      	e.  	
              Educating
                providers about conditions under which members may directly access
                services including, but not limited to, mental health and substance
                abuse,
                family planning, and public health
                services;

            

    

    

    
      	f.  	
              Educating
                providers about how a member can access emergency care and after-hour
                services;

            

    

    

    
      	g.  	
              Educating
                providers about pharmacy benefits and formulary guidelines;
                and

            

    

    

    
      	h.  	
              Handling
                provider inquiries and complaints.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.10.2 and subparagraphs a-h. 

    

    Upon
      signing a contract, providers will receive a provider manual that educates
      and
      informs providers about Harmony’s processes and procedures. A Provider Service
      Representative will review the manual with the physician and staff to ensure
      they are aware of Harmony’s expectations. Harmony also sends a periodic
      newsletter to its providers. Provider Service Representatives also periodically
      visit providers to ensure a good working relationship and that all policies
      and
      procedures are being adhered to.

    

    Prior
      to accepting calls from providers associated with Missouri MC+ managed care
      program, all representatives will go through a formal training program detailing
      the benefits, covered services, and policy and procedures associated with the
      product. Representatives will also have at their disposal training material
      to
      reference while speaking with providers. The representatives also receives
      training materials with written documentation for handling incoming calls.
      The
      training program includes education on member or provider policies and
      procedures, Harmony plan and benefit information and training on the MIS system
      for call tracking.

    

    Policy
      and procedures will be updated as necessary to respond to the specific
      requirements of the Missouri MC+ managed care program. During training, each
      representative also has side-by-side training with multiple representatives
      to
      gain exposure to the types of calls and typical responses to calls.
      Representatives are trained to respond to the following situations; (1)
      questions about covered services; (2) PCP change requests; (3) identification
      of
      patient conditions that could benefit from case management; (4) access to care
      issue; (5) member complaints and grievances; (6) disenrollment requests; (7)
      potential fraud and abuse, (8) claim inquiries and (9) member eligibility
      questions.

    

    

    
      	2.10.3  	
              The
                health plan shall develop, distribute, and maintain a provider manual.
                The
                health plan shall obtain and document the approval of the provider
                manual
                by the health plan’s Medicaid Plan Administrator and Medical Director and
                shall review the provider manual at least annually and maintain
                documentation verifying such. The health plan shall issue a copy
                of the
                provider manual to providers at the time of inclusion in the provider
                network, and shall educate the provider as to its full content and
                usage.

            

    

    

    
      	a.  	
              At
                a minimum, the provider manual shall contain, sections
                regarding:

            

    

    

    
      	1)  	
              Specific
                covered health services for which the provider shall be responsible,
                including any limitations or conditions on
                services;

            

    

    

    
      	2)  	
              Claims
                submission instructions and the procedure for review of denied
                claims;

            

    

    

    
      	3)  	
              Prior
                authorization procedures, and referral procedures including exceptions,
                second, or third opinions;

            

    

    

    
      	4)  	
              Primary
                care provider responsibilities;

            

    

    

    
      	5)  	
              Specialist/ancillary
                provider responsibilities;

            

    

    

    
      	6)  	
              Provider
                complaint, grievance, and appeal
                processes;

            

    

    

    
      	·  	
              Any
                State-determined provider appeal rights to challenge the failure
                of the
                health plan to cover a service.

            

    

    

    
      	7)  	
              Member
                Grievance System;

            

    

    

    
      	·  	
              The
                member’s right to file grievances and appeals and their requirements and
                timeframes for filing;

            

    

    
      	·  	
              The
                availability of assistance in
                filing;

            

    

    
      	·  	
              The
                toll-free numbers to file oral grievances and
                appeals;

            

    

    
      	·  	
              The
                member’s right to request continuation of benefits during an appeal or
                State fair hearing filing and, if the health plan’s action is upheld in a
                hearing, the member may be liable for the cost of any continued
                benefits.

            

    

    
      	·  	
              The
                member’s right to a state fair hearing, how to obtain a hearing, and
                representation rules at a hearing;

            

    

    

    
      	(a)  	
              A
                member may request a State fair hearing within 90 calendar days from
                the
                health plan’s notice of action.

            

    

    

    
      	(b)  	
              The
                State must reach its decisions within the specified
                timeframes:

            

    

    

    
      	1)  	
              Standard
                resolution: within 90 calendar days of the date the member filed
                the
                appeal with the health plan if the member filed initially with the
                health
                plan (excluding the days the member took to subsequently file for
                a State
                fair hearing) or the date the member filed for direct access to a
                State
                fair hearing.

            

    

    

    
      	2)  	
              Expedited
                resolution (if the appeal was heard first through the health plan
                appeal
                process): within 3 working days from the state agency’s receipt of a
                hearing request for a denial of a service
                that:

            

    

    

    
      	·  	
              Meets
                the criteria for an expedited appeal process but was not resolved
                using
                the health plan’s expedited appeal timeframes,
                or

            

    

    
      	·  	
              Was
                resolved wholly or partially adversely to the member using the health
                plan’s expedited appeal timeframes.

            

    

    
      	3)  	
              Expedited
                resolution (if the appeal was made directly to the State Fair Hearing
                process without accessing the health plan appeal process): within
                3
                working days from the state agency’s receipt of a hearing request for a
                denial of a service that meets the criteria for an expedited appeal
                process.

            

    

    

    
      	8)  	
              Procedure
                for obtaining member eligibility
                status;

            

    

    

    
      	9)  	
              Appointment/access
                standards;

            

    

    

    
      	10)  	
              Multilingual
                and TDD availability;

            

    

    

    
      	11)  	
              Quality
                Assessment and Improvement;

            

    

    

    
      	12)  	
              Provider
                Credentialing;

            

    

    

    
      	13)  	
              Management
                and retention of medical records;

            

    

    

    
      	14)  	
              Confidentiality;

            

    

    

    
      	15)  	
              Advance
                directives; and

            

    

    

    
      	16)  	
              Fraud
                and abuse guidelines.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.10.3 and subparagraph a. 

    

    
      	2.10.4  	
              The
                health plan shall supply the state agency with the federal tax
                identification number and professional license number of each provider
                performing services for the health
                plan.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.10.4. 

     

    
      	2.10.5  	
              The
                health plan should specify in writing the following to out-of-network
                providers at the time a service is approved to be performed by the
                out-of-network provider:

            

    

    

    
      	a.  	
              Claims
                submission instructions and the procedure for review of denied
                claims;

            

    

    

    
      	b.  	
              Prior
                authorization procedures and referral procedures including exceptions,
                second, or third opinions;

            

    

    

    
      	c.  	
              Provider
                complaint, grievance, and appeal
                procedures;

            

    

    

    
      	1)  	
              Any
                State-determined provider appeal rights to challenge the failure
                of the
                health plan to cover a service.

            

    

    

    
      	d.  	
              Member
                Grievance System;

            

    

    

    
      	·  	
              The
                member’s right to file grievances and appeals and their requirements and
                timeframes for filing;

            

    

    
      	·  	
              The
                availability of assistance in
                filing;

            

    

    
      	·  	
              The
                toll-free numbers to file oral grievances and
                appeals;

            

    

    
      	·  	
              The
                member’s right to request continuation of benefits during an appeal or
                State fair hearing filing and, if the health plan’s action is upheld in a
                hearing, the member may be liable for the cost of any continued
                benefits.

            

    

    
      	·  	
              The
                member’s right to a state fair hearing, how to obtain a hearing, and
                representation rules at a hearing;

            

    

    

    
      	(a)  	
              A
                member may request a State fair hearing within 90 calendar days from
                the
                health plan’s notice of action.

            

    

    
      	(b)  	
              The
                State must reach its decisions within the specified
                timeframes:

            

    

    

    
      	1)  	
              Standard
                resolution: within 90 calendar days of the date the member filed
                the
                appeal with the health plan if the member filed initially with the
                health
                plan (excluding the days the member took to subsequently file for
                a State
                fair hearing) or the date the member filed for direct access to a
                State
                fair hearing.

            

    

    

    
      	2)  	
              Expedited
                resolution (if the appeal was heard first through the health plan
                appeal
                process): within 3 working days from the state agency’s receipt of a
                hearing request for a denial of a service
                that:

            

    

    

    
      	·  	
              Meets
                the criteria for an expedited appeal process but was not resolved
                using
                the health plan’s expedited appeal timeframes,
                or

            

    

    
      	·  	
              Was
                resolved wholly or partially adversely to the member using the health
                plan’s expedited appeal timeframes.

            

    

    

    
      	3)  	
              Expedited
                resolution (if the appeal was made directly to the State Fair Hearing
                process without accessing the health plan appeal process): within
                3
                working days from the state agency’s receipt of a hearing request for a
                denial of a service that meets the criteria for an expedited appeal
                process.

            

    

    

    
      	e.  	
              Procedure
                for obtaining member eligibility
                status;

            

    

    

    
      	f.  	
              Multilingual
                and TDD availability; and

            

    

    

    
      	g.  	
              Confidentiality.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.10.5 and subparagraphs a - g.

    

    
      	2.11  	
              Release
                for Ethical Reasons:

            

    

    

    
      	2.11.1  	
              As
                a condition to participating in, or contracting with the health plan,
                the
                health plan may not:

            

    

    

    
      	a.  	
              Require
                a provider to perform any treatment or procedure which is contrary
                to the
                provider's conscience, religious beliefs, or ethical principles or
                policies; or

            

    

    

    
      	b.  	
              Prohibit
                a provider from making a referral to another health care provider
                licensed
                to provide care appropriate to the member's medical
                condition.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.11.1.

    

    
      	2.11.2  	
              The
                health plan shall have a process by which the provider may refer
                a member
                to another health care provider licensed to provide care appropriate
                to
                the member's medical condition or withdraw from the case and the
                health
                plan shall assign the member to another provider licensed to provide
                care
                appropriate to the member's medical
                condition.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.11.2. Harmony has policies and procedures to ensure
      compliance with the aforementioned Performance Requirements.  Please refer
      to the Appendix Binder, Tab 1, Item 6 for Referrals
      to Non-Contracted Providers Policy
      and Procedure.  This policy and procedure may be updated from time to time,
      but shall remain compliant with DSS standards 

    

    
      	2.11.3  	
              A
                health plan that is otherwise required to provide, reimburse for,
                or
                provide coverage of, a counseling or referral service because of
                the
                requirement herein may object to the service on moral or religious
                grounds. If the health plan objects to service on moral or religious
                grounds, the health plan must notify the state agency. Additionally,
                the
                health plan shall notify the state agency whenever
                the health plan adopts the policy during the term of the
                contract.
                The health plan agrees that such an objection and subsequent release
                from
                providing, reimbursing for, or providing coverage of, a counseling
                or
                referral service shall result in a reduction to the applicable capitation
                rates paid to the health plan to reflect such a release as outlined
                in
                paragraph 2.28.4. 

            

    

    

    
      	a.  	
              Information
                to potential members must be provided prior to enrollment regarding
                the
                health plan's release of provision of such
                service.

            

    

    
      	b.  	
              The
                health plan shall be required to notify its members 30 calendar days
                prior
                to any change in its policy regarding coverage of a counseling or
                referral
                service.

            

    

    
      	c.  	
              The
                health plan shall be required to notify its members of how and where
                to
                obtain the service.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.11.3 and subparagraphs a-c. 

    

    Harmony
      does not object to any services based on moral or religious grounds, and
      therefore does not seek a release from providing coverage for any services
      included in the Comprehensive Benefit Package. 

    

    
      	2.12  	
              Coordination
                With Services not Included in the Comprehensive Benefit
                Package:

            

    

    

    The
      health plan is not obligated to provide or pay for any services not included
      in
      the comprehensive benefit package. However, the health plan must perform care
      coordination of covered services with services not included within the
      comprehensive benefit package. These services include, but are not limited
      to,
      the following:

    

    
      	2.12.1  	
              School
                Based Services:

            

    

    

    
      	a.  	
              When
                communities and school boards agree, schools may operate school based
                clinics to address unmet medical needs of children. The state agency
                supports the efforts of such communities. The health plan shall perform
                care coordination with school based clinic services with comprehensive
                benefit services that are the responsibility of the health plan.
                In
                addition, the health plan shall have a written process for coordination
                and collaboration with school based
                clinics.

            

    

    

    
      	b.  	
              The
                health plan shall not be financially liable for physical therapy
                (PT),
                occupational therapy (OT), or speech therapy (ST) included in an
                Individualized Family Service Plan (IFSP) developed under the First
                Steps
                Program or included in an Individual Education Plan (IEP) developed
                by the
                public school. First Steps is an early intervention program required
                by
                the Individuals with Disabilities Education Act (IDEA) - Part C (34
                CFR
                303 Early Intervention Program for Infants and Toddlers with Disabilities)
                which also defines the IFSP. IEP services are required by the IDEA
                Part B
                (34 CFR 300 and 301). IFSPs and IEPs will include therapies which
                are
                needed due to developmental and educational needs. The health plan
                shall
                be responsible for all other medically necessary therapy services
                that are
                not identified in an IEP or IFSP including maintenance and developmental
                therapy. The health plan shall be financially responsible for all
                other
                Medicaid reimbursable services identified in the IFSP or IEP and
                are
                medically necessary. The health plan shall be responsible for medically
                necessary equipment and supplies used in connection with PT, OT,
                and ST
                services for all members. Equipment and supplies are covered as a
                Durable
                Medical Equipment benefit. The health plan shall not delay the provision
                of therapies that are medically necessary pending completion of the
                IFSP
                or IEP.

            

    

    

    
      	1)  	
              The
                First Steps program serves children from birth to age three (3) who
                are
                developmentally delayed or have diagnosed conditions associated with
                developmental disabilities. Enrollment in the First Steps program
                is
                voluntary at the choice of the child's parent or guardian. The intent
                of
                the program is, through early detection and intervention, to improve
                functioning or decrease deterioration in order to better prepare
                the child
                to participate in school. The Missouri Department of Elementary and
                Secondary Education (DESE) operates the First Steps program. Service
                Coordinators who contract with DESE are responsible for determining
                program eligibility. A multi-disciplinary team determines the child's
                service needs including if medical treatment is needed. The team
                shall
                include the child's physician. With the parent/guardian consent,
                the
                health plan shall refer children who are potentially eligible for
                First
                Steps services to the local First Steps office (System Point of Entry)
                or
                call the state-wide toll-free number, 866-583-2392, to make a
                referral.

            

    

    

    
      	2)  	
              The
                health plan shall have written policies and procedures for promptly
                transferring medical and developmental data and for coordinating
                ongoing
                care with special education
                services.

            

    

    

    
      	c.  	
              Parents
                as Teachers (PAT) is a home-school-community partnership which supports
                parents in their role as their child’s first and most influential
                teachers. Every parent of a child age 5 or under is eligible for
                PAT,
                regardless of income. PAT services include personal visits from certified
                parent educators, group meetings, developmental screenings, and
                connections with other community resources from the time the child
                is born
                until he/she enters kindergarten.

            

    

    

    
      	1)  	
              PAT
                programs collaborate with other agencies and programs to meet families’
                needs, including Head Start, First Steps, the Women Infants and Children
                Program (nutrition services), local health departments, the Family
                Support
                Division, etc. Independent evaluations of PAT show that children
                served by
                this program are significantly more advanced in language development,
                problem solving, and social development at age 3 than comparison
                children,
                99.5% of participating families are free of abuse or neglect, and
                early
                gains are maintained in elementary school, based on standardized
                tests.

            

    

    

    
      	2)  	
              The
                PAT program is administered at the local level by each public school
                district in the state of Missouri. Families interested in PAT may
                contact
                their local district directly. PAT also accepts referrals from other
                sources including medical providers. Providers who have contact with
                families with children age 5 and under are encouraged to refer those
                families to PAT. Additional information about PAT is available at
                the
                Department of Elementary and Secondary Education’s website at .
                (Look under programs, then Early Childhood Education, then Parents
                as
                Teachers.)

            

    

    

    Harmony
      Health Plan understands and will comply with the requirements set forth in
      RFP
      B3Z06118 paragraph 2.12.1, subsections a-c. 

    

    

    
      	2.12.2  	
              Public
                Health Programs:
                Services offered by the Department of Health and Senior Services
                and local
                public health agencies and the method of reimbursement shall
                include:

            

    

    

    
      	a.  	
              Environmental
                lead assessments
                for health plan children with elevated blood levels shall be reimbursed
                directly by the state agency on a fee-for-service basis according
                to the
                terms and conditions of the Medicaid
                program.

            

    

    

    
      	b.  	
              State
                Public Health Laboratory Services to Members:
                In cases where the health plan is required by law to use the State
                Public
                Health Laboratories (e.g., metabolic testing for newborns) and in
                cases
                where the State Public Health Laboratory and Department of Health
                and
                Senior Services designated local public health agency laboratories
                perform
                tests, other than those services listed herein, on members for public
                health purposes, the laboratory shall be reimbursed directly by the
                state
                agency on a fee-for-service basis according to the terms and conditions
                of
                the Medicaid program, and such costs shall not be included in the
                Medicaid
                State plan capitated rates.

            

    

    

    
      	c.  	
              Newborn
                Screening Collection Kits:
                According to RSMo 191.331, health care providers must purchase pre-paid
                newborn screening collection kits from the Department of Health and
                Senior
                Services. The Department of Health and Senior Services sells the
                kit to
                providers. When the provider submits a specimen to the State Department
                of
                Health and Senior Services Laboratory, the laboratory shall process
                the
                test, determine if the member is MC+ eligible, and bill the state
                agency
                for the test.

            

    

    

    
      	d.  	
              Special
                Supplemental Nutrition for Women, Infants and Children (WIC)
                Program
                -
                Sections 1902(a)(11)(C) and 1902(a)(53) of the Social Security Act
                and
                Title 42, CFR 431.635 require coordination between the state agency
                and
                the WIC program. While WIC services are not the responsibility of
                the
                health plan, the in-network provider shall document and refer eligible
                members for WIC services. As part of the initial assessment of members,
                and as a part of the initial evaluation of newly pregnant women,
                the
                in-network providers shall provide and document the referral of pregnant,
                breast-feeding, or postpartum women, or a parent/guardian of a child
                under
                the age of five, as indicated, to the WIC Program. Upon contract
                award and
                upon request, the Department of Health and Senior Services shall
                provide
                the health plan with WIC program eligibility and referral
                criteria.

            

    

    

    Harmony
      Health Plan understands and will comply with the requirements set forth in
      RFP
      B3Z06118 paragraph 2.12.2, subsections a-d. 

    

    
      	2.12.3  	
              Transplant
                Services:
                Solid organ and bone marrow/stem cell transplant services are not
                included
                in the comprehensive benefit package as covered benefits. These services
                will be delivered for all populations through separate arrangements.
                Transplant services are defined as the hospitalization from the date
                of
                transplant procedure until the date of discharge, including solid
                organ or
                bone marrow/stem cell procurement charges, and related physician
                services
                associated with both procurement and the transplant procedure. The
                health
                plan shall be responsible for any services before and after this
                admission, including the evaluation that may be related to the condition,
                even though these services may be delivered
                out-of-network.

            

    

    

    
      	a.  	
              According
                to 42 CFR 431.51, Medicaid must insure freedom of choice of providers
                for
                services provided to Medicaid beneficiaries when those services are
                paid
                on a fee-for-service basis outside the health plan. When in-network
                providers identify a member as a potential transplant candidate,
                the
                member must be referred to a transplant facility of their choice
                without
                regard to health plan preference.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.12.3 and subparagraph a. 

    

    
      	2.12.4  	
              Comprehensive
                Substance Treatment Abuse and Rehabilitation (C-STAR)
                programs are carved out of the MC+ managed care program. Services
                provided
                by a C-STAR Medicaid provider shall be reimbursed by the state agency
                on a
                fee-for-service basis according to the terms and conditions of the
                Medicaid program. In order to ensure quality of care, the health
                plan and
                its mental health subcontractors shall maintain open and consistent
                dialogue with C-STAR providers. The health plan shall be responsible
                for
                care coordination of services included in the benefit package and
                C-STAR
                services in accordance with the MC+ managed care policy statement
                titled,
                Mental Health and Substance Abuse Fee-For-Service
                Coordination.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.12.4. 

    

    
      	2.12.5  	
              Mental
                Health Services for Category Of Aid 4:
                For children covered under the health plan within the COA 4 group,
                the
                health plan shall not be financially responsible for the following
                medically necessary mental health and substance abuse
                services:

            

    

    

    
      	a.  	
              Inpatient
                Mental Health and Substance Abuse Services
                shall be any psychiatric stay in an acute care hospital, or in a
                private
                or State psychiatric hospital. The health plan primary care provider
                and
                the child's caseworker shall coordinate services. Admissions must
                be in
                accordance with established guidelines of the Department of Social
                Services in conjunction with the Department of Mental Health. The
                Department of Social Services in conjunction with the Department
                of Mental
                Health will determine the appropriateness of inpatient placement,
                appropriate facility, alternative placement, and psychiatric diversion.
                The state agency’s Medical Review Agency must certify medically necessary
                inpatient days for mental health and substance abuse services (billable
                on
                an inpatient hospital claim form) beyond the days deemed medically
                necessary for physical health.

            

    

    

    
      	b.  	
              For
                inpatients with a dual diagnoses (physical and mental) identified
                at
                either admission or during the stay, the health plan shall be financially
                responsible for all inpatient hospital days if the primary, secondary,
                or
                tertiary diagnosis is a combination of physical and mental health.
                These
                admissions are subject to the health plan’s prior authorization and
                concurrent review process.

            

    

    

    
      	c.  	
              Outpatient
                Mental Health and Substance Abuse Services
                are those services not provided in an inpatient setting. Examples
                of
                appropriate settings are outpatient facility, office, or clinic setting.
                These services must be provided by a licensed psychiatrist, licensed
                psychologist, licensed clinical social worker, provisional licensed
                clinical social worker, licensed counselor, provisional licensed
                professional counselor, licensed psychiatric advanced practice nurse,
                licensed home health psychiatric nurse, or state certified mental
                health
                or substance abuse program. The services will be provided subject
                to
                Medicaid program benefits and
                limitations.

            

    

    

    Paragraph
      2.12.5 d. revised by Amendment #002

     

    
      	d.  	
              Comprehensive
                Community Support Services: Comprehensive
                Community Support Services are provided to children in the custody
                of the
                Children's Division and are found to have behavioral conditions which
                require rehabilitative services at a residential treatment or specialized
                foster care level of care or who are being discharged from these
                two
                treatment levels, and who require comprehensive community support
                services
                in order to maintain the rehabilitation treatment outcome in a less
                restrictive environment. The Children's Division identifies children
                in
                the custody of the Children's Division qualifying for these services
                and
                authorizes provision of comprehensive community support. Comprehensive
                community support services include any medical or remedial service
                reasonable and necessary for maximum reduction of a behavioral disability
                and restoration of the child to his or her best possible functional
                level.
                Examples include, but are not limited to: Intake, Assessment, Evaluation
                and Treatment Planning; Community Support; Specialized Sexual Abuse
                Treatment: 24-hour Crisis Intervention and Stabilization; Intensive
                In-Home Services; Medication Management and Monitoring; Day
                Treatment/Psychosocial Rehabilitation; Therapeutic Counseling or
                Consultation Services not Covered Separately through the HCY or
                Physician's Services Program,  Supported Independent Living and
                Transitional Living Services; and School-Based Behavioral Support
                Services
                not included in the IEP.   The
                services will be provided subject to Medicaid program benefits and
                limitations.  The health plan is not financially liable for
                comprehensive community support
                services.

            

    

    

    Harmony
      Behavioral understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.12.5.

    

    
      	2.12.6  	
              SAFE-CARE
                Exams:
                Sexual Assault Forensic Examination and Child Abuse Resource Education
                (SAFE-CARE) examinations and related diagnostic studies which ascertain
                the likelihood of sexual or physical abuse performed by SAFE-CARE
                trained
                providers shall continue to be reimbursed by the state agency on
                a
                fee-for-service basis according to the terms and conditions of the
                Medicaid program. The state agency shall define which services will
                continue to be reimbursed by the state agency on a fee-for-service
                basis
                according to the terms and conditions of the Medicaid program when
                performed or requested by a SAFE-CARE trained provider. Other medically
                necessary services may be ordered by the SAFE-CARE provider by referring
                to an in-network provider when possible. The health plan shall be
                responsible for these services, regardless whether the SAFE-CARE
                provider
                is in or out of the health plan
                network.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.12.6. 

    

    
      	2.12.7  	
              Pharmacy
                Services: Pharmacy
                services not included in the health plan’s awarded proposal shall be
                reimbursed by the state agency on a fee-for-service basis according
                to the
                terms and conditions of the Medicaid
                program.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.12.7. 

    

    
      	2.12.8  	
              Protease
                Inhibitors:
                Protease inhibitors shall be reimbursed by the state agency on a
                fee-for-service basis according to the terms and conditions of
                the Medicaid program.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.12.8. 

    

    
      	2.12.9  	
              Abortion
                Services:
                Abortion services subject to Medicaid program
                benefits and limitations shall continue to be reimbursed by the state
                agency on a fee-for-service basis according to the terms and conditions
                of
                the Medicaid program.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.12.9. 

    

    
      	2.12.10  	
              Mentally
                Retarded and Developmental Disabilities (MRDD) Waiver:
                Home
                and community based waiver services for persons in the MRDD waiver
                are
                carved out of the MC+ managed care program. The health plan shall
                be
                responsible for MC+ managed care covered services for MRDD waiver
                clients
                enrolled in MC+ managed care, unless specifically excluded. The health
                plan shall be responsible for care coordination of services included
                in
                the benefit package and the Home and Community based waiver. The
                state
                agency shall identify the MRDD Waiver participants to the health
                plan.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.12.10. 

    

    
      	2.12.11  	
              Home
                Birth Services:
                In
                accordance with the MC+ managed care home birth policy statement,
                if a
                member elects a home birth the member shall be disenrolled from MC+
                managed care. The disenrolled member shall then receive services
                through
                the MC+ fee-for-service program for the home
                birth.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.12.11. 

    

    
      	2.12.12  	
              Services
                for Children in the Custody of the Jackson County Office of the Missouri
                Children’s Division: Under
                court order (G.L. v. Stangler, also called the Consent Decree), children
                in the custody of the Jackson County office of the Missouri Children’s
                Division (CD) and residing in Cass, Clay, Henry, Jackson, Johnson,
                Lafayette, Platte, Ray, or St. Clair counties have additional medical
                care
                requirements.

            

    

    

    
      	a.  	
              In
                addition to the services outlined herein, the health plan shall provide
                the following services following the effective date of enrollment
                with the
                health plan. If the child is already enrolled with the health plan
                and
                enters custody, the health plan shall provide the following services
                from
                the time the child enters CD custody. The time frames for these
                examinations begin with the time and date the child enters CD
                custody.

            

    

    

    
      	1)  	
              A
                physical examination within 36 hours. The 36 hour exam is due the
                next
                working day following entry into custody. (This shall be paid by
                Medicaid
                on a fee-for-service basis and arranged by CD if the child is not
                enrolled
                in a health plan at the time of entry into CD custody.) A complete
                physical examination may be replaced by partial physical examination
                if
                the CD caseworker and the provider agree that a complete physical
                examination is unnecessary, repetitive, or would cause undue stress
                for
                the child. If agreement is reached that a partial physical examination
                is
                adequate, the provider shall decide the scope of the partial physical
                examination. Agreement that a complete physical examination is not
                necessary shall be documented in the child’s medical record. In all cases,
                if a child is enrolled with the health plan prior to the 36-hour
                deadline,
                the health plan shall be responsible for providing the examination.
                If the
                health plan does not provide the examination, the health plan shall
                reimburse the provider that performs the examination in accordance
                with
                the current Medicaid fee schedule. CD, the Medical Case Management
                Agency,
                and the health plan shall work together to establish a notification
                process so that the health plan receives notification of the enrollment
                of
                a Consent Decree-covered child in a timely
                manner.

            

    

    

    
      	2)  	
              Within
                30 calendar days - Follow-up examinations recommended by the provider
                during the 36-hour examination; i.e.: hearing and eye exams, dental
                screens or a full HCY screen shall be done in accordance with the
                most
                recent periodicity schedule. A partial HCY screening may be administered
                if the child is current with his or her HCY screening schedule and
                the CD
                caseworker and provider agree that a full HCY screening is unnecessary,
                repetitive, or would cause undue stress for the child. If agreement
                is
                reached that a partial HCY screening is adequate, the provider shall
                decide the scope of the partial HCY screening. Agreement that a full
                HCY
                screening is not necessary shall be documented in the child’s medical
                record.

            

    

    

    
      	b.  	
              Following
                the 30 calendar day screening requirements, the HCY schedule shall
                be
                followed for children up to five years of age with annual examinations
                after age five unless the child has physical health, mental health,
                or
                developmental health problems identified by the provider that require
                medically necessary treatment on a more frequent
                basis.

            

    

    

    
      	c.  	
              The
                health plan shall be responsible for determinations regarding medically
                necessary treatments, medically necessary appointments, and medically
                necessary services.

            

    

    

    
      	d.  	
              Consent
                Decree Medical Case Management:
                Children in the custody of the Jackson County office of the Missouri
                Children’s Division and residing in Jackson County also receive targeted
                medical case management services. Medical case management services
                are
                intended to facilitate access to medical services for the targeted
                children. Although this medical case management will be provided
                through a
                separate contract between the Department of Social Services and a
                Medical
                Case Management agency, the health plan shall provide the medical
                care
                required by the Consent Decree and all services specified herein
                for
                children in State custody. Per the Consent Decree, G.L. v. Stangler
                Amended Revised Operational Guide; March 14, 2002, and the contract
                with
                Medical Case Management agencies, children are followed at three
                different
                levels: Category 1, well children; Category 2, children with behavioral
                or
                mental health needs; and Category 3, children with medical needs.
                Children
                identified as Category 2 and Category 3 will remain in targeted medical
                case management during the entire time they are in custody. Category
                1
                children will be enrolled for targeted medical case management only
                during
                the first 30 calendar days of custody. The medical case management
                services provided by the Medical Case Management Agency include,
                but are
                not limited to:

            

    

    

    
      	1)  	
              Promoting
                the effective and efficient access to comprehensive medical services
                for
                the targeted children,

            

    

    
      	2)  	
              Facilitating
                the coordination of medical
                services,

            

    

    
      	3)  	
              Maintaining
                confidential centralized files for each
                child,

            

    

    
      	4)  	
              Assisting
                in the education of CD staff, caregivers, and health care providers
                regarding the child’s medical care,

            

    

    
      	5)  	
              Providing
                information regarding the need for specialized health
                services,

            

    

    
      	6)  	
              Coordinating
                and monitoring all primary and specialty care necessary for the child,
                and

            

    

    
      	7)  	
              Ensuring
                that essential medical care received by the child complies with the
                Consent Decree, Part III.

            

    

    

    
      	e.  	
              The
                health plan and providers shall cooperate with the Medical Case Management
                Agency in securing medical histories and providing medical records
                as
                required by the Consent Decree. The health plan shall allow case
                managers
                to file an appeal immediately (or within 12 hours if a concern arises
                after regular business hours) to the health plan’s MC+ Medical Director if
                a Consent Decree case managed child is denied services or has difficulty
                accessing services covered in the
                contract.

            

    

    

    
      	f.  	
              The
                health plan shall designate a person within the health plan as a
                primary
                contact for CD staff, caregivers, and health care providers for issues
                involving these targeted children. The health plan shall also participate
                and attend medical oversight
                meetings.

            

    

    

    Harmony
      Health Plan is not applying to the state to serve members in the western region
      at this time. 

    

    
      	2.13  	
              Second
                Opinion: Members
                have a right to second opinions from qualified health care professionals,
                and the health plan shall have policies and procedures for rendering
                second opinions both in-network and out-of-network when requested
                by a
                member. The health plan’s policies and procedures shall address whether
                there is a need for referral by the primary care provider or
                self-referral. The adequacy of these policies and procedures shall
                be
                examined during quality assessment reviews. Missouri Revised Statutes
                Section 208.152 states that certain elective surgical procedures
                require a
                second medical opinion be provided prior to the surgery. A third
                surgical
                opinion, provided by a third provider, shall be allowed if the second
                opinion fails to confirm the primary recommendation that there is
                a
                medical need for the specific surgical operation, and if the member
                desires the third opinion.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.13. Harmony has policies and procedures to ensure
      compliance with the aforementioned Performance Requirements.  Please refer
      to the Appendix Binder, Tab 1, Item 7 for Second
      Surgical/Medical Opinion Policy
      and Procedure.  This policy and procedure may be updated from time to time,
      but shall remain compliant with DSS standards. 

    

    
      	2.14  	
              Service
                Accessibility Standards:

            

    

    

    
      	2.14.1  	
              Twenty-Four
                Hour Coverage:
                The health plan shall provide coverage to members on a twenty-four
                (24)
                hour per day, seven (7) day per week basis. The health plan shall
                have
                written policies and procedures describing how members and providers
                can
                contact the health plan to receive individual instruction or authorization
                for treatment of an emergent or urgent medical, mental health, or
                substance abuse problem and instruction regarding receiving care
                when the
                member is out of the health plan's geographic area. The health plan
                must
                make the policies and procedures available in an accessible format
                upon
                request. The health plan must provide for direct contact with qualified
                clinical staff through a toll-free member or provider services telephone
                number and a telecommunication device for the deaf telephone number.
                Recorded messages are not acceptable. The health plan shall provide
                an
                accommodation, if needed, to ensure all members equal access to
                twenty-four hour per day health care
                coverage.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.14.1. Harmony has policies and procedures to ensure
      compliance with the aforementioned Performance Requirements.  Please refer
      to the Appendix Binder, Tab 1, Item 3 for Authorization
      and Availability Policy
      and Procedure.  This policy and procedure may be updated from time to time,
      but shall remain compliant with DSS standards. 

     

    
      	2.14.2  	
              Prior
                Authorization:

            

    

    

    
      	a.  	
              The
                health plan shall ensure that prior authorization requirements are
                not
                applied to emergency medical/mental health services as defined
                herein.

            

    

    

    
      	b.  	
              The
                health plan shall specify, in writing, the procedures for prior
                authorization of non-emergency services and the time frames in which
                authorizations will be processed (approved or denied) and providers
                and
                members are notified.

            

    

    

    
      	c.  	
              If
                the health plan requires a referral, assessment, or other requirement
                prior to the member accessing requested medical or mental health
                services,
                such requirements shall not be an impediment to the timely delivery of the
                medically necessary service. The health plan shall assist the member
                to
                make any necessary arrangements to fulfill such requirements (i.e.,
                scheduling appointments, providing comprehensive lists of available
                providers, etc.). If such arrangements cannot be made timely, the
                requested services shall be
                approved.

            

    

    

    
      	d.  	
              The
                health plan shall ensure that its prior authorization procedures
                meet the
                following minimum requirements:

            

    

    

    
      	1)  	
              All
                appeals and denials must be reviewed by a professional with experience
                or
                expertise comparable to the provider requesting the
                authorization.

            

    

    

    
      	2)  	
              There
                is a set of written criteria for review based on sound medical evidence
                that is updated regularly and consistently applied and for consultations
                with the requesting provider when
                appropriate.

            

    

    

    
      	3)  	
              Reasons
                for decisions are clearly documented and assigned a prior authorization
                number which refers to and documents approvals and
                denials.

            

    

    

    
      	4)  	
              Documentation
                shall be maintained on any alternative service(s) approved in lieu
                of the
                original request.

            

    

    

    
      	5)  	
              There
                is a well-publicized review process for both providers and
                members.

            

    

    

    
      	6)  	
              The
                review process is completed and communicated to the provider in a
                timely
                manner, as indicated below, or the denials shall be deemed approved.
                For
                the purpose of this section, “necessary information” includes the results
                of any face-to-face clinical evaluation or second opinion that may
                be
                required.

            

    

    

    
      	·  	
              Approval
                or denial of non-emergency services when determined as such by emergency
                room staff shall be provided by the health plan within thirty (30)
                minutes
                of request.

            

    

    

    
      	·  	
              Approval
                or denial shall be provided within twenty-four (24) hours of request
                for
                services determined to be urgent by the treating
                provider.

            

    

    

    
      	·  	
              Approval
                or denial shall be provided within two (2) business days of obtaining
                all
                necessary information for routine services. The health plan shall
                notify
                the requesting provider within two business days following the receipt
                of
                the request of service regarding any additional information necessary
                to
                make a determination. In no case shall a health plan exceed fourteen
                (14)
                calendar days following the receipt of the request of service to
                provide
                approval or denial.

            

    

    

    
      	·  	
              Involuntary
                detentions (96 hour detentions or court ordered detentions) or commitments
                shall not be prior authorized.

            

    

    

    
      	e.  	
              The
                health plan shall ensure that members are not without necessary medical
                supplies, oxygen, nutrition, pharmaceutical products, etc., and must
                have
                written procedures for making an interim supply of an item
                available.

            

    

    

    
      	f.  	
              The
                health plan shall ensure that the member's treatment regimens are
                not
                interrupted or delayed (i.e. physical, occupational, and speech therapy;
                psychological counseling; home health services; personal care, etc.)
                by
                the prior authorization process.

            

    

    

    
      	g.  	
              If
                the health plan approves purchase of a custom or power wheelchair,
                eyeglasses, hearing aids, dentures (excluding orthodontic services),
                custom HCY/EPSDT equipment, augmentative communication devices placed
                within six months of approval, etc. which is delivered or placed
                after
                enrollment in the health plan ends, the health plan shall be responsible
                for payment.

            

    

    

    
      	h.  	
              If
                the health plan requires prior authorization for pharmacy products,
                the
                health plan shall provide a response by telephone or other
                telecommunication device within 24 hours of a request for prior
                authorization. Approvals must be granted for claims meeting established
                criteria approved by the state. The state will approve criteria that
                follows accepted national guidelines for appropriate product use.
                The
                criteria shall be based on medical and clinical information and
                Missouri-specific data, consistent with the predetermined standards
                set by
                one or more of the following: 

            

    

    

    
      	·  	
              The
                American Hospital Formulary Service - Drug Information
                

            

    

    
      	·  	
              The
                United States Pharmacopoeia Drug Information

            

    

    
      	·  	
              Peer-reviewed
                medical literature.

            

    

    

    Specific
      details describing pharmacy prior authorization and step therapy criteria shall
      be made available to prescribers upon request. Prescribers shall be informed
      of
      the availability of the criteria when a prescription is denied. The health
      plan
      shall provide for the dispensing of at least a 72-hour supply or a sufficient
      supply to the next business day of a drug product that requires prior
      authorization in an emergency situation.

    

    
      	i.  	
              If
                the health plan prior authorizes health care services, the health
                plan
                shall not subsequently retract its authorization after the services
                have
                been provided, or reduce payment for an item or service unless:
                

            

    

    

    
      	·  	
              The
                authorization is based on material misrepresentation or omission
                about the
                treated person’s health condition or the cause of the health condition; or
                

            

    

    
      	·  	
              The
                health plan terminates before the health care services are provided;
                or
                

            

    

    
      	·  	
              The
                covered person’s coverage under the health plan terminates before the
                health care services are provided. 

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.14.2 and subparagraphs a - i. Harmony has policies and
      procedures to ensure compliance with the aforementioned Performance
      Requirements.  Please refer to the Appendix Binder, Tab 1,
Items
      4, 5, 8
      for policies and procedures on Service
      Authorization Decisions; Application of Criteria; and Inpatient Concurrent
      Review. 
      These policies and procedures may be updated from time to time, but shall remain
      compliant with DSS standards 

     

    
      	2.14.3  	
              Travel
                Distance: The
                health plan shall comply with travel distance standards as set forth
                by
                the Department of Insurance in 20 CSR 400-7.095 regarding Provider
                Network
                Adequacy Standards. For those providers not addressed under 20 CSR
                400-7.095, the health plan shall ensure members have access to those
                providers within a reasonable travel distance. For those providers
                addressed under 20 CSR 400-7.095 but not applicable to the MC+ Managed
                Care Program (e.g. chiropractors), the health plan shall not be held
                accountable for the distance standards for those
                providers.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.14.3. Please refer to Appendix Binder, Tab 5, for the
      most
      current listing of providers with whom Harmony has executed Letters of Intent
      (LOI) or executed Letters of Agreement (LOA) with negotiated rates and/or
      executed contracts.

    

    Harmony
      will monitor the adequacy of its provider network on an on-going basis. The
      Director of Network Contracting and Services will evaluate the provider network
      and make reports to the Executive Director. A formal evaluation and report
      will
      be completed periodically identifying areas that are less than adequate while
      the network is in the process of development. Geo access reports will be
      monitored for compliance and resolution of any deficiency identified will be
      monitored.

    

    Additionally,
      Harmony may use information from member surveys, member complaints and access
      standards to determine if any deficiencies arise. Harmony will monitor the
      ratio
      of Medicaid members to PCP’s.  

    

    In
      specialties where Harmony could use additional providers, Harmony intends to
      continue contracting efforts in those specialties to make them more available
      to
      Harmony members.
      Furthermore, where continuation of care dictates that a non-network provider
      is
      necessary, Harmony has established policies and procedures to support this
      function. 

    

    Paragraph
      2.14.4 revised by Amendment #002

     

    
      	2.14.4  	
              Appointment
                Standards: For
                mental health and substance abuse services, aftercare appointments
                shall
                occur within seven (7) calendar days after hospital discharge.
                

            

    

    

    
      	a.  	
              The
                average waiting times for primary care appointments shall not exceed
                one
                hour from scheduled appointment time. This includes time spent both
                in the
                lobby and in the examination room prior to being seen by a provider.
                Providers can be delayed when they "work in" urgent cases, when a
                serious
                problem is found, or when the member had an unknown need that requires
                more services or education than was described at the time the appointment
                was made.

            

    

    

    
      	b.  	
              The
                health plan shall have procedures in place that
                ensure:

            

    

    

    
      	1)  	
              Urgent
                care appointments for illness injuries which require care immediately
                but
                do not constitute emergencies, within 24 hours (e.g. high temperature,
                persistent vomiting or diarrhea, symptoms which are of sudden or
                severe
                onset but which do not require emergency room
                services).

            

    

    

    
      	2)  	
              Routine
                care, with symptoms, appointments must be available within one (1)
                week or
                five (5) business days whichever is earlier (e.g. persistent rash,
                recurring high grade temperature, nonspecific pain,
                fever).

            

    

    

    
      	3)  	
              Routine
                care, without symptoms, appointments must be available within thirty
                (30)
                calendar days (e.g. well child exams, routine physical
                exams).

            

    

    

    
      	4)  	
              For
                mental health and substance abuse services, aftercare appointments
                shall
                occur within one (1) week or five (5) business days after hospital
                discharge whichever is earlier. 

            

    

    

    
      	c.  	
              For
                maternity care, the health plan shall be able to provide initial
                prenatal
                care appointments for enrolled pregnant members as
                follows:

            

    

    

    
      	1)  	
              First
                trimester, must be available within seven (7) calendar days of first
                request.

            

    

    

    
      	2)  	
              Second
                trimester, must be available within seven (7) calendar days of first
                request.

            

    

    

    
      	3)  	
              Third
                trimester, must be available within three (3) calendar days of first
                request.

            

    

    

    
      	4)  	
              High
                risk pregnancies, must be available within three (3) calendar days
                of
                identification of high risk to the health plan or maternity care
                provider,
                or immediately if an emergency
                exists.

            

    

    

    
      	d.  	
              Policies
                and Procedures: The health plan shall disseminate its appointment
                standards to the network. The health plan shall monitor the adequacy
                of
                its appointment standards to ensure the reduction of unnecessary
                use of
                emergency room visits.

            

    

    

    
      	1)  	
              The
                health plan shall have written policies and procedures concerning
                educating the provider network about appointment standards. The health
                plan shall monitor compliance with appointment standards and shall
                have a
                corrective action plan when appointment standards are not
                met.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.14.4 and subparagraphs a-d. 

    

    The
      Director of Network Contracting and Services will maintain responsibility for
      developing and maintaining a network that will provide adequate access to
      covered services and meet the needs of all members in the MC+ service
      area.  

     

    
      	·  	
              Geo
                Access analysis will be conducted and provided to the Director to
                ensure
                an adequate network exists based upon the current membership. 
                

            

    

    
      	·  	
              The
                Director will review the Geo-Access reports quarterly to readily
                identify;
                

            

    

    
      	·  	
              Availability
                of services, based on current membership, in need of additional network
                development and;

            

    

    
      	·  	
              Present
                corrective action plans to the Executive Director on a quarterly
                basis,
                when required to ensure compliance with the requirements of network
                adequacy.

            

    

    
      	·  	
              Harmony
                will utilize provider education visits by Provider Relations staff
                to
                monitor, on an on-going basis, appointment availability 24 hours/7
                days a
                week, waiting times, open panels of PCP’s within Harmony’s provider
                network. Such documentation shall be recorded on the provider visit
                form.
                Any non-compliance issues will be monitored by the Provider Relations
                Manager and Provider Relations staff. This will allow for any
                non-compliance issues to be immediately addressed with education
                to the
                participating provider. 

            

    

    
      	·  	
              The
                Provider Relations staff will address any member complaints received
                within 48 hours of any participating provider
                accessibility.

            

    

    

    Harmony
      has policies and procedures to ensure compliance with the aforementioned
      Performance Requirements.  Please refer to the Appendix Binder, Tab 1,
Item
      3
      for Availability
      of Services Policy
      and Procedure.  This policy and procedure may be updated from time to time,
      but shall remain compliant with DSS standards. 

    

    
      	2.14.5  	
              The
                health plan shall have established written policies and procedures
                concerning how a member may obtain a referral to an out-of-network
                provider when the health plan does not have a health care provider
                with
                appropriate training or experience in the network to meet the particular
                health care needs of the member.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.14.5. Harmony has policies and procedures to ensure
      compliance with the aforementioned Performance Requirements.  Please refer
      to the Appendix Binder, Tab 1, Item 6 for Referrals
      to Non-Contracted Providers Policy
      and Procedure.  This policy and procedure may be updated from time to time,
      but shall remain compliant with DSS standards 

    

    
      	2.14.6  	
              The
                health plan shall have established written policies and procedures
                concerning how a member, with a condition which requires on-going
                care
                from a specialist, may request a standing referral to such a
                specialist.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.14.6. Harmony has policies and procedures to ensure
      compliance with the aforementioned Performance Requirements.  Please refer
      to the Appendix Binder, Tab 1, Item 9 for Standing
      Referrals Policy
      and Procedure.  This policy and procedure may be updated from time to time,
      but shall remain compliant with DSS standards 

    

    
      	2.14.7  	
              The
                health plan shall have established written policies and procedures
                concerning how a member, with a life-threatening condition or disease
                either of which requires a specialized medical care over a prolonged
                period of time, may request and obtain access to a specialty care
                center.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.14.7. 

    

    
      	2.14.8  	
              In
                accordance with State law, the health plan must allow members direct
                access to the services of the in-network OB/GYN of their choice for
                the
                provision of covered services.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.14.8. Members shall be granted direct access to a women’s
      health specialist for routine and preventative health care services, including
      but not limited to, breast exams, mammograms and pap smears.

    

    
      	2.14.9  	
              In
                accordance with State law, the health plan must notify the member
                on an
                annual basis, in writing, of cancer screenings covered by the health
                plan
                and provide the current American Cancer Society guidelines for all
                cancer
                screenings.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.14.9. 

    

    
      	2.14.10  	
              The
                health plan shall have policies and procedures concerning how it
                will
                appropriately work with an out-of-network provider and/or the previous
                health plan to effect a transfer of care to appropriate in-network
                providers when a newly enrolled member has an existing relationship
                with a
                provider that is not in the health plan’s network. For continuity of care,
                there are instances in which care shall continue with the out-of-network
                provider (e.g. third trimester pregnancy, in the middle of a course
                of
                treatment for cancer, etc.)

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.14.10. Harmony has policies and procedures to ensure
      compliance with the aforementioned Performance Requirements.  Please refer
      to the Appendix Binder, Tab 1, Item 10 for Transition
      of Care Policy
      and Procedure.  This policy and procedure may be updated from time to time,
      but shall remain compliant with DSS standards 

    

    
      	2.14.11  	
              Care
                Management:
                The health plan shall provide care management to members. Care management
                is coordination of care provided to
                members.

            

    

    

    
      	a.  	
              The
                health plan shall coordinate and deliver services designed to achieve
                the
                following outcomes:

            

    

    

    
      	1)  	
              Improved
                patient care;

            

    

    
      	2)  	
              Improved
                health outcomes;

            

    

    
      	3)  	
              Reduction
                of inappropriate inpatient
                hospitalization;

            

    

    
      	4)  	
              Reduction
                of inappropriate utilization of emergent
                services;

            

    

    
      	5)  	
              Lower
                total costs; and

            

    

    
      	6)  	
              Better
                educated providers and patients.

            

    

    

    
      	b.  	
              The
                health plan should have the following components in the care management
                program:

            

    

    

    
      	1)  	
              Use
                of clinical practice guidelines;

            

    

    
      	2)  	
              Provider
                and patient profiling;

            

    

    
      	3)  	
              Specialized
                physician and other practitioner care targeted to meet members special
                needs;

            

    

    
      	4)  	
              Provider
                education;

            

    

    
      	5)  	
              Patient
                education;

            

    

    
      	6)  	
              Claims
                analyses; and

            

    

    
      	7)  	
              Quarterly
                and yearly outcome measurement and reporting. The reporting requirements
                specified in Attachment 6 will satisfy this component. (Definition
                used
                with permission of The Center for Case Management, 6 Pleasant Street,
                South Natick, MA 01760.)

            

    

    

    
      	c.  	
              The
                health plan must have implemented and effective policies and procedures
                for case management, care coordination, and disease
                management:

            

    

    

    
      	1)  	
              Case
                management is a clinical system that focuses on the accountability
                of an
                identified individual or group for coordinating a patient’s care (or group
                of patients) across an episode or continuum of care; negotiating,
                procuring, and coordinating services and resources needed by
                patients/families with complex issues; insuring and facilitating
                the
                achievement of quality, clinical, and cost outcomes; intervening
                at key
                points for individual patients; addressing and resolving patterns
                of
                issues that have a negative quality cost impact; and creating
                opportunities and systems to enhance outcomes. (Definition used with
                permission of The Center for Case Management, 6 Pleasant Street,
                South
                Natick, MA 01760.) Case management is understood as including, but
                not
                limited to the development of individualized treatment plans and
                ongoing
                communication and coordination with other systems of care. The treatment
                plans must be:

            

    

    

    
      	·  	
              Developed
                by the member’s primary care provider with member participation, and in
                consultation with any specialists caring for the
                member;

            

    

    
      	·  	
              Approved
                by the entity in a timely manner, if this approval is required;
                and

            

    

    
      	·  	
              In
                accord with any applicable State quality assurance and utilization
                review
                standards.

            

    

    

    
      	2)  	
              Care
                Coordination is a method of coordinating the provision of health
                care so
                as to improve its continuity and quality. (Definition used with permission
                of the Center for Health Care Strategies, Inc., Princeton, New Jersey.
                “Case Management in Managed Care For People With Developmental
                Disabilities: Models, Cost and Outcomes. January,
                1999”.)

            

    

    

    
      	3)  	
              Disease
                Management is the process of intensively managing a particular disease
                or
                syndrome. Disease management encompasses all settings of care and
                places a
                heavy emphasis on prevention and maintenance. It is similar to case
                management, but more focused on a defined set of problems relative
                to an
                illness or syndrome. (Definition used with permission of Center for
                Health
                Care Strategies, Inc., Princeton, New Jersey, “Case Management in Managed
                Care For People With Developmental Disabilities: Models, Costs and
                Outcomes, January, 1999”.)

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.14.11 and subparagraphs a - c. Harmony’s care management
      program is part of its health services management activities. Harmony believes
      that improving the health status of our members and reducing the cost of health
      care provided are not mutually exclusive goals. In order to help patients get
      the most appropriate care in the most appropriate setting and improve health
      outcomes, Harmony has developed utilization management (UM) and case management
      (CM) procedures that re implemented by the Health Services Management
      Department. Harmony’s UM procedures are designed to ensure that members receive
      medically necessary care in the appropriate inpatient or outpatient setting
      and
      to safeguard against over-utilization and under-utilization of Health care
      services.

    

    Harmony’s
      case management program promotes a continuum of care in lieu of managing care
      on
      an episodic, illness-oriented basis and ensures that discharge and referral
      from
      inpatient care is done in a coordinated manner. Harmony’s program coordinates
      the care of those individuals with chronic, complex or catastrophic illnesses
      or
      injuries. For inpatient case management, Harmony’s Health Services Management
      department works with the attending physician and hospital discharge planner
      to
      refer the member to quality, contracted, ancillary providers in a timely manner,
      which avoids delays and lack of care coordination at the time of the patient’s
      discharge.

    

    Harmony
      has also developed a number of case management programs to promote preventive
      care and health awareness for populations with conditions that require ongoing
      case management. 

    

    Harmony
      has a number of policies and procedures which support the requirements of care
      management. Please refer to Appendix Binder, Tab 1, item #’s
10,11,12,13,14,
      and 15
      respectively, for P&P’s titled “Prenatal Reward Program”; “Complex Case
      Management”; “HIV/Aids”; “Pediatric Case Management”; “Wound Care”; Asthma
      Disease Management and Diabetes Disease Management. These policies and
      procedures may be updated from time to time, but shall remain compliant with
      DSS
      standards.

    

    

    
      	2.14.12  	
              Certification
                Review:

            

    

    

    
      	a.  	
              The
                health plan shall specify, in writing, the procedures for obtaining
                initial, concurrent, and retrospective reviews for inpatient admissions
                and the time frames in which authorizations will be processed (approved
                or
                denied) and providers and members are notified. The health plan shall
                ensure that the procedures meet the following minimum
                requirements:

            

    

    

    
      	·  	
              A
                professional with experience or expertise comparable to the provider
                requesting the authorization must review all appeals and
                denials.

            

    

    
      	·  	
              There
                are standard policies and procedures for inpatient hospital admissions,
                continued stay reviews, and retrospective reviews and for making
                determinations on certifications or extensions of stays based on
                sound
                medical evidence that is updated regularly and consistently applied
                and
                for consultations with the requesting provider when
                appropriate.

            

    

    
      	Ø  	
              For
                inpatient hospital admissions, continued stay reviews, and retrospective
                reviews to specialty pediatric hospitals, the health plan must use
                the
                same criteria as Medicaid
                fee-for-service.

            

    

    
      	Ø  	
              For
                psychiatric inpatient hospital admissions, continued stay reviews,
                and
                retrospective reviews, the health plan must use the same criteria
                as
                Medicaid fee-for-service
                (LOCUS/CALOCUS).

            

    

    
      	·  	
              Reasons
                for decisions are clearly documented and assigned a certification
                number,
                which refers to and documents approvals and
                denials.

            

    

    
      	·  	
              Documentation
                shall be maintained on any alternative service approved in lieu of
                the
                original request.

            

    

    
      	·  	
              There
                are fair and unbiased policies and procedures for reconsideration
                requests
                when the attending physician, the hospital, or the member disagrees
                with
                the health plan’s determination regarding inpatient hospital admission or
                continued stays.

            

    

    
      	·  	
              There
                are written policies and procedures followed to address the failure
                or
                inability of a provider or a member to provide all necessary information
                for review. In cases where the provider or a member will not release
                necessary information, the health plan may deny certification of
                an
                admission.

            

    

    
      	·  	
              There
                is a well-publicized review process for both provider and
                members.

            

    

    
      	·  	
              To
                the extent known, inform inpatient providers of the enrollees recent
                health care service history at the time of authorization of a psychiatric
                inpatient admission. Such information shall include psychiatric inpatient
                admissions and emergency room visits for the prior year, psychiatric
                outpatient services for the prior six months, and medications for
                the
                prior 90 calendar days. Information about specific episodes of care
                shall
                include date, diagnosis, provider, and procedure. Services related
                to
                substance abuse or HIV disorders are exempt from this
                requirement.

            

    

    

    
      	b.  	
              The
                review process shall be completed and communicated to the provider
                and
                member in a timely manner, as indicated below, or the denials shall
                be
                deemed approved. For the purpose of this section, “necessary information”
                includes the results of any face-to-face clinical evaluation or second
                opinion that may be required.

            

    

    

    
      	·  	
              Approval
                or denial for initial determinations shall be provided by the health
                plan
                within two (2) working days of obtaining all necessary
                information.

            

    

    
      	·  	
              Approval
                or denial for concurrent review determinations shall be provided
                by the
                health plan within one (1) working day of obtaining all necessary
                information.

            

    

    
      	·  	
              Approval
                or denial for retrospective review determinations shall be provided
                by the
                health plan within thirty (30) working days of receiving all necessary
                information.

            

    

    
      	·  	
              The
                health plan shall notify the requesting provider within two (2) working
                days following the receipt of the request of service regarding any
                additional information necessary to make a
                determination.

            

    

    
      	·  	
              In
                no case shall a health plan exceed fourteen (14) calendar days following
                the receipt of the request of service to provide approval or denial
                for an
                initial or concurrent review. 

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.14.12 and subparagraphs a - b, and has a number of policies
      and procedures which support these requirements. These
      P&Ps are entitled 2.1 Service Authorization, 3.4 Application of Criteria and
      5.4 Inpatient Concurrent Review. Please refer to Appendix Binder, Tab 1, Item
      #’s 4, 5, and 8.
      These policies and procedures may be updated from time to time, but shall remain
      compliant with DSS standards.

    

    
      	2.15  	
              Member
                Grievance System: The
                health plan shall have a system in place for members which includes
                a
                grievance process, an appeal process, and access to the state agency’s
                fair hearing system.

            

    

    

    
      	2.15.1  	
              For
                purposes of the health plan’s grievance system, the following definitions
                shall apply:

            

    

    

    Action
      - The
      denial or limited authorization of a requested service, including the type
      or
      level of service; the reduction, suspension, or termination of a previously
      authorized service; the denial, in whole or in part, of payment for a service;
      the failure of the health plan to provide services in a timely manner as defined
      in the appointment standards described herein; or the failure of the health
      plan
      to act within timeframes for the health plan’s Prior Authorization review
      process specified herein. 

    

    Appeal
      - A
      request
      for review of an action, as action is defined in this section.

    

    Appeal
      Process -- The
      health plan’s process for handling of appeals that complies with the
      requirements specified herein, including, but not limited to, the procedural
      steps for a member to file an appeal, the process for resolution of an appeal,
      the right to access the State fair hearing system, and the timing and manner
      of
      required notifications.

    

    Grievance
      - An
      expression of dissatisfaction about any matter other than an action, as action
      is defined in this section. Possible subjects for grievances include, but are
      not limited to, the quality of care or services provided, and aspects of
      interpersonal relationships such as rudeness of a provider or employee, or
      failure to respect the member’s rights.

    

    Grievance
      Process -- The
      health plan process for handling of grievances that complies with the
      requirements specified herein, including, but not limited to, the procedural
      steps for a member to file a grievance, the process for disposition of a
      grievance, and the timing and manner of required notifications.

    

    Grievance
      System - The
      overall system in place for members that includes a grievance process, an appeal
      process, and access to the State fair hearing system.

    

    Inquiry
      - A
      request from a member for information that would clarify health plan policy,
      benefits, procedures, or any aspect of health plan function but does not express
      dissatisfaction.

    

    Harmony
      Health Plan understands and will adhere to the definitions set forth in RFP
      B3Z06118 paragraph 2.15.1. 

    

    
      	2.15.2  	
              General
                Requirements:
                The health plan shall develop and implement written policies and
                procedures that detail the operation of the grievance system and
                provides
                simplified instructions on how to file a grievance or appeal and
                how to
                request a state fair hearing.

            

    

    

    
      	a.  	
              The
                policies and procedures must be approved by the state agency prior
                to
                implementation.

            

    

    

    
      	b.  	
              The
                policies and procedures shall be approved by the health plan's governing
                body and be the direct responsibility of the governing
                body.

            

    

    

    
      	c.  	
              The
                health plan shall distribute an information packet to members upon
                enrollment which contains the grievance system policies and procedures,
                specific instructions regarding how to contact the health plan’s member
                services, and identifies the person from the health plan who receives
                and
                processes grievances and appeals. The health plan shall also distribute
                the information packet to all in-network providers at the time they
                enter
                into a contract and to out-of-network providers within ten (10) calendar
                days of prior approval of a service or the date of receipt of a claim
                whichever is earlier.

            

    

    

    
      	d.  	
              The
                policies and procedures shall identify specific individuals who have
                authority to administer the grievance system
                policies.

            

    

    

    
      	e.  	
              The
                grievance system policies and procedures shall be readily available
                verbally and in the member's primary language. In addition, the health
                plan shall demonstrate that they have procedures in place to notify
                all
                members in their primary language of grievance dispositions and appeal
                resolutions.

            

    

    

    
      	f.  	
              As
                part of the grievance system, the health plan shall ensure that health
                plan executives with the authority to require corrective action are
                involved in the grievance and appeal
                processes.

            

    

    

    
      	g.  	
              The
                health plan shall thoroughly investigate each grievance and appeal
                using
                applicable statutory, regulatory, contractual provisions, and the
                health
                plan’s written policies and procedures. Pertinent facts from all parties
                must be collected during the
                investigation.

            

    

    

    
      	h.  	
              The
                health plan shall probe inquiries so as to validate the possibility
                of any
                inquiry actually being a grievance or appeal. The health plan shall
                identify any inquiry pattern.

            

    

    

    
      	i.  	
              The
                health plan’s grievance system shall not be a substitute for the State
                fair hearing process. The state agency shall maintain an independent
                State
                fair hearing process as required by federal law and regulation, as
                amended. The State fair hearing process shall provide members an
                opportunity for a State fair hearing before an impartial hearing
                officer.
                The parties to the State fair hearing include the health plan as
                well as
                the member and his or her representative or the representative of
                a
                deceased member’s estate. The health plan shall comply with decisions
                reached as a result of the State fair hearing process. Health plan
                members
                shall have the right to request information
                regarding:

            

    

    

    
      	·  	
              The
                right to request a State fair hearing.

            

    

    
      	·  	
              The
                procedures for exercising the rights to appeal or request a State
                fair
                hearing.

            

    

    
      	·  	
              Representing
                themselves or use legal counsel, a relative, a friend, or other
                spokesperson.

            

    

    
      	·  	
              The
                specific regulations that support or the change in Federal or State
                law
                that requires the action.

            

    

    
      	·  	
              The
                individual’s right to request a state fair hearing, or in cases of an
                action based on change in law, the circumstances under which a hearing
                will be granted.

            

    

    
      	·  	
              A
                State fair hearing within 90 calendar days from the health plan’s notice
                of action.

            

    

    

    
      	j.  	
              The
                State must reach its decisions within the specified
                timeframes:

            

    

    

    
      	1)  	
              Standard
                resolution: within 90 calendar days of the date the member filed
                the
                appeal with the health plan if the member filed initially with the
                health
                plan (excluding the days the enrollee took to subsequently file for
                a
                State fair hearing) or the date the member filed for direct access
                to a
                State fair hearing.

            

    

    

    
      	2)  	
              Expedited
                resolution (if the appeal was heard first through the health plan
                appeal
                process): within 3 working days from the state agency’s receipt of a
                hearing request for a denial of a service
                that:

            

    

    

    
      	·  	
              Meets
                the criteria for an expedited appeal process but was not resolved
                using
                the health plan’s expedited appeal timeframes,
                or

            

    

    
      	·  	
              Was
                resolved wholly or partially adversely to the member using the health
                plan’s expedited appeal timeframes.

            

    

    

    
      	3)  	
              Expedited
                resolution (if the appeal was made directly to the State Fair Hearing
                process without accessing the health plan appeal process): within
                3
                working days from the state agency’s receipt of a hearing request for a
                denial of a service that meets the criteria for an expedited appeal
                process.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.15.2 and subparagraphs a - j. 

    

    The
      objective of the Grievance System is to provide standard processes for resolving
      

    expressions
      of dissatisfaction and appeals from members. It is Harmony’s policy to

    resolve
      all grievances, and appeals promptly, fairly, and in compliance with applicable
      

    laws,
      regulations, and contracts. 

     

    Procedure
      outline:

     

    Members
      are given instructions in their Member Handbook on how to notify the Plan of
      issues they may have. They are told to contact the Customer Service department
      to request that their concern be addressed or to submit their request in writing
      to the Customer Service Department.

     

    A
      member or member’s representative can file an appeal or grievance either in
      writing or orally. All requests are acknowledged. Oral requests are received
      in
      the Customer Service department and this is the date the request is considered
      received. Customer Service handles all administrative type grievances and
      resolves them in accordance with the Contract. Potential quality of care
      grievances and appeals are assigned to the Appeals and Grievance department
      in
      the Paradigm Customer Management Resource (CMR). Expedited requests are
      immediately forwarded to the A&G department via e-mail and via call routing.
      Expedited requests are resolved within 3-working days from receipt.

     

    When
      a Customer Service Representative (CSR) receives a call from a member they
      work
      to the best of their ability within guidelines to ensure that any issue is
      resolved while the customer is on the phone. At the time of the call, the CSR
      will identify the issue as a grievance, appeal or both.

     

    Complaints/Grievances
      must be submitted to the Plan within 365 days of the event giving rise to the
      complaint /grievance. If the complaint cannot be resolved immediately by the
      Customer Service Representative, the member’s complaint is escalated to the
      Customer Service Grievance Coordinator (CSGC) for
      resolution.

     

    Once
      the CSGC receives the member’s call or letter, he or she rigorously attempts to
      resolve the issue to the member’s satisfaction. If the grievance involves
      medical-related issues, a physician reviews the case.

     

    The
      grievance process is completed within 30-calendar days of the Plan receiving
      the
      grievance, unless the grievance involves the collection of additional
      information. If so, the Plan may take a 14-calendar day extension to obtain
      additional information required to render a decision. If we need to do so,
      we
      notify the member in writing and explain why we need to take the extension.
      The
      CSGC also sends a request for information to the Provider or other party
      involved in the grievance to expedite the receiving of the required information.
      

     

    Quality
      of care complaints or potential quality of care issues are assigned to the
      Appeals & Grievance department. All medical records pertaining to the issue
      are gathered and reviewed by a nurse. Potential quality of care issues
      identified in the review are forwarded to a Medical Director for
      review.

     

    Upon
      completion of the investigation, we send the member a response letter that
      delineates the outcome of the investigation along with the right to request
      a
      redress (2nd
      level grievance) of the grievance decision. To initiate the
      2nd
      level grievance, the member must submit the request in writing and within
      30-calendar days of receipt, to the Appeals and Grievance Committee
      (AGC).

     

    In
      addition to submitting in writing, the member has the option to present the
      case
      to the Committee in person or by teleconference. To do this, the member must
      state so in the request. The Plan further contacts the member to set up a
      convenient date to have the meeting.

     

    During
      the AGC conference, the member is given fifteen minutes to present his/her
      side
      of the case. This is followed by any questions the Committee members have.
      The
      member is then sent a formal decision letter within 5-business days of the
      AGC
      meeting.

     

    The
      entire 2nd
      level process is completed within 30-calendar days of receipt, based on all
      available information at that time.

     

     

    Tracking
      of complaints:

     

    All
      complaints, grievances, and appeals are logged into an Oracle database that
      has
      the ability for reports to be generated from it. Reports are generated daily,
      weekly, and monthly to ensure that issues are being resolved timely and to
      identify trends in issues. 

     

    Monthly
      reports are given to and reviewed with senior management that identify what
      the
      issues were for the previous month, how many cases were received, what was
      done
      with them, and what the timeliness was on the cases closed for that
      month.

     

    Issues
      raised by members are forwarded to a company-wide interdisciplinary team known
      as the Customer Service Quality Improvement Workgroup (CSQIW). This workgroup
      addresses trends identified from reports provided by plan departments. The
      CSQIW
      is comprised of representatives from Customer Service, Health Services, Quality
      Improvement, Provider Relations, Claims, Appeals and Grievances, Regulatory
      Affairs, Enrollment, Operations Training and Process Audits. CSQIW identifies
      quality of service issues and develops and implements solutions. At least
      quarterly, reports are reviewed at the Customer Service Quality Improvement
      Workgroup. Trends are identified through the group and action plans are
      developed to attempt to reduce the number of complaints. These findings, action
      plans, and future monitoring of outcomes are reported in the Medical Advisory
      Committee. 

     

    The
      committee functions as a multidisciplinary task force to identify opportunities
      for improvement in customer service. The committee reviews data relevant to
      member and provider complaints and appeals to ensure that individual member
      and
      provider issues are addressed, resolutions are appropriate and timely, the
      process is compliant with regulatory standards, and identified issues are
      referred for system response through the quality improvement process. Dedicated
      to the continuous quality improvement process, the committee facilitates open
      and consistent communication among, members, providers, the QIC and the
      company’s departments. The committee’s focus is on systemic analysis of access
      and quality of service provided to the members under the health care
      contract.

     

    The
      committee is responsible for:

     

    
      	1)  	
              Identifying
                areas of needed quality improvement through analysis of trends found
                in
                member satisfaction surveys, complaint and appeal data, requests
                for PCP
                changes, and member
                dis-enrollments.

            

    

     

    
      	2)  	
              Targeting
                interventions, implementing process improvements and establishing
                tracking
                mechanisms to monitor and evaluate
                progress.

            

    

     

    
      	3)  	
              Developing
                performance goals and indicators, reviewing trends, and evaluating
                progress

            

    

     

    
      	4)  	
              Facilitating
                member focus groups for the purpose of improving the delivery of
                health
                care by obtaining member input to policies and
                benefits.

            

    

     

    
      	5)  	
              Reporting
                identified barriers to improvement in processes, progress, and
                implementation to the MAC.

            

    

     

    Examples
      of what constitutes an appealable situation;

     

    An
      appeal is defined as a request by a member or member’s representative (member
      appointed or the estate representative of a deceased member with appropriate
      documentation) to reconsider a “proposed action” by the
      Company.

     

    A
      proposed action is defined as an expression of dissatisfaction in relation
      to:

     

    
      	·  	
              Denial
                or limited authorization of a requested service, including the type
                or
                level of service;

            

    

     

    
      	·  	
              Reduction,
                suspension, or termination of a previously authorized service;
                

            

    

     

    
      	·  	
              Denial,
                in whole or in part, of payment for a service;
                

            

    

     

    
      	·  	
              Failure
                to provide services in a timely manner, as defined by the State*;
                

            

    

     

    
      	·  	
              Failure
                of the Company to act within the timeframes;
                or

            

    

     

    
      	·  	
              For
                a rural area resident with only one MCO, the denial of a Medicaid
                member’s
                request to obtain services outside the network**:
                

            

    

     

    
      	o  	
              From
                any other provider (in terms of training, experience, and specialization)
                not available within the
                network

            

    

     

    
      	o  	
              From
                a provider not part of the network, who is the main source of a service
                to
                the member - provided that the provider is given the same opportunity
                to
                become a participating provider as other similar provider. If the
                provider
                does not choose to join the network or does not meet the qualifications,
                the member is given a choice of participating providers and is
                transitioned to a participating provider within 60
                days.

            

    

     

    
      	o  	
              Because
                the only Plan or provider available does not provide the service
                because
                of moral or religious
                objections.

            

    

     

    
      	o  	
              Because
                the member’s provider determines that the member needs related services
                that would subject the member to unnecessary risk if received separately
                and not all related services are available within the network.
                

            

    

     

    Levels
      available and proposed time frames to be used in resolving standard
      appeals;

     

    The
      Plan will have one level of appeal. All appeals will be resolved and responded
      to within 45-calendar days of receipt of the verbal or written request. A
      14-calendar day extension may be taken if the member requests or the Plan
      determines an extension could potentially benefit the member, such as acquiring
      more documentation to support the request or additional testing or evaluations.
      If an extension is taken by the Plan, the member will be notified orally and
      in
      writing. The written notification informs the member of the reason for imposing
      an extension and gives the member Expedited Grievance rights to follow if he/she
      does not agree with the extension. 

     

    All
      Harmony members will have access to the State Fair Hearing
      process.

     

    D.
      Criteria used in determining the necessity for offering an expedited appeal
      process; and

     

    An
      expedited appeal is defined as an appeal for a service that has not already
      been
      rendered and is defined as the process followed when the Company determines
      (if
      requested by the 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
      or
      ability to attain, maintain, or regain maximum function. These cases will be
      completed within 3-business days of receipt of the request, with a possible
      14-calendar day extension. The Company has further defined what shall constitute
      a request that is automatically processed as expedited, which
      are:

     

    
      	·  	
              Any
                request by a physician for urgent determination/reconsideration review.
                The request can be requested written or verbally. If in writing,
                the
                request must be signed by the physician and include a statement why
                he/she
                feels the request should be processed as expedited. If a verbal request,
                the physician must be the one requesting and must state why he/she
                feels
                the request should be processed as expedited. If a verbal request,
                the
                physician must be the one requesting and must state
                why.

            

    

     

    
      	·  	
              All
                appealed Rehabilitation hospital continued-stay
                denials.

            

    

     

    
      	·  	
              All
                appealed Skilled Nursing Facility continued-stay denials, where the
                facility is attempting to discharge the member based on the Company’s
                decision.

            

    

     

    
      	·  	
              All
                denials for continued home health
                services.

            

    

     

    
      	·  	
              All
                denials of Physical Therapy within 6 months of a Cerebral Vascular
                Accident (CVA), head injury or surgery or other acute
                trauma.

            

    

     

    
      	·  	
              All
                requests for continuing Physical Therapy within 6 months of a CVA,
                head
                injury or surgery or other acute
                trauma.

            

    

     

    
      	·  	
              All
                denials for continuing Physical Therapy within 3 months of major
                joint
                (e.g. hip, total knee)
                surgery.

            

    

     

    
      	·  	
              Denials
                for chemotherapy, radiation therapy or proposed surgical treatment
                of a
                known malignancy.

            

    

     

    
      	·  	
              Denials
                of a proposed AIDS therapy in an AIDS
                patient.

            

    

     

    
      	·  	
              Any
                denial of a proposed “experimental/investigational” treatment in a
                terminal patient.

            

    

     

    Harmony
      has policies and procedures to ensure compliance with the aforementioned
      Performance Requirements.  Please refer to the Appendix Binder, Tab 1,
Item
      17
      for the appeals and grievance Policy and Procedure titled TRUST. 
      This policy and procedure may be updated from time to time, but shall remain
      compliant with DSS standards 

    

    
      	2.15.3  	
              Record
                Keeping and Reporting
                Requirements:

            

    

    

    
      	a.  	
              The
                health plan shall log and track all inquiries, grievances, and
                appeals.

            

    

    

    
      	b.  	
              The
                health plan shall maintain records of grievances, whether received
                verbally or in writing, that include a short, dated summary of the
                problems, name of the grievant, date of grievance, date of decision,
                and
                the disposition. If the health plan does not have a separate log
                for MC+
                managed care members, the log shall distinguish MC+ managed care
                members
                from other health plan members.

            

    

    

    
      	c.  	
              The
                health plan shall maintain records of appeals, whether received verbally
                or in writing, that include a short, dated summary of the issues,
                name of
                the appellant, date of appeal, date of decision, and the resolution.
                If
                the health plan does not have a separate log for MC+ managed care
                members,
                the log shall distinguish MC+ managed care members from other health
                plan
                members.

            

    

    

    
      	d.  	
              The
                health plan must report grievances and appeals to the state agency
                in the
                format and frequency specified by the state agency. The state agency
                shall
                provide the health plan with no less than ninety (90) days notice
                of any
                change in the format or frequency
                requested.

            

    

    

    
      	e.  	
              The
                state agency may publicly disclose summary information regarding
                the
                nature of grievances and appeals and related dispositions or resolutions
                in consumer information materials.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.15.3 and subparagraphs a - e. Harmony maintains records
      of
      all grievances and appeals, and will adhere to the reporting requirements
      specified herein.

    

    

    
      	2.15.4  	
              Notice
                of Action Requirements:

            

    

    

    
      	a.  	
              The
                health plan’s notice must be in writing and must meet the language and
                content requirements specified herein to ensure ease of
                understanding.

            

    

    

    
      	b.  	
              The
                health plan’s notice must explain the
                following:

            

    

    

    
      	1)  	
              The
                action the health plan has taken or intends to
                take.

            

    

    
      	2)  	
              The
                reasons for the action.

            

    

    
      	3)  	
              The
                member’s or the provider’s right to file an
                appeal.

            

    

    
      	4)  	
              The
                member’s right to request a State fair
                hearing.

            

    

    
      	5)  	
              The
                procedures for exercising the rights to appeal or request a State
                fair
                hearing.

            

    

    
      	6)  	
              That
                the member may represent himself or use legal counsel, a relative,
                a
                friend, or other spokesperson.

            

    

    
      	7)  	
              Must
                explain the specific regulations that support, or the change in Federal
                or
                State law that requires the action.

            

    

    
      	8)  	
              The
                member’s right to request a state agency hearing, or in cases of an action
                based on change in law, the circumstances under which a hearing will
                be
                granted.

            

    

    
      	9)  	
              The
                circumstances under which expedited resolution is available and how
                to
                request it.

            

    

    
      	10)  	
              The
                member’s right to have benefits continue 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.

            

    

    

    
      	c.  	
              The
                health plan must mail the notice to the member within the following
                timeframes:

            

    

    

    
      	1)  	
              For
                termination, suspension, or reduction of previously authorized covered
                services, at least ten (10) calendar days before the date of action.
                The
                health plan may mail a notice not later than the date of action under
                the
                following circumstances:

            

    

    

    
      	·  	
              The
                health plan has factual information confirming the death of a
                member.

            

    

    
      	·  	
              The
                health plan receives a clear written statement signed by the member
                that
                he or she no longer wishes services or gives information that requires
                termination or reduction of services and indicates that he or she
                understands that this must be the result of supplying that
                information.

            

    

    
      	·  	
              The
                member’s whereabouts are unknown and the post office returns health plan
                mail directed to the member indicating no forwarding address (refer
                to 42
                CFR 431.231 (d) for procedures if the member’s whereabouts become
                known).

            

    

    
      	·  	
              The
                member’s physician prescribes a change in the level of medical
                care.

            

    

    
      	·  	
              The
                health plan may shorten the period of advance notice to 5 calendar
                days
                before date of action if the health plan has facts indicating that
                action
                should be taken because of probable fraud by the member and the facts
                have
                been verified, if possible, through secondary
                sources.

            

    

    
      	·  	
              The
                member’s admission to an institution where he is ineligible for further
                services.

            

    

    
      	·  	
              The
                member has been accepted for Medicaid services by another local
                jurisdiction.

            

    

    

    
      	2)  	
              For
                denial of payment decisions that result in member liability, at the
                time
                of any action affecting the claim.

            

    

    
      	3)  	
              For
                service authorization decisions that deny or limit services, within
                the
                timeframes required by the service accessibility standards for prior
                authorization specified herein.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.15.4 and subparagraphs a - c. Harmony shall ensure the
      Notice of Action meets all requirements and has obtained state approval prior
      to
      use. All time frames required by the state shall be
      met.

    

    
      	2.15.5  	
              Grievance
                Process:

            

    

    

    
      	a.  	
              A
                member may file a grievance either orally or in writing. A member’s
                authorized representative including the member’s provider may file a
                grievance on behalf of the member.

            

    

    

    
      	b.  	
              The
                health plan shall give members any reasonable assistance in completing
                forms and taking other procedural steps. This includes, but is not
                limited
                to, providing interpreter services and toll-free numbers that have
                adequate TTY/TTD and interpreter
                capability.

            

    

    

    
      	c.  	
              The
                health plan shall acknowledge receipt of each grievance in writing
                within
                ten (10) business days after receiving a
                grievance.

            

    

    

    
      	d.  	
              The
                health plan shall ensure that the individuals who make decisions
                on
                grievances are individuals who were not involved in any previous
                level of
                review or decision-making; and who, if deciding any of the following,
                are
                health care professionals who have the appropriate clinical expertise,
                as
                determined by the state agency, in treating the member’s condition or
                disease:

            

    

    

    
      	1)  	
              A
                grievance regarding denial of expedited resolution of an
                appeal.

            

    

    
      	2)  	
              A
                grievance that involves clinical
                issues.

            

    

    

    
      	e.  	
              The
                health plan shall dispose of each grievance and provide written notice
                of
                the disposition of the grievance, as expeditiously as the member’s health
                condition requires but shall not exceed thirty (30) calendar days
                of the
                filing date.

            

    

    

    
      	f.  	
              The
                health plan may extend the timeframe for disposition of a grievance
                for up
                to fourteen (14) calendar days if the member requests the extension
                or the
                health plan demonstrates (to the satisfaction of the state agency,
                upon
                its request) that there is need for additional information and how
                the
                delay is in the member’s interest. If the health plan extends the
                timeframe, it must, for any extension not requested by the member,
                give
                the member written notice of the reason for the
                delay.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.15.5 and subparagraphs a - r. Harmony has policies and
      procedures to ensure compliance with the aforementioned Performance
      Requirements.  Please refer to the Appendix Binder, Tab 1,
Item
      17
      for the appeals and grievance Policy and Procedure titled TRUST. 
      This policy and procedure may be updated from time to time, but shall remain
      compliant with DSS standards

    

    
      	2.15.6  	
              Appeal
                Process:

            

    

    

    
      	a.  	
              A
                member may file an appeal and may request a State fair hearing within
                90
                calendar days from the date on the health plan’s notice of action. A
                provider, acting on behalf of the member and with the member’s written
                consent, may file an appeal.

            

    

    

    
      	b.  	
              The
                member or provider may file an appeal either orally or in writing.
                Unless
                he or she requests expedited resolution, must follow an oral filing
                with a
                written, signed appeal.

            

    

    

    
      	c.  	
              The
                health plan shall give members any reasonable assistance in completing
                forms and taking other procedural steps. This includes, but is not
                limited
                to, providing interpreter services and toll-free numbers that have
                adequate TTY/TTD and interpreter
                capability.

            

    

    

    
      	d.  	
              Appeals
                shall be filed directly with the health plan’s governing body, or its
                delegated representatives. The governing body may delegate this authority
                to an appeal committee, but the delegation must be in
                writing.

            

    

    

    
      	e.  	
              The
                health plan shall acknowledge receipt of each appeal in writing within
                ten
                (10) business days after receiving an
                appeal.

            

    

    

    
      	f.  	
              The
                health plan shall ensure that the individuals who make decisions
                on
                appeals are individuals who were not involved in any previous level
                of
                review or decision-making; and who, if deciding any of the following,
                are
                health care professionals who have the appropriate clinical expertise,
                as
                determined by the state agency, in treating the member’s condition or
                disease:

            

    

    

    
      	1)  	
              An
                appeal of a denial that is based on lack of medical
                necessity.

            

    

    
      	2)  	
              An
                appeal that involves clinical
                issues.

            

    

    

    
      	g.  	
              The
                appeals process must provide that oral inquiries seeking to appeal
                are
                treated as appeals (to establish the earliest possible filing date
                for the
                appeal) and must be confirmed in writing, unless the member or the
                provider requests expedited
                resolution.

            

    

    

    
      	h.  	
              The
                appeals process must provide the member a reasonable opportunity
                to
                present evidence, and allegations of fact or law, in person as well
                as in
                writing. The health plan must inform the member of the limited time
                available for this in the case of expedited
                resolution.

            

    

    

    
      	i.  	
              The
                appeals process must provide the member and his or her representative
                opportunity, before and during the appeals process, to examine the
                member’s case file, including medical records, and any other documents and
                records considered during the appeals
                process.

            

    

    

    
      	j.  	
              The
                appeals process must include as parties to the appeal the member
                and his
                or her representative or the legal representative of a deceased member’s
                estate.

            

    

    

    
      	k.  	
              The
                health plan shall resolve each appeal and provide written notice
                of the
                appeal resolution, as expeditiously as the member’s health condition
                requires but shall not exceed forty-five (45) calendar days from
                date the
                health plan receives the appeal. For expedited resolution of an appeal
                and
                notice to affected parties, the health plan has no longer than three
                (3)
                working days after the health plan receives the appeal. For notice
                of an
                expedited resolution, the health plan must also make reasonable efforts
                to
                provide oral notice.

            

    

    

    
      	l.  	
              The
                health plan may extend the timeframe for standard or expedited resolution
                of the appeal by up to fourteen (14) calendar days if the member
                requests
                the extension or the health plan demonstrates (to the satisfaction
                of the
                state agency, upon its request) that there is need for additional
                information and how the delay is in the member’s interest. If the health
                plan extends the timeframe, it must, for any extension not requested
                by
                the member, give the member written notice of the reason for the
                delay.

            

    

    

    
      	m.  	
              The
                written notice of the appeal resolution must include the
                following:

            

    

    

    
      	1)  	
              The
                results of the resolution process and the date it was
                completed.

            

    

    
      	2)  	
              For
                appeals not resolved wholly in the favor of the members the right
                to
                request a State fair hearing, and how to do so; the right to request
                to
                receive benefits while the hearing is pending, and how to make the
                request; and that the member may be held liable for the cost of those
                benefits if the hearing decision upholds the health plan’s
                action.

            

    

    

    
      	n.  	
              The
                health plan must establish and maintain an expedited review process
                for
                appeals when the health plan determines (for a request from the member)
                or
                the provider indicates (in making the request on the member’s behalf) that
                taking the time for a standard resolution could seriously jeopardize
                the
                member’s life or health or ability to attain, maintain, or regain maximum
                function. The health plan must ensure that punitive action is neither
                taken against a provider who requests an expedited resolution or
                supports
                a member’s appeal.

            

    

    

    
      	o.  	
              If
                the health plan denies a member’s request for expedited resolution, it
                must transfer the appeal to the timeframe for standard resolution
                specified herein and must make reasonable efforts to give the member
                prompt oral notice of the denial, and follow up within two (2) calendar
                days with a written notice.

            

    

    

    
      	p.  	
              Continuation
                of benefits while the health plan appeal and State fair hearing are
                pending.

            

    

    

    
      	1)  	
              As
                used in this section, “timely” filing means filing on or before the later
                of the following:

            

    

    

    
      	·  	
              Within
                ten (10) calendar days of the health plan mailing the notice of
                action.

            

    

    
      	·  	
              The
                intended effective date of the health plan’s proposed
                action.

            

    

    

    
      	2)  	
              The
                health plan must continue the member’s benefits if the member or the
                provider files the appeal timely; the appeal involves the termination,
                suspension, or reduction of a previously authorized course of treatment;
                the services were ordered by an authorized provider; the original
                period
                covered by the original authorization has not expired; and the member
                requests extension of the benefits.

            

    

    

    
      	3)  	
              If,
                at the member’s request, the health plan continues or reinstates the
                member’s benefits while the appeal is pending, the benefits must be
                continued until one of the following
                occurs:

            

    

    

    
      	·  	
              The
                member withdraws the appeal.

            

    

    
      	·  	
              Ten
                (10) calendar days pass after the health plan mails the notice, providing
                the resolution of the appeal against the member, unless the member,
                within
                the ten (10) calendar day timeframe, has requested a State fair hearing
                with continuation of benefits until a State fair hearing decision
                is
                reached.

            

    

    
      	·  	
              A
                State fair hearing officer issues a hearing decision adverse to the
                member.

            

    

    
      	·  	
              The
                time period or service limits of a previously authorized service
                has been
                met.

            

    

    

    
      	4)  	
              If
                the final resolution of the appeal is adverse to the member, that
                is,
                upholds the health plans action, the health plan may recover the
                cost of
                the services furnished to the member while the appeal is pending,
                to the
                extent that they were furnished solely because of the requirements
                of this
                section.

            

    

    

    
      	q.  	
              If
                the health plan or the State fair hearing officer reverses a decision
                to
                deny, limit, or delay services that were not furnished while the
                appeal
                was pending, the health plan must authorize or provide this disputed
                services promptly, and as expeditiously as the member’s health condition
                requires.

            

    

    

    
      	r.  	
              If
                the health plan or the 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 health plan must pay for
                those
                services.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.15.6 and subparagraphs a-r. 

    

    Harmony
      has policies and procedures to ensure compliance with the aforementioned
      Performance Requirements.  Please refer to the Appendix Binder, Tab 1,
Item
      17
      for the appeals and grievance Policy and Procedure titled TRUST. 
      This policy and procedure may be updated from time to time, but shall remain
      compliant with DSS standards.

    

    
      	2.16  	
              Provider
                Inquiries, Complaints, Grievances, and
                Appeals:

            

    

    

    The
      health plan shall establish a complaint, grievance, and appeal process that
      guarantees the right for a review to any provider of medical services for a
      member of the health plan.

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.16. 

    

    
      	2.16.1  	
              For
                purposes of this document, the following definitions shall
                apply:

            

    

    

    Inquiry
      - A
      request from a provider regarding information that would clarify health plan
      policy benefits, procedures, or any aspect of health plan function that may
      be
      in question.

    

    Complaint
      - A
      verbal or written expression by a provider which indicates dissatisfaction
      or
      dispute with health plan policy, procedure, claims, or any aspect of health
      plan
      functions. All complaints must be logged and tracked whether received by
      telephone, in person or in writing.

    

    Grievance
      - A
      written request for further review of a provider's complaint that remains
      unresolved after completion of the complaint process.

    

    Appeal
      - The
      formal mechanism which allows a provider the right to appeal a grievance
      decision.

    

    Harmony
      Health Plan understands and will adhere to the definitions set forth in RFP
      B3Z06118 paragraph 2.16.1. 

    

    
      	2.16.2  	
              The
                health plan shall develop written policies and procedures which detail
                the
                operation of the provider inquiry, complaint, grievance, and appeal
                process and provides instructions on how to file a complaint, grievance,
                or appeal.

            

    

    

    
      	a.  	
              The
                policies and procedures must be approved by the state agency prior
                to
                implementation.

            

    

    

    
      	b.  	
              The
                policies and procedures shall be approved by the health plan governing
                body and be the direct responsibility of the governing
                body.

            

    

    

    
      	c.  	
              The
                health plan shall distribute an information packet to providers containing
                the complaint, grievance, and appeal policies and procedures, specific
                instructions regarding how to contact the health plan’s provider services,
                and identifies the person from the health plan who receives and processes
                complaints, grievances, and appeals. The health plan shall distribute
                the
                policies and procedures to in-network providers at time of subcontract
                and
                to out-of-network providers with the remittance advice of the processed
                claim.

            

    

    

    
      	d.  	
              The
                process must be addressed in the provider
                manual.

            

    

    

    
      	e.  	
              The
                policies and procedures shall identify specific individuals who have
                authority to administer the inquiry, complaint, grievance, and appeal
                process.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.16.2 and subparagraphs a - e. 

    

    Harmony
      will instruct providers on how to notify the Company of issues they may have
      through a Provider notification and the Provider Manual. 

    

    Harmony
      has policies and procedures to ensure compliance with the aforementioned
      Performance Requirements.  Please refer to the Appendix Binder, Tab 1,
Item
      17
      for the appeals and grievance Policy and Procedure titled TRUST. 
      This policy and procedure may be updated from time to time, but shall remain
      compliant with DSS standards.

    

    
      	2.16.3  	
              Provider
                Inquiry, Complaint, Grievance, and Appeal
                Process:

            

    

    

    
      	a.  	
              Inquiry:
                The health plan shall operate a provider services function, which
                providers can use to ask questions, file inquiries and complaints,
                and get
                problems resolved. The health plan’s provider services function shall be
                adequately staffed to receive telephone calls and meet personally
                with
                providers. The health plan shall identify a person from the health
                plan
                specifically designated to receive and process complaints, grievances,
                and
                appeals. The health plan shall probe the inquiries so as to validate
                the
                possibility of any inquiry actually being a complaint. The health
                plan
                shall identify any inquiry
                patterns.

            

    

    

    
      	b.  	
              Complaint:
                A
                complaint can be filed verbally or in writing within one year of
                the
                incident that resulted in a complaint. Complaints shall be resolved
                within
                ten (10) calendar days of their filing. The provider(s) and health
                plan
                should attempt to resolve complaints before proceeding to a
                grievance.

            

    

    

    
      	1)  	
              At
                the time of the health plan’s decision regarding a complaint, the health
                plan shall notify providers in writing of their right to file a grievance
                with the health plan. This notification must be prior approved by
                the
                state agency.

            

    

    

    
      	c.  	
              Grievance:
                The health plan shall provide a grievance process which providers
                can use
                to file their dissatisfaction with the complaint resolution. If a
                provider
                is dissatisfied with the complaint resolution, the provider may file
                a
                grievance in writing with the health plan within ninety (90) calendar
                days
                of the complaint resolution. The provider must deliver a written,
                substantiated disagreement with the complaint resolution to the health
                plan. The health plan must acknowledge the receipt of grievances
                in
                writing within ten (10) business days after receiving a grievance.
                Grievances shall be investigated by the health plan and reviewed
                by a
                designated authority within the health plan. The health plan shall
                reach
                decisions on grievances within thirty (30) calendar days of their
                filing
                date.

            

    

    

    
      	1)  	
              At
                the time of the health plan’s decision regarding a grievance, the health
                plan shall notify the provider in writing of their right to file
                an appeal
                with the health plan. This notification must be prior approved by
                the
                state agency.

            

    

    

    
      	d.  	
              Appeal:
                The health plan shall operate an appeals process through which providers
                can challenge a negative decision to their grievances. Providers
                shall
                have ninety (90) calendar days following written notification of
                a
                grievance decision to appeal. The appeal must be filed in writing
                either
                by the provider or the provider’s representative, or through the
                provider’s instruction to the health plan’s representative that the
                provider wishes to appeal. The health plan shall acknowledge receipt
                of
                each appeal in writing within ten (10) business days after receiving
                an
                appeal. Appeals shall be filed directly to the health plan’s governing
                body, or its delegated representatives (The governing body may delegate
                this authority to an appeal committee, but the delegation must be
                in
                writing.). The appeal process shall include an opportunity for providers
                or their representatives to present their cases in person to the
                appellate
                body. The health plan shall reach a final decision on an appeal and
                provide written notice of the appeal resolution within sixty (60)
                calendar
                days of receipt of the appeal, with extensions possible if approved
                by the
                state agency.

            

    

    

    
      	e.  	
              Expedited
                Review:
                The health plan shall have a procedure for expedited review of the
                complaint or grievance if the standard time frame could seriously
                jeopardize the member’s life, physical or mental health, or the member’s
                ability to regain maximum function. The expedited review shall be
                resolved
                no later than 72 hours or as expeditiously as the member’s physical or
                mental health requires.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.16.3 and subparagraphs a - e. Harmony has policies and
      procedures to ensure compliance with the aforementioned Performance
      Requirements.  Please refer to the Appendix Binder, Tab 1, Item 17 for the
      appeals and grievance Policy and Procedure titled TRUST. 
      This policy and procedure may be updated from time to time, but shall remain
      compliant with DSS standards

    

    
      	2.16.4  	
              As
                a part of the provider complaint, grievance, and appeal process,
                the
                health plan shall:

            

    

    

    
      	a.  	
              Ensure
                that health plan executives with the authority to require corrective
                action are involved in the complaint, grievance, and appeal
                process.

            

    

    
      	b.  	
              Thoroughly
                investigate each complaint, grievance, and appeal using applicable
                statutory, regulatory, contractual provisions, and the health plan’s
                written policies and procedures. Pertinent facts from all parties
                must be
                collected during the investigation.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.16.4 and subparagraphs a - b. Harmony has policies and
      procedures to ensure compliance with the aforementioned Performance
      Requirements.  Please refer to the Appendix Binder, Tab 1,
Item
      17
      for the appeals and grievance Policy and Procedure titled TRUST. 
      This policy and procedure may be updated from time to time, but shall remain
      compliant with DSS standards

    

    
      	2.16.5  	
              Records/Reporting:

            

    

    

    
      	a.  	
              The
                health plan shall log and track all
                inquiries.

            

    

    

    
      	b.  	
              The
                health plan shall maintain records of complaints that include a short,
                dated summary of each of the questions or problems, name of the
                complainant, date of complaint, the response, and the resolution.
                If the
                health plan does not have a separate log for in-network providers,
                the log
                shall distinguish in-network providers from other health plan
                providers.

            

    

    

    
      	c.  	
              The
                health plan shall maintain grievance records that include a copy
                of the
                original grievance, the response, and the resolution. This system
                shall
                distinguish in-network providers from other health plan providers
                and
                identify the grievant and the date of
                filing.

            

    

    

    
      	d.  	
              The
                health plan must report provider complaints, grievances, and appeals
                to
                the state agency in the format requested by the state
                agency.

            

    

    

    
      	e.  	
              The
                health plans must maintain records of all provider complaints, grievances,
                appeals, and resolutions.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.16.5 and subparagraphs a - e. 

    

    
      	2.17  	
              Quality
                Assessment and
                Improvement:

            

    

    

    
      	2.17.1  	
              The
                state agency regulates the quality assessment and improvement functions
                of
                the health plan. The health plan therefore must comply with all the
                state
                agency's quality assessment and improvement programs as described
                herein.
                The health plan shall participate in the State’s efforts to promote the
                delivery of services in a culturally competent manner to all members,
                including those with limited English proficiency and diverse cultural
                and
                ethnic backgrounds. The health plan shall be held accountable for
                the
                ongoing monitoring, evaluation, and actions as necessary to improve
                the
                health of its members and the care delivery systems for those members.
                The
                health plan shall be held accountable for the quality of care delivered
                by
                providers. The state agency’s quality assessment and improvement program
                shall consist of internal monitoring by the health plan, oversight
                by
                federal and state governments, and evaluations by an independent,
                external
                review organization. The health plan shall have a quality assessment
                and
                improvement program which integrates an internal quality assessment
                process that conforms to Quality Improvement System for Managed Care
                (QISMC) and additional current standards and guidelines prescribed
                by CMS.
                The health plan shall adhere to the requirements contained within
                the
                state agency’s, Quality Management Plan located in Attachment 6. The
                health plan shall have a quality assessment and improvement program
                composed of:

            

    

    

    
      	a.  	
              An
                internal system of monitoring, analysis, evaluation, and improvement
                of
                the delivery of care that includes care provided by all
                providers;

            

    

    

    
      	b.  	
              Designated
                staff with expertise in quality assessment, utilization management
                and
                continuous quality improvement;

            

    

    

    
      	c.  	
              Written
                policies and procedures for quality assessment, utilization management,
                and continuous quality improvement that are periodically analyzed
                and
                evaluated for impact and
                effectiveness;

            

    

    

    
      	d.  	
              Results,
                conclusions, team recommendations, and implemented system changes
                which
                are reported to the health plan’s governing body at least quarterly,
                and

            

    

    

    
      	e.  	
              Reports
                that are evaluated, recommendations that are implemented when indicated,
                and feedback provided to providers and
                members.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.17.1 and subparagraphs a - e. Please see Harmony’s Missouri
      Quality Improvement Management Program Description attached in Appendix Binder,
      Tab # 6 .

    

    
      	2.17.2  	
              Internal
                Staff:
                The health plan shall designate a Quality Assessment and Improvement
                and
                Utilization Management Coordinator(s). Specifically, the Quality
                Assessment and Improvement and Utilization Management Coordinator
                must:

            

    

    

    
      	a.  	
              Be
                a registered nurse, nurse practitioner, or physician. The registered
                nurse
                or nurse practitioner must be licensed in the State of Missouri.
                The
                physician must be Missouri licensed and practice medicine in the
                United
                States. He/she must be board-certified, board-eligible, or have sufficient
                experience in his or her field or specialty to be determined competent
                by
                the health plan’s Medical Director or the Credentials
                Committee.

            

    

    

    
      	b.  	
              Be
                responsible for assisting the governing body and their designee in
                the
                process of continually developing, implementing, evaluating, and
                improving
                the written quality assessment and improvement program. The continuous
                improvement process shall include care delivery objectives, specific
                activities implemented from issues identified as a result of the
                on-going
                monitoring process, systems methodologies for continuous tracking
                of care
                delivery, and provider review. The process must include a focus on
                health
                outcomes and action plans for improvement of those
                outcomes.

            

    

    

    
      	c.  	
              Be
                responsible for the health plan's utilization management and quality
                assessment committee, assist the governing board in directing the
                development and implementation of the health plan's internal quality
                assessment and improvement program, and monitor the quality of care
                that
                members receive.

            

    

    

    
      	d.  	
              Oversee
                the development of clinical care standards and practice guidelines
                and
                protocols for the health plan. The health plan must adopt practice
                guidelines that meet the following
                requirements:

            

    

    

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

            

    

    
      	2)  	
              Consider
                the needs of the members;

            

    

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

            

    

    
      	4)  	
              Are
                reviewed and updated periodically as
                appropriate.

            

    

    
      	5)  	
              Dissemination
                of the guidelines to all affected providers and, upon request, to
                members
                and potential members.

            

    

    
      	6)  	
              Ensure
                that decisions for utilization management, member education, coverage
                of
                services, and other areas to which the guidelines apply should be
                consistent with the guidelines.

            

    

    

    
      	e.  	
              Review
                all potential quality of care problems, both physical and mental
                health,
                and oversee development and implementation of continuous assessment
                and
                improvement of the quality of care provided to
                members.

            

    

    

    
      	f.  	
              Maintain
                current medical information pertaining to clinical practice and
                guidelines.

            

    

    

    
      	g.  	
              Ensure
                that health education resources are available for the provision of
                proper
                medical care to members.

            

    

    

    
      	h.  	
              Utilize
                staff in an effective and efficient manner to monitor and assess
                care
                delivery.

            

    

    

    
      	i.  	
              Specify
                clinical or health services areas to be
                monitored.

            

    

    

    
      	j.  	
              Specify
                the use of quality indicators that are objective, measurable, and
                based on
                current knowledge and clinical experience for priority areas selected
                by
                the state agency as well as for areas the health plan
                selects.

            

    

    

    
      	k.  	
              Monitor
                and report on the management of the health plan's EPSDT
                program.

            

    

    

    
      	l.  	
              Monitor
                and report on the health plan's referral process for specialty and
                out-of-network services.

            

    

    

    
      	m.  	
              Ensure
                that all denied services are reviewed by a physician, physician assistant,
                or advanced nurse practitioner. The reason for the denial must be
                documented and logged. Any alternative services authorized must be
                documented. All denials must identify appeal rights of the
                member.

            

    

    

    
      	n.  	
              Monitor
                and report on the health plan's credentialing and recredentialing
                activities.

            

    

    

    
      	o.  	
              Monitor
                and report on the health plan's process for prior authorizing and
                denying
                services.

            

    

    

    
      	p.  	
              Monitor
                and report on the health plan's process for ensuring the confidentiality
                of medical records and member
                information.

            

    

    

    
      	q.  	
              Monitor
                and report on the health plan's process for ensuring the confidentiality
                of the appointments, treatments, and required state agency reporting
                of
                adolescent STDs.

            

    

    

    
      	r.  	
              Monitor
                provider for compliance that reports of disease and conditions are
                made to
                the State Department of Health and Senior Services in accordance
                with all
                applicable State statutes, rules, guidelines, and policies and with
                all
                metropolitan ordinances and
                policies.

            

    

    

    
      	s.  	
              Monitor
                provider for compliance that control measures for tuberculosis, STDs,
                and
                communicable diseases are carried out in accordance with applicable
                laws
                and guidelines and such measures are defined in the provider
                manual.

            

    

    

    
      	t.  	
              Serve
                as a liaison between the health plan and the in-network providers
                and
                communicate at least quarterly with the in-network providers, including
                oversight of provider education, in service training, and orientation.
                Newsletter, web sites, and other media may be used to meet this
                criteria.

            

    

    

    
      	u.  	
              Be
                available to the health plan's medical staff for consultation on
                referrals, denials, grievances and appeals, and
                problems.

            

    

    

    
      	v.  	
              Monitor
                and report at least annually 24-hour access and after hours availability
                of primary care providers.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.17.2 and subparagraphs a - v. Please see Appendix Binder,
      Tab 3 for Key Management Staffing Table, Position Descriptions and applicable
      Resumes.

    

    
      	2.17.3  	
              In
                addition to internal monitoring of quality of care, the health plan
                shall
                submit to the state agency reports regarding the results of their
                internal
                monitoring, evaluation, and action plan implementation. The reports
                shall
                include targeted health indicators monitored by the state agency
                and
                specific quality data periodically requested by the federal government.
                The reports may be required on a monthly, quarterly or annual basis
                or as
                specified by the state agency. (Refer to the Quality Management Plan
                located at Attachment 6 for the current report format.) The report
                format
                shall be periodically reviewed and updated by the state agency. The
                state
                agency shall provide the health plan with no less than ninety (90)
                calendar days notice of any changes in the format requested. The
                health
                plan shall comply with all subsequent changes specified by the state
                agency. The health plan shall provide access to documentation, medical
                records, premises, and staff as deemed necessary by the state
                agency.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.17.3. 

    

    
      	2.17.4  	
              The
                state agency shall contract with independent, external evaluators
                to
                examine the quality of care provided by the health plan. The health
                plan
                shall provide access to documentation, medical records, premises,
                and
                staff as deemed necessary by the state agency for the independent
                external
                review.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.17.4. 

    

    
      	2.17.5  	
              Internal
                Procedures:
                The health plan shall have an internal written quality assessment
                and
                improvement program. The health plan shall include monitoring, assessment,
                evaluation, and improvement of the quality of care for all clinical
                and
                health service delivery areas. Emphasis should be placed on, but
                need not
                be limited to, clinical areas relating to maternity, pediatric and
                adolescent development, EPSDT, family planning, and well woman care,
                as
                well as on key access or other priority issues for members such as
                reducing the incidence of STDs, acquired immune deficiency syndrome,
                and
                smoking related illnesses. The health plan must have implemented
                mechanisms to assess the quality and appropriateness of care furnished
                to
                members with special health care needs. The health plan’s quality review
                mechanisms shall address members
                with special needs as well as COA 1, COA 4, and COA 5 members
                in the written monitoring, assessment, evaluation, and improvement
                plan.

            

    

    

    
      	a.  	
              Internal
                policies and procedures must:

            

    

    

    
      	1)  	
              Ensure
                that the utilization management and quality assessment committees
                have
                established operating parameters. The committees shall meet at least
                quarterly, on a regular schedule. Committee members must be clearly
                identified and representative of the health plan’s providers. The
                committee shall be accountable to the Medical Director and governing
                body.
                The committees must maintain appropriate documentation of the committees’
                activities, findings, recommendations, actions, and follow
                up.

            

    

    

    
      	2)  	
              Provide
                for regular utilization management and quality assessment reporting
                to the
                health plan management and health plan providers, including profiling
                of
                provider utilization patterns.

            

    

    

    
      	3)  	
              Be
                developed and implemented by professionals with adequate and appropriate
                experience in quality assessment and improvement: quality assessment,
                utilization management, and continuous improvement
                processes.

            

    

    

    
      	4)  	
              Provide
                for systematic data collection, analysis, and evaluation of performance
                and member results.

            

    

    

    
      	5)  	
              Provide
                for interpretation of this data to
                practitioners.

            

    

    

    
      	6)  	
              Provide
                timelines for correction, and assign a specific staff person to be
                responsible for ensuring compliance and follow
                up.

            

    

    

    
      	7)  	
              Clearly
                define the roles, functions, and responsibilities of the quality
                assessment committee and the Medical
                Director.

            

    

    

    The
      Board of Directors has overall accountability and responsibility for the quality
      of health care and other services rendered to its members. The Board of
      Directors will support and have the final authority and responsibility for
      the
      assurance of a comprehensive and integrated Quality Assessment and Improvement
      program. The Board of Directors delegates all QAPI responsibilities to the
      Chief
      Executive Officer who is the Chairman of the Quality Improvement Committee
      (QIC), which is overseen by the Senior Vice President of Health Services, the
      Medical Director, the Corporate Director of Quality and the State Director
      of
      Quality.

    

    The
      QIC is responsible for promoting the goals and objectives of the health plan
      by:

    
      	·  	
              Demonstrating
                corporate commitment to high quality care and to the organization’s
                quality improvement. 

            

    

    
      	·  	
              Requiring
                that objective measures be used to evaluate the quality of care and
                service being provided. 

            

    

    
      	·  	
              Ensuring
                that quality improvement processes are in place and working effectively
                to
                improve quality.

            

    

    
      	·  	
              Reviewing
                and approving the annual Quality Improvement and Utilization Management
                Program Descriptions, work plans, and evaluations.
                

            

    

    
      	·  	
              Centralizing
                and coordinating the integration of health plan
                activities.

            

    

    
      	·  	
              Monitoring
                ongoing health plan activity toward health plan goals and objectives.
                

            

    

    
      	·  	
              Providing
                oversight recommendations for improvement of the following
                activities:

            

    

    Quality
      measurement studies; HEDIS performance measures; Disease management programs;
      Member and provider surveys; Medical record review; Appeals and grievance;
      Pharmacological reviews; Utilization Management reviews; Credentialing and
      recredentialing reviews; Pharmacy and Therapeutics review; Overseeing
      credentialing and recredentialing activities for the health plan providers.
      

    
      	·  	
              Approving
                all credentialing and recredentialing
                activities.

            

    

    
      	·  	
              Monitoring
                activities of contracted and delegated
                agencies.

            

    

    
      	·  	
              Providing
                a forum for the review, revision, and approval of health plan policies
                and
                procedures, guidelines,
                standards.

            

    

    
      	·  	
              Overseeing
                application and enforcement of national confidentiality
                policy.

            

    

    
      	·  	
              Ensuring
                compliance with regulatory and accrediting
                bodies.

            

    

    
      	·  	
              Monitoring
                activities of the Quality and Utilization Management
                subcommittees.

            

    

    

    The
      Quality Improvement Committee (QIC) meets monthly, but not less than ten (10)
      times per year, and minutes are recorded and maintained for each meeting. The
      membership consists of the President & CEO or designee (Chairperson), Senior
      Vice President, Health Services or designee, Senior Vice President, Legal
      Affairs or designee, Senior Vice President, Marketing or designee, Senior Vice
      President, Operations or designee, Senior Vice President, Sales or designee,
      Vice President, Human Resources or designee, Vice President, Finance or
      designee, Vice President, Provider Relations or designee, Medical Directors,
      Utilization Management Medical Director, Quality Management Medical Director,
      Inpatient Services, Vice President, Behavioral Health, Vice President, Pharmacy,
      Director, Corporate Regulatory Affairs or designee, Director, Corporate
      Compliance and Special Investigations, Director, Health Services Projects,
      Director, Quality Improvement, Director, Corporate Quality
      Improvement.

    

    
      	b.  	
              Utilization
                Management:
                The health plan shall have written utilization management policies
                and
                procedures that include protocols for denial of services, prior approval,
                hospital discharge planning, physician profiling, and concurrent,
                prospective, and retrospective review of claims that comply with
                federal
                and state laws and regulations, as amended. The utilization management
                policies and procedures must be clearly specified in provider contracts
                or
                provider manuals and consistently applied in accordance with the
                established utilization management guidelines. As part of the health
                plan’s utilization management function, the health plan also must have
                processes to identify both over and under utilization problems for
                inpatient and outpatient services, undertake corrective action, and
                follow
                up. This review must consider the expected utilization of services
                regarding the characteristics and health care needs of the member
                population. In addition, the health plan shall use an emergency room
                log,
                or equivalent method, to track emergency room services. Compensation
                to
                individuals or entities that conduct utilization management activities
                shall not be structured so as to provide incentives for the individual
                or
                entity to deny, limit, or discontinue medically necessary services
                to any
                member.

            

    

    

    Harmony
      Health Plans understands and will adhere to the requirements set forth in RFP
      B3Z06118, Paragraph 2.17. subparagraph b, and has a number of policies and
      procedures which support these requirements. These P&Ps are entitled 1.2
      Under and Over Utilization of Services, 2.1 Service Authorization, 2.2 Adverse
      Determinations,  and 5.4 Inpatient Concurrent Review. Please refer to
      Appendix Binder, Tab #1, Items 18, 4, 19, 5 respectively. These policies and
      procedures may be updated from time to time, but shall remain compliant with
      DSS
      standards

    

    Additionally,
      Harmony Health Plan has an ER Program to track and monitor ER
      services.

    

    
      	c.  	
              Provider
                Credentialing:
                The health plan shall have written credentialing and re-credentialing
                policies and procedures for determining and assuring that all in-network
                providers are licensed by the state in which they practice and qualified
                to perform their services. The health plan shall have written policies
                and
                procedures for monitoring the in-network providers, reporting the
                results
                of the monitoring process, and disciplining in-network providers
                found to
                be out-of-compliance with the health plan's medical management standards.
                The health plan shall use the Missouri Standardized Credentialing
                Form
                (MoSCF), pursuant to RSMo 354.442.1 (15) and 20 CSR 400.7.180, as
                amended.

            

    

    

    Harmony
      has policies and procedures for Initial Credentialing: Re-credentialing every
      three years; Corrective Action, Suspension and Termination of provider
      participation; Hearing and Appellate Review; and Immediate Suspension and
      Termination of Medicaid/Medicare Sanctioned providers.

     

    Initial
      Credentialing

     

    Harmony
      has the responsibility of providing a network of qualified physicians to be
      providers of care to its enrolled membership. Credentialing is the process
      by
      which the peer review body (Credentialing Committee made up of participating
      providers) evaluates an individual applicant’s background, education, training,
      experience, demonstrated ability, patient admitting capabilities, licensure,
      regulatory compliance and health status, by means of approved primary and
      secondary source verifications obtained in accordance with regulatory,
      accreditation, and Company policy and procedure. The Credentialing Committee
      reports its findings to the Quality Improvement
      Committee.

     

    Credentialing
      policy and procedure specifies the types of physicians to credential, and the
      baseline criteria for participation. The policy requires the completion of
      the
      Missouri required application, including the completion of a questionnaire
      and
      an attestation of accuracy and completeness of the information provided. The
      policy outlines the supporting documentation to be included with the
      application; the need for a site survey at the offices of primary care
      physicians and Obstetricians and Gynecologists; the primary sources that will
      be
      used to obtain verifications, and includes a query to the National Practitioner
      Data Bank, and verification of the Office of Inspector General’s Report to
      confirm eligibility to participate in Medicaid. The policy outlines the
      credentialing process; the timeframe for processing; the peer review process
      for
      review and approval or non-approval; and the approval period. In the event
      of
      non-approval, the applicant is entitled to appeal.

     

    Re-credentialing
      

     

    Re-credentialing
      is required at least every three years. A pre-printed application is provided
      to
      the physician. The policy outlines the primary and secondary sources that may
      be
      used to obtain verifications, and includes a query to the National Practitioner
      Data Bank, and verification of the Office of Inspector General’s Report to
      confirm eligibility to continue participation in Medicaid. The policy outlines
      the re-credentialing process; the inclusion of review of performance monitoring
      at the time of re-credentialing; and the peer review process for review and
      approval for continuation of provider status for a period not to exceed three
      years, or non-approval. In the event of non-approval, the physician is entitled
      to appeal. The OIG Sanctions report is checked against the Company’s databases
      on a monthly basis.

     

    Suspension
      or Termination of Physicians 

     

    Whenever
      the activity or professional conduct of any physician is, or is reasonably
      probable of being, detrimental to member safety or to the delivery of quality
      care, or is reasonably probable of being disruptive to the Company, corrective
      action against such physician may be initiated. An outline of the acts
      constituting grounds for corrective action, suspension or termination of
      membership are, but are not limited to:

    

    
      	·  	
              issues
                of availability or other issues identified through internal monitoring
                processes;

            

    

    
      	·  	
              gross
                or repeated quality of care issues, or the failure to practice medicine
                with the level of care and skill recognized by peers as
                acceptable;

            

    

    
      	·  	
              restriction,
                suspension or revocation of licensure in the State in which practice
                is
                located;

            

    

    
      	·  	
              loss
                of eligibility of participation in the Medicare/Medicaid
                program;

            

    

    
      	·  	
              inability
                to currently practice medicine with reasonable skill and safety due
                to
                medical condition or chemical substance
                abuse;

            

    

    
      	·  	
              be
                convicted or plead guilty to a crime which directly relates to medicine
                or
                the ability to practice
                medicine;

            

    

    
      	·  	
              misrepresentation
                of information on a re-credentialing
                application;

            

    

    
      	·  	
              failure
                to comply with previously imposed corrective
                action.

            

    

    

    All
      requests for corrective action are coordinated through the Medical Director.
      The
      Medical Director is responsible for conducting a thorough investigation in
      accordance with policy and procedure. The results of the investigation are
      forwarded to the Credentialing Committee for review and recommendation.
      Recommendation of suspension and/or termination entitles the affected physician
      to the appellate review process.

    

    Notification
      of an adverse participation recommendation is provided to the physician, and
      includes reasons for the action, rights to the appellate review process, and
      the
      process for obtaining appellate review. Notification is provided to the
      physician within 10 days in the case of immediate suspension action, and 30
      calendar days from the date of the suspension or termination recommendation,
      if
      the action is to be taken following final appeal outcome. Notification to the
      physician is mailed by certified return receipt mail.

    

    The
      physician has a period of 30 calendar days in which to file a written request
      for an appellate review. The request is to be mailed via certified return
      receipt mail to the Chief Executive Officer or his designee as notified to
      the
      physician. Upon timely receipt of the request, the Chief Executive Officer
      or
      his designee notifies the physician of the date, time and place of the appellate
      review. An appellate review shall not take place less than 30 calendar days
      from
      the date of the notice.

    

    The
      personal appearance of the physician requesting the appellate review is required
      in all cases where quality of care or conduct are under review, and a where
      an
      adverse recommendation will result in a report to the National Practitioner
      Data
      Bank. A physician who fails, without good cause, to appear and proceed at such
      hearing, is deemed to have waived rights to the hearing and appellate review.
      The physician and the organization are entitled to legal representation at
      the
      hearing.

    

    The
      physician has the burden of proving by clear and convincing evidence that the
      reason for the suspension or termination recommendation lacks any factual basis,
      or that such basis or the conclusion(s) drawn there-from, are arbitrary,
      unreasonable or capricious. 

    

    The
      peer review Committee considers and decides the case objectively and in good
      faith. Within 30 calendar days after final adjournment of the peer review
      Committee, the Committee makes a written report and forwards its recommendation
      to the QI Committee. Notification of the final decision is provided to the
      physician within 30 calendar days.

    

    In
      all cases where suspension of provider services exceeds a period of 30 days
      and
      where the suspension is the result of a professional review action, and relates
      to professional competence or professional conduct, such a case is reportable
      to
      the National Practitioner Data Bank. In the event the peer review Committee
      recommends reinstatement, following a 30-day suspension an appropriate Revision
      to Action notice is to be provided to the National Practitioner Data
      Bank.

    

    
      	d.  	
              Performance
                Improvement Projects:
                The health plan must conduct performance improvement projects that
                are
                designed to achieve, through ongoing measurements and intervention,
                significant improvement, sustained over time, in clinical care and
                nonclinical care areas that are expected to have a favorable effect
                on
                health outcomes and member satisfaction. The health plan must report
                the
                status and results of each project to the state agency as requested.
                The
                performance improvement projects must involve the
                following:

            

    

    

    
      	1)  	
              Measurement
                of performance using objective quality
                indicators.

            

    

    
      	2)  	
              Implementation
                of system interventions to achieve improvement in
                quality.

            

    

    
      	3)  	
              Evaluation
                of the effectiveness of the
                interventions.

            

    

    
      	4)  	
              Planning
                and initiation of activities for increasing or sustaining
                improvement.

            

    

    
      	5)  	
              Completion
                of the performance improvement project in a reasonable time period
                so as
                to generally allow information on the success of performance improvement
                projects in the aggregate to produce new information on quality of
                care
                every year.

            

    

    
      	6)  	
              Performance
                measures and topics for performance improvement projects specified
                by CMS
                in consultation with the state agency and other
                stakeholders.

            

    

    

    The
      purpose of Harmony’s Quality Improvement Program (QIP) is to establish a
      systematic process of quality improvement that will ensure a comprehensive,
      integrated plan-wide system to assess and improve the quality of clinical care
      and services provided to WellCare members in all lines of business. The Quality
      Improvement Program description, with details of our quality assessment and
      performance improvement approach, is attached in Appendix Binder, Tab
      #6.

    

    WellCare’s
      ongoing quality assessment and performance improvement approach provides for
      the
      monitoring, analysis, evaluation, and improvement of the delivery, quality,
      and
      appropriateness of health care furnished to all members in compliance with
      good
      clinical practice and federal Medicaid regulations. The program is governed
      by
      the written QIP description and related policies and procedures. The QIP
      addresses the key areas of access, availability, utilization, quality of care,
      clinical competence, credentialing, appeals and grievances, member satisfaction,
      provider satisfaction, and administrative services. The QIP spans all product
      lines, demographic groups, care settings, and types of services. To ensure
      that
      the QIP capitalizes on the most recent research and data, the Quality
      Improvement Program Description and Workplan, which determine the annual program
      structure and activities, are formally evaluated and updated each year.

    

    As
      one of the country’s largest Medicaid, Medicare, and SCHIP managed care plans,
      WellCare works closely with public sector purchasers to monitor the quality
      of
      care provided to program beneficiaries. We understand that the State of
      Missouri, Department of Social Services, Division of Medical Services is
      delegating much of the responsibility for the quality of care provided to MC+
      enrollees to the contracted are management organizations. Therefore, as a
      Managed Care contractor to the State, WellCare will not only conduct its
      internal processes for quality assessment and performance improvement, but
      document these processes and their outcomes to DSS for oversight of the plan
      and
      reporting to the State’s other stakeholders. 

    

    
      	e.  	
              Member
                Incentives:
                The health plan may offer member incentives with a value of $30.00
                or less
                per eligible member per month.  All member incentives must be prior
                approved by the state agency.  The purpose of the health plan's
                member incentives: 

            

    

     

    ·  Must
      be
      directly related to a health plan quality initiative 

    ·  Must
      be
      measurable via the quality activity 

    ·  Cannot
      have any relationship to the health plan's marketing activities

    ·  Cannot
      be
      convertible to cash or redemption in any way for alcohol, tobacco products,
      firearms or ammunition.

     

    
      	1)  	
              The
                health plan must monitor their member incentives program to ensure
                that
                the program has met the health plan's quality initiative and to evaluate
                on an ongoing basis the effectiveness of the member incentive
                program.

            

    

    

    
      	2)  	
              The
                health plan must report the status and results of member incentives
                to the
                state agency as requested.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.17.5 and subparagraphs a - e. 

    

    
      	2.18  	
              Community
                Health Assessment:

            

    

    

    
      	2.18.1  	
              The
                health plan shall participate in a community health status assessment
                and
                improvement initiative as approved by the Department of Health and
                Senior
                Services. The health status assessment and improvement initiative
                shall be
                developed by a community-based coalition and include community benchmarks
                for measuring access, quality, and health status. The Department
                of Health
                and Senior Services shall provide a list of active community-based
                health
                status assessment and improvement initiatives to the health plan.
                If there
                is no approved health status assessment and improvement initiative
                in the
                health plan's region, the Department of Health and Senior Services
                shall
                provide technical assistance to the health plan to develop the health
                status assessment and improvement initiative. Participation in a
                health
                status assessment and improvement initiative shall
                include:

            

    

    

    
      	a.  	
              Becoming
                a member of a community-wide planning coalition. Community means
                a
                geographic entity (a county(ies) for the most part) with broad based
                representation from community providers, businesses, local organizations,
                schools, etc. The Department of Health and Senior Services would
                notify
                the health plan of coalitions that meet the community standard. Where
                no
                such coalition exists, the Department of Health and Senior Services
                shall
                work with the health plan to develop one. The health plan shall not
                be
                required to be the lead agency in establishing a
                coalition.

            

    

    

    
      	b.  	
              Assisting
                with the collection and/or analysis of relevant health data and
                information as defined by the
                coalition.

            

    

    

    
      	c.  	
              Active
                involvement in the assessment process including prioritizing community
                problems.

            

    

    

    
      	d.  	
              Active
                involvement in the development and implementation of the community
                strategic plan to implement health improvement
                programs.

            

    

    

    
      	e.  	
              Providing
                feedback on the community strategic plan and its
                effectiveness.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.18.1 and subparagraphs a - e. 

    

    
      	2.19  	
              State
                and Federal Reviews:

            

    

    

    
      	2.19.1  	
              The
                health plan shall make available to the state agency or its outside
                reviewers, on an annual basis and on an as needed basis, medical
                and other
                records for review of quality of care, access, financial, and other
                issues. The state agency's quality assessment and improvement review
                may
                include but is not limited to:

            

    

    

    
      	a.  	
              On-site
                visits and inspections of
                facilities;

            

    

    

    
      	b.  	
              Staff
                and member interviews;

            

    

    

    
      	c.  	
              Review
                of utilization, denial of services, and other areas that will indicate
                quality of care delivered to
                members;

            

    

    

    
      	d.  	
              Medical
                records reviews;

            

    

    

    
      	e.  	
              Financial
                records reviews;

            

    

    

    
      	f.  	
              Review
                of all quality assessment procedures, reports, committee activities
                and
                recommendations, and corrective
                actions;

            

    

    

    
      	g.  	
              Review
                of staff and provider
                qualifications;

            

    

    

    
      	h.  	
              Review
                of the complaint, grievance, and appeal process and
                resolutions;

            

    

    

    
      	i.  	
              Review
                of requests for transfers between primary care providers within each
                health plan;

            

    

    

    
      	j.  	
              Review
                of fraud and abuse detection, prevention, and review process, procedures,
                cases, and reports; and

            

    

    

    
      	k.  	
              Evaluation
                and analysis of coordination and continuity of
                care.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.19.1 and subparagraphs a - k. 

    

    

    
      	2.19.2  	
              External
                Reviews:
                The state agency contracts with independent external evaluators to
                examine
                the quality of care provided by the health plan. CMS designates an
                outside
                review agency to conduct an evaluation of the program and its progress
                toward achieving program goals. The health plan shall make available
                to
                CMS’s outside review agency and the state agency's external evaluator
                medical and other records for review as requested. The health plan
                shall
                provide information for External Quality Reviews in the format specified
                by the state agency. 

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.19.2. 

    

    

    
      	2.20  	
              Financial
                Reporting:

            

    

    

    
      	2.20.1  	
              The
                health plan shall not hold a member liable for the
                following:

            

    

    

    
      	a.  	
              The
                debts of the health plan, in the event of the health plan’s
                insolvency;

            

    

    

    
      	b.  	
              Services
                provided to the member in the event the health plan fails to receive
                payment from the state agency for such
                services;

            

    

    

    
      	c.  	
              Services
                provided to the member in the event a health care provider with a
                contractual, referral, or other arrangement with the health plan
                fails to
                receive payment from the state agency or health plan for such services;
                or

            

    

    

    
      	d.  	
              Payments
                to a provider that furnishes covered services under a contractual,
                referral, or other arrangement with the health plan in excess of
                the
                amount that would be owed by the member if the health plan had directly
                provided the services.

            

    

    

    
      	e.  	
              In
                the case of insolvency, the health plan shall continue to cover services
                to members during insolvency for the duration of period for which
                payment
                has been made by the state agency, as well as for inpatient admissions
                up
                until discharge.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.20.1 and subparagraphs a - e. 

    

    
      	2.20.2  	
              Financial
                Data Reporting: The
                health plan shall submit unaudited semi-annual reports and an unaudited
                and audited annual report for their MC+ managed care book of business
                to
                the state agency. The health plan shall submit the semi-annual and
                annual
                reports in the format and audit guidelines specified by the state
                agency.
                The current report format and audit guidelines can be found in Attachment
                10. Changes to the report format must be approved by the state agency
                prior to submission.

            

    

    

    
      	a.  	
              The
                semi-annual and unaudited and audited annual reports must be certified
                by
                one of the following:

            

    

    

    
      	1)  	
              The
                health plan’s Chief Executive
                Officer.

            

    

    
      	2)  	
              The
                health plan’s Chief Financial
                Officer.

            

    

    
      	3)  	
              An
                individual who has delegated authority to sign for, and who reports
                directly to, the health plan’s Chief Executive Officer or Chief Financial
                Officer.

            

    

    

    
      	b.  	
              The
                certification must attest, based on best knowledge, information,
                and
                belief, as follows:

            

    

    

    
      	1)  	
              To
                the accuracy, completeness, and truthfulness of the
                data.

            

    

    
      	2)  	
              To
                the accuracy, completeness, and truthfulness of the semi-annual and
                annual
                reports.

            

    

    

    
      	c.  	
              The
                health plan must submit the certification concurrently with the
                semi-annual and annual reports.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.20.2 and subparagraphs a - c. 

    

    
      	2.20.3  	
              Physician
                Incentive Plan Requirements:
                The Department of Health and Human Services published a federal regulation
                regarding physician incentive plans in the March 27, 1996, Federal
                Register.
                This regulation is designed to protect beneficiaries enrolled in
                Medicare
                and Medicaid Managed Care Organizations by placing certain limitations
                on
                physician incentive plans that could influence a physician’s care
                decisions.

            

    

    

    
      	a.  	
              In
                addition, the physician incentive plan regulation applies to all
                subcontractors, including any health care services subcontractors.
                The
                physician incentive plan regulation does not apply outside the scope
                of
                incentive plans for physicians providing services to Medicare or
                MC+
                managed care members.

            

    

    

    
      	b.  	
              The
                health plan shall not offer financial incentives to induce physicians
                to
                limit or reduce medically necessary services to a specific member.
                The
                health plan shall not offer non-financial incentives to limit or
                reduce
                medically necessary services to a specific
                member.

            

    

    

    
      	c.  	
              A
                physician group is at "substantial" financial risk if more than 25%
                of its
                potential payment is at risk for services it does not
                provide.

            

    

    

    
      	1)  	
              If
                the physician group is at “substantial” financial risk, the health plan
                shall provide adequate protection to limit financial losses. The
                health
                plan has the option of: 1) retaining the risk in its direct provider
                contracts, or 2) the MCO, intermediate entity, physician or physician
                group can reinsure the risk through a reinsurance carrier. Stop-loss
                protection must cover at least ninety percent (90%) of the costs
                of
                referral amounts that exceed 25% of the total potential payment on
                either
                a per member per year or an aggregate
                basis.

            

    

    

    For
      the
      purposes of the PIP regulation, the term “physician” is defined as: Doctors of
      medicine, doctors of osteopathy, doctors of dental surgery or dental medicine,
      doctors of podiatric medicine, doctors of optometry, chiropractors, and any
      limited practice provider that provides services on State authority to perform
      such services.

    

    
      	2)  	
              If
                the physician group is at "substantial risk", the health plan must
                conduct
                annual member surveys. The health plan shall survey enrolled and
                disenrolled members with questions on satisfaction, quality, and
                access to
                services. The result should be submitted to the state
                agency.

            

    

    

    
      	d.  	
              In
                compliance with the federal regulation, the health plan shall disclose
                to
                the members, upon request, whether the health plan used a physician
                incentive plan, what type of physician incentive plan it uses, whether
                stop-loss insurance is provided, and a summary of any survey results
                if a
                survey was required to be
                conducted.

            

    

    

    
      	e.  	
              On
                an annual basis and in compliance with the federal regulation, the
                health
                plan must disclose physician incentive plans to CMS, and the state
                agency.
                The information to be disclosed shall include the
                following:

            

    

    

    
      	1)  	
              Effective
                date of the physician incentive
                plan;

            

    

    
      	2)  	
              The
                type of incentive arrangement;

            

    

    
      	3)  	
              The
                amount and type of stop-loss
                protection;

            

    

    
      	4)  	
              The
                patient panel size;

            

    

    
      	5)  	
              If
                pooled, a description of the
                method;

            

    

    
      	6)  	
              The
                computations of significant financial
                risk;

            

    

    
      	7)  	
              Whether
                the health plan does not have a physician incentive plan;
                and

            

    

    
      	8)  	
              Name,
                address, phone number, and other contact information for a person
                from the
                health plan who may be contacted with questions regarding the physician
                incentive plan.

            

    

    

    
      	f.  	
              The
                health plan shall notify the state agency within five (5) business
                days of
                any change to the health plan or the subcontractors’ physician incentive
                plan(s).

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.20.3 and subparagraphs a - f. Harmony believes that none
      of
      its Missouri contracts puts Missouri MC+ Providers in “substantial” financial
      risk as described in the Department of Health and Human Services’ federal
      regulation regarding physician incentive plans in the March 27, 1996, Federal
      Register. 

    

    Harmony
      has conducted a review of all its contracts and letters of agreement with all
      providers in its current network of providers for Missouri, and confirms that
      no
      Missouri MC+ Providers are in contract where more than 25% of its potential
      payment is at risk for services it does not provide.

    

    
      	2.20.4  	
              The
                health plan shall provide quarterly reports to the state agency detailing
                third party savings in a format prescribed by the state agency. The
                state
                agency shall provide the health plan with no less than ninety (90)
                calendar days notice of any change in the format requested. These
                reports
                are due on the thirtieth (30) day following the close of the quarter.
                The
                health plan shall maintain records in such a manner as to ensure
                that all
                money collected from third party resources may be identified on behalf
                of
                members. The health plan shall make these records available for audit
                and
                review and certify that all third party collections are identified
                and
                used as a source of revenue.

            

    

    

    
      	a.  	
              The
                quarterly reports must be certified by one of the
                following:

            

    

    

    
      	1)  	
              The
                health plan’s Chief Executive
                Officer.

            

    

    
      	2)  	
              The
                health plan’s Chief Financial
                Officer.

            

    

    
      	3)  	
              An
                individual who has delegated authority to sign for, and who reports
                directly to, the health plan’s Chief Executive Officer or Chief Financial
                Officer.

            

    

    

    
      	b.  	
              The
                certification must attest, based on best knowledge, information,
                and
                belief, as follows:

            

    

    

    
      	1)  	
              To
                the accuracy, completeness, and truthfulness of the
                data.

            

    

    
      	2)  	
              To
                the accuracy, completeness, and truthfulness of the quarterly
                reports.

            

    

    

    
      	c.  	
              The
                health plan must submit the certification concurrently with the quarterly
                reports.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.20.4 and subparagraphs a - c. 

    

    

    
      	2.20.5  	
              The
                health plan shall report the categories of all third party liability
                collections to the state agency and shall include a complete disclosure
                demonstrating its efforts to obtain payment from liable third parties
                and
                the amounts and nature of all third party payments recovered for
                members
                including, but not limited to, payments for services and conditions
                which
                are:

            

    

    

    
      	a.  	
              Employment
                related injuries or illnesses;

            

    

    
      	b.  	
              Related
                to motor vehicle accidents, whether injured as pedestrians, drivers,
                passengers, or bicyclists; and

            

    

    
      	c.  	
              Contained
                in diagnosis codes 800 through 999 (ICD 9-M), with the exception
                of Code
                994.6.

            

    

    

    The
      reports must be certified by one of the following:

    

    a. The
      health plan’s Chief Executive Officer.

    b. The
      health plan’s Chief Financial Officer.

    
      	 	
              c.

            	
              An
                individual who has delegated authority to sign for, and who reports
                directly to, the health plan’s Chief Executive Officer or Chief Financial
                Officer.

            

    

    

    The
      certification must attest, based on best knowledge, information, and belief,
      as
      follows:

    

    
      	a.  	
              To
                the accuracy, completeness, and truthfulness of the
                data.

            

    

    
      	b.  	
              To
                the accuracy, completeness, and truthfulness of the
                reports.

            

    

    

    The
      health plan must submit the certification concurrently with the
      reports.

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.20.5. 

    

    
      	2.21  	
              Operational
                Data Reporting:

            

    

    

    
      	2.21.1  	
              To
                measure the MC+ managed care program's actual accomplishments in
                the areas
                of access to care, utilization, medical outcomes, health status,
                and
                satisfaction, the health plan shall provide the state agency with
                information concerning uniform utilization, quality assessment and
                improvement, member satisfaction, complaint, grievance, and appeal,
                and
                fraud and abuse detection data on a regular basis. On a periodic
                basis,
                the health plan shall make available clinical outcome data in areas
                of
                concern to the state agency. The health plan shall cooperate with
                the
                state agency in carrying out data validation
                steps.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.21.1. 

    

    
      	2.21.2  	
              The
                state agency shall provide report formats and variable definitions
                for the
                health plan to use in reporting operational data. Data elements and
                reporting requirements are outlined in the Performance Requirements
                segment. Final formats will be made available as
                finalized.

            

    

    

    Harmony
      Health Plan has reviewed available data elements and reporting requirements
      currently available in RFP B3Z06118 Performance Requirements segment.

    

    
      	2.21.3  	
              Quarterly
                Complaint, Grievance, and Appeal Report:
                On
                a quarterly basis, the health plan shall submit to the state agency
                a
                Quarterly Complaint, Grievance, and Appeal Report, in accordance
                with the
                State Management Plan included as Attachment
                6.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.21.3. 

    

    
      	2.21.4  	
              Quality
                Assessment and Improvement Evaluation and Reports:
                The health plan shall submit an annual Quality Assessment and Improvement
                Evaluation and Report. The format will be periodically reviewed and
                updated by the state agency. The health plan shall comply with all
                changes
                as specified by the state agency. The state agency shall provide
                the
                health plan with no less than ninety (90) calendar days notice of
                any
                change in the format requested.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.21.4. 

    

    
      	2.21.5  	
              Member
                Satisfaction Report:
                The Department of Health and Senior Services has authority under
                RSMo
                192.068, as amended, to collect the member satisfaction survey data
                from
                the health plan. To reduce duplication and ensure consistent survey
                methodology, the state agency shall rely upon the member satisfaction
                survey data from this process. The health plan shall submit member
                satisfaction data to the Department of Health and Senior Services
                in
                accordance with 19 CSR 10-5.010, as amended. The health plan shall
                use the
                survey instrument specified by the Department of Health and Senior
                Services and must fund the cost of the
                survey.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.21.5. 

    

    
      	2.21.6  	
              Presentation
                of Findings:
                The health plan shall obtain the state agency's approval prior to
                publishing or making formal public presentations of statistical or
                analytical material based on the health plan’s MC+ managed care
                membership.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.21.6. 

    

    
      	2.22  	
              Third
                Party Liability: Third
                Party Liability is defined as any individual, entity, or program
                that is
                or may be liable to pay all or part of the health care expenses of
                a
                Medicaid beneficiary. Under Section 1902(a) (25) of the Social Security
                Act, the State is required to take all reasonable measures to identify
                legally liable third parties and treat third party liability as a
                resource
                of the Medicaid beneficiary.

            

    

    

    
      	2.22.1  	
              Coordination
                of Benefits:
                By
                law, Medicaid is the payer of last resort. Therefore, the health
                plan
                shall be used as a source of payment for covered services only after
                all
                other sources of payment have been exhausted. The two methods used
                in the
                coordination of benefits are cost avoidance and post-payment recovery
                (i.e., "pay and chase "). The health plan shall act as an agent of
                the
                state agency for the purpose of coordination of
                benefits.

            

    

    

    
      	a.  	
              If
                health plan has established the probable existence of liability of
                a third
                party health insurance carrier at the time a claim is filed, the
                health
                plan shall reject the claim and return it to the provider for a
                determination of the amount of liability except in certain defined
                situations referenced below. This rejection is called cost avoidance.
                If a
                service is medically necessary, the health plan shall ensure that
                its cost
                avoidance efforts do not prevent a member from receiving such service
                and
                that the member is not required to pay any cost-sharing for use of
                the
                other insurer's providers. 

            

    

    

    
      	b.  	
              The
                establishment of liability takes place when the health plan receives
                confirmation from the provider or the third party health insurance
                carrier
                indicating the extent of liability taking into account any agreement
                between the provider and third party health insurance carrier regarding
                acceptance of the carrier’s payment as payment in full with the exception
                of any patient cost-sharing. If the probable existence of a liable
                third
                party cannot be established or third party benefits are not available
                to
                pay the member's medical expenses at the time the claim is filed,
                the
                health plan shall pay the full amount allowed under the health plan's
                payment schedule. When the amount of liability is determined, the
                health
                plan shall pay the claim to the extent that payment allowed under
                the
                health plan's payment schedule exceeds the amount of the third party
                health insurance carrier's payment taking into account any agreement
                between the provider and the third party health insurance carrier
                regarding acceptance of the carrier’s payment as payment in full with the
                exception of any patient cost-sharing. If a third party health insurance
                carrier (other than Medicare) requires the member to pay any cost-sharing
                (such as copayment, coinsurance, or deductible) the health plan shall
                pay
                the cost-sharing amounts, even if services were provided by an
                out-of-network provider. The health plan may require prior authorization
                of out-of-network services. The health plan's liability for such
                cost-sharing amounts shall not exceed the amount the health plan
                would
                have paid under the health plan's payment schedule for the service.
                The
                out-of-network provider must agree in writing to accept the amount
                of the
                health plan’s payment as payment in full prior to the service being
                provided. If the out-of-network provider does not agree to accept
                the
                health plan’s payment as payment in full, the health plan shall inform the
                member verbally and in writing that due to lack of such agreement,
                the
                member will be liable for the cost sharing amounts to the out-of-network
                provider or the member may seek services without charge from an in-network
                provider.

            

    

    

    
      	1)  	
              For
                additional clarity on establishment of the health plan’s liability, the
                following examples are provided: 

            

    

    

    
      	·  	
              A
                provider submits a charge for $100 to the health plan for which the
                health
                plan’s allowable is $80. The provider received $75 from the third party
                insurance carrier. There is no agreement between the provider and
                third
                party insurance carrier that the amount paid by the carrier is payment
                in
                full. The provider normally bills all patients with this carrier
                the
                remaining balance of $25. The provider would submit a claim to the
                health
                plan indicating the remaining balance of $25 is owed after receiving
                $75
                from the third party carrier. The amount the health plan pays the
                provider
                is the difference between the health plan’s allowable ($80) and the
                carrier’s payment ($75) or $5. 

            

    

    
      	·  	
              A
                provider has a charge of $100.00. The third party carrier and provider
                have agreed that the amount paid by the carrier is payment in full
                except
                for any cost-sharing. The carrier has an allowable of $50 with the
                remaining $25 to be a contractual write-off. The member has a co-payment
                of $25.00. The provider bills all patients with this carrier only
                the
                co-payment amount. The provider bills the health plan the $25 co-payment.
                The health plan’s liability is not $30 ($80-$50) in this situation as
                there exists an agreement between the provider and third party carrier
                that there is no liability by the patient other than cost-sharing.
                The
                health plan’s pays the provider $25 as the co-payment does not exceed its
                allowable of $80.

            

    

    

    
      	c.  	
              The
                requirement of cost avoidance applies to all covered services except
                claims for labor and delivery and postpartum care (costs associated
                with
                the inpatient hospital stay for labor and delivery and postpartum
                care
                must be cost avoided); prenatal care for pregnant women; preventive
                pediatric services; or if the claim is for a service that is provided
                to a
                member on whose behalf child support enforcement is being carried
                out by
                the Missouri Department of Social Services, Family Support Division.
                For
                these services, the health plan shall provide such service and then
                recover payment from the third party health insurance carrier ("pay
                and
                chase"). 

            

    

    

    
      	d.  	
              The
                health plan may retain up to 100 percent of its third party collections
                if
                all of the following conditions
                exist:

            

    

    

    
      	1)  	
              Total
                collections received do not exceed the total amount of the health
                plan's
                financial liability for the member.

            

    

    

    
      	2)  	
              There
                are no payments made by the state agency related to
                fee-for-service.

            

    

    

    
      	3)  	
              Such
                recovery is not prohibited by Federal or State
                law.

            

    

    

    
      	e.  	
              The
                state agency shall provide the health plan with a daily file of third
                party health insurance carrier information (other than Medicare)
                for the
                purpose of updating the health plan's files. The state agency shall
                continue to perform verification of the health insurance information.
                The
                state agency does not warrant that the information is complete or
                accurate. The file is to be considered a "lead" file to assist the
                health
                plan in identifying legally liable third parties. The health plan
                shall
                timely notify the state agency of any known changes, additions, or
                deletions of coverage in a format prescribed by the state
                agency.

            

    

    

    
      	f.  	
              The
                state agency shall annually perform a data match with the United
                States
                Department of Defense to identify members covered by TRICARE. The
                state
                agency shall provide the health plan with the results of the data
                match
                annually and in a format specified by the state agency. The health
                plan
                shall perform post-payment recovery and cost avoidance activities
                as
                appropriate based on the information supplied by the data
                match.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.22.1. Harmony employs an aggressive and multifaceted
      strategy to ensure optimized identification, cost avoidance and/or recovery
      of
      expenditures related to TPL/subrogation and COB. Internal policies and
      procedures in Health Services, claims, and Enrolment departments facilitate
      the
      systematic capture of information streaming from diagnoses, providers, members
      and state agencies. This information is coded in the claims payment system
      generating a primary payer obligation status of a third party, thus avoiding
      direct cost for associated services and/or eligibility segments.

    

    
      	2.22.2  	
              Casualty/Tort:
                The health plan shall act as an agent of the state agency for purposes
                of
                third party reimbursement pursuant to RSMo 208.215, as amended. In
                addition to coordination of benefits, the health plan shall pursue
                reimbursement in the following circumstances: Workers' Compensation,
                Tortfeasors, Motorist Insurance, and Liability/Casualty
                Insurance.

            

    

    

    
      	a.  	
              The
                health plan shall take action to identify those paid claims for members
                that contain diagnosis codes 800 through 999 (ICD 9-CM), with the
                exception of 994.6, for the purpose of determining the legal liability
                of
                third parties so that the health plan may process claims under the
                third
                party liability payment procedures specified in 42 CFR 433.139 (b)
                through
                (f), as amended.

            

    

    

    
      	b.  	
              The
                state agency shall perform a data match with the Department of Labor,
                Division of Workers' Compensation to identify members that the Division
                of
                Workers' Compensation has a record of a work-related injury claim.
                The
                state agency shall provide the health plan with the results of the
                data
                match monthly and in a format specified by the state agency. The
                health
                plan shall perform post payment recovery and cost avoidance activities
                as
                appropriate based on the information supplied by the data match.
                If the
                probable existence of third party liability cannot be established
                or third
                party benefits are not available to pay the member's medical expenses
                at
                the time the claim is filed, the health plan shall pay the full amount
                allowed under the health plan's payment
                schedule.

            

    

    

    
      	c.  	
              The
                state agency shall perform a data match with the State Traffic Accident
                Reporting System (STARS) of the Missouri Highway Patrol to identify
                members that the STARS system has a record of a member involved in
                a motor
                vehicle accident. The state agency shall provide the health plan
                with the
                results of the match monthly and in a format specified by the state
                agency. The health plan shall perform further validation activities
                when
                using information supplied by the data match to ensure the member
                is in
                fact the person referenced in the match. If the probable existence
                of
                third party liability cannot be established or third party benefits
                are
                not available to pay the member's medical expenses at the time the
                claim
                is filed, the health plan shall pay the full amount allowed under
                the
                health plan's payment schedule.

            

    

    

    
      	d.  	
              The
                health plan shall perform all research, investigations, and payment
                of
                lien-related costs, including but not limited to, attorney fees and
                costs
                related to such cases.

            

    

    

    
      	e.  	
              If
                a member initiates a legal action as a result of an injury that occurred
                during the health plan contract period, the health plan may file
                a lien
                for reimbursement for medical services provided to treat the injury
                that
                occurred during the contract period even after the contract period
                has
                ended.

            

    

    

    
      	f.  	
              If
                the health plan initiates a lien during the contract period but the
                case
                remains unsettled at the end of the contract period, the health plan
                may
                continue pursuit of the action for the medical services related to
                the
                injury that were provided during the contract
                period.

            

    

    

    
      	g.  	
              If
                the member enrolls with a new health plan while legal action is pending,
                each health plan may file separate liens to recover reimbursement
                for
                medical services related to the injury that were provided during
                the
                respective contract periods.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.22.2 and subparagraphs a - g. 

    

    
      	2.23  	
              Reinsurance:
                The
                state agency will not administer a reinsurance program funded from
                capitation payment withholdings.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.23. 

    

    
      	2.24  	
              Reserving: As
                part of its accounting and budgeting function, the health plan shall
                establish an actuarially sound process for estimating and tracking
                incurred but not reported costs. The health plan should reserve funds
                by
                major categories of service (e.g., hospital inpatient; hospital
                outpatient) to cover both incurred but not reported, and reported
                but
                unpaid claims. As part of its reserving methodology, the health plan
                should conduct annual reviews to assess its reserving methodology
                and make
                adjustments as necessary.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.24. 

    

    
      	2.25  	
              Claims
                Processing and Management Information System: 

            

    

    

    
      	2.25.1  	
              The
                health plan shall have a Claims Processing and Management Information
                System (MIS) capable of meeting the MC+ managed care program requirements
                and maintaining satisfactory performance throughout the life of the
                contract. The health plan shall have the capability to transmit and
                receive data, support provider payments, and data reporting requirements
                as specified herein. The health plan shall have the capability to
                process
                claims, retrieve and integrate enrollment data, assign primary care
                providers, maintain provider network data, and submit encounter data.
                The
                Claims Processing and MIS should be of sufficient capacity to expand
                as
                needed due to member enrollment or program
                changes.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.25.1. 

     

    Harmony
      employs the Diamond 950 system as the core transaction processing system for
      the
      maintenance of provider, member, benefit, and contract information. This
      top-tier commercial system supports our core transaction processing functions.
      Operating on Sun hardware and an Oracle database, Diamond is designed to be
      scalable to accommodate internal growth and growth from acquisitions. We use
      our
      systems for premium billing, claims processing, utilization management,
      reporting, medical cost trending, planning and analysis. The systems also
      supports member and provider service functions, including enrollment, member
      eligibility verification, primary care and specialists physician roster access,
      claims status inquiries, and referrals an authorizations.

     

     

    Harmony
      uses Diamond to adjudicate and pay healthcare claims submitted to the plan
      by
      providers on behalf of the eligible beneficiaries. Harmony also uses Diamond
      to
      store and record non-financial transactions (so-called “encounters”) submitted
      to the plan as evidence of healthcare services rendered under pre-paid and
      capitated arrangements. Additionally, Harmony uses Diamond to manage and record
      authorizations and referrals among the various healthcare providers who deliver
      health care services on behalf of Harmony’s beneficiaries. The Diamond system
      provides for the storage and maintenance of demographic information about
      beneficiaries.

     

     

    Harmony
      has included a Claim Adjudication Process flow chart and written description
      which details the flow of claims from receipt until payment. Please refer to
      Appendix Binder, Tab #7 to review these documents.

     

    The
      Actuarial Services department is charged with producing monthly estimate of
      Incurred But Not Reported (IBNR) liability associated with all the lines of
      business at WellCare Health Plans, Inc. (WellCare).

    

    Various
      actuarial assumptions and methodologies are applied during the process.
      WellCare’s policy is that all actuarial assumptions and methodologies applied in
      the IBNR process should follow applicable Actuarial Standards of Practice as
      promulgated by the Actuarial Standards Board.    

    

    
      	2.25.2  	
              The
                health plan shall transmit encounter data and all required files
                in
                accordance with the Health Plan Record Layout Manual, as amended.
                The
                health plan shall maintain an encounter overall acceptance rate of
                at
                least 95 % as measured by the state agency.

            

    

    

    
      	a.  	
              The
                health plan shall submit encounter data for all services provided
                including those services that are reimbursed by the health plan through
                a
                capitated arrangement or other subcontracted
                arrangement.

            

    

    

    
      	1)  	
              The
                encounter data must be certified by one of the
                following:

            

    

    

    
      	·  	
              The
                health plan’s Chief Executive
                Officer.

            

    

    
      	·  	
              The
                health plan’s Chief Financial
                Officer

            

    

    
      	·  	
              An
                individual who has delegated authority to sign for, and who reports
                directly to, the health plan’s Chief Executive Officer or Chief Financial
                Officer.

            

    

    

    
      	2)  	
              The
                certification must attest, based on best knowledge, information,
                and
                belief, as to the accuracy, completeness, and truthfulness of the
                encounter data.

            

    

    

    
      	3)  	
              The
                health plan must submit the certification concurrently with the encounter
                data.

            

    

    

    
      	b.  	
              The
                health plan shall transmit primary care provider assignments and
                changes
                or additions to the provider demographic
                file.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.25.2 and subparagraphs a - b. 

    

    
      	2.25.3  	
              The
                health plan shall accept claims electronically from all providers.
                The
                health plan shall make every effort to encourage providers to submit
                claims electronically using HIPAA compliant formats.
                

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.25.3. 

    

    

    
      	2.25.4  	
              The
                health plan shall employ or have available, the resources necessary
                to
                make modifications to claims processing edits or expansion of MIS
                capabilities as a result of changes in MC+ managed care policies
                and/or
                procedures. The state agency shall make every effort to give the
                health
                plan 60 calendar days notice of changes in the MC+ managed care program
                that may require the health plan to make system changes in order
                to
                comply.

            

    

    

    Harmony
      Health Plan understands the requirements set forth in RFP B3Z06118 paragraph
      2.25.4. 

    

    Paragraph
      2.25.5 inserted by Amendment #001

     

    
      	2.25.5  	
              Timeliness
                of Claim Adjudication Report:
                On a quarterly basis, the health plan shall submit to the state agency
                a
                "Timeliness of Claims Adjudication Report" in accordance with the
                quarterly reporting schedule outlined in Attachment 6 in a format
                specified by the state agency. 

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.25.5. 

     

    
      	2.26  	
              Records
                Retention:

            

    

    

    
      	2.26.1  	
              The
                health plan shall maintain books and records relating to MC+ managed
                care
                services and expenditures, including reports to the state agency
                and
                source information used in preparation of these reports. The books
                and
                records shall include, but are not limited to, financial statements,
                records relating to quality of care, medical records, and prescription
                files.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.26.1. 

    

    
      	2.26.2  	
              The
                health plan shall also comply with all standards for record keeping
                specified by the state agency.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.26.2. 

    

    
      	2.26.3  	
              The
                health plan shall maintain and retain all financial and programmatic
                records, supporting documents, statistical records, and other records
                of
                members for five (5) years. If any litigation, claim, negotiation,
                audit
                or other action involving the records has been started before the
                expiration of the five (5) year period, the health plan shall retain
                the
                records until completion of the action and resolution of all issues
                which
                arise from it or until the end of the regular five (5) year period,
                whichever is later.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.26.3. 

    

    
      	2.26.4  	
              The
                health plan shall retain the source records for the health plan’s data
                reports for a minimum of five (5) years and must have written policies
                and
                procedures for storing this
                information.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.26.4. 

    

    
      	2.26.5  	
              Medical
                Records:
                The health plan shall have written policies and procedures for the
                maintenance of medical records so that the records are documented
                accurately and in a timely manner, are readily accessible, and permit
                prompt and systematic retrieval of information. Complete medical
                records
                shall include but are not limited to medical charts, health status
                screens, prescription files, hospital records, physician specialists,
                consultant and other health care professionals' findings, and other
                documentation sufficient to disclose the quantity, quality,
                appropriateness, and timeliness of services provided. The health
                plan
                shall make such medical records available to duly authorized
                representatives of the state agency and the United States Department
                of
                Health and Human Services to evaluate, through inspections or other
                means,
                the quality, appropriateness, and timeliness of services performed.
                The
                health plan must have procedures to provide for prompt transfer of
                member
                records upon request to other in-network or out-of-network providers
                for
                the medical management of the
                member.

            

    

    

    
      	a.  	
              In
                accordance with Senate Bill No. 1024, enacted by the General Assembly
                of
                the State of Missouri, Section A., Chapter 334, RSMo, amended to
                be known
                as Section 334.097, physicians shall maintain an adequate and complete
                patient record for each patient and may maintain electronic records
                provided the record keeping format is capable of being printed for
                review.
                An adequate and complete patient record shall include documentation
                of the
                following information:

            

    

    

    
      	·  	
              Identification
                of the patient, including name, birthdate, address and telephone
                number;

            

    

    
      	·  	
              The
                date or dates the patient was seen;

            

    

    
      	·  	
              The
                current status of the patient, including the reason for the
                visit;

            

    

    
      	·  	
              Observation
                of pertinent physical findings;

            

    

    
      	·  	
              Assessment
                and clinical impression of
                diagnosis;

            

    

    
      	·  	
              Plan
                for care and treatment, or additional consultations or diagnostic
                testing,
                if necessary. If treatment includes medication, the physician shall
                include in the patient record the medication and dosage of any medication
                prescribed, dispensed or administered;
                and

            

    

    
      	·  	
              Any
                informed consent for office
                procedures.

            

    

    

    
      	1)  	
              Patient
                records remaining under the care, custody, and control of the physician
                shall be maintained by the physician, or the physician’s designee, for a
                minimum of seven (7) years from the date of when the last professional
                service was provided.

            

    

    

    
      	2)  	
              Any
                correction, addition, or change in any patient record made more than
                forty-eight hours after the final entry is entered in the record
                and
                signed by the physician shall be clearly marked and identified as
                such,
                and the date, time, and name of the person making the correction,
                addition, or change shall be included, as well as the reason for
                the
                correction, addition, or change.

            

    

    

    
      	3)  	
              A
                consultative report shall be considered an adequate medical record
                for a
                radiologist, pathologist, or a consulting
                physician.

            

    

    

    
      	b.  	
              The
                member’s medical record is the property of the provider who generates the
                record. Upon the written request of a member, guardian, or legally
                authorized representative of a member the health plan shall furnish
                a copy
                of the medical records of the member's health history and treatment
                rendered. Such medical records shall be furnished within a reasonable
                time
                of the receipt of the written request. Each member is entitled to
                one free
                copy of his or her medical records annually. The fee for additional
                copies
                shall not exceed the actual cost of time and materials used to compile,
                copy, and furnish such records.

            

    

    

    
      	c.  	
              The
                health plan shall provide the state agency with access to all members'
                medical records, whether electronic or paper, within thirty (30)
                calendar
                days of receipt of written request at no charge. The health plan
                shall
                provide the state agency with access to a single or small volume
                of
                medical records within five (5) calendar days of receipt of written
                request at no charge. The health plan shall provide the state with
                immediate access for on-site review of medical records. For on-site
                review
                of medical records, the state agency may provide the health plan
                with an
                advance notice of a partial list of medical records. The health plan
                shall
                fax or send by overnight mail to the state agency all medical records
                involving an emergency or urgent care issue when requested by the
                state
                agency at no charge. Access to record requirements applies to the
                health
                plan and all providers.

            

    

    

    
      	d.  	
              The
                health plan shall have written standards for documentation on the
                medical
                record for legibility, accuracy, and plan of
                care.

            

    

    

    
      	e.  	
              The
                health plan shall require its providers to maintain medical records
                in a
                detailed and comprehensive manner which conforms to good professional
                medical practice, permits effective professional medical review and
                medical audit processes, and facilitates an adequate system for follow-up
                treatment. Medical records must be legible, signed and
                dated.

            

    

    

    
      	f.  	
              When
                a member changes primary care providers, upon request, his or her
                medical
                records or copies of medical records must be forwarded to the new
                primary
                care provider within ten (10) business days from receipt of request
                or
                prior to the next scheduled appointment to the new primary care provider
                whichever is earlier.

            

    

    

    
      	g.  	
              The
                state agency is not required to obtain written approval from a member
                before requesting the member's record from the
                provider.

            

    

    

    
      	h.  	
              If
                the state agency requests, the health plan shall gather all medical
                records from their providers.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.26.5 and subparagraphs a-h.

    

    Harmony
      reviews medical record requirements with providers at the time of orientation.
      Harmony’s
      system, in accordance with its Policies and Procedures, limits access to ensure
      that only authorized personnel are accessing Protected Health Information
      (PHI).  Harmony audits provider offices to ensure that medical records are
      stored confidentially and released in a consistent fashion in accordance with
      all applicable state and federal laws.  Additionally, each
Harmony
      provider
      is subject to the state and federal laws including HIPAA regulations, as a
      covered entity.  For Company providers confidentiality is reinforced
      through the Provider Manual, the Provider Contract and credentialing visits.
      Harmony
      has policies and procedures to ensure compliance with the aforementioned
      Performance Requirements.  Please refer to the Appendix Binder, Tab 1,
Item
      20 and 21
      for the Medical Records Review Policies and Procedures.  These policies and
      procedures may be updated from time to time, but shall remain compliant with
      DSS
      standards

    

    
      	2.27  	
              Health
                Plan Disputes With Other Providers: All
                disputes between the health plan and any affiliated or unaffiliated
                provider, or between the health plan and any other subcontractors,
                shall
                be solely between such provider or subcontractors and the health
                plan. The
                health plan shall indemnify, defend, save and hold harmless the State
                of
                Missouri, the Department of Social Services and its officers, employees
                and agents and enrolled MC+ managed care members from any and all
                actions,
                claims, demands, damages, liabilities, or suits of any nature whatsoever
                arising out of the contract because of any breach of the contract
                by the
                health plan, its subcontractors, agents, providers or employees,
                including
                but not limited to any negligent or wrongful acts, occurrence of
                omission
                of commission or negligence of the health plan, its subcontractors,
                agents, providers or employees.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.27. 

    

    
      	2.28  	
              Rate
                Adjustments for Performance Based on HCY/EPSDT Participant Ratio
                and
                Remedies for Violation, Breach, or Non-Compliance of Contract
                Requirements: 

            

    

    

    Rate
      Adjustments for Performance Based on HCY/EPSDT Participant
      Ratio:
      In
      accordance with CMS guidelines, the state agency requires 80 percent of eligible
      members to have HCY/EPSDT well child visits and, accordingly, has included
      an 80
      percent participant ratio in the rates paid to the health plan. In accordance
      with CMS 416 reporting methodology, the state agency shall measure the health
      plan’s performance regarding the percentage of eligible members having HCY/EPSDT
      well child visits (participant ratio). The state agency applies state specific
      criteria to the CMS methodology to reflect the MC+ managed care program. The
      state specific criteria reflects performance by Category of Aid and rate cell,
      the measurement schedule in Attachment 11, and recognition of a month to be
      greater than 27 days. The participant ratio is defined as the number of total
      eligibles receiving at least one initial or periodic well child visit divided
      by
      the number of total eligibles who should receive at least one initial or
      periodic well child visit. The current HCY/EPSDT Measurement Schedule is
      reflected in Attachment 11. The state agency reserves the right to amend the
      HCY/EPSDT Measurement Schedule and shall give the health plan prior written
      notice of such amendment.

    

    
      	a.  	
              In
                the event that the HCY/EPSDT participant ratio is not equal to 80
                percent
                of eligible members having an HCY/EPSDT well child visit as calculated
                using the HCFA 416 reporting methodology, the state agency shall
                with five
                (5) calendar days prior notice make a pro rata adjustment to the
                monthly
                capitation payment to the health plan for each percentage point above
                or
                below 80 percent, but not to exceed 100 percent. This pro rata adjustment
                shall be based on the portion of the monthly capitation payment related
                to
                HCY/EPSDT well child visits and shall be applied to each rate cell
                in
                which well child visits are required. Refer to Attachment 13. The
                state
                agency shall continue making such adjusted monthly capitation payments
                until the next scheduled
                measurement.

            

    

    

    
      	b.  	
              If
                the health plan is new to a MC+ managed care region, the health plan
                shall
                agree that its capitation rate shall reflect the average participant
                ratio
                of the MC+ managed care health plans that are not new to the region
                by
                rate cell and category of assistance for the applicable measurement
                period
                reflected in Attachment 11. Beginning January 2007, the new health
                plan
                shall agree that their future capitation rates shall be adjusted
                by the
                health plan’s actual 12-month HCY/EPSDT participant
                ratio.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.28.1 and subparagraphs a- b. 

    

    
      	2.28.2  	
              Adjustments
                for Performance Based on HEDIS Performance Ratings:
                The health plan's results of HEDIS performance measures as identified
                in
                Attachment 6 shall annually be rated by the state agency as high
                (HI),
                average (AV), low (LO), Not Applicable (NA), or Not Reported (NR).
                This
                rating shall be determined by computing the statewide average of
                all
                health plans in all regions and determining whether a health plan's
                individual results, from a statistical level of confidence, vary
                from the
                statewide average and to what degree the results are precise and
                accurate.
                Those HEDIS performance measures that are rated as high shall be
                assigned
                a numeric value of three (3). Those HEDIS performance measures that
                are
                rated as average shall be assigned a numeric value of two (2). Those
                HEDIS
                performance measures that are rated as low shall be assigned a numeric
                value of one (1). Any performance measure that according to HEDIS
                specifications should not be reported shall be rated as Not Applicable
                and
                shall be assigned a value of zero (0). Any performance measure not
                reported due to the health plan's failure shall be rated as Not Reported
                and assigned a value of negative one (-1). The state agency shall
                then
                total the numeric value of each HEDIS measure. The HEDIS measures
                relating
                to the CAHPS member satisfaction shall not be included in the total.
                The
                state agency shall use only combined measures, where applicable,
                when
                computing the total. The totals are then averaged ignoring values
                of zero
                (0) and rounded to the nearest whole number. The health plan shall
                maintain a minimum performance standard of an overall score of average
                with a value of two (2).

            

    

    

    
      	a.  	
              The
                first annual rating shall occur upon receipt of the HEDIS measures
                due
                June 30, 2007.

            

    

    

    
      	b.  	
              The
                second annual rating shall occur upon receipt of the HEDIS measured
                due
                June 30, 2008. 

            

    

    

    
      	c.  	
              The
                third annual rating shall occur upon receipt of the HEDIS measured
                due
                June 30, 2009.

            

    

    

    
      	d.  	
              The
                first time a health plan achieves an average of low with a value
                of one
                (1), the health plan shall develop and implement a corrective action
                to
                improve the substandard performance.

            

    

    

    
      	1)  	
              The
                state agency shall inform enrollees in enrollment materials that
                the
                health plan failed to achieve the minimum performance
                standard.

            

    

    

    
      	2)  	
              The
                state agency shall reduce the random auto assignment percentage assigned
                to the health plan by one half (1/2). The random auto assignment
                percentage that was removed from the low performing health plan shall
                be
                distributed to the highest rated health plan(s) within the same MC+
                Managed Care region.

            

    

    

    
      	e.  	
              The
                first time a health plan achieves an average of high with a value
                of three
                (3), the state agency shall inform enrollees in enrollment materials
                that
                the health plan(s) achieved above the minimum performance standard.
                

            

    

    

    
      	f.  	
              The
                second time a health plan achieves an average of low with a value
                of one
                (1), the health plan shall develop and implement a corrective action
                to
                improve the substandard
                performance.

            

    

    

    
      	1)  	
              The
                state agency shall inform enrollees in enrollment materials that
                the
                health plan failed to achieve the minimum performance
                standard.

            

    

    

    
      	2)  	
              The
                state agency shall reduce the random auto assignment percentage assigned
                to the health plan by one half (1/2). The random auto assignment
                percentage that was removed from the low performing health plan shall
                be
                distributed to the highest rated health plan(s) within the same MC+
                Managed Care region.

            

    

    

    
      	g.  	
              The
                second time a health plan achieves an average of high with a value
                of
                three, the state agency shall inform enrollees in enrollment materials
                that the health plan or health plans achieved above the minimum
                performance standard. 

            

    

    

    
      	h.  	
              The
                third time a health plan achieves an average of low with a value
                of one
                (1), the state agency shall with five (5) calendar days prior notice
                make
                a .25 percent reduction to the total amount paid the health plan
                in
                monthly capitation payments.

            

    

    

    
      	1)  	
              The
                state agency shall inform enrollees in enrollment materials that
                the
                health plan failed to achieve the minimum performance
                standard.

            

    

    

    
      	2)  	
              The
                reduction of total monthly capitation payments from any low performing
                health plan shall be distributed equally to the health plan(s) rated
                high
                within the same MC+ Managed Care
                region.

            

    

    

    
      	i.  	
              The
                third time a health plan achieves an average of high with a value
                of three
                (3), the state agency shall inform enrollees in enrollment materials
                that
                the health plan achieved above the minimum performance
                standard.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.28.2 and subparagraphs a-i.

    

    
      	2.28.3  	
              Federal
                Sanctions: Section
                1903(m)(5)(A) and (B) of the Social Security Act vests the Secretary
                of
                the Department of Health and Human Services with the authority to
                deny Medicaid payments
                to a health plan for members who enroll after the date on which the
                health
                plan has been found to have committed one or more of the violations
                identified below. Therefore, whenever, and for so long as, federal
                payments are denied, the state agency shall deduct the total amount
                of
                federal payments denied from the next monthly capitation payment
                made to
                the health plan.

            

    

    

    
      	a.  	
              Substantial
                failure to provide required medically necessary items or services
                when the
                failure had adversely affected (or has substantial likelihood of
                adversely
                affecting) a member,

            

    

    

    
      	b.  	
              Discrimination
                among members with respect to enrollment, re-enrollment, or disenrollment
                on the basis of the member’s health status or requirements for health care
                services,

            

    

    

    
      	c.  	
              Misrepresentation
                or falsification of certain information,
                or

            

    

    

    
      	d.  	
              Failure
                to comply with the requirements for physician incentive plans as
                specified
                herein.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.28.3 and subparagraphs a-d.

    

    
      	2.28.4  	
              Liquidated
                Damages for Failure to Provide Covered Services:
                In the event the state agency determines the health plan failed to
                provide
                one or more of the covered services, the state agency shall direct
                the
                health plan to provide such service. If the health plan continues
                to
                refuse to provide the covered service(s), the state agency shall
                authorize
                the member to obtain the covered service from another source and
                shall
                notify the health plan in writing that the health plan shall be charged
                the actual amount of the cost of such service. In such event, the
                charges
                to the health plan shall be obtained by the state agency in the form
                of
                deductions of that amount from the next monthly capitation payment
                made to
                the health plan. With such deductions, the state agency shall provide
                a
                list of the members from whom payments were deducted, the nature
                of the
                service(s) denied, and payments the state agency made or will make
                to
                provide the medically necessary covered
                services.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.28.4.

    

    
      	2.28.5  	
              Remedies
                for Failure to Perform Administrative Services: Whenever
                the state agency determines that the health plan has failed to perform
                an
                administrative function required per the requirements of the contract,
                the
                state agency shall notify the health plan of the health plan’s failure to
                perform required administrative services pursuant to the requirements
                of
                the contract and shall give the health plan five (5) working days
                to
                develop an acceptable action plan for correcting the administrative
                services failure. For the purposes these provisions, “administrative
                services” are defined as any contract requirements other than the actual
                provision of covered services.

            

    

    

    
      	a.  	
              If
                the health plan submits an action plan for correcting the failure
                and if
                the plan is acceptable to the state agency, no action shall be taken
                at
                that time, provided that the health plan implements the corrective
                action
                as approved by the state agency.

            

    

    

    
      	b.  	
              If
                the health plan fails to submit an action plan within the five working
                days or if the health plan does not implement the corrective action
                plan
                within the time frame stated in the action plan, the state agency
                shall
                withhold payment from the next capitation payment due the health
                plan as
                stated below:

            

    

    

    
      	1)  	
              The
                amount withheld shall be up to three percent (3%) of the total amount
                of
                the next capitation payment due the health
                plan.

            

    

    
      	2)  	
              The
                state agency shall continue to withhold up to three percent (3%)
                until
                successful correction of the administrative services failure by the
                health
                plan.

            

    

    
      	3)  	
              After
                successful correction of the administrative services failure, the
                state
                agency shall pay the health plan the total amount of all payments
                withheld.

            

    

    

    
      	c.  	
              If
                the health plan implements the corrective action according to the
                approved
                plan but does not successfully correct the administrative services
                failure
                within the time frame approved in the action plan, the state agency
                shall
                withhold payment from the next capitation payment due the health
                plan
                according to the same provisions as stated
                above.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.28.5 and subparagraphs a-c.

    

    
      	2.28.6  	
              Remedies
                for Failure to Comply with Marketing Requirements: In
                the event the
                state agency determines that the health plan has failed to comply
                with any
                of the marketing requirements of the contract, one or more of the
                remedial
                actions listed below shall apply. The state agency shall notify the
                health
                plan in writing of the determination of the non-compliance, of the
                action(s) that must be taken, and of any other conditions related
                thereto
                such as the length of time the remedial actions shall continue and
                of the
                corrective actions that the health plan must
                perform.

            

    

    

    
      	a.  	
              The
                state agency shall require the health plan to recall the previously
                authorized marketing materials.

            

    

    

    
      	b.  	
              The
                state agency shall suspend enrollment of new members to the health
                plan.

            

    

    

    
      	c.  	
              The
                state agency shall deduct the amount of capitation payment for members
                enrolled as a result of non-compliant marketing practices from the
                next
                monthly capitation payment made to the health plan and shall continue
                to
                deduct such payment until correction of the
                failure.

            

    

    

    
      	d.  	
              The
                state agency shall require the health plan to contact each member
                who
                enrolled during the period while the health plan was out of compliance,
                in
                order to explain the nature of the non-compliance and inform the
                member of
                his or her right to transfer to another health
                plan.

            

    

    

    
      	e.  	
              The
                state agency shall prohibit future marketing activities by the health
                plan
                for an amount of time specified by the state
                agency.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.28.6 and subparagraphs a-e.

    

    
      	2.28.7  	
              Attorney
                Fees: In
                the event the state agency should prevail in any legal action arising
                out
                of the performance or non-performance of the contract, the health
                plan
                shall pay, in addition to any damages, all expenses of such action
                including reasonable attorney’s fees and costs. The term “legal action”
                shall be deemed to include administrative proceedings of all kinds,
                as
                well as all actions at law or
                equity.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.28.7.

    

    
      	2.28.8  	
              Remedial
                Actions:
                The state agency may pursue all remedial actions with the health
                plan that
                are taken with fee-for-service providers. The state agency will work
                with
                the health plan and the health plan providers to change and correct
                problems and will recoup funds only if the health plan fails to correct
                a
                problem within a timely manner.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.28.8.

    

    
      	2.28.9  	
              In
                addition to above referenced described rate adjustments and remedies,
                if
                the state agency determines that the health plan is not taking proper
                action to correct the identified failures, the state agency shall
                have the
                right to implement any other legal processes deemed necessary including
                cancellation of the contract, recovery of damages, suspension of
                enrollment to the health plan, etc.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.28.9.

    

    
      	2.28.10  	
              Intermediate
                Sanctions. The
                state agency may establish and specify intermediate sanctions that
                may be
                imposed when a health plan acts or fails to act as specified below.
                The
                state agency may require a corrective action plan, as referenced
                in
                section 2.28.5, to be developed and approved by the state agency
                in
                situations where intermediate sanctions may be imposed. The state
                agency
                shall approve and monitor implementation of such a plan and set
                appropriate timelines to bring activities of the health plan into
                compliance with state and federal regulations. The state agency may
                monitor via required reporting on a specified basis and/or through
                on-site
                evaluations, the effectiveness of the plan. Before imposing intermediate
                sanctions, the state agency shall give the health plan timely written
                notice that explains the basis and nature of the sanction and any
                other
                due process protections that the state agency elects to
                provide.

            

    

    

    
      	a.  	
              Fails
                substantially to provide medically necessary services that the health
                plan
                is required to provide, under law or under the contract, to a member
                covered under the contract.

            

    

    

    
      	b.  	
              Imposes
                on members premiums or charges that are in excess of the premiums
                or
                charges permitted under the Medicaid
                program.

            

    

    

    
      	c.  	
              Acts
                to discriminate among members on the basis of their health status
                or need
                for health care services.

            

    

    

    
      	d.  	
              Misrepresents
                or falsifies information that it furnishes to CMS or to the state
                agency.

            

    

    

    
      	e.  	
              Misrepresents
                or falsifies information that it furnishes to a member, potential
                member,
                or a health care provider.

            

    

    

    
      	f.  	
              Fails
                to comply with the requirements for physician incentive plans, as
                set
                forth (for Medicare) in 42 CFR 422.208 and
                422.210.

            

    

    

    
      	g.  	
              Distributes
                directly, or indirectly through any agent or independent contractor,
                marketing materials that have not been approved by the state agency
                or
                that contain false or materially misleading
                information.

            

    

    

    
      	h.  	
              Violates
                any of the other applicable requirements of sections 1903(m) or 1932
                of
                the Act and any implementing
                regulations.

            

    

    

    
      	i.  	
              Violates
                any of the other applicable requirements of sections 1932 or 1905(t)(3)
                of
                the Act and any implementing
                regulations.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.28.10 and subparagraphs a-i.

     

    
      	2.28.11  	
              Intermediate
                Sanctions: Types. The
                types of intermediate sanctions that the state agency may impose
                upon the
                health plan include:

            

    

    

    
      	a.  	
              Civil
                monetary penalties in the following specified
                amounts:

            

    

    

    
      	1)  	
              A
                maximum of $25,000 for each determination of failure to provide services;
                misrepresentation or falsification of statements to members, potential
                members or health care providers; failure to comply with physician
                incentive plan requirements; or marketing
                violations.

            

    

    

    
      	2)  	
              A
                maximum of $100,000 for each determination of discrimination among
                members
                on the basis of their health status or need for services; or
                misrepresentation or falsification to CMS or the state
                agency.

            

    

    

    
      	3)  	
              A
                maximum of $15,000 for each member the state agency determines was
                discriminated against based on the member’s health status or need for
                services (subject to the $100,000 limit
                above).

            

    

    

    
      	4)  	
              A
                maximum of $25,000 or double the amount of the excess charges (whichever
                is greater), for charging premiums or charges in excess of the amounts
                permitted under the Medicaid program. The state agency shall return
                the
                amount of overcharge to the affected
                member(s).

            

    

    

    
      	b.  	
              Appointment
                of temporary management for a health plan as provided in 42 CFR
                438.706.

            

    

    

    
      	c.  	
              Granting
                members the right to terminate enrollment without cause and notifying
                the
                affected members of their right to
                disenroll.

            

    

    

    
      	d.  	
              Suspension
                of all new enrollment, including default enrollment, after the effective
                date of the sanction.

            

    

    

    
      	e.  	
              Suspension
                of payment for members enrolled after the effective date of the sanction
                and until CMS or the state agency is satisfied that the reason for
                imposition of the sanction no longer exists and is not likely to
                recur.

            

    

    

    
      	f.  	
              Additional
                sanctions allowed under state statutes or regulations that address
                areas
                of noncompliance described above.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.28.11 and subparagraphs a-f.

    

    

    
      	2.28.12  	
              Sanction
                by Centers for Medicare and Medicaid Services: Special Rules for
                MCOs and
                Denial of Payment. Payments
                provided for under the contract for new members when, and for so
                long as
                payment for those members is denied by CMS in accordance with the
                requirements in 42 CFR 438.730.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.28.12.

    

    
      	2.28.13  	
              Special
                Rules for Temporary Management. The
                state agency shall specify the circumstances under which the sanction
                of
                temporary management will be imposed upon the health
                plan.

            

    

    

    
      	a.  	
              Optional:
                Temporary management may be imposed by the state agency only if it
                finds
                that:

            

    

    

    
      	1)  	
              There
                is continued egregious behavior by the health plan, including, but
                not
                limited to behavior that is described in 42 CFR 438.700, or that
                is
                contrary to any requirements of sections 1903(m) and 1932 of the
                Act;
                or

            

    

    
      	2)  	
              There
                is substantial risk to members’ health;
                or

            

    

    
      	3)  	
              The
                sanction is necessary to ensure the health of the health plan’s members
                while improvements are made to remedy violations under 42 CFR 438.700
                or
                until there is an orderly termination or reorganization of the health
                plan.

            

    

    

    
      	b.  	
              Required:
                The state agency shall impose temporary management if it finds that
                the
                health plan has repeatedly failed to meet substantive requirements
                in
                section 1903(m) or section 1932 of the Act. The state agency shall
                also
                grant members the right to terminate enrollment without cause and
                shall
                notify the affected members of their right to terminate
                enrollment.

            

    

    

    
      	c.  	
              The
                state agency’s election to appoint temporary management shall not act as
                an implied waiver of the state agency’s right to terminate the contract,
                suspend enrollment, or to pursue any other remedy available to the
                state
                agency under the contract.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.28.13 and subparagraphs a-c.

    

    
      	2.28.14  	
              Termination
                of a Health Plan Contract:

            

    

    

    
      	a.  	
              Nothing
                in this section shall limit the state agency’s right to terminate the
                contract or to pursue any other legal or equitable remedies. Pursuant
                to
                42 CFR 438.708, the state agency may terminate the contract as a
                sanction
                and enroll that health plan’s members in other health plans or provide
                their benefits through other options included in the state plan if
                the
                state agency, at its sole discretion, determines that the health
                plan has
                failed to:

            

    

    

    
      	1)  	
              Carry
                out the substantive terms of the
                contract.

            

    

    
      	2)  	
              Meet
                applicable requirements in sections 1932, 1903(m) and 1905(t) of
                the
                Act.

            

    

    

    
      	b.  	
              After
                a state agency notifies the health plan that it intends to terminate
                the
                contract, the state agency may do the
                following:

            

    

    

    
      	1)  	
              Give
                the health plan’s members written notice of the state agency’s intent to
                terminate the contract.

            

    

    
      	2)  	
              Allow
                members to disenroll immediately without
                cause.

            

    

    

    
      	c.  	
              Before
                terminating a health plan’s contract under 42 CFR 438.708, the state
                agency shall provide the health plan a pre-termination hearing. The
                state
                agency shall:

            

    

    

    
      	1)  	
              Give
                the health plan written notice of its intent to terminate, the reason
                for
                termination, and the time and place of
                hearing;

            

    

    
      	2)  	
              Give
                the health plan (after the hearing) written notice of the decision
                affirming or reversing the proposed termination of the contract,
                and for
                an affirming decision, the effective date of termination;
                and

            

    

    
      	3)  	
              For
                an affirming decision, give members of the health plan notice of
                the
                termination and information, consistent with 42 CFR 438.10, on their
                options for receiving Medicaid services following the effective date
                of
                termination.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.28.14 and subparagraphs a-c.

    

    
      	2.29  	
              Access
                to Premises: During
                normal business hours (defined as 8:00 a.m. through 5:00 p.m., Monday
                through Friday, except State designated holidays), the health plan
                shall
                allow duly authorized agents or representatives of the Federal or
                State
                government access to the health plan's premises or the health plan's
                subcontractor's premises to inspect, audit, monitor, or otherwise
                evaluate
                the performance of the health plan or its
                subcontractors.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.29.

    

    
      	2.30  	
              Advance
                Directives:

            

    

    

    
      	2.30.1  	
              The
                health plan shall maintain written policies and procedures related
                to
                advance directives. At the time of enrollment, the health plan shall
                provide written information to all adult members regarding the member's
                rights under the Missouri law to make decisions concerning medical
                care.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.30.1. Harmony will notify members of their rights under
      the
      Missouri law regarding advance directives in member communications to include
      the Member Handbook. 

    

    
      	2.30.2  	
              As
                part of recredentialing, the health plan shall audit records of primary
                care provider, hospitals, home health agencies, personal care providers,
                and hospices to determine whether the provider is following the policies
                and procedures related to advance
                directives.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.30.2.

    

    
      	2.30.3  	
              The
                health plan shall provide education to the health plan’s staff and members
                on issues concerning advance
                directives.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.30.3. 

    

    
      	2.30.4  	
              The
                above provisions shall not be construed to prohibit the application
                of any
                Missouri law which allows for an objection on the basis of conscience
                for
                any provider or agent of such
                provider.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.30.4.

    

    
      	2.31  	
              Fraud
                and Abuse:

            

    

    

    
      	2.31.1  	
              The
                following definitions are taken from “Guidelines for Addressing Fraud and
                Abuse in Medicaid Managed Care”, A Product of the National Medicaid Fraud
                and Abuse Initiative, Health Care Financing Administration National
                Initiative, October 2000. These definitions are provided to assist
                the
                health plan in preventing, identifying, investigating, reporting,
                and
                prosecuting fraud and abuse:

            

    

    

    Medicaid
      Managed Care Fraud: Any
      type
      of intentional deception or misrepresentation made by an entity or person in
      a
      capitated MCO, PCCM program, or other managed care setting with the knowledge
      that the deception could result in some unauthorized benefit to the entity,
      himself, or some other person.

    

    Medicaid
      Managed Care Abuse: Practices
      in a capitated MCO, PCCM program, or other managed care setting that are
      inconsistent with sound fiscal, business, or medical practices, and result
      in an
      unnecessary cost to the Medicaid program, or in reimbursement for services
      that
      are not medically necessary or that fail to meet professionally recognized
      standards or contractual obligations for health care. The abuse can be committed
      by an MCO, contractor, subcontractor, provider, State employee, Medicaid
      beneficiary, or Medicaid managed care enrollee, among others. It also includes
      beneficiary practices in a capitated MCO, PCCM program, or other managed care
      setting that result in unnecessary cost to the Medicaid program or MCO,
      contractor, subcontractor, or provider. It should be noted that Medicaid funds
      paid to an MCO, then passing to subcontractors, are still Medicaid funds from
      a
      fraud and abuse perspective.

    

    Harmony
      Health Plan understands the definitions set forth in RFP B3Z06118 paragraph
      2.31.1.

    

    
      	2.31.2  	
              The
                health plan shall implement internal controls, policies, and procedures
                designed to prevent, detect, review, report to the state agency,
                and
                assist in the prosecution of fraud and abuse activities by providers,
                subcontractors, and members. The policies and procedures shall articulate
                the health plan’s commitment to comply with all applicable Federal and
                State standards. In order to implement the above, the health plan
                must
                submit a written fraud and abuse plan to the state agency for approval
                prior to implementation. Any
                changes to the approved fraud and abuse plan must have state agency
                approval prior to implementation.

            

    

    

    
      	a.  	
              The
                health plan’s fraud and abuse plan must include, but is not limited to the
                following components:

            

    

    

    
      	1)  	
              The
                designation of a compliance officer and a compliance committee that
                are
                responsible for the health plan’s fraud and abuse program and activities.
                The compliance officer is supervised by and reports to the Chief
                Executive
                Officer (CEO), health plan administrator, or the governing
                body;

            

    

    

    
      	2)  	
              Provision
                for a data system, resources and staff to perform the fraud, abuse,
                and
                other compliance responsibilities;

            

    

    

    
      	3)  	
              Procedures
                for internal prevention, detection, reporting, review, and corrective
                action; 

            

    

    

    
      	4)  	
              Procedures
                for prompt response to detected
                offenses;

            

    

    

    
      	5)  	
              Procedures
                for reporting to the state agency, including timelines and use of
                state
                approved forms;

            

    

    

    
      	6)  	
              Written
                standards for organizational
                conduct;

            

    

    

    
      	7)  	
              A
                compliance committee that periodically meets and documents review
                of
                compliance issues. These issues include fraud, abuse, and regulatory
                and
                contractual compliance.

            

    

    

    
      	8)  	
              Effective
                training and education for the compliance officer and the organization’s
                employees, management, board members, and
                subcontractors;

            

    

    

    
      	9)  	
              Inclusion
                of information about fraud and abuse identification and reporting
                in
                provider and member materials; and

            

    

    

    
      	10)  	
              Enforcement
                of standards through well-publicized disciplinary
                guidelines.

            

    

    

    
      	b.  	
              The
                health plan’s fraud and abuse activities should include, but not be
                limited to the following:

            

    

    

    
      	1)  	
              Conducting
                regular reviews and audits of operations to guard against fraud and
                abuse;

            

    

    

    
      	2)  	
              Assessing
                and strengthening internal controls to ensure claims are submitted
                and
                payments are made properly;

            

    

    

    
      	3)  	
              Educating
                employees, network providers, and beneficiaries about fraud and abuse
                and
                how to report it;

            

    

    

    
      	4)  	
              Effective
                organizational resources to respond to complaints of fraud and
                abuse;

            

    

    

    
      	5)  	
              Establishing
                procedures to process fraud and abuse
                complaints;

            

    

    

    
      	6)  	
              Establishing
                procedures for reporting information to the state agency;
                and

            

    

    

    
      	7)  	
              Developing
                procedures to monitor utilization/service patterns of providers,
                subcontractors, and beneficiaries.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.31.2 a - b. 

    

    
      	2.31.3  	
              The
                health plan must report possible fraud or abuse activity to the state
                agency. The health plan must initiate an immediate investigation
                to gather
                facts regarding the possible fraud or abuse. Documentation of the
                findings
                of the investigation must be delivered to the state agency within
                ten (10)
                calendar days of the identification of suspected fraud or abuse activity.
                In addition, the health plan shall provide reports of its investigative,
                corrective, and legal activities to the state agency in accordance
                with
                contractual and regulatory
                requirements.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.31.3.

    

    
      	2.31.4  	
              The
                health plan and its subcontractors shall cooperate fully in any state
                reviews or investigations and in any subsequent legal action. The
                health
                plan must implement corrective actions in instances of fraud and
                abuse
                detected by the state agency, or other authorized agencies or
                entities.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.31.4.

    

    
      	2.31.5  	
              The
                health plan must also provide a quarterly report of fraud and abuse
                activities to the state agency. The report must be submitted in accordance
                with state agency guidelines contained within the fraud and abuse
                policy
                statement. An annual evaluation of the effectiveness of the fraud
                and
                abuse program must be provided to the state agency. This evaluation
                must
                be a component of the annual evaluation of the effectiveness of the
                quality assessment and improvement
                program.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.31.5.

    

    
      	2.31.6  	
              Identification
                of Debarred Individuals or Excluded Providers in Health Plans:
                The
                health plan shall exclude providers from the health plan network
                that have
                been identified as having Office of Inspector General (OIG)
                sanctions, having
                failed to renew license or certification registration, having a revoked
                professional license or certification, or have been terminated by
                the
                state agency. The health plan can access debarred and OIG sanction
                information on the Internet. The health plan should also access
                information from the Professional Registration Boards Internet site
                to
                identify State initiated terminations. The state agency or its authorized
                agent shall conduct a periodic review to determine if appropriate
                exclusions and corrective action have
                occurred.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.31.6. The OIG Sanctions report is checked against Harmony’s
      databases on a regular basis.

    

    
      	2.31.7  	
              Health
                Plan Pharmacy Lock-In:
                The health plan must submit its lock-in policies and procedures to
                the
                state agency for approval prior to implementation. The policies and
                procedures must include the member and provider communication documents
                that shall be utilized for the lock-in process. The lock-in policy
                must
                comply with the requirements located in 13 CSR 70-4.070, Title XIX
                Recipient Lock-In Program.

            

    

    

    The
      health plan must provide services in accordance with the requirements located
      in
      Attachment 3, Managed Care Policies Governing MC+ Services. If the health plan
      determines inappropriate utilization of pharmacy services by a member, the
      health plan may restrict the member to obtaining pharmacy services from one
      pharmacy provider. The health plan must initiate an investigation to identify
      the extent of the fraud or abuse. When a member is suspected of fraud or abuse
      (i.e., presenting an altered prescription), the health plan should notify the
      state agency within ten (10) calendar days of identification of the suspected
      activity in accordance with 2.31.2 and 2.31.3.

    

    Harmony
      understands this requirement and complies. Walgreens Health Initiatives,
      Inc. (WHI) is the PBM for Harmony.  Its extensive pharmacy network in the
      eastern region has processes in place to support this requirement.  WHI has
      previous experience in several other states working with pharmacy lock-in
      programs.

    

    
      	2.31.8  	
              Member
                Explanation of Benefits (EOB): The
                health plan must provide an EOB to members upon request. The EOB
                will
                consist of a list of services that were billed to the health plan.
                The
                list shall contain paid and unpaid claims; for any unpaid claims,
                the list
                shall provide the reason the claim was not paid.
                

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.31.8.

    

    
      	2.32  	
              Other
                Requirements:

            

    

    

    
      	2.32.1  	
              Unless
                otherwise specified herein, the health plan shall furnish all materials,
                labor, facilities, equipment, and supplies necessary to perform the
                service required herein.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.32.1.

    

    
      	2.32.2  	
              Within
                five (5) business days after issuance of the Notice of Award by the
                Division of Purchasing and Materials Management, the health plan
                shall
                submit a written identification and notification to the state agency
                of
                the name, title, address, and telephone number of one (1) individual
                within its organization as a duly authorized representative to whom
                all
                correspondence, official notices, and requests related to the health
                plan's performance under the contract shall be addressed. The health
                plan
                shall have the right to change or substitute the name of the individual
                described above as deemed necessary provided that the state agency
                is
                notified immediately.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.32.2.

    

    
      	2.32.3  	
              The
                health plan shall understand and agree that the contract, in part,
                shall
                implement the MC+ managed care program. Therefore, the health plan
                shall
                conform to such requirements or regulations as the United States
                Department of Health and Human Services
                issues.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.32.3.

    

    
      	2.32.4  	
              If
                the state agency receives written notice from the United States Department
                of Health and Human Services that the health plan does not meet the
                definition of a Health Maintenance Organization as set forth in the
                Medicaid State Plan and 42 CFR 434 or receives written notice from
                the
                Department of Insurance that the health plan does not have a certificate
                of authority to establish or operate a HMO, the Division of Purchasing
                and
                Materials Management may cancel the contract with the health plan
                pursuant
                to contract cancellation provisions contained
                herein.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.32.4.

    

    
      	2.32.5  	
              In
                the event that changes in federal or state law require the Division
                of
                Purchasing and Materials Management to modify the contract, a written
                amendment shall be issued to the health plan pursuant to provisions
                for
                contract amendment stated herein.

            

    

    

    
      	a.  	
              The
                terms of the contract and any amendment thereto must receive the
                approval
                of the United States Department of Health and Human Services. The
                United
                States Department of Health and Human Services failure to approve
                a
                provision of the contract shall render the provision null and void.
                The
                contract is contingent on the health plan meeting the definition
                of a
                Health Maintenance Organization as set forth in the Medicaid State
                Plan
                and 42 CFR 434.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.32.5 and subparagraph a.

    

    
      	2.32.6  	
              The
                health plan shall guarantee and certify that no State of Missouri
                legislator or State of Missouri employee holds a controlling interest
                in
                the health plan.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.32.6. Please see Appendix Binder, Tab
      8.

    

    
      	2.32.7  	
              The
                health plan shall guarantee and certify that no funds paid to the
                health
                plan by the state agency shall be used for the purpose of influencing
                or
                attempting to influence an officer or employee of any Federal or
                State
                agency, a member of the United States Congress, or State Legislature.
                The
                health plan shall disclose if any funds other than those paid to
                the
                health plan by the state agency have been used or will be used to
                influence the persons or entities indicated above and will assist
                the
                state agency in making such disclosures to
                CMS.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.32.7. Please see Appendix Binder, Tab
      8.

    

    
      	2.32.8  	
              Termination
                or cancellation of the contract does not eliminate the health plan's
                responsibility to the state agency for overpayments made to the health
                plan. If the contract is terminated or canceled, the health plan
                shall
                return to the state agency any payments advanced to the health plan
                for
                coverage of members for periods after the date of contract termination
                or
                cancellation. The health plan shall return such payments to the state
                agency within ninety (90) calendar days of contract
                termination/cancellation.

            

    

    

    
      	a.  	
              If
                the contract is terminated, the health plan shall promptly supply
                all
                information necessary for the reimbursement of any outstanding
                claims.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.32.8 and subparagraph a. 

    

    
      	2.32.9  	
              In
                the event the contract is canceled, the state agency shall notify
                all
                members of the date of cancellation and process by which the members
                will
                continue to receive contract services and the health plan shall be
                responsible for all expenses related to said notification under these
                circumstances. In the event the contract is terminated by mutual
                consent,
                the state agency shall notify all members of the date of termination
                and
                process by which the members will continue to receive contract services;
                and the state agency shall be responsible for all expenses relating
                to
                said notification.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.32.9.

     

    
      	2.32.10  	
              The
                health plan shall have a written policy regarding the illegality
                of sexual
                harassment. At a minimum, the policy shall
                include:

            

    

    

    
      	a.  	
              The
                definition of sexual harassment under federal and state law, as
                amended;

            

    

    

    
      	b.  	
              The
                health plan's internal complaint process including
                penalties;

            

    

    

    
      	c.  	
              The
                legal recourse, investigative, and complaint process available for
                members
                through the state agency and for employees through the Missouri Commission
                on Human Rights; and

            

    

    

    
      	d.  	
              Instructions
                on how to contact the state agency and the Missouri Commission on
                Human
                Rights.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.32.10 and subparagraph a - d.

    

    
      	2.32.11  	
              The
                health plan shall understand and agree that the State of Missouri
                (its
                departments and employees) does not maintain commercial liability
                insurance.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirement set forth in RFP
      B3Z06118 paragraph 2.32.11.

    

    
      	2.32.12  	
              If
                the performance of any part of the contract is prevented, hindered
                or
                delayed by fire, flood or an act of God, then the health plan or
                the state
                agency shall be excused from such performance during the continuance
                of
                such events. This clause shall not become operative until the party
                whose
                performance is hindered notifies the other party of the occurrence
                and the
                reasons for the delay.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.32.12.

    

    
      	2.32.13  	
              Members
                are the intended beneficiaries of the contracts and as such are entitled
                to the remedies accorded to third party beneficiaries under the
                law.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.32.13.

    

    
      	2.32.14  	
              The
                health plan is prohibited from using MC+ managed care funds for services
                provided in the following
                circumstances:

            

    

    

    
      	a.  	
              Non-emergency
                services provided by or under the direction of an excluded
                individual,

            

    

    
      	b.  	
              Any
                funds not used under the Assisted Suicide Funding Restriction Act
                of
                1997,

            

    

    
      	c.  	
              Any
                amount expended for roads, bridges, stadiums, or any other
                item.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.32.14. and subparagraphs a-c.

    

    
      	2.32.15  	
              The
                Missouri Department of Insurance regulates the health plans licensed
                in
                Missouri including their financial stability. Therefore, the health
                plan
                must comply with all Department of Insurance applicable
                standards.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.32.15.

    

    
      	2.33  	
              Invoicing
                and Payment Requirements: On
                a monthly basis, as near as practical to the fifth day of the calendar
                month following the month for which services have been performed
                and for
                which payment is being made, the state agency shall make payments
                to the
                health plan via electronic funds transfer in accordance with the
                following:

            

    

    

    
      	2.33.1  	
              For
                each member enrolled on the first of the month, the state agency
                shall pay
                the health plan the firm fixed per member, per month net capitation
                amount
                specified on the specific region's Pricing Page for the Category
                of Aid
                Rate Subgroup for the member. The per member, per month net capitation
                amount shall reflect any reduction or increase pursuant to the health
                plan’s performance in screening 80 percent of eligible members as measured
                in accordance with the CMS 416 reporting
                methodology.

            

    

    

    
      	a.  	
              The
                state agency shall pro-rate the net capitation amount when the member’s
                birth date necessitates a change to a different Category of Aid or
                Rate
                Subgroup in a given month.

            

    

    

    
      	b.  	
              For
                members enrolled at any time after the beginning of the month’s payment
                cycle, the state agency shall pro-rate the net capitation amount
                for the
                first partial month.

            

    

    

    
      	c.  	
              For
                members whose enrollment lapses for any period of a month in which
                a
                capitation payment was made due to loss of eligibility, death, or
                other
                circumstance, the state agency shall adjust its next monthly capitation
                payment to recoup the portion of the capitation payment to which
                it is due
                a refund.

            

    

    

    
      	d.  	
              Any
                payment pro-rations shall be on a daily
                basis.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.33.1 and subparagraph a - d.

    

    
      	2.33.2  	
              The
                health plan shall accept capitation payments as specified herein
                and must
                have written policies and procedures for receiving and processing
                the
                capitation payments.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.33.2.

    

    
      	2.33.3  	
              The
                health plan shall agree and understand that the capitation payments
                specified herein shall be the only payments made to the health plan
                for
                all services required herein and that no other payment or reimbursement
                for any reason whatsoever shall be made to the health plan. In exchange
                for the capitation payments, the health plan shall be liable or “at risk”
                for the costs of all covered
                services.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.33.3.

    

    
      	2.33.4  	
              In
                the event that the Missouri General Assembly appropriates funds expressly
                for the services required herein, the State of Missouri shall amend
                the
                contract. In such event, the health plan shall pass fee increases
                to its
                providers commensurate with the Missouri General Assembly’s intent. It
                must clearly be the intent of the Missouri General Assembly that
                increases
                be added during an ongoing contract period for any such amendment
                to take
                place.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.33.4.

    

    
      	2.34  	
              Business
                Associate Provisions:

            

    

    

    
      	2.34.1  	
              Health
                Insurance Portability and Accountability Act of 1996 (HIPAA) - The
                state
                agency is subject to and must comply with provisions of the Health
                Insurance Portability and Accountability Act of 1996 (HIPAA) and
                all
                regulations promulgated pursuant to authority granted therein. The
                health
                plan constitutes a “Business Associate” of the state agency as such term
                is defined in the Code of Federal Regulations (CFR) at 45 CFR 160.103.
                Therefore, the term, “health plan” as used in this section shall mean
                “Business Associate.”

            

    

    

    
      	a.  	
              The
                health plan shall agree and understand that for purposes of the Business
                Associate Provisions contained herein, terms used but not otherwise
                defined shall have the same meaning as those terms defined in 45
                CFR parts
                160 and 164, including, but not limited to the
                following:

            

    

    

    
      	1)  	
              “Privacy
                Rule” shall mean the Standards for Privacy of Individually Identifiable
                Health Information at 45 CFR part 160 and part 164, subparts A and
                E.

            

    

    
      	2)  	
              “Security
                Rule” shall mean the Security Standards for the Protection of Electronic
                Protected Health Information at 45 CFR part 164, subpart
                C.

            

    

    
      	3)  	
              “Individual”
                shall have the same meaning as the term “individual” in 45 CFR 164.501 and
                shall include a person who qualifies as a personal representative
                in
                accordance with 45 CFR 164.502 (g).

            

    

    
      	4)  	
              “Protected
                Health Information” shall mean individually identifiable health
                information:

            

    

     

    -
      (1)
      Except as provided in paragraph (2) of this definition, that is: (i) Transmitted
      by electronic media; or (ii) Maintained in electronic media; or (iii)
      Transmitted or maintained in any other form or medium.

     

    -
      (2)
      Protected Health Information excludes individually identifiable health
      information in (i) Education records covered by the Family Educational Rights
      and Privacy Act, as amended, 20 U.S.C. 1232g; (ii) Records described at 20
      U.S.C. 1232g(a)(4)(B)(iv); and (iii) Employment records held by a covered entity
      [state agency] in its role as employer.

    
      	5)  	
              “Electronic
                Protected Health Information” shall mean information that comes within
                paragraphs (1)(i) or (1)(ii) of the definition of protected health
                information as specified above.

            

    

    

    
      	b.  	
              The
                health plan shall agree and understand that wherever in this document
                the
                term Protected Health Information is used, it shall also be deemed
                to
                include Electronic Protected Health
                Information.

            

    

    

    
      	c.  	
              The
                health plan shall agree the state agency must comply with 45 CFR
                160 and
                45 CFR 164, as currently in effect and as may be amended at some
                later
                date, and that to achieve such compliance, the health plan must
                appropriately safeguard Protected Health Information (as that term
                is
                defined in 45 CFR 164.501), which the health plan receives from or
                creates
                or receives on behalf of the state agency. To provide reasonable
                assurance
                of appropriate safeguards, the health plan shall comply with the
                business
                associate provisions stated herein.

            

    

    

    
      	d.  	
              The
                state agency and the health plan agree to amend the contract as is
                necessary for the state agency to comply with the requirements of
                the
                Privacy Rule and HIPAA requirements.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.34.1 and subparagraph a - d.

    

    
      	2.34.2  	
              Permitted
                uses and disclosures of Protected Health
                Information:

            

    

    

    
      	a.  	
              The
                health plan may use or disclose Protected Health Information to perform
                functions, activities, or services for, or on behalf of, the state
                agency
                as specified in the contract, provided that such use or disclosure
                would
                not violate the Privacy Rule as the Privacy Rule applies to the state
                agency. 

            

    

    

    
      	b.  	
              The
                health plan may use Protected Health Information to report violations
                of
                law to appropriate Federal and State authorities, consistent with
                45 CFR
                164.502(j)(1) and shall notify the state agency by no later than
                ten (10)
                calendar days after the health plan becomes aware of the disclosure
                of the
                Protected Health Information.

            

    

    

    
      	c.  	
              If
                required to properly perform the contract and subject to the terms
                of the
                contract, the health plan may use or disclose Protected Health Information
                if necessary for the proper management and administration of the
                health
                plan’s business.

            

    

    

    
      	d.  	
              If
                the disclosure is required by law, the health plan may disclose Protected
                Health Information to carry out the legal responsibilities of the
                health
                plan.

            

    

    

    
      	e.  	
              The
                health plan may use Protected Health Information to provide Data
                Aggregation services to the state agency as permitted by 45 CFR
                164.504(e)(2)(i)(B).

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.32.8 and subparagraph a - e.

    

    
      	2.34.3  	
              Obligations
                of the Health plan:

            

    

    

    
      	a.  	
              The
                health plan shall not use or disclose Protected Health Information
                other
                than as permitted or required by the contract or as otherwise required
                by
                law.

            

    

    

    
      	b.  	
              The
                health plan shall use appropriate safeguards to prevent use or disclosure
                of the Protected Health Information other than as provided for by
                the
                contract. Such safeguards may include, but shall not be limited
                to:

            

    

    

    
      	1)  	
              Workforce
                training on the appropriate uses and disclosures of Protected Health
                Information pursuant to the terms of the
                contract.

            

    

    
      	2)  	
              Policies
                and procedures implemented by the health plan to prevent inappropriate
                uses and disclosures of Protected Health Information by its
                workforce.

            

    

    
      	3)  	
              Any
                other safeguards necessary to prevent the inappropriate use or disclosure
                of Protected Health Information.

            

    

    

    
      	c.  	
              With
                respect to Electronic Protected Health Information, the health plan
                shall
                implement administrative, physical and technical safeguards that
                reasonably and appropriately protect the confidentiality, integrity
                and
                availability of the Electronic Protected Health Information that
                health
                plan creates, receives, maintains or transmits on behalf of the state
                agency.

            

    

    

    
      	d.  	
              The
                health plan shall require that any agent or subcontractor to whom
                the
                health plan provides any Protected Health Information received from,
                created by, or received by the health plan pursuant to the contract,
                also
                agrees to the same restrictions and conditions stated herein that
                apply to
                the health plan with respect to such
                information.

            

    

    

    
      	e.  	
              By
                no later than ten (10) calendar days of receipt of a written request
                from
                the state agency, or as otherwise required by state or federal law
                or
                regulation, or by another time as may be agreed upon in writing by
                the
                state agency, the health plan shall make the health plan’s internal
                practices, books, and records, including policies and procedures
                and
                Protected Health Information, relating to the use and disclosure
                of
                Protected Health Information received from, created by, or received
                by the
                health plan on behalf of the state agency available to the state
                agency
                and/or to the Secretary of the Department of Health and Human Services
                or
                designee for purposes of determining compliance with the Privacy
                Rule.

            

    

    

    
      	f.  	
              The
                health plan shall document any disclosures and information related
                to such
                disclosures of Protected Health Information as would be required
                for the
                state agency to respond to a request by an individual for an accounting
                of
                disclosures of Protected Health Information in accordance with 45
                CFR
                164.528. By no later than five (5) calendar days of receipt of a
                written
                request from the state agency, or as otherwise required by state
                or
                federal law or regulation, or by another time as may be agreed upon
                in
                writing by the state agency, the health plan shall provide an accounting
                of disclosures of Protected Health Information regarding an individual
                to
                the state agency.

            

    

    

    
      	g.  	
              In
                order to meet the requirements under 45 CFR 164.524, the health plan
                shall, within five (5) calendar days following a state agency request,
                or
                as otherwise required by state or federal law or regulation, or by
                another
                time as may be agreed upon in writing by the state agency, provide
                the
                state agency access to the Protected Health Information in an individual’s
                Designated Record Set. However, if requested by the state agency,
                the
                health plan shall provide access to the Protected Health Information
                in a
                Designated Record Set directly to the individual for whom such information
                relates.

            

    

    

    
      	h.  	
              At
                the direction of the state agency, the health plan shall promptly
                make any
                amendment(s) to Protected Health Information in a Designated Record
                Set
                pursuant to 45 CFR 164.526.

            

    

    

    
      	i.  	
              The
                health plan shall report to the state agency’s Security Officer any
                security incidents no later than five (5) calendar days of becoming
                aware
                of such incident. For purposes of this paragraph, security incident
                shall
                mean the unauthorized access, use, modification or destruction of
                information or interference with systems operations in an information
                system.

            

    

    

    
      	j.  	
              By
                no later than five (5) calendar days after the health plan becomes
                aware
                of any use or disclosure of the Protected Health Information not
                permitted
                or required as stated herein, the health plan shall notify the state
                agency’s Privacy Officer, in writing, of the unauthorized use or
                disclosure and shall take immediate action to stop the unauthorized
                use or
                disclosure. The health plan shall include a description of any remedial
                action taken to mitigate any harmful effect of such disclosure. The
                health
                plan shall also provide the state agency’s Privacy Officer with a proposed
                written plan of action for approval that describes plans for preventing
                any such future unauthorized uses or
                disclosures.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.34.3 and subparagraph a - j. Harmony has a duty to protect
      the confidentiality and integrity of Protected Health Information.

    

    Provider
      Relations staff perform provider orientations soon after placing a provider
      in
      active status. This includes orientation on, but is not limited to,
      Confidentiality of Member Information and Release of
      Records.

    

    The
      Provider Manual is an extension of the Provider Contract and is provided to
      each
      provider office during the orientation. Within the manual, details are provided,
      specifically Confidentiality of Member Information and Release of Medical
      Records.

    

    
      	2.34.4  	
              Obligations
                of the State Agency:

            

    

    

    
      	a.  	
              The
                state agency shall notify the health plan of limitation(s) that may
                affect
                the health plan’s use or disclosure of Protected Health Information, by
                providing the health plan with the state agency’s notice of privacy
                practices in accordance with 45 CFR
                164.520.

            

    

    

    
      	b.  	
              The
                state agency shall notify the health plan of any changes in, or revocation
                of, authorization by an Individual to use or disclose Protected Health
                Information.

            

    

    

    
      	c.  	
              The
                state agency shall notify the health plan of any restriction to the
                use or
                disclosure of Protected Health Information that the state agency
                has
                agreed to in accordance with 45 CFR
                164.522.

            

    

    

    
      	d.  	
              The
                state agency shall not request the health plan to use or disclose
                Protected Health Information in any manner that would not be permissible
                under the Privacy Rule as the Privacy Rule applies to the state
                agency.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.34.4 and subparagraphs a - d.

    

    
      	2.34.5  	
              Expiration/Termination/Cancellation
                - Except as provided in the subparagraph below, upon the expiration,
                termination, or cancellation of the contract for any reason, the
                health
                plan shall return to the state agency or shall destroy all Protected
                Health Information received by the health plan from the state agency,
                or
                created or received by the health plan on behalf of the state agency,
                and
                shall not retain any copies of such Protected Health Information.
                This
                provision shall also apply to Protected Health Information that is
                in the
                possession of subcontractors or agents of the health
                plan.

            

    

    

    
      	a.  	
              In
                the event the health plan determines and the state agency agrees
                that
                returning or destroying the Protected Health Information is not feasible,
                the health plan shall extend the protections of the contract to the
                Protected Health Information for as long as the health plan maintains
                the
                Protected Health Information and shall limit the use and disclosure
                of the
                Protected Health Information to those purposes that made return or
                destruction of the information infeasible. If at any time it becomes
                feasible to return or destroy any such Protected Health Information
                maintained pursuant to this paragraph, the health plan must notify
                the
                state agency and obtain instructions from the state agency for either
                the
                return or destruction of the Protected Health
                Information.

            

    

    

    Harmony
      Health Plan understands and will adhere to the requirements set forth in RFP
      B3Z06118 paragraph 2.34.5 and subparagraph a.

    

    
      	2.34.6  	
              Breach
                of Contract - In the event the health plan is in breach of contract
                with
                regard to the business associate provisions included herein, the
                health
                plan shall agree and understand that in addition to the requirements
                of
                the contract related to cancellation of contract, if the state agency
                determines that cancellation of the contract is not feasible, the
                State of
                Missouri may elect not to cancel the contract, but the state agency
                shall
                report the contractual breach to the Secretary of the Department
                of Health
                and Human Services.

            

    

     

    Harmony
      Health Plan understands and will adhere
      to the requirements set forth in RFP B3Z06118 paragraph
      2.34.6.

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

       

    

    
      	3.  	
              GENERAL
                CONTRACTUAL REQUIREMENTS:

            

    

     

    
      
        	3.1  	
                Contract
                  : A
                  binding contract shall consist of: (1) the RFP, amendments thereto,
                  and
                  any Best and Final Offer (BAFO) request(s) with RFP changes/additions,
                  (2)
                  the health plan’s proposal including any BAFOs and (3) the Division of
                  Purchasing and Materials Management’s acceptance of the proposal by
                  “notice of award” or by “purchase order”. All Exhibits and Attachments
                  included in the RFP shall be incorporated into the contract by
                  reference.

              

        

        	3.1.1  	
                The
                  notice of award does not constitute a directive to proceed. Before
                  providing equipment, supplies and/or services, the health plan
                  must
                  receive a properly authorized purchase order unless the purchase
                  is equal
                  to or less than $3,000. Purchases
                  equal to or less than $3,000 may be processed with a purchase order
                  at the
                  discretion of the state agency.

              

        

        	3.1.2  	
                The
                  contract expresses the complete agreement of the parties and performance
                  shall be governed solely by the specifications and requirements
                  contained
                  therein.

              

        

        	3.1.3  	
                Any
                  change to the contract, whether by modification and/or supplementation,
                  must be accomplished by a formal contract amendment signed and
                  approved by
                  and between the duly authorized representative of the health plan
                  and the
                  Division of Purchasing and Materials Management or by a modified
                  purchase
                  order prior to the effective date of such modification. The health
                  plan
                  expressly and explicitly understands and agrees that no other method
                  and/or no other document, including correspondence from the state
                  agency,
                  acts, and oral communications by or from any person, shall be used
                  or
                  construed as an amendment or modification to the
                  contract.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.1 and subparagraphs 3.1.1 - 3.1.3.

        

        	3.2  	
                Contract
                  Period: The
                  original contract period shall be as stated on page 1 of the Request
                  for
                  Proposal (RFP). The contract shall not bind, nor purport to bind,
                  the
                  state for any contractual commitment in excess of the original
                  contract
                  period. The Division of Purchasing and Materials Management shall
                  have the
                  right, at its sole option, to renew the contract for two (2) additional
                  one-year periods, or any portion thereof. In the event the Division
                  of
                  Purchasing and Materials Management exercises such right, all terms
                  and
                  conditions, requirements and specifications of the contract shall
                  remain
                  the same and apply during the renewal period, pursuant to the
                  following:

              

        

        	3.2.1  	
                The
                  state agency will include in each year's budget request to the
                  Office of
                  Administration, Division of Budget and Planning, a rate change
                  based on
                  the state agency's review of recent health plan financial experience,
                  medical trends from other state Medicaid programs and national
                  trend
                  indices (CPI/DRI), and pharmacy market trends including specific
                  drug
                  introductions and expiring patents. The rate changes will be reflective
                  of
                  anticipated programmatic changes.

              

        

        	3.2.2  	
                If
                  the State of Missouri elects to renew the contract for the first
                  renewal
                  option, the health plan shall accept the amount appropriated by
                  the
                  Governor and the Missouri General
                  Assembly.

              

        

        	3.2.3  	
                If
                  the State of Missouri elects to renew the contract for the second
                  renewal
                  option and if the health plan intends to renew the contract for
                  the second
                  renewal option, the State of Missouri and the health plan shall
                  negotiate
                  the firm, fixed rates applicable to the second renewal period.
                  The State
                  of Missouri shall commence such negotiation process approximately
                  six
                  months prior to the expiration of the first renewal period. Individual
                  negotiations shall be conducted with each health plan in accordance
                  with
                  the negotiation provisions provided elsewhere
                  herein.

              

        

        	a.  	
                The
                  health plan must submit information which establishes and supports
                  the
                  actuarial soundness of the proposed rates and a certification of
                  said
                  soundness from an Associate of the Society of Actuaries (ASA),
                  a Fellow of
                  Society of Actuaries (FSA), or a Member of the American Academy
                  of
                  Actuaries (MAAA). 

              

        

        	b.  	
                If
                  the State of Missouri and the health plan are unable to agree upon
                  the
                  firm, fixed rates for the second renewal period, the pending contract
                  renewal shall be canceled. In the event of such, the State of Missouri
                  reserves its right to extend the contract at the current firm,
                  fixed rates
                  for no more than 180 days from the date such determination is
                  made.

              

        

        	c.  	
                If
                  the health plan does not intend to renew the contract for the second
                  renewal option and does not desire to enter into the negotiation
                  process,
                  the health plan shall provide written notification to the State
                  of
                  Missouri of such within at least 180 calendar days prior to the
                  expiration
                  of the contract period.

              

        

        

        	3.2.4  	
                During
                  the second and final renewal option, the State of Missouri may
                  issue a
                  public notice of the pending contract expiration and the upcoming
                  opportunity to contract with the State of Missouri for MC+ managed
                  care
                  services. If no health plans, other than the health plans the State
                  of
                  Missouri currently contracts with, indicate interest in contracting
                  with
                  the State of Missouri for such, the State of Missouri may elect
                  to renew
                  the contract with the health plan for the continuation of the MC+
                  managed
                  care services. In the event of such, the State of Missouri and
                  the health
                  plan shall negotiate the firm, fixed rates applicable to the renewal
                  period. The State of Missouri shall have the option of issuing
                  such
                  notification on an annual basis.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.2 and subparagraphs 3.2.1 - 3.2.4. 

        

        	3.3  	
                Price: All
                  prices shall be as indicated on the specific region's Pricing Page.
                  The
                  state shall not pay nor be liable for any other additional costs
                  including
                  but not limited to taxes, shipping charges, insurance, interest,
                  penalties, termination payments, attorney fees, liquidated damages,
                  etc.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.3. 

        

        	3.4  	
                Termination:
                  The
                  Division of Purchasing and Materials Management reserves the right
                  to
                  terminate the contract at any time, for the convenience of the
                  State of
                  Missouri, without penalty or recourse, by giving written notice
                  to the
                  health plan at least thirty (30) calendar days prior to the effective
                  date
                  of such termination. In the event of termination pursuant to this
                  paragraph, all documents, data, reports, supplies, equipment, and
                  accomplishments prepared, furnished or completed by the health
                  plan
                  pursuant to the terms of the contract shall, at the option of the
                  Division
                  of Purchasing and Materials Management, become the property of
                  the State
                  of Missouri. The health plan shall be entitled to receive just
                  and
                  equitable compensation for services and/or supplies delivered to
                  and
                  accepted by the State of Missouri pursuant to the contract prior
                  to the
                  effective date of termination.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.4. 

        

        	3.5  	
                Transition:

              

        

        	3.5.1  	
                Upon
                  expiration, termination, or cancellation of the contract, the health
                  plan
                  shall assist the state agency to insure an orderly transfer of
                  responsibility and/or the continuity of those services required
                  under the
                  terms of the contract to an organization designated by the state
                  agency,
                  if requested in writing. At a minimum, the health plan shall perform
                  the
                  following related to transition:

              

        

        	a.  	
                For
                  a period not to exceed ninety (90) calendar days after the expiration,
                  termination, or cancellation of the contract, the health plan shall
                  continue providing any part or all of the services in accordance
                  with the
                  terms and conditions, requirements, and specifications of the contract
                  for
                  a price not to exceed those prices set forth in the
                  contract.

              

        

        	b.  	
                In
                  addition, for 365 calendar days after expiration, termination,
                  or
                  cancellation of the contract, the health plan shall provide those
                  administration functions that cannot be completed prior to the
                  expiration,
                  termination, or cancellation of the contract due to the nature
                  of the
                  function. Such administrative functions, shall include, but are
                  not
                  limited to, payment of claims for service dates prior to expiration,
                  termination, or cancellation of the contract; operation of the
                  member
                  grievance system and provider complaints, grievances, and appeals;
                  operational data reporting, financial reporting, and communication
                  links
                  with the state agency.

              

        

        	c.  	
                The
                  health plan shall deliver, FOB destination, all records, documentation,
                  reports, data, recommendations, master, or printing elements, etc.,
                  which
                  were required to be produced under the terms of the contract to
                  the state
                  agency and/or to the state agency's designee within thirty (30)
                  days after
                  receipt of the written request.

              

        

        	d.  	
                The
                  state agency, at its sole option, may discontinue enrolling new
                  membership
                  to the health plan, on a date specified by the state agency, prior
                  to
                  expiration, cancellation, or termination of the
                  contract.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.5 and subparagraphs a - d. 

        

        	3.6  	
                Health
                  Plan Liability: The
                  health plan shall be responsible for any and all personal injury
                  (including death) or property damage as a result of the health
                  plan's
                  negligence involving any equipment or service provided under the
                  terms and
                  conditions, requirements and specifications of the contract. In
                  addition,
                  the health plan assumes the obligation to save the State of Missouri,
                  including its agencies, employees, and assignees, from every expense,
                  liability, or payment arising out of such negligent
                  act.

              

        

        	a.  	
                The
                  health plan also agrees to hold the State of Missouri, including
                  its
                  agencies, employees, and assignees, harmless for any negligent
                  act or
                  omission committed by any subcontractor or other person employed
                  by or
                  under the supervision of the health plan under the terms of the
                  contract.

              

        

        	b.  	
                The
                  health plan shall not be responsible for any injury or damage occurring
                  as
                  a result of any negligent act or omission committed by the State
                  of
                  Missouri, including its agencies, employees, and
                  assignees.

              

        

        	c.  	
                Under
                  no circumstances shall the health plan be liable for any of the
                  following:
                  (1) third party claims against the state for losses or damages
                  (other than
                  those listed above); (2) loss of, or damage to, the state’s records or
                  data; or (3) economic consequential damages (including lost profits
                  or
                  savings) or incidental damages, even if the health plan is informed
                  of
                  their possibility.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.6 and subparagraphs a - c. 

        

        	3.7  	
                Insurance:
                  The
                  health plan shall understand and agree that the State of Missouri
                  cannot
                  save and hold harmless and/or indemnify the health plan or employees
                  against any liability incurred or arising as a result of any activity
                  of
                  the health plan or any activity of the health plan's employees
                  related to
                  the health plan's performance under the contract. Therefore, the
                  health
                  plan shall maintain adequate liability insurance in the form(s)
                  and
                  amount(s) sufficient to protect the State of Missouri, its agencies,
                  its
                  employees, its clients, and the general public against any loss,
                  damage,
                  and/or expense related to his/her performance under the
                  contract. 

              

        

        	a.  	
                The
                  insurance coverage shall include, but shall not necessarily be
                  limited to,
                  general liability, professional liability, etc. In addition, automobile
                  liability coverage for the operation of any motor vehicle must
                  be
                  maintained if the terms of the contract require any form of transportation
                  services.

              

        

        	b.  	
                The
                  limits of liability for all types of coverage shall not be less
                  than
                  $2,000,000 per occurrence. 

              

        

        	c.  	
                The
                  health plan shall provide written evidence of the insurance to
                  the state
                  agency. Such evidence shall include, but shall not necessarily
                  be limited
                  to: effective dates of coverage, limits of liability, insurer’s name,
                  policy number, endorsement by representatives of the insurance
                  company,
                  etc. Evidence of self-insurance coverage or of another alternate
                  risk
                  financing mechanism may be utilized provided that such coverage
                  is
                  verifiable and irrevocably reliable. The evidence of insurance
                  coverage
                  must be submitted before or upon award of the contract. The contract
                  number must be identified on the evidence of insurance
                  coverage.

              

        

        	d.  	
                In
                  the event the insurance coverage is canceled, the state agency
                  must be
                  notified immediately.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.7 and subparagraphs a - d. 

        

        	3.8  	
                Subcontractors:
                  Any
                  subcontracts for the products/services described herein must include
                  appropriate provisions and contractual obligations to ensure the
                  successful fulfillment of all contractual obligations agreed to
                  by the
                  health plan and the State of Missouri and to ensure that the State
                  of
                  Missouri is indemnified, saved, and held harmless from and against
                  any and
                  all claims of damage, loss, and cost (including attorney fees)
                  of any kind
                  related to a subcontract in those matters described in the contract
                  between the State of Missouri and the health
                  plan.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.8. 

        

        Harmony
          holds 5 subcontracts as defined in this section. Harmony’s subcontractors and
          the specific areas of delegated activity are indicated in the Active Delegation
          Chart located in Appendix Binder, Tab # 9. 

        

        Harmony
          has several well-established relationships with subcontractors that serve
          our
          populations and product lines in other markets (including those contiguous
          to
          the MO Eastern Region). These subcontractors have a proven history of meeting
          Harmony’s delegated contractual requirements, are responsive to members’ needs,
          and fulfill the obligations of Harmony’s MCO contracts. Examples of these
          long-established, multi-plan contracts include Walgreens Health Initiatives,
          Inc., MTM, PsycHealth, and Primary Care Net.

        

        When
          establishing new subcontractors specific to the Missouri Plan, Harmony
          first
          investigates the use of local businesses. Harmony solicits the recommendation
          of
          local PCP’s as they provide an excellent source of information on potential
          subcontractors for services such as durable medical equipment and laboratory.
          

        

        	3.8.1  	
                The
                  health plan shall expressly understand and agree that he/she shall
                  assume
                  and be solely responsible for all legal and financial responsibilities
                  related to the execution of a subcontract.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.8.1.

         

        Harmony
          understands that it is the sole responsibility of Harmony to ensure that
          all
          delegated functions are performed in accordance with applicable standards.
          Harmony ensures compliance with the National Committee on Quality Assurance
          (NCQA) and the State of Missouri standards through t he delegation process
          and
          the oversight of the Executive Committee on Quality.

        

        	3.8.2  	
                The
                  health plan shall agree and understand that utilization of a subcontractor
                  to provide any of the products/services in the contract shall in
                  no way
                  relieve the health plan of the responsibility for providing the
                  products/services as described and set forth herein. The health
                  plan must
                  obtain acknowledgement from the State of Missouri prior to establishing
                  any new subcontracting arrangements and before changing any
                  subcontractors. 

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.8.2. 

         

        	3.8.3  	
                All
                  subcontracts for health care services must be in writing and shall
                  comply
                  with all provisions of the contract and shall include at least
                  the items
                  listed below. In addition, all subcontractors shall comply with
                  the
                  applicable provisions of federal and state laws and regulations,
                  as
                  amended, and policies. Before any delegation of any functions and
                  responsibilities to any subcontractor, the health plan shall evaluate
                  the
                  prospective subcontractor’s ability to perform the activities to be
                  delegated. The health plan shall have policies and procedures to
                  monitor
                  the performance of health care service subcontractors to ensure
                  that such
                  subcontractors comply with the provisions of the RFP. The health
                  plan
                  shall prepare and issue an annual report to the state agency regarding
                  the
                  results of its monitoring activities in previous calendar year
                  for each
                  health care service subcontractor and any corrective actions implemented
                  as a result of its monitoring activities. The annual report shall
                  be due
                  by November 30 of each year. In addition, the health plan shall
                  fully
                  investigate and timely respond to issues involving subcontractors
                  upon
                  request of the state agency.

              

        

        	a.  	
                A
                  description of services to be provided or other activities performed.
                  This
                  description shall be in such form as to permit the state agency
                  to
                  ascertain definitively which contractual obligations have been
                  subcontracted.

              

        

        	b.  	
                Provision(s)
                  for release to the health plan of any information necessary for
                  the health
                  plan to perform any of its obligations under the contract including
                  but
                  not limited to compliance with all reporting requirements (for
                  example
                  encounter data reporting requirements), timely payment requirements,
                  and
                  quality assessment requirements.

              

        

        	c.  	
                The
                  provision available to a health care provider to challenge or appeal
                  the
                  failure of the health plan to cover a
                  service.

              

        

        	d.  	
                Provision(s)
                  that (1) the subcontractor’s facilities and records shall be open to
                  inspection by the health plan and appropriate federal and state
                  agencies
                  and, (2) the medical records, or copies thereof, shall be provided
                  to the
                  health plan, upon request, for transfer to subsequent subcontractors
                  for
                  review by the state agency.

              

        

        	e.  	
                Provisions
                  that require each health care provider to maintain comprehensive
                  medical
                  records for a minimum of five years.

              

        

        	f.  	
                A
                  provision that when no member co-payment is required, the subcontractor
                  shall look solely to the health plan for compensation for services
                  provided to member.

              

        

        	g.  	
                Provision(s)
                  that prohibit any financial incentive arrangement to induce subcontractors
                  to limit medically necessary services. A description of all financial
                  incentive arrangements shall be included in the subcontract. In
                  the event
                  of a change to these financial incentive arrangements, the subcontractor
                  shall immediately notify the health plan of such change so the
                  health plan
                  can meet its requirement to notify the state
                  agency.

              

        

        	h.  	
                Provisions
                  that the health plan may not prohibit, or otherwise restrict, a
                  health
                  care professional acting within the lawful scope of practice, from
                  advising or advocating on behalf of a member who is his or her
                  patient:

              

        

        	1)  	
                For
                  the member’s health status, medical care, or treatment options, including
                  any alternative treatment that may be
                  self-administered.

              

        	2)  	
                For
                  any information the member needs in order to decide among all relevant
                  treatment options.

              

        	3)  	
                For
                  the risks, benefits, and consequences of treatment or
                  non-treatment.

              

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

              

        

        	i.  	
                Provisions
                  that subcontractors shall not conduct or participate in health
                  plan
                  enrollment, disenrollment, transfer, or opt out activities. The
                  subcontractors shall not influence a member’s enrollment. Prohibited
                  activities include:

              

        

        	1)  	
                Requiring
                  or encouraging the member to apply for an assistance category not
                  included
                  in MC+ managed care;

              

        

        	2)  	
                Requiring
                  or encouraging the member and/or guardian to use the opt out provision
                  as
                  an option in lieu of delivering health plan
                  benefits;

              

        

        	3)  	
                Mailing
                  or faxing health plan enrollment forms;

              

        

        	4)  	
                Aiding
                  the member in filling out health plan enrollment
                  forms;

              

        

        	5)  	
                Photocopying
                  blank health plan enrollment forms for potential
                  members;

              

        

        	6)  	
                Distributing
                  blank health plan enrollment forms;

              

        

        	7)  	
                Participating
                  in three way calls to the MC+ managed care enrollment
                  helpline;

              

        

        	8)  	
                Suggesting a
                  member transfer to another health plan;
                  or

              

        

        	9)  	
                Other
                  activities in which subcontractors are engaged in to enroll a member
                  in a
                  particular health plan or in any way assisting a member to enroll
                  in a
                  health plan.

              

        

        	j.  	
                If
                  a subcontract is with a federally qualified health center (FQHC)
                  or rural
                  health clinic (RHC) to provide services to members under a prepayment
                  arrangement, a provision that the state agency shall reimburse
                  the FQHC or
                  RHC 100% of its reasonable cost for covered
                  services.

              

        

        	k.  	
                All
                  hospital subcontracts must require that the hospital subcontractor
                  notify
                  the health plan of births where the mother is a member. The subcontracts
                  must specify which entity is responsible for notifying the Family
                  Support
                  Division of the birth.

              

        

        	l.  	
                For
                  contracted services, the subcontractor shall follow the claim processing
                  requirements set forth by RSMo 376.383 and 376.384, as
                  amended.

              

        

        	m.  	
                Provisions
                  in accordance with federal and state laws and regulations, as amended,
                  and
                  policy regarding termination of the subcontract between the health
                  plan
                  and the subcontractor.

              

        

        	n.  	
                Provisions
                  that in the event of the subcontractor’s insolvency or other cessation of
                  operations, covered services to members shall continue through
                  the period
                  for which a capitation payment has been made to the health plan
                  or until
                  the member’s discharge from an inpatient facility, whichever time is
                  greater.

              

        

        	o.  	
                The
                  health plan and its subcontractors shall establish reasonable timely
                  filing requirements for claims to be filed by a provider for
                  reimbursement. The subcontractor shall inform its provider network
                  of the
                  timely filing requirements.

              

        

        	1)  	
                In
                  the case of capitated arrangements with providers, the subcontractor
                  shall
                  establish reasonable reporting of encounters to the health plan
                  in
                  sufficient detail to meet the health plan’s encounter data reporting
                  requirements.

              

        

        	2)  	
                In
                  the case of services provided by out-of-network providers, the
                  health plan
                  shall comply with state law regarding timely filing
                  requirements.

              

        

        	p.  	
                Provision
                  for revoking the subcontract agreement or imposing other sanctions
                  if the
                  subcontractor’s performance is
                  inadequate.

              

        

        	q.  	
                The
                  health plan shall agree and understand that consumer protection
                  shall be
                  integral to the MC+ managed care program. All contracts between
                  the health
                  plan and providers shall ensure that the provider complies with
                  the
                  consumer protection provisions outlined in the marketing
                  guidelines.

              

        

        	r.  	
                Provision(s)
                  that entitle each member to one free copy of his or her medical
                  records
                  annually. The fee for additional copies shall not exceed the actual
                  cost
                  of time and materials used to compile, copy, and furnish such
                  records.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.8.3 and subparagraphs a - r. 

        

        Harmony
          will perform a pre-delegation audit to ensure that the above providers
          are able
          to perform these functions for its Missouri MC+ managed care membership.
          Following each audit, Harmony will produce an audit report as well as a
          plan of
          correction, if necessary. The audit reports and plans of correction will
          be
          presented to the providers and WellCare’s Delegation Oversight Committee. Based
          on the findings, the Delegation Oversight Committee will make recommendations
          to
          the Quality Improvement Committee. WellCare’s Quality Improvement Committee has
          final authority to approve or reject delegation.

        

        Following
          the Quality Improvement Committee’s approval for delegation, Harmony will obtain
          written delegation agreements from the providers. The agreements will specify
          Harmony’s responsibilities, the agency’s responsibilities, the activities to be
          delegated, frequency of reporting to Harmony, the process by which Harmony
          will
          evaluate the delegated provider’s performance, and the remedies available to
          Harmony if the providers do not fulfill their obligations

        

        Once
          implemented, Harmony will oversee the above delegated providers through
          regularly scheduled operating meetings, predetermined reports, and annual
          delegation site visits.

        

        	3.9  	
                Assignment:

              

        

        	3.9.1  	
                The
                  health plan shall not transfer any interest in the contract, whether
                  by
                  assignment or otherwise, without the prior written consent of the
                  Division
                  of Purchasing and Materials Management.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.9.1.

        

        	3.9.2  	
                The
                  health plan shall agree and understand that, in the event the Division
                  of
                  Purchasing and Materials Management consents to a financial assignment
                  of
                  the contract in whole or in part to a third party, any payments
                  made by
                  the State of Missouri pursuant to the contract, including all of
                  those
                  payments assigned to the third party, shall be contingent upon
                  the
                  performance of the prime health plan in accordance with all terms
                  and
                  conditions, requirements and specifications of the
                  contract.

              

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.9.2.

        

        	3.10  	
                Substitution
                  of Personnel: The
                  health plan agrees and understands that the State of Missouri's
                  agreement
                  to the contract is predicated in part on the utilization of the
                  specific
                  individual(s) and/or personnel qualifications identified in the
                  proposal.
                  The health plan further agrees that any substitution made pursuant
                  to this
                  paragraph must be equal or better than originally proposed. 

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.10.

        

        	3.11  	
                Health
                  Plan Status: The
                  health plan represents himself or herself to be an independent
                  health plan
                  offering such services to the general public and shall not represent
                  himself/herself or his/her employees to be an employee of the State
                  of
                  Missouri. Therefore, the health plan shall assume all legal and
                  financial
                  responsibility for taxes, FICA, employee fringe benefits, workers
                  compensation, employee insurance, minimum wage requirements, overtime,
                  etc., and agrees to indemnify, save, and hold the State of Missouri,
                  its
                  officers, agents, and employees, harmless from and against, any
                  and all
                  loss; cost (including attorney fees); and damage of any kind related
                  to
                  such matters.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.11.

        

        	3.12  	
                Coordination:
                  The
                  health plan shall fully coordinate all contract activities with
                  those
                  activities of the state agency. As the work of the health plan
                  progresses,
                  advice and information on matters covered by the contract shall
                  be made
                  available by the health plan to the state agency or the Division
                  of
                  Purchasing and Materials Management throughout the effective period
                  of the
                  contract.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.13.

        

        	3.13  	
                Property
                  of State:

              

        

        	3.13.1  	
                All
                  reports, documentation, and material developed or acquired by the
                  health
                  plan as a direct requirement specified in the contract shall become
                  the
                  property of the State of Missouri. 

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.13.1.

        

        	3.13.2  	
                The
                  health plan shall agree and understand that all discussions with
                  the
                  health plan and all information gained by the health plan as a
                  result of
                  the health plan's performance under the contract, including member
                  information, medical records, data, and data elements established,
                  collected, maintained, or used in the administration of the contract
                  shall
                  be confidential and that no reports, documentation, or material
                  prepared
                  as required by the contract shall be released to the public without
                  the
                  prior written consent of the state agency.

              

        

        	a.  	
                The
                  health plan shall provide safeguards that restrict the use or disclosure
                  of information concerning members to purposes directly connected
                  with the
                  administration of the contract.

              

        

        	b.  	
                The
                  health plan shall not disclose the contents of member information
                  or
                  records to anyone other than the state agency, the member or the
                  member's
                  legal guardian, or other parties with the member’s written
                  consent.

              

        

        	c.  	
                In
                  complying with the requirements of this section, the health plan
                  and the
                  state agency shall follow the requirements of 42 Code of Federal
                  Regulations Part 431, Subpart F, as amended, regarding confidentiality
                  of
                  information concerning applicants and members of public assistance
                  and 42
                  Code of Federal Regulations Part 2, as amended, regarding confidentiality
                  of alcohol and drug abuse patient
                  records.

              

        

        	d.  	
                The
                  health plan shall have written policies and procedures for maintaining
                  the
                  confidentiality of data, including medical records, member information,
                  and appointment records for adult and adolescent STDs and adolescent
                  family planning services.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.13.2 and subparagraphs a - d.

        

        	3.14  	
                Performance
                  Security Deposit: The
                  health plan must furnish a performance security deposit in the
                  form of an
                  original bond issued by a surety company authorized to do business
                  in the
                  State of Missouri (no copy or facsimile is acceptable), check,
                  cash, bank
                  draft, or irrevocable letter of credit to the Office of Administration,
                  Division of Purchasing and Materials Management within thirty (30)
                  days
                  after award of the contract and prior to performance of service
                  under the
                  contract.

              

        

        	a.  	
                The
                  performance security deposit must be made payable to the State
                  of Missouri
                  in an amount equal to the in the amount of $1,000,000. In the event
                  the
                  health plan is awarded a contract for more than one region, the
                  health
                  plan shall provide a separate performance security deposit in the
                  amount
                  of $1,000,000.00 for each region. 

              

        

        	b.  	
                The
                  contract number and contract period must be specified on the performance
                  security deposit.

              

        

        	c.  	
                In
                  the event the Division of Purchasing and Materials Management exercises
                  an
                  option to renew the contract for an additional period, the health
                  plan
                  shall maintain the validity and enforcement of the security deposit
                  for
                  the said period, pursuant to the provisions of this paragraph,
                  in an
                  amount stipulated at the time of contract
                  renewal

              

        

        	d.  	
                Additionally,
                  during the 365 day transition period, the health plan shall maintain
                  the
                  validity and enforcement of the performance security deposit for
                  performance of the administrative functions pursuant to the provisions
                  of
                  this paragraph, in an amount stipulated via written notification
                  by
                  DPMM.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.14 and subparagraphs a - d.

        

        	3.15  	
                Federal
                  Funds Requirements - The
                  health plan shall understand and agree that the contract may involve
                  the
                  use of federal funds. 

              

        

        	3.15.1  	
                Steven’s
                  Amendment - In accordance with the Departments of Labor, Health
                  and Human
                  Services, and Education and Related Agencies Appropriations Act,
                  Public
                  Law 101-166, Section 511, “Steven's Amendment”, the health plan shall not
                  issue any statements, press releases, and other documents describing
                  projects or programs funded in whole or in part with Federal money
                  unless
                  the prior approval of the state agency is obtained and unless they
                  clearly
                  state the following as provided by the state
                  agency:

              

        

        	a.  	
                The
                  percentage of the total costs of the program or project which will
                  be
                  financed with Federal money;

              

        	b.  	
                The
                  dollar amount of Federal funds for the project or program; and
                  

              

        	c.  	
                The
                  percentage and dollar amount of the total costs of the project
                  or program
                  that will be financed by nongovernmental
                  sources.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 3.15.1.

        

        	3.16  	
                Terminology

              

        

        	3.16.1  	
                All
                  references to the term “contractor” as used in the Terms and Conditions
                  attached hereto shall mean “health plan”.

              

        

        Harmony
          Health Plan understands the terms set forth in RFP B3Z06118 paragraph
          3.16.1.

         

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        

        	4.  	
                PROPOSAL
                  SUBMISSION INFORMATION

              

        

        	4.1  	
                Submission
                  of Proposals:

              

        

        	4.1.1  	
                ELECTRONIC
                  SUBMISSION OF PROPOSALS THROUGH THE ON-LINE BIDDING WEB SITE IS
                  NOT
                  AVAILABLE FOR THIS RFP.

              

        

        	4.1.2  	
                Proposal
                  Security Deposit Required: The offeror must furnish a proposal
                  security
                  deposit in the form of an original bond (copies or facsimiles shall
                  not be
                  acceptable), check, cash, bank draft, or irrevocable letter of
                  credit to
                  the Office of Administration, Division of Purchasing and Materials
                  Management by the proposal opening date and time. The Request for
                  Proposal
                  number must be specified on the proposal security
                  deposit.

              

        

        	a.  	
                The
                  proposal security deposit must be made payable to the State of
                  Missouri in
                  the amount of $500,000 for each proposed
                  region.

              

        

        	b.  	
                Any
                  proposal security deposit submitted shall remain in force until
                  such time
                  as the health plan submits a performance security deposit pursuant
                  to the
                  contract requirements specified elsewhere herein. Failure to submit
                  a
                  performance security deposit in the time specified or failure to
                  accept
                  award of the contract shall be deemed sufficient cause to forfeit
                  the
                  proposal security deposit.

              

        

        	c.  	
                If
                  the proposal security deposit is submitted in the form of cash
                  or a check,
                  it will be deposited. However, the Division of Purchasing and Materials
                  Management shall issue a check in the same amount as the offeror's
                  proposal security deposit to the offeror either once the performance
                  security deposit is received if the offeror is awarded the contract,
                  or at
                  the time of award of the contract if the offeror is not awarded
                  a
                  contract.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 4.1.2. Harmony has submitted the Proposal Security Deposit
          under separate cover. 

        

        	4.1.3  	
                When
                  submitting a proposal, the offeror should include nine (9) additional
                  copies along with their original proposal. The front cover of the
                  original
                  proposal should be labeled “original” and the front cover of all copies
                  should be labeled “copy”.

              

        

        	a.  	
                In
                  addition the offeror should provide one (1) copy of their entire
                  proposal,
                  including all attachments, in Microsoft compatible format on diskette(s)
                  or CD(s).

              

        	b.  	
                Both
                  the original and the copies should be printed on recycled paper
                  and double
                  sided. 

              

        	c.  	
                Imaging
                  Ready - In addition, all proposals are scanned into the Division
                  of
                  Purchasing and Materials Management imaging system after a contract
                  is
                  executed, or all proposals are rejected.

              

        

        	1)  	
                The
                  scanned information will be able to be viewed through the Internet
                  from
                  the Public Record Search system. Therefore, the offeror is advised
                  not to
                  include personal identifying information such as social security
                  numbers
                  in the proposal.

              

        	2)  	
                In
                  preparing a proposal, the offeror should be mindful of document
                  preparation efforts for imaging purposes and storage capacity that
                  will be
                  required to image the proposals. Glue bound materials should not
                  be
                  used.

              

        

        Harmony
          Health Plan understands and will adhere to the proposal submission requirements
          set forth in RFP B3Z06118 paragraph 4.1.3 and subparagraphs a-c.

        

        	4.1.4  	
                To
                  facilitate the evaluation process, the offeror is encouraged to
                  organize
                  their proposal into distinctive sections that correspond with the
                  individual evaluation categories described herein. The offeror
                  is
                  cautioned that it is the offeror’s sole responsibility to submit
                  information related to the evaluation categories and that the State of
                  Missouri is under no obligation to solicit such information if
                  it is not
                  included with the proposal. The offeror’s failure to submit such
                  information may cause an adverse impact on the evaluation of the
                  proposal.

              

        

        	a.  	
                Each
                  distinctive section should be titled with each individual evaluation
                  category and all material related to that category should be included
                  therein.

              

        	b.  	
                The
                  proposal should be page numbered.

              

        	c.  	
                The
                  signed page one from the original RFP and all signed amendments
                  should be
                  placed at the beginning of the proposal.

              

        

        Harmony
          Health Plan understands and will adhere to the proposal submission requirements
          set forth in RFP B3Z06118 paragraph 4.1.4 and subparagraphs a-c.

         

        	4.1.5  	
                The
                  offeror should complete and submit Exhibit A, Miscellaneous
                  Information.

              

        

        Harmony
          Health Plan has completed Exhibit A. Please refer to Exhibits Tab in this
          Response Binder.

        

        	4.1.6  	
                Offeror’s
                  Contacts: 

              

        

        	a.  	
                Offerors
                  and their agents (including subcontractors, employees, consultants,
                  or
                  anyone else acting on their behalf) must direct all of their questions
                  or
                  comments regarding the RFP, the evaluation, etc. to the buyer of
                  record
                  indicated on the first page of this RFP. The buyer may be contacted
                  via
                  e-mail or phone as shown on the first page, or via facsimile to
                  573-526-9817.

              

        

        	b.  	
                Offerors
                  and their agents may not contact any other state employee regarding
                  any of
                  these matters during the solicitation and evaluation process.
                  Inappropriate contacts are grounds for suspension and/or exclusion
                  from
                  specific procurements. Offerors and their agents who have questions
                  regarding this matter should contact the buyer of
                  record.

              

        

        	c.  	
                Offerors
                  are advised that any questions received less than three weeks prior
                  to the
                  RFP opening date may not be answered.

              

        

        Harmony
          Health Plan understands and will adhere to the protocols set forth in RFP
          B3Z06118 paragraph 4.1.6 and subparagraphs a-c. 

        

        	4.2  	
                Competitive
                  Negotiation of Proposals - The
                  offeror is advised that under the provisions of this Request for
                  Proposal,
                  the Division of Purchasing and Materials Management reserves the
                  right to
                  conduct negotiations of the proposals received or to award a contract
                  without negotiations. If such negotiations are conducted, the following
                  conditions shall apply:

              

        

        	4.2.1  	
                Negotiations
                  may be conducted in person, in writing, or by
                  telephone.

              

        

        	4.2.2  	
                Negotiations
                  will only be conducted with potentially acceptable proposals. The
                  Division
                  of Purchasing and Materials Management reserves the right to limit
                  negotiations to those proposals which received the highest rankings
                  during
                  the initial evaluation phase. All offerors involved in the negotiation
                  process will be invited to submit a best and final
                  offer.

              

        

        	4.2.3  	
                Terms,
                  conditions, prices, methodology, or other features of the offeror’s
                  proposal may be subject to negotiation and subsequent revision.
                  As part of
                  the negotiations, the offeror may be required to submit supporting
                  financial, pricing and other data in order to allow a detailed
                  evaluation
                  of the feasibility, reasonableness, and acceptability of the proposal.
                  

              

        

        	a.  	
                The
                  offeror must submit information which establishes and supports
                  the
                  actuarial soundness of the proposed rates and a certification of
                  said
                  soundness from an Associate of the Society of Actuaries (ASA),
                  a Fellow of
                  Society of Actuaries (FSA), or a Member of the American Academy
                  of
                  Actuaries (MAAA).

              

        

        	b.  	
                The
                  offeror shall understand that the decision of the State of Missouri
                  regarding whether or not a rate is within actuarially sound rate
                  ranges
                  and does not exceed the cost to the state agency of providing those
                  same
                  services on a fee-for-service basis shall be final and without
                  recourse.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 4.2.3 and subparagraphs a and b. Please refer to Appendix
          Binder, Tab #10 for Harmony’s Actuarial Soundness Certification document.

        

        	4.2.4  	
                The
                  mandatory requirements of the Request for Proposal shall not
                  be
                  negotiable and shall remain unchanged unless the Division of Purchasing
                  and Materials Management determines that a change in such requirements
                  is
                  in the best interest of the State of Missouri.

              

        

        	4.3  	
                Evaluation
                  and Award Process:

              

        

        	4.3.1  	
                After
                  determining that a proposal was submitted by a responsible and
                  reliable
                  offeror and after confirming that the offeror is responsive to
                  the
                  mandatory requirements stated in the Request for Proposal, a subjective
                  evaluation and an objective analysis of the proposals shall be
                  conducted
                  in accordance with the evaluation criteria stated below and further
                  described elsewhere herein. . 

              

        

        	a.  	
                Objective
                  Criteria:

              

        

        	1)  	
                Cost
                  Evaluation20
                  points

              

        	2)  	
                Blind/Sheltered
                  Workshops
                  5
                  points

              

        

        	b.  	
                Subjective
                  Criteria:

              

        

        	1)  	
                Organizational
                  Experience 45
                  points

              

        	2)  	
                Proposed
                  Method of Performance30
                  points

              

        

        	4.3.2  	
                After
                  an initial screening process, a question and answer conference,
                  interview,
                  and/or negotiation discussion may be conducted with the offeror,
                  if deemed
                  necessary by the Division of Purchasing and Materials Management.
                  In
                  addition, the offeror may be asked to make an oral presentation
                  of their
                  proposal during the conference. Attendance cost at the conference
                  shall be
                  at the offeror’s expense. All arrangements and scheduling shall be
                  coordinated by the Division of Purchasing and Materials
                  Management.

              

        

        	4.3.3  	
                Separate
                  evaluations shall be conducted by each area (East, Central, and
                  West). One
                  subjective evaluation shall be conducted as identified in the Subjective
                  Criteria section of the RFP and points assigned accordingly. Two
                  separate
                  cost evaluations shall be conducted as identified in the Objective
                  Criteria, Evaluation of Cost. The first evaluation of cost shall
                  be for
                  those offerors proposing to include pharmacy services from the
                  MC+ managed
                  care benefit package benefits and points assigned accordingly.
                  The second
                  evaluation of cost shall be for those offerors proposing to exclude
                  the
                  pharmacy services from the MC+ managed care benefit package and
                  points
                  assigned accordingly. For auto assign purposes, the sum of the
                  subjective
                  points and cost points for all offerors in an area will be grouped
                  together.

              

        

        	4.3.4  	
                The
                  State of Missouri shall award multiple
                  contracts.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 4.0 and all subparagraphs 4.1 - 4.3.4. 

        

        	4.4  	
                Offeror’s
                  Organization (Responsible and
                  Reliable):

              

        

        	4.4.1  	
                If
                  the offeror is not Federally qualified, the offeror must disclose
                  the
                  following information on certain types of business transactions
                  the
                  offeror has with a “party in interest” as defined in the Public Health
                  Services Act.

              

        

        	a.  	
                Any
                  sale, exchange, or lease of any property between the offeror and
                  a “party
                  in interest”;

              

        

        	b.  	
                Any
                  lending of money or other extension of credit between the offeror
                  and a
                  “party in interest”; and

              

        

        	c.  	
                Any
                  furnishing for consideration of goods, services (including management
                  services), or facilities between the offeror and a “party in interest”.
                  This does not include salaries paid to employees for services provided
                  in
                  the normal course of their employment.

              

        

        	d.  	
                If
                  the offeror has operated previously in the commercial or Medicare
                  markets,
                  the offeror must disclose the information listed below regarding
                  business
                  transactions for the previous year. The offeror must report all
                  of the
                  offeror’s business transactions, not just the transactions relating to
                  serving the Medicaid enrollment.

              

        

        	1)  	
                The
                  name of the “party in interest” for each business
                  transaction;

              

        	2)  	
                A
                  description of each business transaction and the quantity or units
                  involved;

              

        	3)  	
                The
                  accrued dollar value of each business transaction during the fiscal
                  year;
                  and

              

        	4)  	
                Justification
                  of the reasonableness of each business
                  transaction.

              

        

        	e.  	
                For
                  purposes of the above information, a “party in interest” shall be defined
                  as:

              

        

        	1)  	
                Any
                  director, officer, partner, or employee responsible for management
                  or
                  administration of an HMO; any person who is directly or indirectly
                  the
                  beneficial owner of more than 5% of the equity of the HMO; any
                  person who
                  is the beneficial owner of a mortgage, deed of trust, note, or
                  other
                  interest secured by, and valuing more than 5% of the HMO; or, in
                  the case
                  of an HMO organized as a nonprofit corporation, an incorporator
                  or member
                  of such corporation under applicable State corporation
                  law;

              

        	2)  	
                Any
                  organization in which a person as described above is director,
                  officer, or
                  partner; has directly or indirectly a beneficial interest of more
                  than 5%
                  of the equity of the HMO; or has a mortgage, deed of trust, note,
                  or other
                  interest valuing more than 5% of the assets of the
                  HMO.

              

        	3)  	
                Any
                  person directly or indirectly controlling, controlled by, or under
                  common
                  control with a HMO; or

              

        	4)  	
                Any
                  spouse, child, or parent of a person as described in
                  above.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 4.4.1 and subparagraphs a - e. Please refer to Appendix
          Binder, Tab #11 for the Transactions Disclosure document.

        

        	4.4.2  	
                The
                  offeror must provide full and complete information by disclosing
                  the
                  following related to the identity of each “person or corporation with an
                  ownership or control interest” in the offeror, or any health service
                  subcontractor in which the offeror has a 5% or more ownership interest
                  for
                  the prior 12-month period. The offeror may satisfy this requirement
                  by
                  providing a completed Form CMS-855 (Medicare and Other Federal
                  Health Care
                  Programs Provider/Supplier Enrollment
                  Application).

              

        

        	a.  	
                The
                  name and address of each person with an ownership or controlling
                  interest
                  of 5% or more in the offeror or in any subcontractor in which the
                  offeror
                  has direct or indirect ownership of 5% or
                  more;

              

        

        	b.  	
                A
                  statement as to whether any such person with ownership or control
                  interest
                  is related to any other of the persons named with ownership or
                  control
                  interest; as spouse, parent, child, or sibling,
                  and

              

        

        	c.  	
                The
                  name of any other organization in which the person also has ownership
                  or
                  control interest. This is required to the extent that the offeror
                  can
                  obtain this information by requesting it in writing. The offeror
                  must keep
                  copies of all of these requests and responses to them, make them
                  available
                  upon request, and advise the State of Missouri when there is no
                  response
                  to a request.

              

        

        	d.  	
                For
                  purposes of providing the above information, the offeror shall
                  understand
                  that a “person with an ownership or control interest” shall mean a person
                  or corporation that (1) owns directly or indirectly, 5% or more
                  of the
                  offeror’s capital or stock or received 5% or more of its profits; or (2)
                  has an interest in any mortgage, deed of trust, note, or other
                  obligation
                  secured in whole or in part by the offeror or by its property or
                  assets,
                  and that interest is equal to or exceeds 5% of the total property
                  and
                  assets of the offeror, or (3) is an officer or director of the
                  offeror (if
                  it is organized as a corporation) or is a partner in the offeror
                  (if it is
                  organized as a partnership).

              

        

        	1)  	
                The
                  percentage of direct ownership or control is calculated by multiplying
                  the
                  percent of interest which a person owns by the percent of the offeror’s
                  assets used to secure the obligation (e.g., if a person owns 10
                  percent of
                  a note secured by 60 percent of the offeror’s assets, the person owns 6%
                  of the offeror).

              

        

        	2)  	
                The
                  percentage of indirect ownership or control is calculated by multiplying
                  the percentages of ownership in each organization (e.g., if a person
                  owns
                  10 percent of the stock in a corporation which owns 80 percent
                  of the
                  stock of the offeror, the person owns 8% of the
                  offeror).

              

        

        	e.  	
                Financial
                  statements for all owners with 5% or more shall be
                  submitted.

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 4.4.2 and subparagraphs a - e. Please refer to Appendix
          Binder, Tab #4 for the Attestation document.

         

        

        	4.4.3  	
                The
                  offeror must provide the following financial information pertaining
                  to the
                  offeror’s organization (the legal entity that is submitting the proposal
                  and that will be the party responsible for any contract
                  awarded).

              

        

        	a.  	
                Audited
                  financial statements and balance sheets for the previous three
                  (3) years,
                  or as many years up to three (3) years that the entity has been
                  in
                  operation. If the offeror has not been in operation for at least
                  one year,
                  the offeror must submit unaudited financial statements and balance
                  sheets.
                  If the offeror is an existing Health Maintenance Organization,
                  a financial
                  statement must be submitted on the form as prescribed by the National
                  Association of Insurance (NAIC) and must include an actuarial
                  certification.

              

        

        	b.  	
                Financial
                  plan for the offeror’s current fiscal
                  year.

              

        

        	c.  	
                Information
                  about the offeror’s financial forecasts for the contract period and
                  possible contract renewal periods. These forecasts shall include
                  at least
                  income statements and enrollment
                  forecasts.

              

        

        	d.  	
                Names
                  and addresses of independent auditors.

              

        

        	e.  	
                Documentation
                  of insurance coverage such as a list of the insurers used (including
                  contact person and address) and the type and amounts of each policy
                  held.

              

        

        	f.  	
                Proof
                  of reinsurance.

              

        

        	g.  	
                Documentation
                  of any outstanding litigation and malpractice settlements since
                  January 1,
                  1998.

              

        

        Please
          refer to Appendix Binder, Tab 12 for documentation requested in Sec. 4.4.3,
          subparagraphs a - g.

        

        	4.4.4  	
                Debarment
                  Certification - The offeror certifies by signing the signature
                  page of
                  this original document and any amendment signature page(s) that
                  the
                  offeror is not presently debarred, suspended, proposed for debarment,
                  declared ineligible, voluntarily excluded from participation, or
                  otherwise
                  excluded from or ineligible for participation under federal assistance
                  programs. The offeror should complete and return the attached
                  certification regarding debarment, etc., Exhibit B with the proposal.
                  This
                  document must be satisfactorily completed prior to award of the
                  contract.

              

        

        Please
          refer to Response Binder, Exhibits Tab for Harmony’s completed Exhibit B -
          Debarment Certification.

        

        	4.4.5  	
                Business
                  Compliance - The offeror must be in compliance with the laws regarding
                  conducting business in the State of Missouri. The offeror certifies
                  by
                  signing the signature page of this original document and any amendment
                  signature page(s) that the offeror and any proposed subcontractors
                  are
                  presently in compliance with such laws. The offeror shall provide
                  documentation of compliance upon request by the Division of Purchasing
                  and
                  Materials Management. The compliance to conduct business in the
                  state
                  shall include, but not necessarily be limited
                  to:

              

        

        	a.  	
                Registration
                  of business name (if applicable)

              

        	b.  	
                Certificate
                  of authority to transact business/certificate of good standing
                  (if
                  applicable)

              

        	c.  	
                Taxes
                  (e.g., city/county/state/federal)

              

        	d.  	
                State
                  and local certifications (e.g.,
                  professions/occupations/activities)

              

        	e.  	
                Licenses
                  and permits (e.g., city/county license, sales
                  permits)

              

        	f.  	
                Insurance
                  (e.g., worker’s compensation/unemployment
                  compensation)

              

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 4.4 which is evidenced by the executed Signature pages
          included in the Response Binder under the Signature Page tab.

        

        	4.5  	
                Confirmation
                  of Compliance with Requirements:

              

        

        The
          offeror must submit all of the following information in order to determine
          if
          the offeror satisfies the mandatory requirements of the Request for Proposal.
          The State of Missouri reserves the right to reject any offeror’s proposal which
          does not include the required information.

        

        In
          addition, the offeror should address the requirements contained in the
          Performance Requirements section of the RFP. Specifically, the offeror
          should
          address the individual requirements in the Performance Requirements section
          of
          the RFP and provide a description of how, when, by whom, with what, to
          what
          degree, why, where, etc., the requirement will be satisfied.

        

        The
          offeror should not provide a separate response to both the Performance
          Requirements section and this section. Rather, the offeror’s response to the
          following items should be included within the offeror’s response to the
          Performance Requirements.

        

        To
          the
          extent possible, the specific paragraph number of the applicable section
          of the
          Performance Requirements is provided with the following items and is denoted
          in
          parenthesis. The State does not guarantee that all references have been
          provided.

        

        Harmony
          Health Plan understands and will adhere to the requirements set forth in
          RFP
          B3Z06118 paragraph 4.5. 

        

        

        	4.5.1  	
                The
                  offeror shall submit proof that the offeror has a Certificate of
                  Authority
                  from the Missouri Department of Insurance to operate a Health Maintenance
                  Organization in each county specified herein. (2.1.2.a)

              

        

        	a.  	
                If
                  the offeror does not currently have a certificate for a certain
                  county,
                  the offeror shall provide documentation that the offeror has or
                  will
                  submit an application to the Department of Insurance for such
                  certification.

              

        

        Please
          refer to Appendix Binder, Tab 2, Harmony’s Proof of Filing for State of Missouri
          Department of Insurance Certificate of Authority.

        

        	4.5.2  	
                Physician
                  Incentive Plans: The offeror must provide a minimum of the following
                  information regarding each of the offeror’s physician incentive plans
                  (PIP) and each of the offeror’s subcontractor’s PIPs with their downstream
                  providers, if the PIPs place the providers at significant financial
                  risk
                  (SFR). (2.20.3)

              

        

        	a.  	
                Effective
                  date of the physician incentive plan,

              

        	b.  	
                The
                  type of incentive arrangement,

              

        	c.  	
                The
                  amount and type of stop-loss protection,

              

        	d.  	
                The
                  patient panel size,

              

        	e.  	
                If
                  the patient panel is pooled, provide a description of the
                  method,

              

        	f.  	
                The
                  computations of significant financial risk,
                  and

              

        	g.  	
                The
                  name, address, telephone number, and other contact information
                  for a
                  person from the offeror’s organization who may be contacted with questions
                  regarding the physician incentive plan.

              

        

        If
          the
          offeror does not have any PIPs with the health care service providers,
          the
          offeror must confirm in the proposal that no such arrangements exist. If
          the
          offeror’s subcontractors do not have any PIPs with their downstream providers,
          the offeror must confirm in the proposal that no such arrangements exist
          and
          maintain documentation that demonstrates that no such arrangements
          exist.

        

        Harmony
          currently has no Physician Incentive Plan arrangements which meet the
          Significant Financial Risk requirements. Please refer to narrative in
          2.20.3.

        

        	4.5.3  	
                Networks

              

        

        	a.  	
                The
                  offeror shall submit documentation demonstrating that the offeror’s
                  networks comply with travel distance access standards as set forth
                  by the
                  Department of Insurance in 20 CSR 400-7.095 regarding Provider
                  Network
                  Adequacy Standards. For any demonstrated access that differs from
                  these
                  standards, the offeror must submit proof of approval of the differences
                  by
                  the Department of Insurance. (2.14.3)

              

        

        	b.  	
                The
                  offeror shall provide documentation verifying that the offeror’s network
                  has adequate capacity. Such documentation shall include, but it
                  is not
                  limited to, appointment availability, 24 hour/7 days a week access,
                  sufficient experienced providers to serve special needs populations,
                  waiting times, open panels, and PCP to member rations. (2.3.1)

              

        

        	c.  	
                The
                  offeror shall describe how it will provide tertiary care providers
                  including trauma centers, burn centers, level III (high risk) nurseries,
                  rehabilitation facilities, and medical sub-specialists available
                  twenty-four (24) hours per day in the region. If the offeror does
                  not have
                  a full range of tertiary care providers, the offeror shall describe
                  how
                  the services will be provided including transfer protocols and
                  arrangements with out of network facilities. (2.3.17)

              

        

        Harmony
          exceeds the requirements set forth in section 4.5.3 and subparagraphs a
          - c.
          Please refer to narrative response in sections 2.14.3, 2.3.1 and 2.3.17
          respectively.

        

        	4.5.4  	
                The
                  offeror shall list each proposed health care service subcontractor
                  to whom
                  the offeror proposes to delegate contract requirements. Examples
                  include,
                  but are not limited to, mental health services, vision, dental,
                  or
                  pharmacy. The offeror shall describe the services and activities
                  that will
                  be provided by such health service subcontractor. (3.8.3)

              

        

        Harmony
          has documented all proposed subcontractors and included those activities
          to be
          delegated in Appendix Binder, Tab 9, Delegation Oversight Chart. Please
          refer to
          our Delegation Program overview in Sec. 3.8.3.

        

        	4.5.5  	
                Personnel/Staffing:
                  The offeror shall submit information related to the qualifications
                  of the
                  proposed personnel concerning their experience in serving the Medicaid
                  population including education, training, and previous work assignments.
                  In particular, the offeror must submit the
                  following:

              

        

        	a.  	
                Resumes,
                  job descriptions, and full time equivalent status for the offeror’s
                  Medicaid Plan Administrator, medical director, quality assessment
                  and
                  improvement and utilization management coordinator, special programs
                  coordinator, mental health coordinator, and chief financial officer.
                  (2.2.2)

              

        

        	b.  	
                Information
                  for other personnel, including dental consultant, grievance and
                  appeal
                  coordinator, MIS director, and compliance officer. (2.2.1)

              

        

        	c.  	
                Information
                  on staffing levels, job descriptions, and qualifications for prior
                  authorization staff, concurrent review staff, member services staff,
                  and
                  providers service staff. (2.2.1)

              

        

        Harmony
          has provided information as requested, please refer to Appendix Binder,
          Tab 3
          for Key Staffing position descriptions and resumes. 

        

        	4.5.6  	
                Claims
                  Payment Processes - The offeror must submit the following information
                  regarding the offeror’s claims payment processes: (2.25)

              

        

        	a.  	
                Information
                  describing the offeror’s claim adjudication processes - The offeror shall
                  provide a flow chart or written description that details the flow
                  of
                  claims from receipt until payment. Information shall be provided
                  documenting the offeror’s audit trail of all claims that enter the system
                  and any review processes that are in
                  place.

              

        

        	b.  	
                The
                  offeror shall document the offeror’s past and current performance with
                  regard to the timely payment to in-network and out-of-network
                  providers.

              

        

        	c.  	
                A
                  description of the offeror’s claims processing and management information
                  system functions, including, but not limited to information about
                  the
                  offeror’s liability management practices regarding its “Incurred But Not
                  Reported Claims” and “Received But Unadjudicated
                  Claims”.

              

        

        The
          processes requested within this section are described in section 2.25 herein.
          

        

        	4.5.7  	
                Additional
                  Benefits - The offeror must provide a listing, description, and
                  conditions
                  under which it will offer additional benefits to its members. Examples
                  of
                  such services are nurse advice lines; non-emergency transportation
                  (NEMT)
                  for those members who do not have NEMT as part of their benefit
                  package;
                  sponsorship in youth programs such as Boy Scouts or YMCA; or smoking
                  cessation programs. This is not an exhaustive list of such services
                  but
                  only provides examples of the types of services that may qualify
                  as an
                  additional benefit. (2.6.1.a.
                  13))

              

        

        	a.  	
                Member
                  Services and Provider Services - The offeror shall describe the
                  hours of
                  operation, holiday schedule, member and provider communication
                  and
                  education plans, and staff training plans for member services and
                  provider
                  services. (2.9
                  and 2.10)

              

        

        	b.  	
                Member
                  Grievance System - The offeror shall describe the offeror’s member
                  grievance system being sure to address the grievance process, the
                  appeal
                  process, expedited resolution process, and process for ensuring
                  that
                  members receive proper notice of action. (2.15)

              

        

        	c.  	
                Release
                  for Ethical Reasons - The offeror must state if reimbursement for,
                  or
                  provider coverage, of a counseling or referral service will be
                  objected to
                  based on moral or religious grounds. (2.11.3)

              

        

        Items
          requested in 4.5.7 are described within the narrative of the indicated
          response
          sections. 

        

        	4.6  	
                Objective
                  Criteria:

              

        

        	4.6.1  	
                Preference
                  for Organizations for the Blind and Sheltered Workshops - Pursuant
                  to
                  34.165 RSMo, a five (5) bonus point preference shall be granted
                  to
                  offerors including products and/or services manufactured, produced
                  or
                  assembled by a qualified nonprofit organization for the blind established
                  pursuant to 41 U.S.C. sections 46 to 48c or a sheltered workshop
                  holding a
                  certificate of approval from the Department of Elementary and Secondary
                  Education pursuant to section 178.920 RSMo. Five bonus points will
                  be
                  added to the total evaluation points for offerors qualifying for
                  the
                  preference.

              

        

        	a.  	
                If
                  the offeror is an organization for the blind or sheltered workshop,
                  the
                  offeror should provide evidence of qualifications (i.e., copy of
                  certificate or certificate number).

              

        

        	b.  	
                If
                  the offeror is utilizing an organization for the blind or a sheltered
                  workshop as a subcontractor, the offeror should submit: (1) a letter
                  of
                  intent signed by the organization for the blind or sheltered workshop
                  describing the products/services they will provide and indicating
                  their
                  commitment to aid the contractor’s performance under the prospective state
                  contract and (2) evidence that the subcontractor qualifies as an
                  organization for the blind or sheltered
                  workshop.

              

        

        	c.  	
                A
                  list of Missouri sheltered workshops can be found at the following
                  internet address: 
                  http://www.dese.mo.gov/divspeced/shelteredworkshops/index.html.

              

         

        Harmony
          does not qualify as a blind or sheltered workshop. Harmony has contracted
          with a
          qualifying organization. Please refer to the completed Exhibit A document
          included within this Response Binder (see Exhibits Tab) along with the
          executed
          LOI and certificate.

        

        Harmony
          has contracted with a qualifying organization, W.A.C. Industries in St.
          Louis,
          MO., certificate # N00011941. The Letter of Understanding with W.A.C. includes
          Harmony’s support of services offered by W.A.C. including but not limited to
          packaging, assemblies of all types, labeling, collating, inserting, shrink
          packaging, and mailing. During the term of this Letter of Understanding
          (“LOU”),
          W.A.C. within the usual and customary range of its facilities, services
          and
          personnel, agrees to provide these services to Harmony upon written request
          by
          Harmony and acceptance of pricing from W.A.C.

        

        	4.6.2  	
                Evaluation
                  of Cost: 

              

        

        	a.  	
                The
                  objective evaluation of cost shall be computed by using the firm,
                  fixed
                  Per Member Per Month (PMPM) Net Capitation Rates for each Category
                  of Aid
                  Rate Subgroup as quoted by the offeror on the Pricing Pages multiplied
                  by
                  the corresponding projected member months stated in UPL/Rate Development
                  Process (see Attachment 9). The State shall not consider awarding
                  a
                  contract to any offeror with a rate for any Category of Aid rate
                  subgroup
                  which exceeds the State’s Maximum Net Capitation Rate listed in Column 1
                  on the Pricing Page.

              

        

        	b.  	
                Requirements
                  promulgated by the federal government stipulate that the State
                  of Missouri
                  can only contract for services at rates that are within actuarially
                  sound
                  rate ranges. The actuarial soundness of rates differing from those
                  of the
                  state shall be reviewed by the State of Missouri during the formal
                  evaluation of proposals.

              

        

        	c.  	
                The
                  offeror must submit information which establishes and supports
                  the
                  actuarial soundness of the proposed rates and a certification of
                  said
                  soundness from an Associate of the Society of Actuaries (ASA),
                  a Fellow of
                  Society of Actuaries (FSA), or a Member of the American Academy
                  of
                  Actuaries (MAAA).

              

        

        	d.  	
                The
                  offeror shall understand that the decision of the State of Missouri
                  regarding whether or not a rate is within actuarially sound rate
                  ranges
                  shall be final and without recourse.

              

        

        	e.  	
                Cost
                  points shall be calculated based on the sum from the above calculation
                  using the following formula:

              

         

         

        
          	 Lowest
                  Responsive Offeror’s Price	
                   X

                	
                   20

                	
                  
                    =

                  

                	 Cost
                  evaluation points
	 Compared
                  Offeror’s Price	 	 	 	 

        

         

         

        Please
          refer to Appendix Binder, Tab #10 for Harmony’s Actuarial Soundness
          Certification.

         

        	4.7  	
                Subjective
                  Criteria:

              

        

        	4.7.1  	
                Organizational
                  Experience: The offeror’s organization and the offeror’s health care
                  service subcontractor’s organizations shall be subjectively judged.
                  Therefore, the offeror should submit sufficient information to
                  document
                  successful and reliable experience in past/current performances
                  of the
                  offeror and the offeror’s health care service subcontractor’s. The offeror
                  should document experience with a Missouri Medicaid population,
                  or if not
                  available, document experience with another State’s Medicaid
                  population.

              

        

        	a.  	
                The
                  offeror should document its experience in positively impacting
                  the
                  healthcare status of Missouri Medicaid population, or if not available,
                  another State’s Medicaid population. Examples of areas of interest
                  include, but are not limited to the
                  following:

              

        

        	1)  	
                EPSDT

              

         

        As
          a leading provider dedicated to offering comprehensive government-sponsored
          health plans across the country, WellCare has a strong record of hands-on
          involvement in the provision of well-child care. We have a history of commitment
          to the goals of the EPSDT (Healthy Children and Youth (HCY)) program.

        

        WellCare
          works closely with its pediatric providers and the community to ensure that
          members that are at risk are identified and their parents and guardians
          are
          encouraged to take every step necessary for them to receive the appropriate
          health screening and care. WellCare staff inform members about the availability
          and importance of HYC services, reach out to members to reinforce the need
          for
          these services, and track HYC utilization rates. WellCare Case Managers
          are
          available to conduct outreach, provide information on WIC and HCY, and
          make
          appointments and arrange for transport when needed. 

        

        In
          order for WellCare’s program to be effective, we inform members of how they can
          access these services and remind them that they are provided at no charge.
          WellCare also takes proactive steps to encourage our providers to participate
          in
          the HCY programs and to ensure compliance with EPSDT screens in all of
          its
          Medicaid programs, and will take these same critical steps in Missouri.
          

        

        WellCare
          uses a combination of written, audio, and web-based material, telephone
          contacts, and face-to-face encounters to provide critical information to
          members
          on HCY at the time of enrollment and throughout their participation with
          WellCare. The importance of health screens and follow-up treatment is emphasized
          and the HYC program is explained. Instructions are given as to how members
          can
          obtain preventive and expanded services and the role of the PCP. WellCare
          continues to reach out to members throughout their enrollment to reinforce
          the
          need for well-child care and to assist members in obtaining these services.
          Key
          informing and outreach activities include:

        

        	·  	
                Enrollment
                  and orientation. As mentioned above, enrollment and orientation
                  is
                  generally WellCare’s first opportunity to educate prospective members
                  about the importance of preventive care. Our staff training programs
                  ensure that WellCare staff have a thorough understanding of HCY
                  and the
                  importance of encouraging participation in this program. Our enrollment
                  checklist ensures that this topic is covered in all enrollment
                  and
                  orientation presentations. New member packets will include a member
                  health
                  status self-assessment form to help identify children’s current
                  immunization and check-up status.

              

        

        	·  	
                Initial
                  PCP visit scheduling. In addition to informing members of EPSDT
                  services
                  within 60 days of enrollment, WellCare encourages them to schedule
                  a visit
                  with a PCP. 

              

        

        	·  	
                Written
                  materials. WellCare’s Member Handbook is our key written means of
                  informing all new members about HCY services. All written materials
                  will
                  be available in alternative formats and in a manner that takes
                  into
                  consideration members’ special needs. Member materials are available in
                  Spanish as well as English, and translation services are provided
                  when
                  needed for other languages.

              

        

        	·  	
                Customer
                  service. WellCare’s Customer Service Department plays an important role in
                  providing information on EPSDT to our members. When a member calls
                  with an
                  issue involving a child, our representative uses that opportunity
                  to
                  reinforce the member’s understanding of the importance of well-child care
                  and the services available through EPSDT. WellCare representatives
                  are
                  also trained to determine whether the child has had an appointment
                  within
                  the appropriate time interval and assists in scheduling an appointment
                  if
                  needed.

              

        

        	·  	
                Informational
                  activities for pregnant women. WellCare recognizes that reaching
                  pregnant
                  women with information about EPSDT services is important in ensuring
                  healthy babies and healthy children. WellCare also uses other means
                  to
                  inform pregnant women of HCY services. Our perinatal coordinator
                  or Case
                  Manager discusses preventive and routine care expectations for
                  children
                  during her contacts with pregnant members. She also assists members
                  in
                  choosing a PCP for the unborn child and scheduling an initial appointment.
                  

              

        

        WellCare
          will take a number of steps in Missouri to encourage PCP participation
          in the
          HCY program and compliance with EPSDT screening requirements. In addition
          to
          ongoing education about the importance of the program, WellCare will offer
          features on program participants in the newsletters and send monthly notices
          to
          providers about members who are not in compliance with periodicity schedules.
          In
          addition, WellCare may make enhanced payments to providers to encourage
          them to
          assist in facilitating appointments for children who are very overdue for
          screens or immunizations. 

        

        WellCare
          collects data on HCY through regular claims data analysis. We regularly
          examine
          EPSDT utilization rates and track the number of screens each month. The
          data are
          then converted to screening rates (number of screens per member under the
          age of
          21) so that the plan can monitor overall provider performance and implement
          additional provider and member interventions at the plan level to improve
          compliance. Providers are also given periodic reports that show specifically
          which patients are not in compliance with preventive care scheduling guidelines.
          

        

        WellCare
          also monitors provider compliance with screening requirements through medical
          chart audits. Individual PCPs who do not meet the threshold for standards
          of
          clinical preventive pediatric care are notified and a corrective action
          plan is
          developed. Information from the chart audits is also used as part of the
          routine
          annual quality improvement planning process.

        

        WellCare’s
          new tracking system will identify members who are not receiving services
          in
          keeping with the specified periodicity schedules. WellCare will provide
          written
          notification to its families with HCY eligible children when appropriate
          periodic assessments or needed services are due. Members are sent a periodicity
          letter in their birthday month, regardless of whether they have been seen
          or
          not, which outlines the preventive services recommended at the appropriate
          age
          according to the USPSTF Preventive Care Guidelines, and the American Academy
          of
          Pediatrics. 

        

        In
          2002, WellCare’s Connecticut Medicaid population EPSDT rates were significantly
          below the threshold required by the Centers for Medicaid and Medicare Services,
          therefore the plan instituted a performance improvement project designed
          to
          improve the rate for EPSDT screenings. A barrier analysis was conducted
          and
          although the rates for member’s in the younger age categories were above the 80%
          requirement, the age groups from 12 - 19 years old were significantly below.
          The
          plan instituted a member incentive program that was focused on this particular
          age group to encourage obtaining an EPSDT visit. Members are sent a letter
          with
          an incentive Blockbuster video card if they receive an EPSDT visit. The
          plan’s
          rates for EPSDT screening have increased from 74% to 84% over a three year
          period, an improvement of 13.5% which is above the Connecticut State
          average.

        

        	2)  	
                Lead

              

        

        Screening
          for lead exposure is an important component of Early Periodic Screening
          Diagnosis Treatment (EPSDT) or Child Health Check Up visits. Early detection
          and
          preventive health services are needed to curtail the potential hazards
          that our
          children will face from lead poisoning such as anemia, learning disability,
          hearing loss and behavioral problems, and at extremely high levels (>70ug/dL)
          can result in seizures, coma, and even death. According to a CDC reported
          national survey from 1991-1994, 4.4% of all children had elevated blood
          lead
          levels. An October 2003 press release issued by Florida Department of Health,
          Agency for Health Care Administration (AHCA), all children aged 6 years
          and
          under can be at risk for lead exposure, especially those between 9 months
          and 2
1⁄2 years due to hand-to-mouth contamination from playing in household dust,
          paint
          chips or exterior soil that contains lead. Therefore, children should have
          a
          blood lead test at one and two years of age and between the ages of three
          and
          six years, if never tested. WellCare recognizes the importance of lead
          screening
          and continues to improve our process for blood lead testing during child
          health
          check-up visits thereby assuring that each member receives the best care
          possible. 

        

        In
          2003, WellCare instituted a unique approach to improving blood lead screening
          tests in the New York Medicaid population. WellCare’s rate for lead screening of
          children 25 months of age was significantly below the State average and
          the CMS
          guidelines for lead screening. WellCare began a two-pronged approach to
          improving screening rates focusing on both members and providers. Providers
          received lists of their members who had not yet received blood lead screening
          tests and an incentive of $25 per member who received a blood lead test
          prior to
          turning 25 months of age. In addition, members were sent a letter to encourage
          and educate them about lead testing. WellCare’s rates for lead screening
          improved from a low of 29% in 2002 to over 78% in 2005. WellCare is above
          the
          state-wide average for lead screening however, opportunities for improvement
          continue to exist. In 2006, WellCare will expand outreach efforts to include
          contacting non-compliant members proactively by telephone to educate them
          about
          the importance of lead screening and to encourage them to obtain blood
          lead
          screening tests.

        

        WellCare’s
          Pediatric Lead Case Management Program recognizes that more than 80% of
          the U.S.
          homes built before 1979 (64 million) contain lead based paint. Lead poisoning
          is
          caused by ingestion and inhalation of common environmental lead sources.
          Lead
          poisoning may cause anemia, permanent brain damage, learning disorders,
          loss of
          balance, kidney damage, blindness, hearing loss, seizures, coma, and death.
          Lead
          poisoning is preventable and the key to prevention is early identification
          through blood level testing.

        

        Members
          are identified for the program through:

        	·  	
                Primary
                  Care Physicians

              

        	·  	
                Health
                  Departments

              

        	·  	
                internal
                  and external sources

              

        	·  	
                laboratory
                  lead level measurement reports,
                  and

              

        	·  	
                WellCare’s
                  Early Periodic Screening Diagnosis Treatment (EPSDT) or Child Health
                  Check-up visits.

              

        

        Member
          Outreach:

        	·  	
                Periodicity
                  letters sent to members who have not seen their PCP within 45 days
                  of
                  enrollment

              

        	·  	
                Reminder
                  periodicity letters sent on member’s birth
                  month

              

        	·  	
                Telephonic
                  outreach for members under six (6) years of age who have inbound
                  or
                  outbound call encounters with Customer Service, Case Management,
                  and/or
                  Disease Management

              

        	·  	
                Articles
                  in Member Newsletters regarding the importance of having children
                  receive
                  a lead level screening.

              

        

        Monthly
          the Pediatric Case Manager receives a list of members whose laboratory
          lead
          level is ≥ 10 mcg/dl and during the month receives information from sources
          noted above. The Pediatric Case Manager contacts the PCP to ascertain when
          the
          member was first tested, is the member scheduled or did the member have
          a 3
          month re-check, was there a home assessment and see if the member has been
          compliant with care plan, etc. Medical records are also requested from
          the PCP.
          The Pediatric Case Manager contacts the member to educate the member on
          lead
          poisoning and available state and community resources, coordinate medical
          care,
          and facilitate communication between the PCP and the member. Members are
          flowed
          until they are no longer with the WellCare, their lead level is ≤ 10 mcg/dl,
          they are not able to contact member, or the member is stable and
          compliant.

        

        	3)  	
                Children
                  with special health care needs

              

        

        WellCare
          Health Plans, Inc, including Harmony Health Plans, has experience with
          Children
          with Special Health Care Needs in seven (7) states. WellCare’s Pediatric Case
          Management interventions are often invaluable for children with chronic
          and
          complex medical conditions such as congenital birth defects, serious chronic
          heart or lung disease and/or inborn errors of metabolism. 

        

        WellCare
          throughout the years has found this program to demonstrate a lower incidence
          of
          re-admission and a higher rate of member compliance. The program is successful
          due to early identification and linking members and families with appropriate
          care and community resources.

        

        Families
          that have children with these serious medical problems are often confronted
          with
          a complex and disconnected set of facilities and providers that make it
          extremely difficult to get timely and appropriate care. Delays in obtaining
          quality care may result in suboptimal clinical outcomes that are also more
          costly. Families are given the opportunity to provide input into their
          child’s
          individual needs.

        

        Children
          with special health care needs require a broad spectrum of services from
          primary
          care, specialty medical care, to prescription medications, medical equipment
          and
          therapies. The families may need respite care or family
          counseling.

        

        WellCare’s
          Pediatric Case Management Program has many benefits that focus on the needs
          of
          this population, including:

        	·  	
                Facilitation
                  of intra-organizational planning

              

        	·  	
                Improved
                  communication between WellCare, the member, and the
                  provider(s)

              

        	·  	
                Care
                  coordination (reduces duplication of
                  services)

              

        	·  	
                Psychosocial
                  support to the family and member while in a stressful
                  situation

              

        	·  	
                Creating
                  a treatment plan to the member’s special needs and covered
                  benefits

              

        	·  	
                Seeking
                  a most appropriate setting for health
                  care

              

        	·  	
                Offering
                  innovative alternatives to lengthy and costly acute care
                  stays

              

        

        A
          key element of the Pediatric Case Management Program (Children with Special
          Health Care Needs) is early identification through:

        	·  	
                authorizations
                  or Health Risk Assessments (HRAs)
                  forms

              

        	·  	
                monthly
                  internal claims data mining “Special Needs” report for members with
                  special needs diagnoses

              

        	·  	
                laboratory
                  reports

              

        	·  	
                Inpatient
                  Census

              

        	·  	
                “Frequent
                  Flyer” report

              

        	·  	
                PCP/Specialist

              

        	·  	
                Member
                  self-referral

              

        

        The
          Case Managers roles and responsibilities in enrollment and program
          participation:

        	·  	
                contact
                  member’s parents and/or guardian to explain Pediatric Case Management
                  Special Needs Program and
                  enrollment

              

        	·  	
                completes
                  an assessment on the member’s medical and psycho-social needs
                  

              

        	·  	
                contacts
                  the PCP and/or Specialists involved in the case to obtain medical
                  history
                  on the member

              

        	·  	
                in
                  collaboration with the family and/or member and the members of
                  the heath
                  care team, identifies immediate, short-term, and ongoing needs,
                  as well
                  as, develops appropriate and necessary case management strategies
                  to
                  address them.

              

        	·  	
                assists
                  the member/family in making informed decisions when developing
                  the plan of
                  care which identifies measurable goals and timeframes for achievable
                  goals
                  that are appropriate to the member and his/her
                  family.

              

        	·  	
                considers
                  contingency plans in the overall plan to anticipate treatment and
                  service
                  gaps or complications, such as:

              

        	o  	
                No
                  benefit

              

        	o  	
                Extra
                  contractual agreement considerations to include negotiations with
                  non-par
                  services/providers when
                  appropriate

              

        	·  	
                coordinates
                  community resource referrals

              

        	·  	
                coordinates
                  the mailing of needs specific educational
                  materials

              

        	·  	
                employs
                  a process of ongoing assessment and documentation to monitor the
                  quality
                  of care, services and products delivered to the member to determine
                  if the
                  goals of the plan of care are being achieved, whether those goals
                  remain
                  appropriate and realistic, and what actions maybe implemented to
                  enhance
                  positive outcomes. 

              

        	·  	
                identifies
                  when a member’s condition has reached a static or regressive situation and
                  proactively facilitate adjustments in the plan of care, providers,
                  and/or
                  services, when possible, to promote enhanced
                  outcomes.

              

        

        Provider
          educational materials, to increase awareness and enrollment into the Pediatric
          Case Management Program:

        	·  	
                Provider
                  Handbook

              

        	·  	
                Provider
                  Newsletters

              

        	·  	
                Telephonic
                  communication educating provider on the program, community resources
                  and
                  disease specific information.

              

        

        Member
          education materials:

        	·  	
                Member
                  Handbook

              

        	·  	
                Member
                  Newsletters

              

        	·  	
                Disease
                  specific educational materials, including complication
                  avoidance

              

        	·  	
                Lists
                  of community resources

              

        

        WellCare’s
          Pediatric Case Management Program, like our Case Management Program utilizes
          a
          two-fold approach to case management, firmly establishing the member’s Primary
          Care Physician (PCP) as the principle case manager with the Pediatric Case
          Management Program augmenting the physician’s role in directing care. Once the
          members have met their goals, are established with their PCP and have developed
          a support system, they are discharged from the program. Members may re-enter
          the
          program should their health status change. 

        

        	4)  	
                Asthma

              

        

        The
          purpose of the Asthma Disease Management program is to identify members
          with
          asthma and provide education for these members and/or their caregivers
          to
          empower them to make behavior changes to ensure the choices they make will
          improve their health and reduce the complications of asthma. In addition,
          the
          program educates members and their caregivers, regarding the standards
          of care
          for asthma, preventive measures, triggers to avoid, and ensures they are
          receiving the appropriate medications. The program focuses on educating
          the
          provider with regards to the standards of care for asthma and current treatment
          recommendations. Intervention and education improves the quality of life
          of
          members, improves health outcomes and decreases medical costs.

        

        The
          objectives of the asthma program are to identify members with asthma early
          in
          their disease process to decrease the likelihood of adverse outcomes, educate
          members regarding the standards of care for asthma, preventing recurrences,
          identifying triggers, and appropriate asthma action planning, identify
          members
          who are at high-risk for adverse outcomes and provide intensive follow-up
          to
          improve outcomes and support and educate physicians in providing appropriate
          care. 

        

        The
          goals of the asthma program are to decrease admissions, re-admissions and
          emergency room visits for members with asthma, to decrease asthma-related
          medical costs and to improve compliance with medication
          therapy.

        

        The
          asthma program proactively identifies and stratifies members who have asthma
          through claims, encounters and pharmacy data. In addition, members can
          self-refer, providers can refer members and members are identified through
          the
          inpatient census, health risk assessments and welcome calls. Members are
          stratified into three levels based on their risk for adverse outcomes.
          All
          members receive an introductory letter and educational material regarding
          their
          disease. Members most at risk are called by an asthma disease nurse to
          complete
          an asthma assessment, evaluate their health status and educate the member
          or
          caregiver about their disease. Members are followed up with on an ongoing
          basis
          until self-care goals are accomplished.

        

        Providers
          of members with asthma receive an introductory letter to the asthma program.
          In
          addition, providers receive asthma clinical practice guidelines based on
          Nationally-recognized evidenced based clinical guidelines published by
          the
          National Institutes of Health, NHLBI Guidelines for Asthma Management.
          Providers
          also receive a monthly membership list that identifies members with asthma
          who
          have not had a visit with their PCP in greater than 3 months.

        

        Over
          a period of 6 months, WellCare’s 30 day readmission rate for members with asthma
          has decreased by 66% for the members that were contacted by the asthma
          disease
          management program nurses demonstrating a positive trend in outcomes for
          members
          impacted by the Disease management program.

        

        	5)  	
                Reduction
                  of inappropriate utilization of emergent
                  services

              

        

        Harmony
          Health Plan in Illinois and Indiana and the other WellCare Medicaid markets
          have
          implemented multiple member outreach and education programs to decrease
          inappropriate Emergency Room (ER) utilization, without success.

        

        The
          following initiative has been developed to focus on more than just member
          outreach and education, to provide more intensive case management action
          items
          as well as identification of potential provider access issues.

        

        Member
          education/case management: 

        Member
          education will be initiated with the following information in the Member
          Handbook and an ER brochure that describes the following:

        	·  	
                Description
                  of emergency 

              

        	·  	
                Alternatives
                  to the hospital emergency room for non-emergency conditions
                  

              

        	·  	
                Reminders
                  of how to contact PCP or covering
                  service

              

        	·  	
                Description
                  of the services provided by the 24 hour nurse call line
                  

              

        

        An
          Emergency Room log will document all requests for Emergency Room services
          by the
          Emergency Room staff for non-emergent conditions. Members identified through
          the
          Emergency Room log will be contacted immediately for identification of
          the
          reason for inappropriate use of the ER, follow-up care and
          education.

        

        Additionally,
          members identified as frequent utilizers of Emergency Room services for
          non-emergent conditions/services will be placed in a case management program
          for
          follow-up. 

        	·  	
                Members
                  that have had one-three visits will receive an auto-generated outreach
                  letter with urgent care listings and magnets.
                  

              

        

        	·  	
                Members
                  that have had more than three Emergency Room visits/quarter will
                  receive
                  an outreach call or home visit by the Harmony Social Worker to
                  determine
                  the reason(s) for frequent utilization of Emergency Room services.
                  Action
                  plans will be developed to solve the underlying gap in care, including,
                  but not limited to:

              

        	o  	
                a
                  PCP change, 

              

        	o  	
                referral
                  to specialists, 

              

        	o  	
                enrollment
                  in a case management and/or disease management program,
                  

              

        	o  	
                information
                  on alternative after-hours service
                  providers

              

        	o  	
                other
                  plans as appropriate 

              

        

        Provider
          Outreach:

        Primary
          care providers (PCPs) receive a new membership list each month. They are
          expected to see their newly enrolled members within thirty (30) days of
          enrollment. The current Member ER Brochure will be issued to providers
          for
          member education. 

        

        The
          standard report of ER utilization by PCP assignment will be sorted by the
          PCPs
          with the highest member utilization. The provider groups showing the highest
          percentage of ER utilization per member will be visited by WellCare staff
          to
          determine if there is an access or availability opportunity.

        

        	6)  	
                Case
                  management

              

        

        WellCare
          Health Plans, Inc, including Harmony Health Plans, has experience with
          Case
          Management Programs in seven (7) states. WellCare’s Case Management Programs
          enhances care coordination, improves member adherence to recommended treatment,
          improves quality, decreases fragmentation and improves
          satisfaction.

        

        In
          today’s health care environment Case Management has been challenged to prove
          its
          economic value as well as its impact on clinical outcomes. The benefits
          of case
          management are considered both tangible and intangible. The following example
          demonstrates our organizational competence in the area of Case Management
          that
          significantly impacted the Florida Medicaid population.

        

        WellCare
          conducted an eight month pilot program in 2005 to prove that Case Management
          has
          a tangible value by determining the impact of case management on the
          re-admission rates of high risk members in the Tampa market. After evaluating
          the population in Florida using member information and claims data, the
          TANF/SSI
          members in the Tampa market were chosen due to their high re-admission
          rate.
          Additional Case Managers were placed on the Tampa Pilot
          Program.

        

        The
          Case Managers targeted members with:

        	·  	
                high
                  re-admission rates by reviewing the daily “Frequent Flyer”
                  report

              

        	·  	
                specific
                  high risk diseases such as asthma, diabetes and CHF, through claims
                  data
                  and “Inpatient Census report

              

        	·  	
                high
                  cost utilizers, through daily “Inpatient Census”
                  report

              

        	·  	
                multiple
                  co-morbities, through claims
                  data

              

        

        Case
          Management Interventions:

        	·  	
                Creating
                  a treatment plan to the member’s special needs and covered
                  benefits

              

        	·  	
                Educating
                  members on their disease state 

              

        	·  	
                Connecting
                  the member with their PCP and other
                  Specialists

              

        	·  	
                Educating
                  providers and members about available state and community
                  resources

              

        	·  	
                Facilitate
                  quality, cost-effective care by preventing fragmentation and duplication
                  of care.

              

        

        WellCare’s
          Case Management Program utilized a two-fold approach to case management,
          firmly
          establishing the member’s Primary Care Physician (PCP) as the principle case
          manager with the Case Management Program augmenting the physician’s role in
          directing care. It is one component used to control, direct, and approve
          access
          to the services available to members in their benefit packages. The Case
          Managers in the Pilot Program became involved with the member while they
          were
          hospitalized, when ever possible. They established a relationship with
          the
          member, assisted the member with their discharge needs and obtained contact
          numbers of where the member would be staying. Next they called the member
          and
          began the case management process, evaluating the member’s medical and
          psycho-social needs. A majority of the members needed education on their
          specific disease, access to transportation and community resources, and
          to
          establish a strong relationship with their PCP and appropriate specialists.
          Once
          the members had met their goals, were established with their PCP and had
          developed a support system, they were discharged from case management.
          The
          members were evaluated 90 days prior to admission into the Pilot Program
          and 90
          days after. The final outcome was a 10% reduction in the re-admission rate
          for
          that population and an increase in member compliance to their treatment
          plan.

        

        	7)  	
                Pre-natal
                  care

              

        

        Harmony
          Health Plans and WellCare combined have multiple years of experience in
          dealing
          with various aspects of pre-natal care and the following example demonstrates
          our organizational competence in the areas of pre-natal care that significantly
          impact our population. 

        

        In
          Illinois and Indiana, Harmony has had a pre-natal program since inception
          (ten
          years) called Harmony Hugs. Throughout the years, this program has demonstrated
          a higher proportion of prenatal visit compliance and a lower incidence
          of low
          birth weight and neonatal intensive care unit (NICU) admissions for newborns
          of
          enrolled members compared to non-enrolled members. The program has been
          most
          successful when members are enrolled early in their
          pregnancy.

        

        This
          program has recently been expanded to include post-natal depression screening
          and more systematic outcomes measurements, as well as some key components
          from
          the WellCare pre-natal program.

        

        	·  	
                Early
                  identification through:

              

        	o  	
                monthly
                  State reports of known pregnancies (EDD
                  list)

              

        	o  	
                monthly
                  prenatal vitamins reports

              

        	o  	
                authorization
                  requests and/or notification/assessment forms from
                  providers

              

        	o  	
                member
                  self-referrals

              

        	o  	
                referrals
                  from other agencies

              

        	o  	
                pre-natal
                  inpatient admissions or authorizations requests for home health
                  or DME
                  pre-natal outpatient services

              

        	·  	
                Member
                  enrollment and participation in the program, achieved by the Hugs
                  educator
                  who:

              

        	o  	
                contacts
                  the member for enrollment in the
                  program

              

        	o  	
                completes
                  a Maternity Health Risk Assessment with the member.
                  

              

        	o  	
                stratifies
                  members into risk categories, determined by number and severity
                  of risk
                  factors 

              

        	o  	
                identifies
                  specific member educational and healthcare
                  needs

              

        	o  	
                completes
                  an individualized care plan with specific follow-up tasks and has
                  member
                  contract for compliance with the care
                  plan

              

        	o  	
                contacts
                  the member’s provider’s office to review the care plan, asks for
                  additional instructions for the care plan, and then issues the
                  care plan
                  to the provider’s office for
                  signature

              

        	o  	
                contacts
                  any external resource to coordinate additional services
                  

              

        	o  	
                coordinates
                  the member’s care according to the care
                  plan

              

        	o  	
                coordinates
                  the mailing of any additional educational materials not included
                  in the
                  system generated trimester educational
                  mailings.

              

        	o  	
                contacts
                  the members at agreed-upon intervals and/or hospital admissions,
                  revise
                  and update the care plan as necessary, and educate and coordinate
                  additional services as appropriate throughout the pregnancy and
                  post
                  partum visit

              

        	o  	
                after
                  delivery, confirms the 6 week post partum office visit and/or assists
                  in
                  scheduling the visit

              

        	o  	
                conducts
                  the health risk assessment and the mental health assessment using
                  the
                  Edinburgh Postnatal Depression Screening tool, and contracts for
                  ongoing
                  compliance parameters, including if indicated referral to/coordination
                  with Harmony’s Behavioral Health Provider and/or Medical
                  Provider.

              

        	o  	
                contacts
                  the member two days prior to the post-partum visit to confirm intended
                  compliance, to prepare the member for the visits and to assist
                  with
                  potential transportation requirements

              

        	o  	
                contacts
                  the member two days after the post natal visit to confirm compliance
                  and/or assist with rescheduling.

              

        	·  	
                Member
                  educational materials, such as:

              

        	o  	
                Material
                  about the specifics of the Hugs
                  program:

              

        	o  	
                Trimester
                  letters automatically generated that provide key milestones on
                  the baby’s
                  growth and the mom’s physical changes specific to each
                  trimester

              

        	o  	
                Nutritional
                  information as it relates to a healthy
                  pregnancy

              

        	o  	
                Risks
                  of using prescription and over the counter medications while pregnant,
                  and
                  dangers of low birth weight babies as a result of smoking, alcohol
                  or
                  drugs

              

        	o  	
                Benefits
                  and recommended schedule of prenatal visits including dental
                  care

              

        	o  	
                Specific
                  educational materials about any complicating
                  conditions

              

        	o  	
                The
                  warning signs of pre-term labor

              

        	o  	
                Preparation
                  for labor and delivery

              

        	o  	
                Planning
                  for the baby’s homecoming

              

        	o  	
                Infant
                  and child care booklets (1-12 moths) and immunization
                  schedules

              

        	·  	
                Member
                  incentives, such as:

              

        	o  	
                Six
                  piece nursery care kit, which contains baby care items such as:
                  a
                  thermometer, nasal aspirator, medicine administration aids, and
                  a nail
                  clipper for enrolling in the Hugs program, and
                  

              

        	o  	
                A
                  baby stroller for members who complete a minimum of six prenatal
                  visits
                  and the post-partum visit.

              

        

        In
          2001, Harmony was awarded a grant to participate in the Robert Woods Johnson
          Foundation workgroup, BCAP Toward Improving Birth Outcomes . Harmony was
          selected as one of 11 Health Plans to participate, with the goal of increasing
          the quality of prenatal care for Medicaid/SCHIP enrollees. Chief medical
          officers from health plans collaborated to identify and pilot practical
          solutions for improving the health of pregnant mothers and their newborns.
          Pilot
          projects included innovative identification, stratification, outreach,
          and
          intervention techniques to improve care. 

        

        Over
          the nine-month pilot phase, the Harmony team increased the number of women
          known
          by the plan to be pregnant prior to delivery by 76 percent. The plan implemented
          an outreach program to high-volume obstetric providers and to members newly
          identified as pregnant. 

        Harmony
          found that while providers may know which members are pregnant, this information
          is not shared with the health plan, or the plan did not have a systematic
          way of
          evaluating sources if identification. Harmony was able to increase knowledge
          of
          pregnancies through several methods:

        

        	·  	
                Analyzing
                  state claims data tapes for pregnancy
                  codes

              

        	·  	
                Provider
                  Incentives

              

        	·  	
                Analyze
                  Pharmacy Records

              

        

        Harmony
          was able to increase its identification rate from three percent in July
          2000 to
          76 percent in June 2001.

        

        The
          lessons learned in the Toward Improving Birth Outcomes initiative are
          incorporated into a toolkit that provides a step-by-step practical approach
          toward achieving improved birth outcomes. This toolkit is available through
          the
          Centers for HealthCare Strategy website.

        

        	8)  	
                Dental

              

        

        Many
          of the oral health problems that arise in infants and toddlers are preventable
          through early detection and prevention programs. Good dental health leads
          to
          overall good health and therefore WellCare is committed to improving the
          rate of
          children who obtain preventive dental care visits during early childhood
          and
          throughout adolescence. 

        

        WellCare
          uses a multifaceted approach to improving dental screenings and has proven
          success in the New York health plan. In 2002 the dental rates were found
          to be
          at 27% compliance for members age 3 to 21 years of age who had seen a dentist
          in
          the previous year. WellCare recognized the need to improve this very important
          screening and began an outreach program designed to educate, inform and
          encourage members to see the dentist. Utilizing our robust data systems
          WellCare
          identified members who had not had a visit with their dentist in the past
          year
          and sent letters to these members to encourage them to see the dentist,
          listed
          who their assigned dentist was and simple preventive measures to take for
          good
          oral health. In addition, the health plan sent membership lists to providers
          for
          the members that were not compliant with their dental screenings. Combining
          the
          provider and member approaches has shown to be an effective way to improve
          compliance rates. The rate of preventive dental visits between the ages
          of 3 and
          21 years of age increased by nearly 81% surpassing the state average in
          2004.
          WellCare will continue our commitment to improved dental health in the
          Missouri
          population and strive to ensure members are receiving dental care as
          appropriate.

        

        	9)  	
                Mental
                  health

              

        

        Harmony
          Health Plans and WellCare combined have multiple years of experience in
          dealing
          with various aspects of Mental Health, and the following examples demonstrate
          our organizational competence in the area of Mental Health, in areas that
          significantly impact our population. 

        

        The
          first example is in Illinois, where Harmony in cooperation with our Behavioral
          Health Partner, PsycHealth, implemented a broad Transitional Care Program
          for
          all hospitalized members and a more intensive Home Intention Program for
          targeted high-risk members. The goal of both these programs was to prevent
          readmissions.

        

        All
          low risk hospitalized members were enrolled in the Transitional Care Program,
          with the focus of establishing appropriate follow-up post-discharge from
          a
          hospitalization. The members with demonstrated follow-up in outpatient
          care
          after being discharged from inpatient care are much less likely to be
          readmitted. Various protocols to increase the ambulatory follow-up rates
          such as
          outreach calls and letters were unsuccessful. Therefore, we determined
          that a
          follow-up in-home visit would be warranted. The Transitional Care Program
          included the following components:

        

        	·  	
                In-home
                  after-care appointment scheduled while the member is still hospitalized.
                  

              

        	·  	
                Home
                  visit occurs within seven (7) days of
                  discharge

              

        	·  	
                Home
                  visit therapist evaluates the member’s current status, outpatient
                  aftercare plan, and ensures that all the roadblocks are
                  eliminated.

              

        

        All
          targeted high-risk members (those with multiple readmissions, multiple
          family
          members admitted to the hospital simultaneously or in close proximity to
          each
          other, or members physically or environmentally unable to access and engage
          in
          traditional outpatient treatment) were enrolled in the more intensive Home
          Intervention Program, where they were provided in-home mental health therapeutic
          services until they could be transitioned to the community providers. In
          Illinois, most of the readmissions were from members with three or more
          admits
          in one year. None of these members had outpatient follow-up. Based on
          literature, staff perception and member surveys, it was determined that
          more
          intensive follow-up and in-home mental health therapeutic services were
          appropriate for these identified members at risk. 

        

        The
          Home Intervention program, (HIP) is an alternative outpatient modality
          which
          provides outreach, assessment and therapy in the member’s home rather than the
          traditional office setting. The goals are to reach and engage members to
          solve
          the core problems which are embedded in the family system, decrease the
          barriers
          to care, facilitate continuity of care and decrease relapse. The program
          includes the following components:

        	·  	
                In-home
                  transitional after-care appointment scheduled while the member
                  is still
                  hospitalized.
                  

              

        	·  	
                Home
                  visit occurs within seven (7) days of
                  discharge

              

        	·  	
                Home
                  intervention therapist evaluates the member’s current status, outpatient
                  aftercare plan, impediments to following through with treatment
                  and
                  possible solutions to those problem areas, and completes the Home
                  Intervention Checklist Assessment form. A plan for weekly home
                  therapy is
                  established.

              

        	·  	
                The
                  therapist confers with other professionals during monthly staffings
                  and as
                  needed. The goal is to establish linkages of these members to appropriate
                  aftercare services when the member is able to
                  follow-through.

              

        

        The
          outcomes are as follows:

        	·  	
                Behavioral
                  health admission rates decreased an average of 2.5 admits, a reduction
                  of
                  86%, following the implementation of the home-based services.
                  

              

        	·  	
                Each
                  age group from the study showed a similar reduction in readmission
                  rates
                  

              

        	·  	
                Participants
                  who received four or more home sessions had, on average, a 22%
                  lower
                  readmission rate than those participants who received fewer than
                  four home
                  sessions.

              

        	·  	
                A
                  majority of the participants (65%) were not re-hospitalized after
                  receiving the HIP services.

              

        

        The
          second example of WellCare’s organizational competence in Mental Health is
          demonstrated in a project in Florida to improve compliance for adults with
          anti-depressant medication management. This was a project for the Florida
          HealthEase and Staywell populations due to the prevalence of this diagnosis
          and
          the increased identification and treatment of depression by Primary Care
          Providers (PCPs). 

        

        The
          preliminary findings for HealthEase (as an example) were as
          follows:

        	·  	
                The
                  members with three or more outpatient follow-up visits increased
                  from
                  10.8% to 26%. 

              

        	·  	
                The
                  members who had filled a sufficient number of separate prescriptions
                  /refills of anti-depressants to provide continuous treatment for
                  three
                  months dercreased from 46.9% to
                  41%

              

        	·  	
                The
                  members who had filled a sufficient number of separate prescriptions
                  /refills of anti-depressants to provide continuous treatment for
                  six
                  months stayed about the same at
                  23%.

              

        As
          a result, additional interventions are underway, including the
          following:

        	·  	
                CME
                  educational sessions on depression

              

        	·  	
                Letters
                  issued to members encouraging them to call for an
                  appointment

              

        	·  	
                FAX
                  alerts issued to notify PCPs when claims data identify a member
                  newly
                  diagnosed with depression and/or placed on an anti-depressant.
                  The alerts
                  include the depression management guidelines being
                  monitored

              

        	·  	
                Article
                  on depression in the Provider
                  newsletter

              

        	·  	
                Depression
                  screening component added to the standard disease management programs
                  to
                  identify members who may require behavioral health screening and
                  follow-up

              

        	·  	
                Developed
                  web site for PCPs that features guidelines for identifying and
                  treating
                  depression in adults, with screening tools, treatment algorithms,
                  referral
                  guidelines and pharmacological
                  recommendations

              

        

        	10)  	
                Partnering
                  with stakeholders for
                  delivery of care

              

        

        Harmony
          Health Plan is active in the development and implementation of health education,
          safety and wellness programs that are offered totally free of charge. These
          programs are designed to raise the health and safety consciousness of the
          individuals and families associated with businesses and organizations throughout
          the community and to improve the delivery of care throughout our provider
          community. Our goal is to teach preventative health care and safety practices
          that can make a real difference in the lives of families.

        

        Some
          of the programs we have implemented over the years are as
          follows:

        

        For
          Keeps Safety Program

        Keeping
          children safe is the toughest task parents must face in the process of
          raising a
          family. Child abductions, in particular, are now an unfortunate reality
          in towns
          and cities across the country.

        

        In
          an effort to help families become more aware of child safety practices,
          Harmony
          Health Plan has partnered with various police and fire departments to present
          “For
          Keeps.”
          This educational and informative safety program is designed to teach
          precautionary safety measures to parents and kids alike. “For
          Keeps” Safety Seminars take
          place in the various communities Harmony serves.

        

        At
          the seminars, interactive sessions begin with an instructional video where
          families learn how to recognize the danger signs and thwart attacks. Following
          the video, workshops are conducted to teach and demonstrate safety techniques.
          Families also gain life-saving information on other safety issues such
          as fire
          prevention and poison control.

        

        “For
          Keeps” is
          a positive way to bring families together to help improve the community
          through
          increased awareness of children’s safety.

        

        Reach
          Our Goals (Immunization Provider Education)

        Harmony
          Health Plan, through a partnership with the American Academy of Pediatrics,
          facilitated and co-sponsored this program aimed at developing knowledge,
          skills
          and professional performance in the area of immunizations. The program,
          funded
          by an AAP grant, focused on assisting pediatricians and family practitioners
          to
          identify opportunities to improve immunization and EPSDT levels. Harmony
          hosted
          this interactive program, free of charge for participants, and encouraged
          Harmony providers to attend. 

        

        Back
          to School Immunizations and Physicals

        Harmony
          Health Plan has partnered with Chicago Public Schools, local aldermen and
          state
          legislators to improve the accessibility of back-to-school immunizations and
          physicals in the communities we serve. By providing doctors and nurses
          to
          administer free physicals and immunizations at numerous community events,
          over
          2,000 school children have received these important services.

        

        Christian
          Activity Center (CAC)

        Harmony
          continues to partner with the Christian Activity Center to promote healthy
          lifestyles and self esteem among the youth residing in the Gomphers homes
          of
          East St. Louis.

        

        The
          Christian Activity Center provides a secure, supportive environment for
          children
          and youth of East St. Louis communities. Harmony participates in the “Sponsor a
          Child Society” which supports the costs of one child’s care for one year and
          other on-going programs and community outreach/education activities. Through
          these partnerships, the youth in this community receive invaluable support
          in
          education, sports, home/life studies, self esteem, and vocational training.
          The
          CAC positively impacts the lives of the most neglected youth in our community.
          Through their mission, they promote healthy lifestyles and impact healthcare
          awareness and decision making for the next generation.

        

        Harmony
          Health Plan also partners with many reputable organizations through the
          presentation of wellness seminars, designed to raise the health consciousness
          of
          individuals and families who live and work in various
          communities.

         

        	11)  	
                Reduction
                  of racial and ethnic health care disparities to improve health
                  status

              

        

        The
          National Healthcare disparities report (NHDR) developed for the U.S. Department
          of Health and Human Services, July 2003, notes that “many racial and ethnic
          minorities and persons of lower socioeconomic position are less likely
          to
          receive screening and treatment for cardiac risk factors.” The combination of
          lower screening rates, for risk factors such as cholesterol, and effective
          treatment options, if risk factors are identified early, lend themselves
          to
          quality improvement opportunities that can potentially reduce heart disease
          disparities among populations at risk. Heart disease risk can be modified
          through early detection of risk factors, life style changes, and medications
          when appropriate.

        

        The
          NHDR reported that Hispanics, American Indians, and Alaskan Natives are
          less
          likely to have their cholesterol checked than other racial and ethnic groups
          in
          the United States. The National Center for health Statistics, national
          health
          Interview survey, 1998, indicated while 68% of non-Hispanic whites had
          their
          blood cholesterol checked within the preceding 5 years, and 67% of non-Hispanic
          African-Americans, the screening percentage was only 59% for Hispanics.
          The
          National Health and Nutrition Examination Surveys (1999-2000) and the National
          Health Interview Survey (1997 and 2001) indicated that while cholesterol
          screening, awareness of dyslipidemias, and overall treatment rates were
          higher
          in white non-Hispanics versus Hispanics, once in a treatment program, a
          greater
          percentage of Hispanic patients attained their LDL treatment goal than
          non-Hispanic whites, 79% versus 55%. 

        

        While
          disparities in health care for minority populations can be linked to levels
          of
          income and education, limited English proficiency (LEP) and cultural differences
          are important sources of barriers. The 2000 census found that close to
          half of
          people age 5 and over who speak a foreign language have difficulty communicating
          in English. The NHDR indicates that “these variables are reflected in the
          markedly higher proportions of Asian and Hispanic respondents who showed
          difficulty communicating at their last health visit.” 

        

        The
          State of Florida Medicaid program, mirroring the general Florida population,
          has
          a significant percentage of Hispanic members. This is also reflected in
          the
          WellCare Florida Medicaid membership. WellCare therefore developed a standard
          method for identification of Spanish speaking members and measured their
          rate of
          cholesterol screening vs. the non-Spanish speaking population and developed
          interventions to modify identified disparities related to barriers such
          as
          limited English proficiency. Baseline data showed that only 50% of members
          aged
          35 and older (males) and 45 and older (females) were receiving preventive
          cholesterol testing. The measurement identified that there was a lack of
          education of providers and members of the need for cholesterol testing
          at the
          appropriate ages, lack of Spanish material available for members and a
          need to
          better identify members whose primary language is not English. Interventions
          were implemented targeted at Spanish speaking members who had not had a
          cholesterol screening test in the past 5 years. Members were mailed a letter
          in
          Spanish educating them about the need for cholesterol testing and were
          also
          called to educate them about the need for cholesterol screening. In addition,
          members receive periodicity letters on their birthdays with age-appropriate
          preventive health screening tests that are due. Re-measurement, analysis
          and
          evaluation occurs on a quarterly basis with additional interventions recommended
          as appropriate. 

        

        WellCare
          translates all member materials into Spanish and other languages as needed.
          In
          addition, WellCare has a Spanish queue line for members and also utilizes
          the
          services of the AT&T language line to ensure that we are providing
          culturally appropriate education and communication with our
          members.

        

        	12)  	
                Complaints,
                  Grievances, and Appeals

              

        

        In
          2003 WellCare instituted a performance improvement project to improve
          efficiencies in the Appeals and Grievance department. The goal of the project
          was to mitigate the driving factors to allow for large increases in membership
          without realizing large increases in submissions.

        

        The
          drivers and the barriers that were affecting the numbers
          were:

        	·  	
                Providers
                  were not obtaining prior authorization for services that required
                  authorization. 

              

        	·  	
                The
                  provider manual had not been updated with authorization requirements
                  timely and in-services had not been provided to
                  hospitals.

              

        	·  	
                Member
                  Services had misinformed providers on what services required
                  authorization. Member Services had not been kept up-to-date on
                  Health
                  Services authorization
                  requirements.

              

        	·  	
                There
                  was a lack of formalized feedback to the department heads of the
                  Company
                  on what was causing complaints, grievances, and
                  appeals.

              

        

        Once
          these were identified, the following interventions were put into
          place:

        	·  	
                Provided
                  current monthly trended report, for 2002 and 2003, to departments
                  that do
                  denials on any errors, misinformation, or miscommunication caused
                  by their
                  department.

              

        	·  	
                Provided
                  complaint, appeal, and grievance data to providers on cases that
                  involve
                  them for use by the NIP team.

              

        	·  	
                Developed
                  and implemented the new Customer Service Quality Improvement Workgroup
                  that met monthly to resolve complaint, grievance, and appeal issues
                  and to
                  identify process improvements within the
                  Company.

              

        	·  	
                Reduced
                  the amount of appeals submitted for no prior authorization
                  denials.

              

        	·  	
                In-services
                  were provided to hospital admission staff at hospitals that were
                  identified as frequent appellants for not getting
                  authorization.

              

        	·  	
                The
                  provider manual was updated with authorization
                  requirements.

              

        

        Through
          these interventions, the following results were realized:

        

        
          	
                  Case
                    Type

                	
                  2002
                    Average/Month

                	
                  2003
                    Average/Month

                
	
                  Grievance

                	
                  28

                	
                  29

                
	
                  Provider
                    appeal

                	
                  623

                	
                  816

                
	
                  Member
                    appeal

                	
                  66

                	
                  52

                
	
                  No
                    prior authorization

                	
                  693

                	
                  692

                

        

        

        Analysis:

        The
          interventions put into place resulted in a 1 case/month increase in grievances,
          193 cases/month increase in Provider appeals, 14 cases/month decrease in
          Member
          appeals, and 1 case/month decrease in no prior authorization appeals.
          Statistically, there was a decrease in all case types when compared to
          membership, which was at approximately 375,000 members at the end of 2002
          and
          ended at approximately 475,000 members by year end 2003 or an approximate
          25%
          increase.

        

        Improvements:

        	·  	
                Grievances
                  increased by 1 case/mo with an overall membership increase of
                  25%

              

        	·  	
                Provider
                  appeals increased from 623 to 816 cases/mo with an overall membership
                  increase of 25%. Of note is that the monthly number had decreased
                  to 642
                  by December 2003. The higher average was caused by higher monthly
                  averages
                  in the 3rd quarter.

              

        	·  	
                Member
                  appeals decreased from 66 to 52
                  cases/mo.

              

        	·  	
                No
                  prior authorization appeals decreased from 693 to 692/month with
                  an
                  overall 25% increase in membership. Of note is that the monthly
                  number had
                  decreased to 557 by year-end after a decreasing trend realized
                  during the
                  last 6 months of the year.

              

        

        	13)  	
                Denials

              

        

        WellCare
          Health Plans, Inc, including Harmony Health Plans, has experience with
          state
          mandated requirements for Service Authorization Decisions and Adverse
          Determinations (denials) in seven (7) states. WellCare has a well structured
          Utilization Management program that facilitates utilization decisions affecting
          the member’s health care services in a fair, impartial and consistent manner.

        

        All
          states require compliance with their state Medicaid contract regarding
          service
          authorization decisions and adverse determinations and most require compliance
          with the Code of Federal Regulations Title 42 Part 438.210. WellCare has
          had no
          deficiencies noted in their 2005 State of Florida audit or their January
          2006
          New York State and City audit. Our over all denial rate for Florida has
          been
          less then 2%, which is an appropriate benchmark range for the Florida
          market.

        

        To
          assure that utilization management decisions rendered are fair and consistent,
          it is essential that medical review criteria is objective and based on
          sound
          medical evidence, and that appropriate health care professionals are involved
          in
          the development, adoption and updating of the utilization medical review
          criteria. 

        

        WellCare
          utilizes the following evidence based criteria:

        	·  	
                InterQual
                  criteria

              

        	·  	
                Hayes
                  Medical Technology

              

        	·  	
                State
                  Medicaid Provider Handbooks

              

        	·  	
                State
                  and Federal, Laws, Statutes, and
                  Regulations

              

        	·  	
                Medicaid
                  fee-for-service criteria

              

        

        WellCare
          also takes individual circumstances and the local delivery system into
          account
          when making a medical appropriate decision on health care services.

        

        The
          medical review criteria stated above is updated and approved at least annually
          by the Medical Director, Medical Advisory Committee and Quality Improvement
          Committee where practitioners with professional knowledge or clinical expertise
          in the area being reviewed have an opportunity to give advice or comment
          on
          development or adoption of Utilization Management criteria and on instructions
          for applying the criteria. 

        

        Wellcare
          refers all provider initiated requests for health care services to the
          Health
          Services Department for processing. 

        	·  	
                Referral
                  Coordinators (non clinical staff) will process requests that do
                  not
                  require application of review criteria.
                  

              

        	·  	
                Review
                  Nurses (clinical staff) will process all requests requiring the
                  application of review criteria, non-participating provider requests
                  and
                  retrospective requests.

              

        

        Any
          decision to deny a service authorization request or to authorize a service
          in an
          amount, duration, or scope that is less than requested will be made by
          a health
          care professional (Medical Director or designee) who has experience or
          expertise
          comparable to the provider requesting the authorization. Compensation to
          individuals or entities that conduct utilization management activities
          is not
          structured so as to provide incentives for the individual or entity to
          deny,
          limit, or discontinue medically necessary services to any member.

        

        WellCare
          utilizes each state specific definition of medical necessity to determine
          medical necessity denials.

        

        WellCare
          adheres to the State specific timeframes in making service authorization
          decisions and adverse determinations. Florida timeframes, as example
          are:

        	·  	
                Standard
                  authorization decisions are made as expeditiously as the members
                  health
                  condition requires but within fourteen 1(4 ) calendar
                  days

              

        	·  	
                Expedited
                  authorization decisions are made as expeditiously as the members
                  health
                  condition requires but no later then 3 working days from receipt
                  of
                  request

              

        	·  	
                The
                  standard and expedited decision timeframes may be extended by up
                  to
                  fourteen (14) calendar days if the member or provider requests
                  the
                  extension or if WellCare justifies a need for additional information
                  and
                  how the extension is in the member’s
                  interest.

              

        

        Wellcare
          must notify the requesting provider and member of any decision to deny
          a service
          authorization request or to authorize a service in an amount, duration,
          or scope
          that is less than requested. In the event of an adverse determination (denial),
          the Health Service Associate notifies the member in writing and also provides
          written or oral notice to the provider. The notice will meet the requirements
          of
          the State specific Medicaid contract.

        

        The
          denial notice must explain: 

        a. The
          action the Company has taken or intends to take

        b. The
          reasons for the action

        c. The
          member’s or the provider’s right to file an appeal. 

        d. The
          member’s right to request a State fair hearing

        e. Procedures
          for exercising member rights to appeal or request a State fair
          hearing

        f.
That
          the member may represent himself or use legal counsel, a friend, a relative,
          or
          other spokes person.

        g. Must
          explain the specific regulations that support or the change in Federal
          or State
          l law
          that requires the action.

        h.
The
          member’s right to request a state agency hearing, or in cases of an action based
          on change in law, the circumstances under which a hearing will be
          granted.

        i. The
          circumstances under which expedited resolution is
          available.

        j. The
          member’s right to have benefits continued 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.

        

        The
          written notification to the providers also includes the Utilization Management
          Department’s contact information to allow providers the opportunity to discuss
          the adverse determination decision.

        

        There
          are times when service requests will be denied either administratively
          or due to
          medical necessity. The Utilization Management Program structure ensures
          fair and
          consistent application of criteria and allows members and providers the
          ability
          to exercise their appeal rights. To ensure this process continues to comply
          with
          State specific Medicaid contracts, the process is reviewed and updated
          annually
          or upon State contract renewal. Consistency of application of criteria
          for
          Health Services Associates is reviewed at least quarterly following C7UM
          05 MD
          1.5 Interrator Reliability policy and procedure and the Medical Directors
          are
          reviewed annually. In 2005 the overall interrator reliability compliance
          was 95%
          for the Health Services Associates and 98& for the Medical
          Directors.

        

        	14)  	
                Access

              

        

        Monitoring
          and measuring network access is an essential component in ensuring member
          and
          provider satisfaction. Provider Relations (PR) representatives provide
          an
          in-service to providers upon contracting with the Plan and as needed thereafter.
          During the in-service, they review the importance of access and availability
          to
          Plan members:

        	·  	
                Primary
                  Care Physicians (PCPs) should be available to
                  members:

              

        	·  	
                24
                  hours a day and 7 days a week;

              

        	·  	
                within
                  60 minutes of the appointment
                  time;

              

        	·  	
                after
                  hours with the option to speak to a clinical person for triage
                  with option
                  to page the physician.

              

        	·  	
                Panels
                  should typically have no less than 50 members and should remain
                  open until
                  they have a full panel (established at the time of
                  contracting).

              

        WellCare
          monitors network adequacy in several ways. Complaints received by our internal
          departments (i.e. Customer Service, Appeals & Grievance, etc.) related to
          access and availability of providers are documented in Peradigm, the main
          provider/member data system. Complaints in need of follow up and feedback
          are
          submitted to Provider Relations for outreach to the respective provider.
          The
          representative either contacts the provider office by telephone, or visits
          the
          office in person depending on the complaint and need. Trends are monitored
          by
          top complaints as well as providers receiving a complaint 3 or more times
          in a 6
          month period. When a trend is identified, Provider Relations shares the
          information with the provider office and discusses specific actions the
          provider
          can accomplish to meet compliance. If the provider is not receptive or
          willing
          to resolve the complaint, provider termination may be
          considered.

        

        Phone
          audits are also used to measure compliance and results of network access.
          WellCare surveys a sampling of the PCP network annually during regular
          hours as
          well as after hours to monitor compliance. The sample group is randomly
          selected. Once the group is surveyed, they are excluded from the list,
          and the
          list is rotated each year to assure that all providers are surveyed over
          time.
          The 2005 survey results reflected marked improvements between the first
          round of
          survey calls and the second. Connecticut specifically improved 98.7% on
          After-Hours Access surveys and 95.5% on Appointment Availability surveys.
          Results of the survey are sent out to the Provider Relations team in the
          respective market for review and education of associates, corrective action
          letters are then mailed to providers for notification and response. Offices
          that
          are under corrective action are resurveyed 30 days after the notice is
          received.
          Should the office still remain non-compliant, a second notification is
          sent out
          by the Regional Medical Director for follow up and response. If the provider
          is
          not receptive or willing to become compliant, provider termination may
          be
          considered.

        

        GEO
          Access reports are developed to monitor network adequacy and accessibility
          of
          experienced providers to serve Plan members, including those with special
          health
          care needs. PCPs, Specialists (top ten by claim volume), Ancillaries (top
          five
          by claim volume) and hospitals are all monitored. Deficiencies are documented
          and reported to internal departments (external as necessary) and specific
          actions are coordinated by PR. PR partners with Case Management to identify
          providers for members with special health care needs and ensure providers
          have
          the tools to communicate effectively with Case Management when members
          are
          identified. 

        

        Results
          and analysis of complaints received by our internal departments, phone
          audits
          and GEO Access reports are presented to the Medical Advisory Committee
          (MAC) and
          reported up through the Quality Improvement Committee (QIC). Trends are
          monitored by our Compliance department within Operations and shared with
          Provider Relations and other key internal departments. 

         

        	b.  	
                The
                  offeror should provide a description of focus studies performed,
                  quality
                  improvement projects, and any improvements the offeror has implemented
                  and
                  their outcomes. Such outcomes should include cost savings realized,
                  process efficiencies, and improvements to member health status.
                  Such
                  descriptions should address such activities since 1998. The offeror
                  should
                  address how issues and root causes were identified, and what was
                  changed.

              

        

        As
          part of the ongoing Quality Improvement Program, WellCare conducts performance
          improvement projects in both clinical and administrative areas. As WellCare
          exclusively enrolls Medicaid, Medicare, and SCHIP beneficiaries, our current
          population is similar to the Missouri Medicaid population. During 2004,
          WellCare
          conducted projects aimed at improving asthma medication management, improving
          compliance with anti-depressant medication management, and improving timeliness
          of prenatal care and postpartum care. Below we detail the asthma medication
          management project as an example of WellCare’s data-driven performance
          improvement activities. 

        

        Asthma
          is the most common chronic disease in children and the sixth most common
          chronic
          condition overall in the U.S. The prevalence of asthma in our Florida Medicaid
          plan (Staywell) population is 2.98%. Asthma was the seventh costliest health
          service, excluding pregnancy and neonatal, for all lines of business in
          2002. In
          2001 asthma was the fourth most common diagnosis necessitating an office
          visit,
          the tenth most common admitting diagnosis for inpatient, and the tenth
          most
          common diagnosis for emergency room utilization. In 2002 asthma was the
          sixth
          most common admitting diagnosis, excluding pregnancy, for all lines of
          business.

        

        WellCare
          measures compliance with asthma medication management monthly, quarterly
          and
          annually according to the NCQA HEDIS specifications, with analysis and
          reporting
          to our QI Interventions Workgroup, Medical Advisory Committee and Quality
          Improvement Committee. The quantifiable measures in our improvement program
          continue to be for the following cohorts: members age 5-9, 10-17, 18-56
          and the
          complete group of members age 5-56 years, all of whom were continuously
          enrolled
          during the measurement year and the year prior to the measurement year,
          and who
          had a diagnosis of persistent asthma and who had at least one dispensed
          prescription for inhaled corticosteroids, nedocromil, cromolyn sodium,
          leukotriene modifiers or methylxanthines in the measurement
          year.

        

        The
          analysis of 2003 data showed that the baseline measures for asthma medication
          management continue to demonstrate need for improvement in asthma medication
          management in the persistent asthma population. The results of the study
          were
          presented to the Quality Improvement Interventions workgroup to discuss
          barriers
          and root cause analysis, and to the Medical Advisory Committee and Quality
          Improvement Committee. The interventions taken to improve asthma medication
          management include obtaining community physician input into interventions,
          analyzing additional data to identify barriers to medical compliance with
          asthma
          control medications, revising the clinical practice guidelines for asthma
          and
          distributing these to providers, provide Continuing Medical Education seminars
          on Management of Asthma for providers, sending physicians fax alerts about
          ER
          visits, inpatient stays, and pharmacy usage for asthmatic patients, and
          expanding the disease management program to provide outreach to all members
          regarding asthma medication management through letter and/or telephonic
          outreach. Upon re-measurement of these data WellCare found that rates of
          compliance for asthma medication management from 2003 to 2004 have risen
          by 7.3%
          and have achieved the National 90th percentile NCQA Quality Compass benchmark.
          

        

        Although
          improvement opportunities continue to exist WellCare believes their
          comprehensive approach of asthma management through the disease management
          programs has attributed to the improved rates of compliance. As described
          in the
          above section, WellCare will provide Asthma disease management to members
          with
          asthma in the Missouri population. 

        

        WellCare
          conducts numerous focused studies. A recent study was conducted for Improving
          the Rate of Mammography Screening. WellCare identified Mammography rates
          that
          were below the state average and below the benchmark of our competitors.
          Utilizing our CRMS software and identifying the members who were non-compliant
          for their mammography, WellCare conducted outreach to the members via a
          mailing
          which included a mammography voucher and an incentive to receive their
          mammography testing. Any member who received a mammogram received an
          Over-the-Counter voucher for $10 to purchase OTC products. In addition,
          outreach
          was conducted to providers of these members. Any provider whose member
          had a
          Mammography performed who could send us the medical record documentation
          was
          paid $20/record and or claim that was obtained for that member. The results
          were
          that Mammography screening rates for the Medicaid population increased
          from 44%
          to 53%. 

        

        We
          expect to implement similar programs for our Missouri members. Performance
          measures to evaluate the effectiveness of the actions within new studies
          will be
          comparing the level of compliance with the HEDIS guidelines and a measurement
          following a repeat study after education of the practitioner and member
          has
          occurred. 

        

        A
          quality improvement activity was initiated in 2003 to improve Customer
          Service
          call quality. A standardized audit tool is used to evaluate each Customer
          Service representatives’ calls twice per week. For the project, we evaluated the
          number of quality audit points earned by the Customer Service representatives
          on
          all Call Quality Audits against the total number of quality audit points
          available.

        

        For
          the baseline measurement, the Customer Service representatives achieved
          an
          overall score of 76%. This was below WellCare’s goal for call quality audits.
          The Quality Auditors identified that the Customer Service Representatives
          perceived that speed of answer was more important than quality. In response
          to
          this perception, the Customer Service area developed a standardized Call
          Monitoring Form. The form is used by Supervisors and Process Auditors when
          monitoring calls for each Customer Service representative at least twice
          weekly.
          They evaluated the greeting, verification of caller demographics, the
          representative’s listening skills and attitude, the representatives ability to
          address the caller’s issues and concerns, the quality of the representative’s
          work, escalation of issues requiring supervisory intervention as well as
          the
          representative’s flow, accent, and tone. This monitoring and evaluation process
          served as a tangible reminder for representatives that speed is not the
          sole
          criterion for success.

        

        During
          the first measurement period, the overall quality score for Customer Service
          representatives increased 13 percentage points, from 76% to 89%. The Customer
          Service area identified that many of the quality issues were attributed
          to other
          departments outside of Customer Service. To address this barrier and facilitate
          interdepartmental communication, the Customer Service department implemented
          the
          Customer Service Quality Improvement Workgroup (CSQIW). The CSQIW, which
          is led
          by the Director of Customer Service, is responsible for identifying quality
          issues and implementing corrective action. The CSQIW is comprised of
          representatives from Appeals and Grievance, Quality Improvement, Provider
          Relations and Operations. In addition to communication barriers, the Customer
          Service Department also identified that the overall call quality scores
          were
          also attributed to the lack of robust and comprehensive Customer Service
          training for new and existing representatives. In response, WellCare developed
          and implemented an improved version of new hire training for Customer Service
          representatives.

        

        During
          the second measurement period, the overall quality score for Customer Service
          representatives improved by one percentage point from the previous measurement
          period, and increased 14 percentage points (76% to 90%) over the baseline
          measurement of 76%. The Customer Service Process Auditors found that
          interventions from the audit team were less effective than interventions
          from
          direct supervisors. In response to this finding, the Customer Service
          Supervisors began providing direct coaching and feedback sessions with
          employees. In addition, the Audit/Customer Service Leadership team identified
          a
          lack of uniformity and consistency in auditing Customer Service calls.
          To
          correct this, the Audit/Customer Service Leadership teams began meeting
          on a
          regular basis to look at quality improvement and to enhance uniformity
          in
          auditing the call quality. The Audit/Customer Service Leadership teams
          now meet
          on a regular basis. 

        

        The
          auditing, coaching, and instruction have resulted in significant improvement
          in
          the service quality, and will remain an ongoing part of managing the Customer
          Service Call Center. In addition, we expanded our Customer Service training
          program to include handling of appeals and grievances, HIPAA, and enrollment
          card history. 

        

        During
          the third measurement period, the overall quality score for Customer Service
          representatives improved five percentage points from the previous measurement
          period, 90% to 95%, and improved 19 percentage points (76% to 95%) when
          compared
          to the baseline measurement. In the 4th quarter of 2003, part-time Customer
          Service representatives were hired to cover peak times, defined as, Mondays
          and
          Tuesdays. The addition of the part-time staff coupled with the other
          quality-related improvements that were implemented over the past year has
          resulted in an overall compliance score of 95%.

        

        	4.7.2  	
                Proposed
                  Method of Performance - 

              

        

        	a.  	
                The
                  offeror’s proposed Quality Improvement Programs shall be subjectively
                  evaluated. Therefore, the offeror should address the Quality Improvement
                  Programs proposed to be implemented during the term of the contract.
                  The
                  offeror should address how the proposed Quality Improvement Programs
                  will
                  expand the quality improvement services beyond what the offeror
                  is
                  currently providing (as addressed in response to item 4.7.1 a.
                  and b.) and
                  the difference between the offeror’s current programs and the proposed
                  programs. The offeror should also indicate how the proposed Quality
                  Improvement Program will improve the health care status of the
                  Missouri
                  Medicaid population. The offeror should address the rationale for
                  selecting the particular programs including the identification
                  of
                  particular health care problems and issues within the Missouri
                  Medicaid
                  population that each program will address and the underlying cause(s)
                  of
                  such problems and issues. The proposed Quality Improvement programs
                  may
                  include, but is not necessarily, limited to the
                  following:

              

        

        	1)  	
                New
                  innovative programs and processes.

              

        	2)  	
                New
                  contracts and/or partnerships being established to enhance the
                  delivery of
                  health care such as contracts/partnerships with school
                  districts.

              

        	3)  	
                The
                  continuation, expansion, and/or increase of the current quality
                  improvement programs as listed in response to 4.7.1 a. and
                  b.

              

        

        WellCare
          Health Plans is dedicated to enhancing our members’ health and quality of life;
          partnering with providers and government clients to deliver quality,
          cost-effective health care solutions; and creating a rewarding and enriching
          environment for our associates. We believe in providing optimum health
          care
          services to our valued members, which will allow a balanced relationship
          between
          the members, health care providers, and the health plan. Our objective
          is to
          furnish an effective preventive health care program to members, while
          maintaining the highest levels of quality care. 

        

        The
          purpose of the Quality Improvement Program (QIP) is to establish a systematic
          process of quality improvement that will ensure a comprehensive, integrated
          plan-wide system to assess and improve the quality of clinical care and
          services
          provided to WellCare members in all lines of business. The Quality Improvement
          Program description, with details of our quality assessment and performance
          improvement approach, is attached in Appendix Binder, Tab
          #6.

        

        WellCare’s
          ongoing quality assessment and performance improvement approach provides
          for the
          monitoring, analysis, evaluation, and improvement of the delivery, quality,
          and
          appropriateness of health care furnished to all members in compliance with
          good
          clinical practice and federal Medicaid regulations. The program is governed
          by
          the written QIP description and related policies and procedures. The QIP
          addresses the key areas of access, availability, utilization, quality of
          care,
          clinical competence, credentialing, appeals and grievances, member satisfaction,
          provider satisfaction, and administrative services. The QIP spans all product
          lines, demographic groups, care settings, and types of services. To ensure
          that
          the QIP capitalizes on the most recent research and data, the Quality
          Improvement Program Description and Workplan, which determine the annual
          program
          structure and activities, are formally evaluated and updated each year.
          

        

        Oversight
          and involvement in the QIP occurs at all levels. At the corporate level
          this
          occurs through the work of the Board of Directors and the Chief Executive
          and
          Medical Officers. At the operational level, the Director of Corporate Quality
          Improvement is accountable for the operation of all quality assessment
          and
          improvement services, functions, and procedures. 

        

        The
          WellCare Missouri Medical Director is the plan-level executive who is delegated
          the authority to develop, implement and evaluate the quality improvement
          program's monitoring activities and improvement actions. The Medical Director
          has overall accountability for the integration, coordination and execution
          of
          the QIP activities. 

        

        The
          WellCare Missouri Director of Quality Improvement will integrate and coordinate
          the overall quality improvement operations of the health plan, with the
          support
          and guidance of the Medical Director, Director of Corporate Quality Improvement,
          Medical Advisory Committee, Quality Improvement Committee, Chief Executive
          Officer and Board of Directors. The WellCare Missouri Director of Quality
          Improvement will manage the ongoing quality improvement activities specific
          to
          the program and ensure that WellCare meets program
          requirements.

        

        In
          addition, Registered Nurses within the Quality Improvement Department work
          with
          personnel in each clinical and administrative department to identify problems
          related to the quality of care for all covered professional services; prioritize
          problem areas for resolution and design strategies for change; implement
          improvement activities; and measure the success of those
          interventions.

        

        The
          primary committee responsible for promoting WellCare’s quality assurance and
          performance improvement goals and objectives is the Quality Improvement
          Committee (QIC). All senior executives are members of this committee, which
          meets monthly. In addition to the QIC, WellCare manages and monitors quality
          improvement activities through a variety of committees and workgroups.
          Standing
          committees include: Medical Advisory; Credentialing; Delegation Oversight;
          Level
          I and Level II Appeals and Grievance; and Pharmacy and Therapeutics.
          Additionally, the following work groups provide important QIP monitoring
          functions: Quality Improvement Interventions; Customer Service Quality
          Improvement; and Utilization Management Review. These committees and workgroups
          will be Missouri-specific and operate on a statewide basis. Details on
          the
          membership, responsibilities, meeting frequency, and reporting relationships
          for
          each committee are provided in WellCare’s Quality Improvement Program
          Description. 

        

        As
          one of the country’s largest Medicaid, Medicare, and SCHIP managed care plans,
          WellCare works closely with public sector purchasers to monitor the quality
          of
          care provided to program beneficiaries. We understand that the State of
          Missouri, Department of Social Services, Division of Medical Services is
          delegating much of the responsibility for the quality of care provided
          to MC+
          enrollees to the contracted are management organizations. Therefore, as
          a
          Managed Care contractor to the State, WellCare will not only conduct its
          internal processes for quality assessment and performance improvement,
          but
          document these processes and their outcomes to DSS for oversight of the
          plan and
          reporting to the State’s other stakeholders. 

        

        WellCare
          uses a software system called CareEnhance Resource Management Software
          (CRMS),
          produced by McKesson. All data is entered into the CRMS system electronically.
          This software is NCQA-certified for HEDIS data reporting and used to generate
          HEDIS reports on a monthly, quarterly and annual basis.

        

        The
          CareEnhance Resource Management Software (CRMS) allows WellCare to generate
          HEDIS reports on a monthly, quarterly and annual basis, providing robust
          data
          for ongoing quality improvement at the provider and plan level much more
          frequently than comparable systems which generally only allow annual HEDIS
          reporting.

        

        PCPs
          will be profiled, as well as certain high-volume specialists such as OB/GYNs.
          The performance measures included in the profile reports will include HEDIS
          measures relevant to primary care such as child health check-ups, adolescent
          immunization rates, asthma medication management, diabetes management,
          chlamydia
          screening, and cervical cancer screening. OB/GYN reports will include analysis
          of prenatal and postnatal care. Reports will be produced quarterly and
          show
          utilization rates on a per 1,000 member basis, with comparisons to the
          PCP’s
          membership roster and the overall plan membership. In addition to sharing
          this
          quarterly report with providers, PCPs will be provided with monthly reports
          indicating which patients are not in compliance with preventive care scheduling
          guidelines. 

        

        On
          an annual basis as part of routine quality improvement planning, WellCare
          will
          analyze the population characteristics and utilization of the MC+ membership
          to
          determine whether additional measures should be added to the list of profile
          measures, or whether it is appropriate to distribute provider profile reports
          to
          additional provider types. 

        

        If
          a provider appears to consistently fall below plan standards for performance,
          our approach for improvement will involve education and then corrective
          action
          second. Provider Relations may perform a one-to-one education of
          physicians/providers based upon issues they identify with a specific provider.
          If a provider is identified as having a significant quality deficiency,
          provider
          services representatives or other plan staff will work with the provider
          to
          develop a Corrective Action Plan (CAP), which the provider must sign.
          Improvement per the CAP will be monitored and the plan will provide assistance
          to providers to help improve any deficient areas before the scheduled re-audit.
          

        

        Providers
          are actively involved in ongoing quality improvement activities and participate
          on QIP committees that oversee provider and plan performance. Compliance
          with
          the established standards is measured, and the results of this measurement
          are
          profiled. The resulting information is used in the identification of
          opportunities for improvement in the quality of health care and other services,
          and the development of program initiatives. Providers may be educated by
          the
          Medical Director or by provider services representatives, who are able
          to
          provide training on specific ways PCPs can improve performance in areas
          of
          importance to their members. 

        

        WellCare
          is continually working toward improving Quality Improvement efforts to
          ensure
          members are receiving quality care from our providers. One of WellCare’s new
          innovative approaches to improving compliance with the quality of EPSDT
          screenings will be the addition of access to our tracking of screenings
          to the
          Provider Web Site. This approach allows providers real time access to data
          on
          the latest EPSDT visit obtained, immunizations, lead tests, TB testing,
          dental
          screens, vision and hearing testing and referrals. This approach will lead
          to
          not only an improvement in the visits being performed but help to ensure
          the
          visit is appropriate for the member who may be missing important preventive
          health screens, enabling the provider to identify and ameliorate defects
          and
          ensure children receive appropriate referrals and follow-up.

        

        As
          a leading provider dedicated to offering comprehensive government-sponsored
          health plans across the country WellCare Health Plans continues to demonstrate
          our commitment to delivering high-quality, cost effective health care to
          the
          members we serve. As we continually improve our programs, WellCare is committed
          to continuing the Quality Improvement Program as outlined above and is
          dedicated
          to ensuring positive outcomes for the Missouri Medicaid
          members.

        

        Harmony
          Health Plan recognizes the strong influence our physician partners, community
          agencies and local advocacy groups have which positively impact health
          outcomes
          of the unique populations they serve. The important services provided by
          these
          community influencers greatly enhance Harmony’s effectiveness in achieving
          meaningful healthcare outcomes. With this in mind, Harmony has identified
          several partnership opportunities which will be fully drafted, executed
          and
          launched upon contract award and over the ensuing contract
          period.

        

        Cultural
          Competency

        Harmony
          believes that a key component of successful health care delivery is the
          concept
          of a “Medical Home” for each member. The medical home represents a one stop
          repository for each member’s health records, and ensures that the primary care
          provider is truly managing and overseeing all aspects of the member’s health and
          well-being. The medical home model is successful through trust, confidence
          and
          compliance from the member which is engendered by the Plan and primary
          care
          provider through an environment of respect and awareness of cultural
          sensitivities.

        

        A
          key component to Harmony’s network development plan for Missouri is the
          promotion of cultural competency in the provider network. St. Louis city
          and the
          outlying nine counties consist of extremely diverse populations (i.e. urban
          vs
          rural; racial; rapidly growing Hispanic population) each representing a
          unique
          set of sensitivities potentially resulting in barriers to care. It is one
          of
          Harmony’s priorities to contract with providers that are able to address the
          unique cultural, racial and linguistic needs of the MC+
          population.

        

        As
          an initial effort to gauge the cultural competency of Harmony’s provider
          network, all provider applicants will be asked to provide information concerning
          their cultural competencies. Information requested will include language(s)
          spoken in a clinic setting, ethnic distribution of their current patients,
          and
          availability of health care materials in languages other than
          English.

        

        On
          the basis of this information, priorities for dealing with nontraditional
          treatment methods and cultural differences will be identified and a program
          to
          support providers in enhancing cultural competence will be implemented.
          Harmony
          will develop informational materials for providers outlining various member
          cultural beliefs or otherwise that may influence care. 

        

        The
          goal of this program will be to reduce the barriers to care resulting from
          cultural insensitiveness. We plan to attain this goal through increased
          levels
          of awareness achieved by collaborative education training among the Plan,
          providers and community influencers.

        

        Hispanic
          Initiative

        Harmony
          has identified a growing need to better understand and communicate with
          the
          minority population experiencing the largest growth in the United States
          - the
          Hispanic population. Effective assimilation of Hispanic Medicaid patients
          into
          the MC+ managed care population will require a focused effort to educate
          and
          communicate with members of this population in a way that they view as
          adding
          value to issues and matters of interest to them. As we have come to understand,
          barriers to trust are high with this group due to fear of government reprisal.
          Therefore, establishing their ability to trust Harmony and our provider
          partners
          would be an important key to the success of this
          initiative.

        

        The
          growth of Hispanic populations in the United States has led to increasing
          knowledge of Hispanic buying patterns, including sources of information
          they
          rely upon to make purchase decisions. For example, a recent study measuring
          level of effectiveness of different methods of contact used by the State
          of
          Colorado to reach under-insured and non-insured Hispanics concluded a wide
          range
          of effectiveness for commonly used methods. Harmony and has identified
          a
          provider partner with whom we would employ these successful methods to
          promote
          trust and effective health care decision making within the Missouri
          populations.

        

        Student
          Nursing Initiative

        This
          new Harmony initiative is being developed to improve the understanding
          of
          managed care programs among student nurse practitioners in the St. Louis
          region.
          Harmony’s goal is to bring awareness to nursing students regarding the benefits
          of managed care programs with specific focus on eliminating common
          misconceptions concerning managed care within the medical community and
          identifying the myriad of positive impact/evidence resulting from effectively
          managing patient care (sighting specific examples/case studies involving
          Harmony/WellCare. Areas of focus would include:

         

        	·  	
                Clearly
                  defining managed care

              

        	·  	
                Benefits
                  to members

              

        	·  	
                Benefits
                  to providers

              

        	·  	
                Case
                  studies/Outcomes

              

        	·  	
                Cost
                  effectiveness of patient care
                  management

              

        	·  	
                Government
                  oversight of programs

              

        

        Student
          participants will be provided an opportunity to gain experience with local
          participating providers. The benefits of this element of the program are
          twofold. First, the student will gain invaluable experience working within
          a
          provider office and providing a community service to that provider; and
          secondly, assisting the local provider with additional short term assistance
          by
          a student nurse. 

        

        The
          benefit of this program will be to improve the understanding of the MC+
          managed
          care program, as well as promote a better understanding of Harmony and
          what it
          can offer to the community, providers and its members. 

        

        We
          believe the above programs will improve healthcare outcomes in the Missouri
          MC+
          program. Over the course of the contract, Harmony’s community outreach
          coordinator will be responsible for identifying opportunities for partnerships
          with community agencies/groups, which will be essential in meeting the
          needs of
          the membership and in removing barriers to care. Involving community-based
          services in the total plan of care allows Harmony to address the social
          impairments the member may be experiencing. The services that are sought
          and
          have been provided in the past include but are not limited to advocacy
          and/or
          community-based groups that provide:

        

        	·  	
                Shelter/housing

              

        	·  	
                Financial
                  assistance

              

        	·  	
                School
                  supplies

              

        	·  	
                Peer
                  counseling

              

        	·  	
                Meals
                  on wheels

              

        	·  	
                Protective
                  services

              

        	·  	
                Special
                  Needs Camps (i.e. Asthma Camp)

              

        

        Harmony
          will continue to focus on partnerships that are critical to the Missouri
          MC+
          population such as prenatal care coordinators, local health departments,
          Smoking
          Cessation Programs, Lead Abatement programs and the local Public School
          systems.

        

        	b.  	
                Economic
                  Impact to Missouri:

              

        

        	1)  	
                The
                  offeror should provide a description of the proposed services that
                  will be
                  performed and/or the proposed products that will be provided by
                  Missourians and/or Missouri products.

              

        

        Harmony
          has already contracted with many Missourians to ensure it will have a robust
          network. At the time this is being written, Harmony has singed
          letter-of-intent’s with 400 Missouri-based PCP’s, 21 Missouri hospitals, and 9
          Missouri FQHC’s sites. This will ensure that we are not only making good use of
          the existing Missouri medical infrastructure, but also make certain that
          Missouri’s MC+ members receive high quality inpatient, outpatient, ER,
          ambulatory surgery, maternity, pharmacy, etc., medical
          services.

         

        	2)  	
                The
                  offeror should provide a description of the economic impact returned
                  to
                  the State of Missouri through tax revenue obligations.
                  

              

        

        As
          outlined in our monthly plan, there will be tax revenue obligations as
          a result
          of this increased business. In the first tax revenue stream, it is Harmony's
          initial estimate that Missouri should recognize $1,301,000 in 2007 and
          $2,147,000 in 2008. In the second tax revenue stream, Harmony has estimated
          the
          amount of provider tax it expects to contribute will be $513,000 in 2006,
          $2,353,000 in 2007, and $3,540,000 in 2008. The build up for theses estimates
          is
          exhibited in section 4.4.3 C.

        

        	3)  	
                The
                  offeror should provide a description of the company's economic
                  presence
                  within the State of Missouri, including employee status.
                  

              

        

        Upon
          confirmation of a contract for services, we look forward to expanding our
          presence in Missouri. Our current plan proposes for one (1) new Harmony
          office
          to be located in the city of St. Louis. Assuming rates and MER’s are in line
          with our projections, we anticipate the creation of the following eight
          (8) new
          positions:

        	·  	
                Provider
                  Relations (2)

              

        	·  	
                In
                  House Provider Relations Rep (1)

              

        	·  	
                Contract
                  Coordinator (1) 

              

        	·  	
                Administrative
                  Assistant (1)

              

        	·  	
                Manager,
                  Community Relations (1)

              

        	·  	
                Community
                  Relations (2)

              

        

        We
          fully anticipate creating these jobs in 2006 and look forward to staffing
          them
          with employees who live in Missouri.

         

         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        	5.  	
                PRICING
                  PAGES

              

        

        	5.1  	
                Instructions
                  for Completing Pricing Page: The
                  offeror shall provide firm, fixed prices for providing all required
                  services for all specified counties within a region pursuant to
                  the
                  requirements of this Request for Proposal. The offeror must choose
                  to
                  include Pharmacy services as a MC+ managed care benefit or choose
                  to
                  exclude Pharmacy services from the MC+ managed care benefit package.
                  The
                  offeror shall provide either a firm, fixed Per Member Per Month
                  (PMPM) Net
                  Capitated Rate for each Category of Aid rate subgroup with Pharmacy
                  services included in the MC+ managed care benefit package or a
                  firm, fixed
                  PMPM Net Capitated Rate for each Category of Aid rate subgroup
                  with
                  Pharmacy services excluded from the MC+ managed care benefit package.
                  All
                  costs associated with providing the required services shall be
                  included in
                  the offeror's quoted rates. 

              

        

        If
          the
          offeror is proposing to provide services for the Western region, the offeror
          must complete Pricing Page 5.2.

        

        If
          the
          offeror is proposing to provide services for the Eastern region, the offeror
          must complete Pricing Page 5.3.

        

        If
          the
          offeror is proposing to provide services for the Central region, the offeror
          must complete Pricing Page 5.4. 

        

        	5.1.1  	
                Requirements
                  promulgated by the federal government stipulate that the State
                  of Missouri
                  can only contract for services at rates that are actuarially sound.
                  Column
                  1A on the Pricing Pages lists the State’s Maximum Net Capitation Rate for
                  each Category of Aid rate subgroup with Pharmacy service costs
                  included in
                  the MC+ managed care benefit package. Each rate listed in Column
                  1A is
                  actuarially sound, compliant with federal regulations, and is the
                  maximum
                  amount that the State will allow. Column 2A on the Pricing Pages
                  lists the
                  State's maximum Net Capitation Rate for each Category of Aid rate
                  subgroup
                  with Pharmacy service costs excluded from the MC+ managed care
                  benefit
                  package. Each rate listed in the Column 2A is actuarially sound,
                  compliant
                  with federal regulations, and is the maximum amount that the State
                  will
                  allow. 

              

        

        	5.1.2  	
                To
                  assist the offeror in completion of the Pricing Page, the offeror
                  should
                  use the information provided in Attachment 9. However, the offeror
                  is
                  advised that this information should not be used as the only source
                  of
                  information in making pricing decisions. The offeror is solely
                  responsible
                  for research, preparation, and documentation of the offeror’s proposal
                  including the offeror’s rates as quoted on the Pricing
                  Page.

              

        

        	5.1.3  	
                The
                  offeror must complete either Column 1B or 2B on the Pricing Page
                  by
                  providing a firm, fixed PMPM rate for each Category of Aid rate
                  subgroup.
                  

              

        

        	a.  	
                The
                  offeror’s firm, fixed rates must not
                  include:

              

        

        	1)  	
                Estimates
                  for services which are not the offeror’s
                  responsibility.

              

        	2)  	
                Cost
                  of marketing as an administrative
                  expense.

              

        	3)  	
                Cost
                  for Pharmacy services, if the offeror chooses to exclude Pharmacy
                  services
                  from the MC+ managed care benefit
                  package.

              

        

        	b.  	
                The
                  offeror’s firm, fixed rates shall be net of Third Party Liability
                  recoveries.

              

        

        	c.  	
                The
                  offeror should calculate medical expenses by specific Category
                  of Aid rate
                  subgroup and make adjustments for administrative, profit, and contingency
                  and risk charges to obtain the proposed Firm Fixed Net Capitation
                  rates.

              

        

        	d.  	
                The
                  offeror’s firm, fixed PMPM Net Capitated Rate for each Category of Aid
                  rate subgroup must not exceed the State’s Maximum Net Capitation Rate
                  listed in Column 1A or 2A. The State shall not consider awarding
                  a
                  contract to an offeror with any quoted rate which exceeds the State’s
                  Maximum Net Capitation Rate list in Column 1A or
                  2A.

              

        

        ******The
          Pricing Pages are a separate link in Excel Format that must be downloaded
          separately from the Division of Purchasing and Materials Management’s Internet
          web site at: https://www.moolb.mo.gov.
          There is separate tab in the excel spreadsheet for each region.
          ******

        

        

        

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

            RFP
              B3Z06118   Page
              

            

          

        

        EXHIBIT
          A

        

        MISCELLANEOUS
          INFORMATION

        

        

        Organizations
          for the Blind or Sheltered Workshop

        If
          the
          offeror qualifies as either a nonprofit organization for the blind or a
          sheltered workshop, or if the offeror is proposing to include products
          and/or
          services manufactured, produced, or assembled by such an organization,
          the
          offeror should identify the name of the organization in the space below
          and
          should attach all supporting documentation, as referenced elsewhere
          herein.

        

        
          	
                  Name
                    & Address of Organization for Blind/Sheltered
                    Workshop:

                	
                  WAC
                    Industries_______________________

                
	
                  _8520
                    Mackenzie, St. Louis, MO 63123

                

        

        

        Outside
          United States

        If
          any
          products and/or services offered under this RFP are being manufactured
          or
          performed at sites outside the continental United States, the offeror MUST
          disclose such fact and provide details in the space below or on an attached
          page.

        

        
          	
                  Are
                    products and/or services being manufactured or performed at sites
                    outside
                    the continental United States?

                	
                  Yes

                	
                  ____

                	
                  No

                	
                  __X__

                
	
                  Describe
                    and provide details:

                   

                

        

        

        Employee
          Bidding/Conflict of Interest

        Offerors
          who are employees of the State of Missouri, a member of the General Assembly
          or
          a statewide elected official must comply with Sections 105.450 to 105.458
          RSMo
          regarding conflict of interest. If the offeror and/or any of the owners
          of the
          offeror’s organization are currently an employee of the State of Missouri, a
          member of the General Assembly or a statewide elected official, please
          provide
          the following information.

         

         

        
          	Name of State Employee, General
                  Assembly
                  Member, or Statewide Elected Official:                   	 Non Applicable
	
                  In
                    what office/agency are they amployed?

                	 Non Applicable
	
                  Employment
                    Title:

                	 Non Applicable
	Percentage of ownership interest
                  in offeror's
                  organization:	  _____0
                  ______________%

        

      

       

       

      
        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

            RFP
              B3Z06118   Page
              

            

          

        

      

      
         

         

        
           

        

        
 

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        STATE
          OF MISSOURI

        DIVISION
          OF PURCHASING AND MATERIALS MANAGEMENT

        TERMS
          AND CONDITIONS -- REQUEST FOR PROPOSAL

        

        1.
          TERMINOLOGY/DEFINITIONS

        Whenever
          the following words and expressions appear in a Request for Proposal (RFP)
          document or any amendment thereto, the definition or meaning described
          below
          shall apply.

        

        a. Agency
          and/or State Agency
          means
          the statutory unit of state government in the State of Missouri for which
          the
          equipment, supplies, and/or services are being purchased by the Division
          of Purchasing and Materials Management (DPMM).
          The
          agency is also responsible for payment.

        b. Amendment
          means a
          written, official modification to an RFP or to a contract.

        c. Attachment
          applies
          to all forms which are included with an RFP to incorporate any informational
          data or requirements related to the performance requirements and/or
          specifications.

        d. Proposal
          Opening Date and Time
          and
          similar expressions mean the exact deadline required by the RFP for the
          receipt
          of sealed proposals. 

        e. Offeror
          means
          the person or organization that responds to an RFP by submitting a proposal
          with
          prices to provide the equipment, supplies, and/or services as required
          in the
          RFP document.

        f. Buyer
          means
          the procurement staff member of the DPMM. The Contact
          Person
          as
          referenced herein is usually the Buyer.

        g. Contract
          means a
          legal and binding agreement between two or more competent parties, for
          a
          consideration for the procurement of equipment, supplies, and/or
          services.

        h. Contractor
          means a
          person or organization who is a successful offeror as a result of an RFP
          and who
          enters into a contract.

        i. Exhibit
          applies
          to forms which are included with an RFP for the offeror to complete and
          submit
          with the sealed proposal prior to the specified opening date and
          time.

        j. Request
          for Proposal (RFP)
          means
          the solicitation document issued by the DPMM to potential offerors for
          the
          purchase of equipment, supplies, and/or services as described in the document.
          The definition includes these Terms and Conditions as well as all Pricing
          Pages,
          Exhibits, Attachments, and Amendments thereto.

        k. May
          means
          that a certain feature, component, or action is permissible, but not
          required.

        l. Must
          means
          that a certain feature, component, or action is a mandatory condition.
          

        m. Pricing
          Page(s)
          applies
          to the form(s) on which the offeror must state the price(s) applicable
          for the
          equipment, supplies, and/or services required in the RFP. The pricing pages
          must
          be completed and submitted by the offeror with the sealed proposal prior
          to the
          specified proposal opening date and time.

        n. RSMo
          (Revised Statutes of Missouri)
          refers
          to the body of laws enacted by the Legislature which govern the operations
          of
          all agencies of the State of Missouri. Chapter 34 of the statutes is the
          primary
          chapter governing the operations of DPMM.

        o. Shall
          has the
          same meaning as the word must.

        p. Should
          means
          that a certain feature, component and/or action is desirable but not
          mandatory.

        

        2.
          APPLICABLE LAWS AND REGULATIONS

        

        a. The
          contract shall be construed according to the laws of the State of Missouri.
          The
          contractor shall comply with all local, state, and federal laws and regulations
          related to the performance of the contract to the extent that the same
          may be
          applicable.

        b. To
          the
          extent that a provision of the contract is contrary to the Constitution
          or laws
          of the State of Missouri or of the United States, the provisions shall
          be void
          and unenforceable. However, the balance of the contract shall remain in
          force
          between the parties unless terminated by consent of both the contractor
          and the
          DPMM.

        c. The
          contractor must be registered and maintain good standing with the Secretary
          of
          State of the State of Missouri and other regulatory agencies, as may be
          required
          by law or regulations.

        d. The
          contractor must timely file and pay all Missouri sales, withholding, corporate
          and any other required Missouri tax returns and taxes, including interest
          and
          additions to tax.

        e. The
          exclusive venue for any legal proceeding relating to or arising out of
          the RFP
          or resulting contract shall be in the Circuit Court of Cole County,
          Missouri.

        

        3.
          OPEN COMPETITION/REQUEST FOR PROPOSAL DOCUMENT

        

        a. It
          shall
          be the offeror's responsibility to ask questions, request changes or
          clarification, or otherwise advise the DPMM if any language, specifications
          or
          requirements of an RFP appear to be ambiguous, contradictory, and/or arbitrary,
          or appear to inadvertently restrict or limit the requirements stated in
          the RFP
          to a single source. Any and all communication from offerors regarding
          specifications, requirements, competitive proposal process, etc., must
          be
          directed to the buyer from the DPMM, unless the RFP specifically refers
          the
          offeror to another contact. Such communication should be received at least
          ten
          calendar days prior to the official proposal opening date.

        b. Every
          attempt shall be made to ensure that the offeror receives an adequate and
          prompt
          response. However, in order to maintain a fair and equitable procurement
          process, all offerors will be advised, via the issuance of an amendment
          to the
          RFP, of any relevant or pertinent information related to the procurement.
          Therefore, offerors are advised that unless specified elsewhere in the
          RFP, any
          questions received less than ten calendar days prior to the RFP opening
          date may
          not be answered.

        c. Offerors
          are cautioned that the only official position of the State of Missouri
          is that
          which is issued by the DPMM in the RFP or an amendment thereto. No other
          means
          of communication, whether oral or written, shall be construed as a formal
          or
          official response or statement.

        d. The
          DPMM
          monitors all procurement activities to detect any possibility of deliberate
          restraint of competition, collusion among offerors, price-fixing by offerors,
          or
          any other anticompetitive conduct by offerors which appears to violate
          state and
          federal antitrust laws. Any suspected violation shall be referred to the
          Missouri Attorney General's Office for appropriate action.

        e. The
          RFP
          is available for viewing and downloading on the state's On-Line Bidding/Vendor
          Registration System website. Premium registered offerors are electronically
          notified of the proposal opportunity based on the information maintained
          in the
          State of Missouri's vendor database. If a Premium registered offeror’s e-mail
          address is incorrect, the offeror must update the e-mail address themselves
          on
          the state's On-Line Bidding/Vendor Registration System website.

        f. The
          DPMM
          reserves the right to officially amend or cancel an RFP after issuance.
          Premium
          registered offerors who received e-mail notification of the proposal opportunity
          when the RFP was established and Premium registered offerors who have responded
          to the RFP on-line prior to an amendment being issued will receive e-mail
          notification of the amendment(s). Premium registered offerors who received
          e-mail notification of the proposal opportunity when the RFP was established
          and
          Premium registered offerors who have responded to the proposal on-line
          prior to
          a cancellation being issued will receive e-mail notification of a cancellation
          issued prior to the exact closing time and date specified in the RFP.

        

        4.
          PREPARATION OF PROPOSALS

        

        a. Offerors
          must
          examine
          the entire RFP carefully. Failure to do so shall be at offeror's
          risk.

        b. Unless
          otherwise specifically stated in the RFP, all specifications and requirements
          constitute minimum requirements. All proposals must meet or exceed the
          stated
          specifications and requirements.

        c. Unless
          otherwise specifically stated in the RFP, any manufacturer names, trade
          names,
          brand names, information and/or catalog numbers listed in a specification
          and/or
          requirement are for informational purposes only and are not intended to
          limit
          competition. The offeror may offer any brand which meets or exceeds the
          specification for any item, but must state the manufacturer's name and
          model
          number for any such brands in the proposal. In addition, the offeror shall
          explain, in detail, (1) the reasons why the proposed equivalent meets or
          exceeds
          the specifications and/or requirements and (2) why the proposed equivalent
          should not be considered an exception thereto. Proposals which do not comply
          with the requirements and specifications are subject to rejection without
          clarification.

        d. Proposals
          lacking any indication of intent to offer an alternate brand or to take
          an
          exception shall be received and considered in complete compliance with
          the
          specifications and requirements as listed in the RFP.

        e. In
          the
          event that the offeror is an agency of state government or other such political
          subdivision which is prohibited by law or court decision from complying
          with
          certain provisions of an RFP, such a offeror may submit a proposal which
          contains a list of statutory limitations and identification of those prohibitive
          clauses which will be modified via a clarification conference between the
          DPMM
          and the offeror, if such offeror is selected for contract award. The
          clarification conference will be conducted in order to agree to language
          that
          reflects the intent and compliance of such law and/or court order and the
          RFP.
          Any such offeror needs to include in the proposal, a complete list of statutory
          references and citations for each provision of the RFP which is affected
          by this
          paragraph.

        f. All
          equipment and supplies offered in a proposal must be new, of current production,
          and available for marketing by the manufacturer unless the RFP clearly
          specifies
          that used, reconditioned, or remanufactured equipment and supplies may
          be
          offered. 

        g. Prices
          shall include all packing, handling and shipping charges FOB destination,
          freight prepaid and allowed unless otherwise specified in the RFP.

        h. Prices
          offered shall remain valid for 90 days from proposal opening unless otherwise
          indicated. If the proposal is accepted, prices shall be firm for the specified
          contract period.

        i. Any
          foreign offeror not having an Employer Identification Number assigned by
          the
          United States Internal Revenue Service (IRS) must submit a completed IRS
          Form
          W-8 prior to or with the submission of their proposal in order to be considered
          for award.

        

        5.
          SUBMISSION OF PROPOSALS

        

        a. Proposals
          may be submitted by delivery of a hard copy to the DPMM office. Electronic
          submission of proposals by Premium registered offerors through the State
          of
          Missouri’s On-Line Bidding/Vendor Registration System website is not available
          unless stipulated in the RFP. Delivered proposals must be sealed in an
          envelope
          or container, and received in the DPMM office located at 301 West High
          St, Rm
          630 in Jefferson City, MO no later than the exact opening time and date
          specified in the RFP. All proposals must (1) be submitted by a duly authorized
          representative of the offeror's organization, (2) contain all information
          required by the RFP, and (3) be priced as required. Hard copy proposals
          may be
          mailed to the DPMM post office box address. However, it shall be the
          responsibility of the offeror to ensure their proposal is in the DPMM office
          (address listed above) no later than the exact opening time and date specified
          in the RFP.

        b. The
          sealed envelope or container containing a proposal should be clearly marked
          on
          the outside with (1) the official RFP number and (2) the official opening
          date
          and time. Different proposals should not be placed in the same envelope,
          although copies of the same proposal may be placed in the same
          envelope.

        c. A
          proposal submitted electronically by a Premium registered offeror may be
          modified on-line prior to the official opening date and time. A proposal
          which
          has been delivered to the DPMM office, may be modified by signed, written
          notice
          which has been received by the DPMM prior to the official opening date
          and time
          specified. A proposal may also be modified in person by the offeror or
          its
          authorized representative, provided proper identification is presented
          before
          the official opening date and time. Telephone or telegraphic requests to
          modify
          a proposal shall not be honored.

        d. A
          proposal submitted electronically by a Premium registered offeror may be
          canceled on-line prior to the official opening date and time. A proposal
          which
          has been delivered to the DPMM office, may only be withdrawn by a signed,
          written notice or facsimile which has been received by the DPMM prior to
          the
          official opening date and time specified. A proposal may also be withdrawn
          in
          person by the offeror or its authorized representative, provided proper
          identification is presented before the official opening date and time.
          Telephone, e-mail, or telegraphic requests to withdraw a proposal shall
          not be
          honored.

        e. When
          submitting a proposal electronically, the Premium registered offeror indicates
          acceptance of all RFP terms and conditions by clicking on the "Submit"
          button on
          the Electronic Bid Response Entry form. Offerors delivering a hard copy
          proposal
          to DPMM must sign and return the RFP cover page or, if applicable, the
          cover
          page of the last amendment thereto in order to constitute acceptance by
          the
          offeror of all RFP terms and conditions. Failure to do so may result in
          rejection of the proposal unless the offeror's full compliance with those
          documents is indicated elsewhere within the offeror's response.

        

        6.
          PROPOSAL OPENING

        

        a. Proposal
          openings are public on the opening date and at the opening time specified
          on the
          RFP document. Only the names of the respondents shall be read at the proposal
          opening. Premium registered vendors may view the same proposal response
          information on the state's On-Line Bidding/Vendor Registration System website.
          The contents of the responses shall not be disclosed at this time.

        b. Proposals
          which are not received in the DPMM office prior to the official opening
          date and
          time shall be considered late, regardless of the degree of lateness, and
          normally will not be opened. Late proposals may only be opened under
          extraordinary circumstances in accordance with 1 CSR 40-1.050.

        

        7.
          PREFERENCES

        

        a. In
          the
          evaluation of proposals, preferences shall be applied in accordance with
          Chapter
          34 RSMo. Contractors should apply the same preferences in selecting
          subcontractors.

        b. By
          virtue
          of statutory authority, a preference will be given to materials, products,
          supplies, provisions and all other articles produced, manufactured, made
          or
          grown within the State of Missouri and to all firms, corporations or individuals
          doing business as Missouri firms, corporations or individuals. Such preference
          shall be given when quality is equal or better and delivered price is the
          same
          or less.

        c. In
          accordance with Executive Order 05-30, contractors are encouraged to utilize
          certified minority and women-owned businesses in selecting
          subcontractors.

        

        8.
          EVALUATION/AWARD

        

        a. Any
          clerical error, apparent on its face, may be corrected by the buyer before
          contract award. Upon discovering an apparent clerical error, the buyer
          shall
          contact the offeror and request clarification of the intended proposal.
          The
          correction shall be incorporated in the notice of award. Examples of apparent
          clerical errors are: 1) misplacement of a decimal point; and 2) obvious
          mistake
          in designation of unit.

        b. Any
          pricing information submitted by an offeror shall be subject to evaluation
          if
          deemed by the DPMM to be in the best interest of the State of
          Missouri.

        c. The
          offeror is encouraged to propose price discounts for prompt payment or
          propose
          other price discounts that would benefit the State of Missouri. However,
          unless
          otherwise specified in the RFP, pricing shall be evaluated at the maximum
          potential financial liability to the State of Missouri. 

        d. Awards
          shall be made to the offeror whose proposal (1) complies with all mandatory
          specifications and requirements of the RFP and (2) is the lowest and best
          proposal, considering price, responsibility of the offeror, and all other
          evaluation criteria specified in the RFP and any subsequent negotiations
          and (3)
          complies with Sections 34.010 and 34.070 RSMo and Executive Order
          04-09.

        e. In
          the
          event all offerors fail to meet the same mandatory requirement in an RFP,
          DPMM
          reserves the right, at its sole discretion, to waive that requirement for
          all
          offerors and to proceed with the evaluation. In addition, the DPMM reserves
          the
          right to waive any minor irregularity or technicality found in any individual
          proposal.

        f. The
          DPMM
          reserves the right to reject any and all proposals.

        g. When
          evaluating a proposal, the State of Missouri reserves the right to consider
          relevant information and fact, whether gained from a proposal, from a offeror,
          from offeror's references, or from any other source.

        h. Any
          information submitted with the proposal, regardless of the format or placement
          of such information, may be considered in making decisions related to the
          responsiveness and merit of a proposal and the award of a contract.

        i. Negotiations
          may be conducted with those offerors who submit potentially acceptable
          proposals. Proposal revisions may be permitted for the purpose of obtaining
          best
          and final offers. In conducting negotiations, there shall be no disclosure
          of
          any information submitted by competing offerors.

        j. Any
          award
          of a contract shall be made by notification from the DPMM to the successful
          offeror. The DPMM reserves the right to make awards by item, group of items,
          or
          an all or none basis. The grouping of items awarded shall be determined
          by DPMM
          based upon factors such as item similarity, location, administrative efficiency,
          or other considerations in the best interest of the State of
          Missouri.

        k. Pursuant
          to Section 610.021 RSMo, proposals and related documents shall not be available
          for public review until after a contract is executed or all proposals are
          rejected.

        l. The
          DPMM
          posts all proposal results on the On-line Bidding/Vendor Registration System
          website for Premium registered offerors to view for a reasonable period
          after
          proposal award and maintains images of all proposal file material for review.
          Offerors who include an e-mail address with their proposal will be notified
          of
          the award results via e-mail.

        m. The
          DPMM
          reserves the right to request clarification of any portion of the offeror's
          response in order to verify the intent of the offeror. The offeror is cautioned,
          however, that its response may be subject to acceptance or rejection without
          further clarification.

        n. 
Any
          proposal award protest must be received within ten (10) calendar days after
          the
          date of award in accordance with the requirements of 1 CSR 40-1.050
          (10).

        o. The
          final
          determination of contract(s) award shall be made by DPMM.

        

        9.
          CONTRACT/PURCHASE ORDER

        

        a. By
          submitting a proposal, the offeror agrees to furnish any and all equipment,
          supplies and/or services specified in the RFP, at the prices quoted, pursuant
          to
          all requirements and specifications contained therein.

        b. A
          binding
          contract shall consist of: (1) the RFP, amendments thereto, and/or Best
          and
          Final Offer (BAFO) request(s) with RFP changes/additions, (2) the contractor's
          proposal including the contractor's BAFO, and (3) DPMM's acceptance of
          the
          proposal by "notice of award" or by "purchase order."

        c. A
          notice
          of award issued by the State of Missouri does not constitute an authorization
          for shipment of equipment or supplies or a directive to proceed with services.
          Before providing equipment, supplies and/or services for the State of Missouri,
          the contractor must receive a properly authorized purchase order unless
          the
          purchase is equal to or less than $3,000. State purchases equal to or less
          than
          $3,000 may be processed with a purchase order or other form of authorization
          given to the contractor at the discretion of the state agency. 

        d. The
          contract expresses the complete agreement of the parties and performance
          shall
          be governed solely by the specifications and requirements contained therein.
          Any
          change, whether by modification and/or supplementation, must be accomplished
          by
          a formal contract amendment signed and approved by and between the duly
          authorized representative of the contractor and the DPMM or by a modified
          purchase order prior to the effective date of such modification. The contractor
          expressly and explicitly understands and agrees that no other method and/or
          no
          other document, including correspondence, acts, and oral communications
          by or
          from any person, shall be used or construed as an amendment or
          modification.

        

        10.
          INVOICING AND PAYMENT

        

        a. The
          State
          of Missouri does not pay state or federal taxes unless otherwise required
          under
          law or regulation.

        b. The
          statewide financial management system has been designed to capture certain
          receipt and payment information. For each purchase order received, an invoice
          must be submitted that references the purchase order number and must be
          itemized
          in accordance with items listed on the purchase order. Failure to comply
          with
          this requirement may delay processing of invoices for payment.

        c. The
          contractor shall not transfer any interest in the contract, whether by
          assignment or otherwise, without the prior written consent of the
          DPMM.

        d. Payment
          for all equipment, supplies, and/or services required herein shall be made
          in
          arrears unless otherwise indicated in the RFP.

        e. The
          State
          of Missouri assumes no obligation for equipment, supplies, and/or services
          shipped or provided in excess of the quantity ordered. Any unauthorized
          quantity
          is subject to the state's rejection and shall be returned at the contractor's
          expense.

        f. All
          invoices for equipment, supplies, and/or services purchased by the State
          of
          Missouri shall be subject to late payment charges as provided in Section
          34.055
          RSMo.

        g. The
          State
          of Missouri reserves the right to purchase goods and services using the
          state
          purchasing card.

        

        11.
          DELIVERY

        

        Time
          is
          of the essence. Deliveries of equipment, supplies, and/or services must
          be made
          no later than the time stated in the contract or within a reasonable period
          of
          time, if a specific time is not stated.

        

        12.
          INSPECTION AND ACCEPTANCE

        

        a. No
          equipment, supplies, and/or services received by an agency of the state
          pursuant
          to a contract shall be deemed accepted until the agency has had reasonable
          opportunity to inspect said equipment, supplies, and/or services.

        b. All
          equipment, supplies, and/or services which do not comply with the specifications
          and/or requirements or which are otherwise unacceptable or defective may
          be
          rejected. In addition, all equipment, supplies, and/or services which are
          discovered to be defective or which do not conform to any warranty of the
          contractor upon inspection (or at any later time if the defects contained
          were
          not reasonably ascertainable upon the initial inspection) may be
          rejected.

        c. The
          State
          of Missouri reserves the right to return any such rejected shipment at
          the
          contractor's expense for full credit or replacement and to specify a reasonable
          date by which replacements must be received.

        d. The
          State
          of Missouri's right to reject any unacceptable equipment, supplies, and/or
          services shall not exclude any other legal, equitable or contractual remedies
          the state may have.

        

        13.
          WARRANTY

        

        a. The
          contractor expressly warrants that all equipment, supplies, and/or services
          provided shall: (1) conform to each and every specification, drawing, sample
          or
          other description which was furnished to or adopted by the DPMM, (2) be
          fit and
          sufficient for the purpose expressed in the RFP, (3) be merchantable, (4)
          be of
          good materials and workmanship, and (5) be free from defect.

        b. Such
          warranty shall survive delivery and shall not be deemed waived either by
          reason
          of the state's acceptance of or payment for said equipment, supplies, and/or
          services.

        

        14.
          CONFLICT OF INTEREST

        

        a. Officials
          and employees of the state agency, its governing body, or any other public
          officials of the State of Missouri must comply with Sections 105.452 and
          105.454
          RSMo regarding conflict of interest.

        b. The
          contractor hereby covenants that at the time of the submission of the proposal
          the contractor has no other contractual relationships which would create
          any
          actual or perceived conflict of interest. The contractor further agrees
          that
          during the term of the contract neither the contractor nor any of its employees
          shall acquire any other contractual relationships which create such a
          conflict.

        

        15.
          REMEDIES AND RIGHTS

        

        a. No
          provision in the contract shall be construed, expressly or implied, as
          a waiver
          by the State of Missouri of any existing or future right and/or remedy
          available
          by law in the event of any claim by the State of Missouri of the contractor's
          default or breach of contract.

        b. The
          contractor agrees and understands that the contract shall constitute an
          assignment by the contractor to the State of Missouri of all rights, title
          and
          interest in and to all causes of action that the contractor may have under
          the
          antitrust laws of the United States or the State of Missouri for which
          causes of
          action have accrued or will accrue as the result of or in relation to the
          particular equipment, supplies, and/or services purchased or procured by
          the
          contractor in the fulfillment of the contract with the State of
          Missouri.

        

        16.
          CANCELLATION OF CONTRACT

        

        a. In
          the
          event of material breach of the contractual obligations by the contractor,
          the
          DPMM may cancel the contract. At its sole discretion, the DPMM may give
          the
          contractor an opportunity to cure the breach or to explain how the breach
          will
          be cured. The actual cure must be completed within no more than 10 working
          days
          from notification, or at a minimum the contractor must provide DPMM within
          10
          working days from notification a written plan detailing how the contractor
          intends to cure the breach.

        b. If
          the
          contractor fails to cure the breach or if circumstances demand immediate
          action,
          the DPMM will issue a notice of cancellation terminating the contract
          immediately.

        c. If
          the
          DPMM cancels the contract for breach, the DPMM reserves the right to obtain
          the
          equipment, supplies, and/or services to be provided pursuant to the contract
          from other sources and upon such terms and in such manner as the DPMM deems
          appropriate and charge the contractor for any additional costs incurred
          thereby.

        d. The
          contractor understands and agrees that funds required to fund the contract
          must
          be appropriated by the General Assembly of the State of Missouri for each
          fiscal
          year included within the contract period. The contract shall not be binding
          upon
          the state for any period in which funds have not been appropriated, and
          the
          state shall not be liable for any costs associated with termination caused
          by
          lack of appropriations.

        

        17.
          COMMUNICATIONS AND NOTICES

        

        Any
          notice to the contractor shall be deemed sufficient when deposited in the
          United
          States mail postage prepaid, transmitted by facsimile, transmitted by e-mail
          or
          hand-carried and presented to an authorized employee of the
          contractor.

        

        18.
          BANKRUPTCY OR INSOLVENCY

        

        a. Upon
          filing for any bankruptcy or insolvency proceeding by or against the contractor,
          whether voluntary or involuntary, or upon the appointment of a receiver,
          trustee, or assignee for the benefit of creditors, the contractor must
          notify
          the DPMM immediately.

        b. Upon
          learning of any such actions, the DPMM reserves the right, at its sole
          discretion, to either cancel the contract or affirm the contract and hold
          the
          contractor responsible for damages.

        

        19.
          INVENTIONS, PATENTS AND COPYRIGHTS

        

        The
          contractor shall defend, protect, and hold harmless the State of Missouri,
          its
          officers, agents, and employees against all suits of law or in equity resulting
          from patent and copyright infringement concerning the contractor's performance
          or products produced under the terms of the contract.

        

        20.
          NON-DISCRIMINATION AND AFFIRMATIVE ACTION

        

        In
          connection with the furnishing of equipment, supplies, and/or services
          under the
          contract, the contractor and all subcontractors shall agree not to discriminate
          against recipients of services or employees or applicants for employment
          on the
          basis of race, color, religion, national origin, sex, age, disability,
          or
          veteran status. If the contractor or subcontractor employs at least 50
          persons,
          they shall have and maintain an affirmative action program which shall
          include:

        

        a. A
          written
          policy statement committing the organization to affirmative action and
          assigning
          management responsibilities and procedures for evaluation and
          dissemination;

        b. The
          identification of a person designated to handle affirmative action;

        c. The
          establishment of non-discriminatory selection standards, objective measures
          to
          analyze recruitment, an upward mobility system, a wage and salary structure,
          and
          standards applicable to layoff, recall, discharge, demotion, and
          discipline;

        d. The
          exclusion of discrimination from all collective bargaining agreements;
          and

        e. Performance
          of an internal audit of the reporting system to monitor execution and to
          provide
          for future planning.

        

        If
          discrimination by a contractor is found to exist, the DPMM shall take
          appropriate enforcement action which may include, but not necessarily be
          limited
          to, cancellation of the contract, suspension, or debarment by the DPMM
          until
          corrective action by the contractor is made and ensured, and referral to
          the
          Attorney General's Office, whichever enforcement action may be deemed most
          appropriate.

        

        21.
          AMERICANS WITH DISABILITIES ACT

        

        In
          connection with the furnishing of equipment, supplies, and/or services
          under the
          contract, the contractor and all subcontractors shall comply with all applicable
          requirements and provisions of the Americans with Disabilities Act
          (ADA).

        

        22.
          FILING AND PAYMENT OF TAXES

        

        
          	 	
                  The
                    commissioner of administration and other agencies to which the
                    state
                    purchasing law applies shall not contract for goods or services
                    with a
                    vendor if the vendor or an affiliate of the vendor makes sales
                    at retail
                    of tangible personal property or for the purpose of storage,
                    use, or
                    consumption in this state but fails to collect and properly pay
                    the tax as
                    provided in chapter 144, RSMo. For the purposes of this section,
                    "affiliate of the vendor" shall mean any person or entity that
                    is
                    controlled by or is under common control with the vendor, whether
                    through
                    stock ownership or otherwise. Therefore offeror’s failure to maintain
                    compliance with chapter 144, RSMo may eliminate their proposal
                    from
                    consideration for award.

                

        

        

        23. 
          TITLES

        

        Titles
          of
          paragraphs used herein are for the purpose of facilitating reference only
          and
          shall not be construed to infer a contractual construction of
          language.

        

        Revised
          01/03/06

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