Document:

Exhibit 10.1

    
      Back
        to Form 8-K

      
        

      
Exhibit
      10.1

     

    
 

    Original
      Contract Number: 093-HUS-WCC-2 

    Amendment
      Number:

    Maximum
      Contact Value:

     

    Contractor
      Contact Person and Telephone: Kathleen M. Brennan, 860-424-5693

    

    Purchase
      Of Service - 1/09/06

    

      STATE
        OF CONNECTICUT

      DEPARTMENT
        OF SOCIAL SERVICES 

      HUMAN
        SERVICE CONTRACT

      

      

      CONTRACT
        SUMMARY

      

      

      
        	
                The
                  State of Connecticut Department: 

              	
                Department
                  of Social Services

              
	
                Street: 

              	
                25
                  Sigourney Street 

              
	
                City:
                  Hartford

              	
                State:
                  CT

              	
                Zip:
                  06106

              
	
                Tel:
                  

              	
                860
                  - 424 5693  

              
	
                hereinafter
                  “the Department”, hereby enters into a contract with
                  

              
	
                Contractor’s
                  Name: 

              	
                WellCare
                  of Connecticut, Inc.

              
	
                Street:
                  

                City:
                  

                State:
                  

                Zip: 

              	
                127
                  Washington Avenue 

                North
                  Haven 

                CT 

                06473

              
	
                Tel
                  #:

              	
                203-239
                  7444 x 3019

              
	
                Hereinafter
                  “the Contractor” , for the provision of services outlined herein in Part
                  I

              
	
                Term
                  of Contract:

              	
                This
                  contract is in effect from 07/01/2005 through 6/30/2007

              
	
                Statutory
                  Authority:

              	
                The
                  Department in authorized to enter into this contract pursuant to
§ 4 -8
                  17b-266 of the Connecticut General Statutes.

              
	
                Set-Aside
                  Status

              	
                Contract
                  o
                  IS
                  x
                  IS
                  NOT a set aside Contractors pursuant to § 32-9e of the Connecticut General
                  Statutes. 

              
	
                Effective
                  date

              	
                This
                  contract shall become effective only as of the date of signature
                  by the
                  Department’s authorized official(s) and, where applicable, the date of
                  approval by the Attorney General. Upon such execution, this contract
                  shall
                  be deemed effective for the entire Term specified above. This contract
                  may
                  be Amended subject to Part II, Section E1 of this
                  contract.

              

      

      

      

      

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

    

    Table
      of Contents

     

    I
      Scope of Services, Contract Performance, Budget, Reports and Other Program-
      and
      Department-Specific Provisions

     

    II.
      Mandatory Terms and Conditions 

     

    A.
      Client-Related Safeguards

    1.
      Inspection of Work Performed

    2.
      Safeguarding Client Information

    3.
      Reporting of Client Abuse or Neglect

    B.
      Contractor Obligations

    1.
      Credits and Rights in Data

    2.
      Organizational Information, Conflict of Interest, IRS Form 990

    3.
      Prohibited Interest

    4.
      Offer
      of Gratuities

    5.
      Related Party Transactions

    6.
      Organizational Information

    7.
      Insurance

    8.
      Reports

    9.
      Delinquent Reports

    10.
      Workforce Analysis

    11.
      Record Keeping and Access

    12.
      Audit
      Requirements

    13.
      Litigation

    14.
      Lobbying 

    C.
      Statutory and Regulatory Compliance

    1.
      Compliance with Law and Policy 

    2.
      Federal Funds

    3.
      Facility Standards and Licensing Compliance

    4.
      Suspension or Debarment

    5.
      Non-discrimination Regarding Sexual Orientation

    6.
      Executive Orders 3, 16, 17 and 7b (NEW)

    7.
      Non-discrimination and Affirmative Action

    8.
      Americans With Disabilities Act of 1990

    9.
      Utilization of Minority Business Enterprises

    10.
      Priority Hiring

    11.
      Non-
      smoking

    12.
      Government Function; Freedom of Information

    13.
      HIPAA
      Requirements 

    D.
      Miscellaneous Provisions

    1.
      Liaison

    2.
      Choice
      of Law and Choice of Forum

    3.
      Subcontracts

    4.
      Mergers and Acquisitions

    5.
      Equipment

    6.
      Independent Capacity of Contractor

    7.
      Settlement of Disputes and Claims Commission

    E.
      Revisions, Reductions, Default and Cancellation

    1.
      Contract Revisions and Amendments

    2.
      Contract Reduction

    3.
      Default by Contractor

    4.
      Non-enforcement Not to Constitute Waiver

    5.
      Cancellation and Recoupment

    6.
      Transition after Termination or Expiration of Contract

    7.
      Program Cancellation

     

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      114

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      

      I.
        SCOPE OF SERVICES, CONTRACT PERFORMANCE, BUDGET, REPORTS
        AND

      OTHER
        PROGRAM-SPECIFIC PROVISIONS

       

      The
        Contractor shall provide the following specific services for the HUSKY B
        Program(s) and agrees to comply with the terms and conditions set forth as
        required by the Department, including but not limited to the requirements
        and
        measurements for scope of services, contract performance, quality assurance,
        reports, terms of payment and budget. No provisions shall be contained in
        this
        Part I which negate, supersede or contradict any provision of Part II. In
        the
        event of any such inconsistency between Part I and Part II, the provisions
        of
        Part II shall control.

       

       

       

       

       

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                2/12/03
                  HUSKY B

                 

              
	
                PART
                  I: GENERAL
                  CONTRACT TERMS FOR MCOS

              
	
                PART
                  II: STANDARD
                  CONNECTICUT CONTRACT TERMS

              
	
                1.
                  

              	
                DEFINITIONS

              
	
                2.

              	
                DELEGATIONS
                  OF AUTHORITY

              
	
                3.

              	
                FUNCTIONS
                  AND DUTIES OF THE MCO

              
	
                3.01

              	
                Provision
                  of Services

              
	
                3.02

              	
                Non-Discrimination

              
	
                3.03

              	
                Gag
                  Rules/Integrity of Professional Advice to Members

              
	
                3.04

              	
                Coordination
                  and Continuation of Care

              
	
                3.05

              	
                Emergency
                  Services

              
	
                3.06

              	
                Geographic
                  Coverage

              
	
                3.07

              	
                Choice
                  of Health Professional

              
	
                3.08

              	
                Provider
                  Network

              
	
                3.09

              	
                Network
                  Adequacy and Maximum Enrollment Levels

              
	
                3.10

              	
                Provider
                  Contracts

              
	
                3.11

              	
                Provider
                  Credentialing and Enrollment

              
	
                3.12

              	
                Specialist
                  Providers and the Referral Process

              
	
                3.13

              	
                PCP
                  Selection, Scheduling and Capacity

              
	
                3.14

              	
                Family
                  Planning Access and Confidentiality

              
	
                3.15

              	
                Pharmacy
                  Access

              
	
                3.16

              	
                Mental
                  Health and Substance Abuse Access

              
	
                3.17

              	
                Children's
                  Issues and Preventive Care and Services

              
	
                3.18

              	
                Well-Care
                  Services for Adolescents

              
	
                3.19

              	
                HUSKY
                  Plus

              
	
                3.20

              	
                Prenatal
                  Care

              
	
                3.21

              	
                Dental
                  Care

              
	
                3.22

              	
                Pre-Existing
                  Conditions

              
	
                3.23

              	
                Prior
                  Authorization

              
	
                3.24

              	
                Newborn
                  Enrollment and Minimum Hospital Stays

              
	
                3.25

              	
                Acute
                  Care Hospitalization at Time of Enrollment or
                  Disenrollment

              
	
                3.26

              	
                Open
                  Enrollment

              
	
                3.27

              	
                Special
                  Disenrollment

              
	
                3.28

              	
                Linguistic
                  Access

              
	
                3.29

              	
                Services
                  to Members

              
	
                3.30

              	
                Information
                  to Potential Members

              
	
                3.31

              	
                DSS
                  Marketing Guidelines

              
	
                3.32

              	
                Health
                  Education

              
	
                3.33

              	
                Quality
                  Assessment and Performance Improvement

              
	
                3.34

              	
                Inspection
                  of Facilities

              
	
                3.35

              	
                Examination
                  of Records

              
	
                3.36

              	
                Medical
                  Records

              
	
                3.37

              	
                Audit
                  Liabilities

              
	
                3.38

              	
                Clinical
                  Data Reporting

              
	
                3.39

              	
                Utilization
                  Management

              
	
                3.40

              	
                Financial
                  Records

              
	
                3.41

              	
                Insurance

              
	
                3.42

              	
                Subcontracting
                  for Services

              
	
                3.43

              	
                Timely
                  Payment of Claims

              
	
                3.44

              	
                Insolvency
                  Protection

              
	
                3.45

              	
                Fraud
                  and Abuse

              

      

       

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                4.
                  

              	
                MCO
                  Responsibility Concerning Payments Made On Behalf Of The
                  Member

              
	
                4.01

              	
                Deductibles,
                  Coinsurance, Annual Benefit Maximums, and Lifetime Benefit
                  Maximums

              
	
                4.02

              	
                Payments
                  for Noncovered Services

              
	
                4.03

              	
                Cost-Sharing
                  Exemption for American Indian/Native American Children

              
	
                4.04

              	
                Copayments

              
	
                4.05

              	
                Copayments
                  Prohibited

              
	
                4.06

              	
                Maximum
                  Annual Limits for Copayments

              
	
                4.07

              	
                Tracking
                  Copayments

              
	
                4.08

              	
                Amount
                  of Premium Paid

              
	
                4.09

              	
                Billing
                  and Collecting the Premium Payments

              
	
                4.10

              	
                Notification
                  of Premium Payments Due

              
	
                4.11

              	
                Notification
                  of Non-payment of the Premium Payments

              
	
                4.12

              	
                Past
                  Due Premium Payments Paid

              
	
                4.13

              	
                Resumption
                  of Services if the Child is Re-enrolled

              
	
                4.14

              	
                Overpayment
                  of Premium

              
	
                4.15

              	
                Member
                  Premium Share Paid by Another Entity

              
	
                4.16

              	
                Tracking
                  Premium Payments

              
	 	 
	
                5.

              	
                LIMITED
                  COVERAGE OF SOME GOODS AND SERVICES AND
                  ALLOWANCES

              
	
                5.01

              	
                Limited
                  Coverage of Some Goods and Services

              
	 	 
	
                6.
                  

              	
                FUNCTIONS
                  AND DUTIES OF THE DEPARTMENT

              
	
                6.01

              	
                Eligibility
                  Determinations

              
	
                6.02

              	
                Ineligibility
                  Determinations

              
	
                6.03

              	
                Enrollment
                  / Disenrollment

              
	
                6.04

              	
                Lock-In
                  / Open Enrollment

              
	
                6.05

              	
                Capitation
                  Payments to the MCO

              
	
                6.06

              	
                Newborn
                  Retroactive Adjustments

              
	
                6.07

              	
                Information

              
	 	 
	
                7.

              	
                DECLARATIONS
                  AND MISCELLANEOUS PROVISIONS

              
	
                7.01

              	
                Competition
                  not Restricted

              
	
                7.02

              	
                Nonsegregated
                  Facilities

              
	
                7.03

              	
                Offer
                  of Gratuities

              
	
                7.04

              	
                Employment/Affirmative
                  Action Clause

              
	
                7.05

              	
                Confidentiality

              
	
                7.06

              	
                Independent
                  Capacity

              
	
                7.07

              	
                Liaison

              
	
                7.08

              	
                Governmental
                  Function and Freedom of Information

              
	
                7.09

              	
                Waivers

              
	
                7.10

              	
                Force
                  Majeure

              
	
                7.11

              	
                Financial
                  Responsibilities of the MCO

              
	
                7.12

              	
                Captilization
                  and Reserves

              
	
                7.13

              	
                Members
                  Held Harmless

              
	
                7.14

              	
                Compliance
                  with Applicable Laws, Rules and Policies

              
	
                7.15

              	
                Federal
                  Requirements and Assurances

              
	
                7.16

              	
                Civil
                  Rights

              
	
                7.17

              	
                Statutory
                  Requirements

              
	
                7.18

              	
                Disclosure
                  of Interlocking Relationships

              
	
                7.19

              	
                DEPARTMENT'S
                  Data
                  Files

              

      

    

    
       

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                7.20

              	
                Hold
                  Harmless

              
	
                7.21

              	
                Executive
                  Orders

              
	 	 
	
                8.

              	
                MCO
                  RESPONSIBILITIES CONCERNING INTERNAL AND EXTERNAL
                  APPEALS

              
	
                8.01

              	
                MCO
                  Responsibilities Concerning Internal and External Appeals and Notices
                  of
                  Denial

              
	
                8.02

              	
                Internal
                  Appeal Process Required

              
	
                8.03

              	
                Denial
                  Notice

              
	
                8.04

              	
                Internal
                  Appeal Process

              
	
                8.05

              	
                Written
                  Appeal Decision

              
	
                8.06

              	
                Expedited
                  Review

              
	
                8.07

              	
                External
                  Appeal Process through the DOI

              
	
                8.08

              	
                Provider
                  Appeal Process

              
	 	 
	
                9.

              	
                CORRECTION
                  ACTION AND CONTRACT TERMINATION

              
	
                9.01

              	
                Performance
                  Review

              
	
                9.02

              	
                Settlement
                  of Disputes

              
	
                9.03

              	
                Administrative
                  Errors

              
	
                9.04

              	
                Suspension
                  of New Enrollment

              
	
                9.05

              	
                Sanctions

              
	
                9.06

              	
                Payment
                  Withhold, Class C Sanctions

              
	
                9.07

              	
                Emergency
                  Services Denials

              
	
                9.08

              	
                Termination
                  for Default

              
	
                9.09

              	
                Termination
                  for Mutual Convenience

              
	
                9.10

              	
                Termination
                  for Financial Instability of the MCO

              
	
                9.11

              	
                Termination
                  for Unavailability of Funds

              
	
                9.12

              	
                Termination
                  for Collusion in Price Determination

              
	
                9.13

              	
                Termination
                  Obligations of Contracting Parties

              
	
                9.14

              	
                Waiver
                  of Default

              
	 	 
	
                10.
                  

              	
                OTHER
                  PROVISIONS

              
	
                10.01

              	
                Severability

              
	
                10.02

              	
                Effective
                  Date

              
	
                10.03

              	
                Order
                  of Precedence

              
	
                10.04

              	
                Correction
                  of Deficiencies

              
	
                10.05

              	
                This
                  is not a Public Works Contract

              
	 	 
	
                11.

              	
                APPENDICES

              
	
                A.

              	
                HUSKY
                  B Covered Benefits

              
	
                B.

              	
                HUSKY
                  Plus Behavioral

              
	
                C.

              	
                HUSKY
                  Plus Physical

              
	
                D.

              	
                Provider
                  Credentialing and Enrollment Requirements

              
	
                E.

              	
                American
                  Academy of Pediatrics Recommendations for Preventative
                  Pediatric

                Health
                  Care

              
	
                F.

              	
                DSS
                  Marketing Guidelines 

              
	
                G

              	
                Quality
                  Improvement System for Managed Care

              
	
                H.

              	
                Unaudited
                  Quarterly Financial Reports

              
	
                I.

              	
                Capitation
                  Payment Amounts

              
	
                J.

              	
                Recategorization
                  Chart

              
	 	 
	
                12.
                  

              	
                SIGNATURES

              

      

       

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    12/12/03
      HUSKY B

     

    PART
      I: GENERAL CONTRACT TERMS FOR MCOs

     

    1.
      DEFINITIONS

     

    As
      used
      throughout this contract, the following terms shall have the meanings set forth
      below.

     

    ACS
      State Healthcare or ACS:
      The
      organization contracted by the DEPARTMENT to perform certain administrative
      and
      operational functions for the HUSKY A and B programs. Contracted functions
      include HUSKY application processing, HUSKY B eligibility determinations,
      passive billing and enrollment brokering.

     

    Abuse:
      MCO
      and/or provider practices that are inconsistent with sound fiscal, business,
      or
      medical practices, and result in an unnecessary cost to the HUSKY program,
      or
      the reimbursement for services that are not medically necessary or that fail
      to
      meet professionally recognized standards for health care, or a pattern of
      failing to provide medically necessary services required by this contract.
      Member practices that result in unnecessary cost to the HUSKY program, also
      constitute abuse.

     

    Allowance:
      The
      amount that a managed care organization (MCO) is responsible to pay a provider
      towards the cost of a limited covered benefit.

     

    American
      Indian/Alaska Native
      (AI):
      (1) A member of a Federally recognized Indian tribe, band, or group; (2); an
      Eskimo or Aleut other Alaska Native enrolled by the Secretary of the Interior
      pursuant to the Alaska Native Claims Settlement Act, 43 U.S.C. 1601 et seq.;
      or
      (3) a person who is considered by the Secretary of HHS to be an Indian for
      any
      purpose.

     

    Applicant
      Any of
      the following individuals who are applying for coverage under HUSKY B on behalf
      of a child, pursuant to Section 17b-290 of the Connecticut General
      Statutes:

     

    
      	1.	
              a
                natural parent, adoptive parent, legal guardian, caretaker relative,
                foster parent, or a stepparent who is over eighteen years of age
                and who
                lives with the child for whom he or she is
                applying;

            

    

    
      	2.	
              a
                non-custodial parent who is under order of a court or family support
                magistrate to provide health insurance for his or her
                child;

            

    

    
      	3.	
              a
                child who is eighteen (18) years of age who is applying on his or
                her own
                behalf or on behalf of a minor dependent with whom he or she lives;
                and

            

    

    
      	4.	
              a
                child who is emancipated in accordance with the provisions of Sections
                46b-150 to 46b-150e, inclusive, of the Connecticut General Statutes,
                who
                is applying on his or her own behalf or on behalf of a minor dependent
                with whom he or she lives.

            

    

     

    A
      child
      is an applicant until the child receives coverage under HUSKY B.

     

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    12/12/03
      HUSKY B

     

    Capitation
      Rate:
      The
      amount paid per Member by the DEPARTMENT to each managed care organization
      (MCO)
      on a monthly basis.

     

    Capitation
      Payment:
      The
      individualized monthly payment made by the DEPARTMENT to the MCO on behalf
      of
      Members.

     

    Child:
      For the
      purposes of the HUSKY B program, an individual under nineteen (19) years of
      age,
      as defined in Section 17b-290 of the Connecticut General Statutes.

     

    Child
      Health Assistance:
      Payment
      for part or all of the cost of health benefits coverage provided to targeted
      low-income children for the services listed at 42 CFR 457.402.

     

    Child
      Preventive Care:
      Preventive care and services which include periodic and well-child visits,
      routine immunizations, health screenings and routine laboratory
      tests.

     

    Children
      with Special Health Care Needs:
      Children
      at elevated risk for (biologic or acquired) chronic physical, developmental,
      behavioral, or emotional conditions and who also require health and related
      (not
      educational or recreational) services of a type and amount not usually required
      by children of the same age.

     

    Clean
      Claim:
      A bill
      for service(s) or goods, a line item of services or all services and/or goods
      for a recipient contained on one bill which can be processed without obtaining
      additional information from the provider of service(s) or a third party. A
      clean
      claim does not include a claim from a provider who is under investigation for
      fraud or abuse or a claim under review for medical necessity.

     

    CMS:
      Centers
      for Medicare and Medicaid Services (CMS), formerly known as the Health Care
      Financing Administration (HCFA), a division within the United States Department
      of Health and Human Services.

     

    Coinsurance:
      The
      sharing of health care expenses by the insured and an insurer in a specified
      ratio, as defined in Section 17b-290 of the Connecticut General
      Statutes.

     

    Commissioner:
      The
      Commissioner of the Department of Social Services, as defined in Section 17b-290
      of the Connecticut General Statutes.

     

    Complaint:
      A
      written or oral communication from a Member expressing
      dissatisfaction

    with
      some
      aspect of the MCO's services.

     

    Consultant:
      A
      corporation, company, organization or person or their affiliates retained by
      the
      DEPARTMENT to provide assistance in administering the HUSKY B program, not
      the
      MCO or subcontractor.

     

    Contract
      Administrator:
      The
      DEPARTMENT employee responsible for fulfilling the administrative
      responsibilities associated with this managed care project.

     

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    12/12/03
      HUSKY B

     

    Contract
      Services:
      Those
      goods and services including limited benefits, which the MCO is required to
      provide Members under this contract.

     

    Copayment:
      A
      payment made by or on behalf of a Member for a specified covered benefit under
      HUSKY B, as defined in Section 17b-290 of the Connecticut General
      Statutes.

     

    Cost-sharing:
      An
      arrangement made by or on behalf of a Member to pay a portion of the cost of
      health services and share costs with the DEPARTMENT and the MCO, which includes
      copayments, premiums, deductibles and coinsurance, as defined in Section 17b-290
      of the Connecticut General Statutes.

     

    Date
      of Application:
      The date
      on which an application for the HUSKY B program is received by the DEPARTMENT
      or
      its agent, containing the applicant's signature.

     

    Day:
      Except
      where the term business day is expressly used, all references in this contract
      will be construed as calendar days.

     

    Deductible:
      The
      amount of out-of-pocket expenses that would be paid for health services by
      or on
      behalf of a Member before becoming payable by the insurer, as defined in Section
      17b-290 of the Connecticut General Statutes.

     

    DEPARTMENT:
      The
      Department of Social Services (DSS), State of Connecticut.

     

    DSM
      IV or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition:
      The
      current listing of descriptive terms and identifying codes for reporting a
      classification of mental and substance abuse disorders.

     

    Durable
      Medical Equipment
      (DME):
      Equipment furnished by a supplier or a home health agency that:

    1.
      Can
      withstand repeated use;

    2.
      Is
      primarily and customarily used to serve a medical purpose;

    3.
      Generally is not useful to an individual in the absence of an
      illness
      or injury;
      and

    4.
      Is
      appropriate for use in the home.

     

    Emergency
      or Emergency Medical Condition:
      A
      medical condition manifesting itself

    by
      acute
      symptoms of sufficient severity (including severe pain) such that a prudent
      layperson, who possesses an average knowledge of health and medicine, could
      reasonably expect the absence of immediate medical attention to result in
      placing the health of the individual (or with respect to a pregnant woman,
      the
      health of the woman or her unborn child) in serious jeopardy, serious impairment
      to body functions or serious dysfunction of any body organ or part.

     

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    12/12/03
      HUSKY B

     

    Emergency
      Services: Covered inpatient and outpatient services that are: 1) furnished
      by a
      qualified provider and 2) needed to evaluate or stabilize an emergency medical
      condition.

     

    External
      Quality Review Organization (EQRO):
      An
      entity responsible for conducting reviews of the quality outcomes, timeliness
      of
      the delivery of care, and access to items and services for which the MCO is
      responsible under this contract.

     

    Family:
      For the
      purposes of this contract, the family is defined as the household that includes
      the child and the following individuals who live with the child:

    1)
      all of
      the child's siblings who are under nineteen (19) years of age, including full
      and half, and siblings who are HUSKY A Members;

    2)
      natural and adoptive parents of the child;

    3)
      the
      spouse of the child; and

    4)
      stepparent and stepsiblings of the child, except when the inclusion of the
      stepparent and stepsiblings in the filing unit make the child ineligible for
      HUSKY B.

     

    Federal
      Poverty Level (FPL):
      The
      poverty guidelines updated annually in the Federal Register by the U.S.
      Department of Health & Human Services under authority of 42 U.S.C. Section
      9902.

     

    Formulary:
      A list
      of selected pharmaceuticals felt to be the most useful and cost effective for
      patient care, developed by a pharmacy and therapeutics committee at the
      MCO.

     

    Fraud:
      Intentional deception or misrepresentation, or reckless disregard or willful
      blindness, by a person or entity with the knowledge that the deception,
      misrepresentation, disregard or blindness could result in some unauthorized
      benefit to himself or some other person, including any act that constitutes
      fraud under applicable federal or state law.

     

    Free-look
      Period:
      The
      ninety (90) day period of time, occurring from the date of onset of a lock-in
      period of the Member with the earliest date of enrollment in the MCO, during
      which time a family of which the Member is a part, shall have the opportunity
      to
      choose another MCO. Such period is contingent upon no Members of the family
      having previously been enrolled in the MCO chosen by the family.

     

    FQHC-Sponsored
      MCO:
      An MCO
      that is more than fifty (50) percent owned by Connecticut Federally Qualified
      Health Centers (FQHC), certified by the Department of Social Services to enroll
      HUSKY B Members.

     

    Global
      Plan of Care:
      The
      treatment plan that integrates the needed services from the benefit packages
      of
      the HUSKY B and the HUSKY Plus programs when a medically eligible Member is
      concurrently receiving services from HUSKY B and either or both of the HUSKY
      Plus programs.

     

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    Health
      Plan Employer Data and Information Set (HEDIS):
      A
      standardized performance measurement tool that enables users to evaluate the
      quality of different MCOs based on the following categories: effectiveness
      of
      care; MCO stability; use of services; cost of care; informed health care
      choices; and MCO descriptive information.

     

    HHS:
      The
      United States Department of Health and Human Services.

     

    HUSKY,
      Part A,
      or HUSKY A:
      For
      purposes of this contract, HUSKY PART A includes all those coverage groups
      previously covered in Connecticut Access, subject to expansion of eligibility
      groups pursuant to Section 17b-266 of the Connecticut General
      Statutes.

     

    HUSKY
      Plan, Part B or HUSKY B:
      The
      health insurance plan for children established pursuant to Title XXI of the
      Social Security Act, the provisions of Sections 17b-289 to 17b-303, inclusive,
      of the Connecticut General Statutes, and Section 16 of Public Act 97-1 of the
      October special session.

     

    HUSKY
      Plus Programs:
      Two (2)
      supplemental physical and behavioral health programs pursuant to Section 17b-294
      of the Connecticut General Statutes, for medically eligible Members of the
      HUSKY
      B program in Income Bands 1 and 2, whose medical needs cannot be accommodated
      within the HUSKY Plan, Part B.

     

    HUSKY
      Plus Behavioral Plan;
      The
      program for Members of the HUSKY B program in
      Income
      Bands 1 and 2, with intensive behavioral health needs.

     

    HUSKY
      Plus Physical Health Plan:
      The
      program for Members of the HUSKY B program in Income Bands 1 and 2, with
      intensive physical health needs.

     

    ICD9-CM
      ("The
      International Classification of Disease.  Revision, Clinical
      Modification."): A widely recognized system of disease classification developed
      and published by the National Center for Health Statistics.

     

    Immigrant:
      A
      non-citizen or North American Indian born in Canada who is lawfully admitted
      into the United States for the express purpose of maintaining permanent
      residence.

     

    Income:
      As
      defined in Section 17b-290 of the Connecticut General Statutes. Income as
      calculated in the same manner as under the Medicaid program pursuant to Section
      17b-261 of the Connecticut General Statutes.

     

    Income
      Band 1:
      Families
      with household incomes over 185% and up to and including 235%
      of
      the federal poverty level.

     

    Income
      Band 2:
      Families with household incomes over 235% and up to and including 3 00% of
      the
      federal poverty level.

     

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    Income
      Band 3:
      Families with household incomes over 300% of the federal poverty
      level.

     

    In-network
      providers or network providers:
      Providers who have contracted with the MCO to provide services to
      Members.

     

    Institution:
      An
      establishment that furnishes food, shelter and some treatment or services to
      four (4) or more persons unrelated to the proprietor.

     

    Limited
      Benefits:
      Goods
      and services that are covered only up to a specified dollar limit.

     

    Lock-in:
      Limitations on Member changes of managed care organizations for a period of
      time, not to exceed twelve (12) months.

     

    Lock-out:
      The
      period of time HUSKY B Members are not permitted to participate in an MCO due
      to
      nonpayment of a premium owed to the MCO in which they were
      enrolled.

     

    Managed
      Care Organization (MCO):
      The
      organization signing this agreement with the Department of Social
      Services.

     

    Marketing:
      Any
      communication from an MCO to a HUSKY B recipient who is not enrolled in that
      MCO, that can be reasonably interpreted as intended to influence the recipient
      to enroll or reenroll in that particular MCO or either to not enroll in, or
      disenroll from, another MCO.

     

    Maximum
      Annual Aggregate Cost-sharing:
      The
      maximum amount which the family is required to pay (out-of-pocket) for services
      under HUSKY B. These payments include copayments and premiums.

     

    Medicaid:
      The
      Connecticut Medical Assistance Program operated by the Connecticut Department
      of
      Social Services under Title XIX of the Federal Social Security Act, and related
      State and Federal rules and regulations.

     

    Medical
      Appropriateness or Medically Appropriate:
      Health
      care that is provided in a timely manner and meets professionally recognized
      standards of acceptable medical care;

    is
      delivered in the appropriate medical setting; and is the least costly of
      multiple, equally-effective alternative treatments or diagnostic
      modalities.

     

    Medically
      Necessary or Medical Necessity:
      Health
      care provided to correct or diminish the adverse effects of a medical condition
      or mental illness; to assist an individual in attaining or maintaining an
      optimal level of health; to diagnose a condition; or prevent a medical condition
      from occurring.

     

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    Member:
      For the
      purposes of HUSKY B, a child who has been deemed eligible for the HUSKY B
      program pursuant to Section 17b-290 of the Connecticut General Statutes. For
      the
      purposes of this contract. Members of the HUSKY B program are enrollees as
      defined by Section 17b-290(l 1) of the Connecticut General
      Statutes.

     

    National
      Committee on Quality Assurance (NCQA):
      A
      not-for-profit organization that develops and defines quality and performance
      measures for managed care, thereby providing an external standard of
      accountability.

     

    Non-citizen:
      A person
      who is not a citizen of the United States.

     

    Open
      Enrollment Period:
      A sixty
      (60) day period, which ends on the fifteenth (15th)
      of the
      last month of the lock-in period, during which time the applicant will be given
      the opportunity to change plans for any reason.

     

    Out-of-network
      Provider:
      A
      provider that has not contracted with the MCO.

     

    Passive
      Billing:
      Automatic capitation payments generated by the DEPARTMENT or its agent based
      on
      enrollment.

     

    Peer
      Review Organization or PRO:
      The
      professional medical organization certified by HCFA/CMS which conducts peer
      review of medical care.

     

    Premium:
      Any
      required payment made by an individual to offset or pay in full the capitation
      rate under HUSKY B, as defined in Section 17b-290 of the Connecticut General
      Statutes.

     

    Preventive
      Care and
      Services: a) Child preventive care, including periodic and interperiodic
      well-child visits, routine immunizations, health screenings and routine
      laboratory tests; b) prenatal care, including care of all complications of
      pregnancy; c) care of newborn infants, including attendance at high-risk
      deliveries and normal newborn care; d) WIC evaluations as applicable e) child
      abuse assessment required under Sections 17a-106a and 46-b-129a of the
      Connecticut General Statutes; f) preventive dental care for children; and g)
      periodicity schedules and reporting based on the standards specified by the
      American Academy of Pediatrics.

     

    Primary
      and Preventive Health Care Services:
      The
      services of licensed health care professionals which are provided on an
      outpatient basis, including routine well-child visits; diagnosis and treatment
      of illness and injury; laboratory tests; diagnostic x-rays; prescription
      drugs; radiation therapy; chemotherapy; hemodialysis; emergency room services;
      and outpatient alcohol and substance abuse services.

     

    Primary
      Care Provider (PCP):
      A
      licensed health professional responsible for performing or directly supervising
      the primary care services of Members.

     

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    Prior
      Authorization:
      The
      process of obtaining prior approval as to the medical necessity or
      appropriateness of a service or plan of treatment.

     

    Redetermination:
      The
      periodic determination of eligibility of the eligible beneficiary for HUSKY
      B
      performed by the DEPARTMENT or its agent.

     

    Risk:
      The
      possibility of monetary loss or gain by the MCO resulting from service costs
      exceeding or being less than the capitation rates negotiated by the
      DEPARTMENT.

     

    Routine
      Cases:
      A
      symptomatic situation (such as a chronic back condition) for which the Member
      is
      seeking care, but for which treatment is neither of an emergency nor an urgent
      nature.

     

    State
      Children's Health Insurance Program (SCHIP):
      Services
      provided in accordance with Title XXI of the Social Security Act.

     

    State-Funded
      HUSKY Plan, Part B or State-Funded HUSKY B:
      A
      program which is funded solely by the State of Connecticut and which provides
      the same benefits as HUSKY B.

     

    Subcontract:
      Any
      written agreement between the MCO and another party to fulfill any requirements
      of this contract.

     

    Subcontractor:
      A party
      contracting with the MCO to manage or arrange for one or more of the health
      care
      services provided by the MCO pursuant to this contract, but excluding services
      provided by a vendor.

     

    Title
      V:
      For
      purposes of this contract, a state and federally funded program based at the
      Centers for Children with Special Health Care Needs at Connecticut Children's
      Medical Center and Yale Center for Children with Special Health
      Care.

     

    Title
      XXI:
      The
      provisions of Title 42 United States Code Sections 1397aa et seq., providing
      funds to enable states to initiate and expand the provision of child health
      assistance to uninsured, low-income children.

     

    Urgent
      Cases:
      Illnesses or injuries of a less serious nature than those constituting
      emergencies but for which treatment is required to prevent a serious
      deterioration in the Member's health and cannot be delayed without imposing
      undue risk on the Member's well-being until the Member is able to secure
      services from his/her regular physician(s).

     

    Vendor:
      Any
      party with which the MCO has subcontracted to provide administrative services
      or
      goods.

     

    Well-Care
      Visits:
      Routine
      physical examinations, immunizations and other preventive services that are
      not
      prompted by the presence of any adverse medical symptoms.

     

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    WIC:
      The
      federal Special Supplemental Food Program for Women, Infants and Children
      administered by the Department of Public Health, as defined in Section 17b-290
      of the Connecticut General Statutes.

     

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    2.
      DELEGATIONS OF AUTHORITY

     

    Connecticut's
      Department of Social Services is the single state agency responsible for
      administering the HUSKY B program. No delegation by either party in
      administering this contract shall relieve either party of responsibility for
      carrying out the terms of the contract.

     

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    3.
      FUNCTIONS AND DUTIES OF THE MCO

    

    The
      MCO agrees to the following duties.

     

    3.01
      Provision of Services

     

    a.
      The
      MCO shall provide to Members enrolled under this contract, directly or through
      arrangements with others, all the covered services described in Appendix A
      of
      this contract.

     

    
      	b.	
              The
                MCO shall ensure that utilization management/review and coverage
                decisions
                concerning acute or chronic care services to each Member are made
                on an
                individualized basis in accordance with the contractual definitions
                for
                Medical Appropriateness or Medically Appropriate at Part I Section
                1,
                Definitions. The MCO shall also ensure that its contracts with network
                providers requires that the decisions of network providers affecting
                the
                delivery of acute or chronic care services to Members are made in
                accordance with the contractual definitions for Medical Appropriateness
                or
                Medically Appropriate and Medically Necessary and Medical
                Necessity.

            

    

     

    
      	c.	
              The
                MCO shall require twenty-four (24) hour accessibility to qualified
                medical
                personnel to Members in need of urgent or emergency care. The MCO
                may
                provide such access to medical personnel through either: 1) a hotline
                staffed by physicians, physicians on-call or registered nurses; or
                2) a
                PCP on-call system. Whether the MCO utilizes a hotline or PCPs on-call,
                Members shall gain access to medical personnel within thirty (30)
                minutes
                of their call. The MCO Member handbook and MCO taped telephone message
                shall instruct Members to go directly to an emergency room if the
                Member
                needs emergency care. If the Member needs urgent care and has not
                gained
                access to medical personnel within thirty (30) minutes, the Member
                shall
                be instructed to go to the emergency room. The DEPARTMENT will randomly
                monitor the availability of such
                access.

            

    

     

    
      	d.	
              Changes
                to HUSKY B covered services mandated by Federal or State law, or
                adopted
                by amendment to the State Plan for SCHIP, subsequent to the signing
                of
                this contract will not affect the contract services for the term
                of this
                contract, unless (1) agreed to by mutual consent of the DEPARTMENT
                and the
                MCO, or (2) unless the change is necessary to continue federal financial
                participation or due to action of a state or federal court of law.
                If
                SCHIP coverage were expanded to include new services, such services
                would
                be paid for outside the capitation rate through a separate financial
                arrangement with the MCO, which may include reimbursement to the
                MCO
                directly. The DEPARTMENT may opt to reimburse the MCO directly based
                on
                claims paid by the MCO. The rate of reimbursement will be negotiated
                between the DEPARTMENT and the MCO. If SCHIP covered services were
                changed
                to exclude services, the DEPARTMENT may determine that such services
                will
                no longer be covered under HUSKY B and the DEPARTMENT
                will propose a contract amendment to reduce the capitation rate
                accordingly.  In
                the event that the DEPARTMENT and the MCO are unable to agree on
                a
                contract amendment, the DEPARTMENT and the MCO shall negotiate a
                termination agreement to facilitate the transition of the MCO's Members
                to
                another MCO within a period of no less than ninety (90)
                days.

            

    

     

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    3.02
      Non-Discrimination

     

    a.
       The
      MCO
      shall comply with all Federal and State laws relating to non-discrimination
      and
      equal employment opportunity, including but not necessarily limited to the
      Americans with Disabilities Act of 1990, 42 U.S.C. Section 12101 et seq.: 47
      U.S.C. Section 225; 47 U.S.C. Section 611; Title VII of the Civil Rights Act
      of
      1964, as amended, 42 U.S.C. Section 2000e; Title IX of the Education Amendments
      of 1972; Title VI of the Civil Rights Act, 42 U.S.C. 2000d et seq.: the Civil
      Rights Act of 1991; Section 504 of the Rehabilitation Act, 29 U.S.C. Section
      794
      et seq.;
      the Age
      Discrimination in Employment Act of 1975, 29 U.S.C. Sections 621-634;
      regulations issued pursuant to those Acts; and the provisions of Executive
      Order
      11246 dated September 26, 1965 entitled "Equal Employment Opportunity" as
      amended by Federal Executive Order 11375, as supplemented in the United States
      Department of Labor Regulations (41 CFR pt. 60-1 et seq., Obligations of
      Contractors and Subcontractors). The MCO shall also comply with Sections 4a-60,
      4a-61, 17b-520, 31-5 Id, 46a-64, 46a-71, 46a-75 and 46a-81 of the Connecticut
      General Statutes.

     

    The
      MCO
      shall also comply with the HCFA Civil Rights Compliance Policy, which mandates
      that all Members have equal access to the best health care, regardless of race,
      color, national origin, age, sex, or disability.

     

    The
      HCFA
      Civil Rights Compliance Policy further mandates that the MCO shall ensure that
      its subcontractors and providers render services to Members in a
      non-discriminatory manner. The MCO shall also ensure that Members are not
      excluded from participation in or denied the benefits of the HUSKY programs
      because of prohibited discrimination.

     

    The
      MCO
      acknowledges that in order to achieve the civil rights goals set forth in the
      HCFA Civil Rights Compliance Policy, CMS has committed itself to incorporating
      civil rights concerns into the culture of its agency and its programs and has
      asked all of its partners, including the DEPARTMENT and the MCO, to do the
      same.
      The MCO further acknowledges that CMS will be including the following civil
      rights concerns into its regular program review and audit activities: collecting
      data on access to and participation of minority and disabled Members; furnishing
      information to Members, subcontractors, and providers about civil rights
      compliance; reviewing CMS publications, program regulations, and instructions
      to
      assure support for civil rights; and initiating orientation and

     

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    training
      programs on civil rights. The MCO shall provide to the DEPARTMENT or to CMS
      upon
      request, any data or information regarding these civil rights
      concerns.

     

    Within
      the resources available through the capitation rate, the MCO shall allocate
      financial resources to ensure equal access and prevent discrimination on the
      basis of race, color, national origin, age, sex, or disability.

     

    b.
      Unless
      otherwise specified in this contract, the MCO shall provide covered services
      to HUSKY B Members under this contract in the same manner as those services
      are
      provided to other Members of the MCO, although delivery sites, covered services
      and provider payment levels may vary. The MCO shall ensure that the locations
      of
      facilities and practitioners providing health care services toMembers
      are sufficient in terms of geographic convenience to low-income areas,
      handicapped accessibility and proximity to public transportation routes, where
      available. The MCO and its providers shall not discriminate among Members
      ofHUSKY
      B
      and other Members of the MCO.

     

    3.03
      Gag Rules/Integrity of Professional Advice to Members

     

    The
      MCO
      shall comply with the provisions of Connecticut General Statutes Section
      38a-478k concerning gag clauses, and with 42 CFR. 457.985, concerning the
      integrity of professional advice to Members, including interference with
      providers' advice to Members and information disclosure requirements related
      to
      physician incentive plans.

     

    3.04
      Coordination and Continuation of Care

     

    a.
       The
      MCO
      shall have systems in place to provide well-managed patient care, which
      satisfies the DEPARTMENT that appropriate patient care is being provided,
      including at a minimum:

     

    1.
      Management and integration of health care through a PCP, gatekeeper or other
      means.

     

    2.
      Systems to assure referrals for medically necessary, specialty, secondary and
      tertiary care.

     

    3.
      Systems to assure provision of care in emergency situations, including an
      education process to help assure that Members know where and how to obtain
      medically necessary care in emergency situations.

     

    4.
      A
      system by which Members may obtain a covered service or services that the MCO
      does not provide or for which the MCO does not arrange because it would violate
      a religious or moral teaching of the religious institution or organization
      by
      which the MCO is owned, controlled, sponsored or affiliated.

     

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    5.
      Coordination and provision of well-child care services in accordance with the
      schedules for immunizations and periodicity of well-child care services as
      established by the DEPARTMENT and recommended by the American Academy of
      Pediatrics.

     

    6.
      Coordinating with and providing a case manager to the HUSKY Plus Physical
      program, as indicated in Section 3.19 of this contract.

     

    7.
      If
      notified, PCPs shall participate in the review and authorization of Individual
      Education Plans for Members receiving School Based Child Health services and
      Individual Family Service Plans for Members receiving services from the Birth
      to
      Three program.

     

    3.05
      Emergency Services

     

    
      	a.	
              The
                MCO shall provide all emergency services twenty-four (24) hours each
                day,
                seven (7) days a week or arrange for the provision of said services
                twenty-four (24) hours each day, seven (7) days a week through its
                provider network.

            

    

     

    
      	b.	
              Emergency
                services shall be provided without regard to prior authorization
                or the
                emergency care provider's contractual relationship with the
                MCO.

            

    

     

    
      	c.	
              The
                MCO shall not limit the number of emergency
                visits.

            

    

     

    
      	d.	
              The
                MCO shall cover emergency care services furnished to a Member by
                a provider
                whether or not the provider is a part of the Member's MCO provider
                network
                at the time of the service.

            

    

     

    
      	e.	
              The
                MCO shall cover emergency care services provided while the Member
                is out
                of the State of Connecticut, including emergency care incurred while
                outside the country.

            

    

     

    
      	f.	
              The
                MCO shall cover all services necessary to determine whether or not
                an
                emergency
                condition exists, even if it is later determined that the condition
                was
                not an emergency.

            

    

     

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

            

    

    
       

      h.
        The
        determination of whether the prudent layperson standard is met must be made
        on a
        case-by-case basis. The only exception to this general rule is that the MCO
        may
        approve coverage on the basis of an ICD-9 code.

    

     

     

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      	i.	
              If
                the screening examination leads to a clinical determination by the
                examining physician that an actual emergency does not exist, then
                the
                nature and extent of payment liability will be based on whether the
                Member
                had acute symptoms under the prudent layperson standard at the time
                of
                presentation.

            

    

     

    
      
        	j.	
                Once
                  the Member's condition is stabilized, the MCO may require authorization
                  for a hospital admission or follow-up
                  care.

              

      

       

    

    
      	k.	
              The
                MCO must cover post-stabilization services attendant to the primary
                presenting
                diagnosis that were either approved by the MCO or were delivered
                by the
                emergency service provider when the MCO failed to respond to a request
                for
                pre-approval of such services within one hour of the request to approve
                post-stabilization care, or could not be contacted for
                pre-approval.

            

    

     

    
      	1.	
              If
                there is a disagreement between a hospital and an MCO concerning
                whether
                the patient is stable enough for discharge or transfer from the emergency
                room, the judgment of the attending physician(s) actually caring
                for the
                Member at the treating facility prevails and is binding on the MCO.
                This
                subsection shall not apply to a disagreement concerning discharge
                or
                transfer following an inpatient admission. The MCO may establish
                arrangements with hospitals whereby the MCO may send one of its own
                physicians or may contract with appropriate physicians with appropriate
                emergency room privileges to assume the attending physician's
                responsibilities to stabilize, treat, and transfer the
                patient.

            

    

     

    
      
        	m.	
                When
                  a Member's PCP or other plan representative instructs the Member
                  to seek
                  emergency care in-network or out-of-network, the MCO is responsible
                  for
                  payment for the screening examination and for other medically necessary
                  emergency services, without regard to whether the patient meets
                  the
                  prudent layperson standard described
                  above.

              

      

    

     

    
      
        	n.	
                If
                  a Member believes that a claim for emergency services has been
                  inappropriately denied by the MCO, the Member may seek recourse
                  through
                  the MCO's internal appeal process and the Department of Insurance's
                  (DOI)
                  external review process pursuant to Section 8, MCO Responsibilities
                  Concerning Notices of Action, Appeals and Administrative Hearings
                  of this
                  contract

              

      

    

     

    
      	o.	
              When
                the MCO reimburses emergency services provided by an in-network
                provider,
                the rate of reimbursement will be subject to the contractual relationship
                that has been negotiated with said provider. When the MCO reimburses
                emergency services provided by an out-of-network provider within
                Connecticut, the rate of reimbursement will be no less than the fees
                established by the DEPARTMENT for the Medicaid fee-for-service program.
                When the MCO reimburses emergency services provided by an out-of-network
                provider outside of Connecticut, the MCO may negotiate a rate of
                reimbursement with said provider.

            

    

     

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    3.06
      Geographic Coverage

     

    
      	a.	
              The
                MCO shall serve Members statewide. The MCO shall ensure that its
                provider
                network includes access for each Member to PCPs, Obstetric/Gynecological
                Providers and mental health providers at a distance of no more than
                fifteen (15) miles for PCPs and Obstetric/Gynecological Providers
                and no
                more than twenty (20) miles for general dentists and mental health
                providers as measured by the Public Utility Commission. The MCO shall
                ensure that its provider network has the capacity to deliver or arrange
                for all the goods and services reimbursable under this
                contract.

            

    

     

    b.
       On
      a
      monthly basis, the MCO will provide the DEPARTMENT or its agent with a list
      of
      all contracted network providers. The list shall be in a format and contain
      such
      information as the DEPARTMENT may specify.

     

    Performance
      Measure:
      Geographic Access. The DEPARTMENT will randomly monitor geographic access by
      reviewing the mileage to the nearest town containing a PCP for every town in
      which the MCO has Members.

     

    3.07
      Choice of Health Professional

     

    The
      MCO
      must inform each Member about the full panel of participating providers in
      their
      network. To the extent possible and appropriate, the MCO must offer each Member
      covered under this contract the opportunity to choose among participating
      providers.

     

    3.08
      Provider Network

     

    
      	a.	
              The
                MCO shall maintain a provider network capable of delivering or arranging
                for the delivery of all covered benefits to all Members. In addition,
                the
                MCO's provider network shall have the capacity to deliver or arrange
                for
                the delivery of all covered benefits reimbursable under this contract
                regardless of whether all the covered benefits are provided through
                direct
                provider contracts. The MCO shall submit a file of its most current
                provider network listing to the DEPARTMENT or its agent. The file
                shall be
                submitted, at a minimum, once a month in the format specified by
                the
                DEPARTMENT.

            

    

     

    
      	b.	
              The
                MCO shall notify the DEPARTMENT or its agent, in a timely manner,
                of any
                changes made in the MCO's provider network. The monthly file submitted
                to
                the DEPARTMENT or its agent should not contain any providers who
                are no
                longer in the MCO's network. The DEPARTMENT will randomly audit the
                provider network file for accuracy and completeness and take corrective
                action with the MCO if the provider network file fails to meet these
                requirements.

            

    

     

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    3.09
      Network Adequacy and Maximum Enrollment Levels

     

    Until
      further notice, in order to assess network adequacy and establish maximum
      enrollment levels for HUSKY B, the DEPARTMENT shall assess the MCO's capacity
      for the HUSKY B program using HUSKY A as a surrogate measure. The DEPARTMENT
      will use the following methodology for assessment:

     

    
      	a.	
              On
                a quarterly basis, except as otherwise specified the DEPARTMENT,
                the
                DEPARTMENT shall evaluate the adequacy of the MCO's provider network.
                Such
                evaluations shall use ratios of Members to specific types of providers
                based on fee-for-service experience in order to ensure that access
                in the
                MCO is at least equal to access experienced in the fee-for-service
                Medicaid program for a similar population. For each county the maximum
                ratio of Members to each provider type shall
                be:

            

    

     

    1.
       adult
      PCPs, including general practice specialists counted at 60.8%, internal medicine
      specialists counted at 88.9%, family practice specialists counted at 66.9%,
      nurse practitioners of the appropriate specialties, and physician assistants,
      387 Members per provider;

     

    2.
       children's
      PCPs, including pediatric specialists counted at 100%, general practice
      specialists counted at 39.2%, internal medicine specialists counted at 11.1%,
      family practice specialists counted at 3 3.1 %, nurse practitioners of the
      appropriate specialties, and physician assistants, 301 Members per
      provider;

    obstetrics
      and gynecology providers, including obstetrics and gynecology specialists,
      nurse
      midwives, and nurse practitioners of the appropriate specialty, 835 Members
      per
      provider;

     

    3.
       dental
      providers, including general and pediatric dentists counted at 100%, and dental
      hygienists counted at 50%, 486 Members per provider; and

     

    4.
       behavioral
      health providers, including psychiatrists, psychologists, social workers, and
      psychiatric nurse practitioners, 459 Members per provider.

     

     

    
      	
              b.

            	
              Based
                on the adequacy of the MCO's provider network, the DEPARTMENT may
                establish a maximum HUSKY (HUSKY A and B) enrollment level for all
                HUSKY
                Members for the MCO on a county-specific basis. The DEPARTMENT shall
                provide the MCO with written notification no less than thirty (30)
                days
                prior to the effective date of the maximum enrollment
                level.

            

    

     

    
      
        	c.	
                Subsequent
                  to the establishment of this limit, if the MCO wishes to change
                  its
                  maximum enrollment level in a specific county, the MCO must notify
                  the
                  DEPARTMENT thirty (30) days prior to the desired effective date
                  of the
                  change. If the change is an increase, the MCO must demonstrate
                  an increase
                  in their provider network which would allow the MCO to serve additional
                  HUSKY (combined
                  A and B) Members. To do so the MCO must provide the DEPARTMENT
                  with the
                  signature pages from the executed provider contracts and/or signed
                  letters
                  of intent. The DEPARTMENT will not accept any other proof or documentation
                  as evidence of a provider's participation in the MCO's provider
                  network.
                  The DEPARTMENT shall review the existence of additional capacity
                  for
                  confirmation no later than thirty (30) days following notice by
                  the MCO.
                  An increase will be effective the first of the month after the
                  DEPARTMENT
                  confirms additional capacity
                  exists.

              

      

    

     

     

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      	d.	
              In
                the event the DEPARTMENT deems that the MCO's provider network is
                not
                capable of accepting additional enrollments, the DEPARTMENT may exercise
                its rights under Section 9 of this contract, including but not limited
                to
                the rights under Section 9.04, Suspensions of New
                Enrollments.

            

    

     

    3.10
      Provider Contracts

     

    All
      provider contracts in the MCO'S provider network shall, at a minimum, include
      each of the following provisions:

     

    
      	a.	
              MCO
                network providers serving HUSKY Members must meet the minimum requirements
                for participation in the HUSKY program stated in the Regulations
                of
                Connecticut State Agencies, Section 17b-262-522 - 17b-262-533, as
                applicable.

            

    

     

    b.
       MCO
      Members shall be held harmless, excluding appropriate cost-sharing for the
      costs
      of all HUSKY covered goods and services provided;

     

    c.
       Providers
      must provide evidence of and maintain adequate malpractice insurance. For
      physicians, the minimum malpractice coverage requirements are $1 million per
      individual episode and $3 million in the aggregate;

     

    d.
       Specific
      terms regarding provider reimbursement as specified in Timely Payment of Claims,
      Section 3.43 of this contract.

     

    e.
       Specific
      terms concerning each party's rights to terminate the contract;

     

    f.
       That
      any
      risk shifted to individual providers does not jeopardize access to care or
      appropriate service delivery;

     

    g.
       The
      exclusion of any provider that has been suspended from Medicare or a Medicaid
      program in any state; and

     

    h.
       For
      PCPs,
      the provision of "on-call" coverage through arrangements with other
      PCPs.

     

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    3.11
      Provider Credentialing and Enrollment

     

    
      	a.	
              The
                MCO shall establish minimum credentialing criteria and shall formally
                re-credential all professional participating providers in their network
                at
                least once every two (2) years or such other time period as established
                by
                the NCQA. The MCO shall create and maintain a credentialing file
                for each
                participating provider that contains evidence that all credentialing
                requirements have been met. The file shall include copies of all
                relevant
                documentation including licenses. Drug Enforcement Agency (DBA)
                certificates and provider statements regarding lack of impairment.
                Credentialing files shall be subject to inspection by the DEPARTMENT
                or
                its agent.

            

    

     

    b.
      The
      MCO's credentialing and re-credentialing criteria for professional providers
      shall include at a minimum:

     

    1.
      Appropriate license or certification as required by Connecticut
      law;

    2.
      Verification that providers have not been suspended or terminated from
      participation in Medicare or the Medicaid program in any state;

    3.
      Verification that providers of covered services meet minimum requirements for
      Medicaid participation;

    4.
      Evidence of malpractice or liability insurance, as appropriate;

    5.
      Board
      certification or eligibility, as appropriate;

    6.
      A
      current statement from the provider addressing:

    a.
      lack
      of impairment due to chemical dependency/drug abuse;

    b.
      physical and mental health status;

    c.
      history of past or pending professional disciplinary actions, sanctions, or
      license limitations;

    d.
      revocation and suspension of hospital privileges; and e. a history of
      malpractice claims.

    7.
      Evidence of compliance with Clinical Laboratory Improvement

    Amendments
      of 1988 (CLIA), Public Law 100-578, 42 USC Section 1395aa et seq. and 42 CFR
      pt.
      493 (as amended, 68 Fed. Reg. 3639-3714 (2003)).

     

    c.
       The
      MCO
      may require more stringent credentialing criteria. Any other criteria shall
      be
      in addition to the minimum criteria set forth above.

     

    d.
      Additional MCO credentialing/recredentialing criteria for PCPs shall include,
      but not be limited to:

     

    1.
      Adherence to the principles of Ethics of the American Medical Association,
      the
      American Osteopathic Association or other appropriate professional
      organization;

    2.
      Ability to perform or directly supervise the ambulatory primary care services
      of
      Members;

     

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    3.
      Membership on the medical staff with admitting privileges to at least one
      accredited general hospital or an acceptable arrangement with a PCP with
      admitting privileges;

    4.
      Continuing medical education credits;

    5.
      A
      valid DBA certification; and

    6.
      Assurances that any Advanced Practice Registered Nurse (APRN), Nurse Midwives
      or
      Physician Assistants are performing within the scope of their
      licensure.

     

    
      	e.	
              For
                purposes of credentialing and recredentialing, the MCO shall perform
                a
                check on all PCPs and other participating providers by contacting
                the
                National Practitioner Data Bank (NPDB). The DEPARTMENT will notify
                the MCO
                immediately if a provider under contract with the MCO is subsequently
                terminated or suspended from participation in the Medicare or Medicaid
                programs. Upon such notification from the DEPARTMENT or any other
                appropriate source, the MCO shall immediately act to terminate the
                provider from participation.

            

    

     

    
      	f.	
              The
                MCO may delegate credentialing functions to a subcontractor. The
                MCO is
                ultimately responsible and accountable to the DEPARTMENT for compliance
                with the credentialing requirements. The MCO shall demonstrate and
                document to the DEPARTMENT the MCO's significant oversight of its
                subcontractors performing any and all provider credentialing, including
                facility or delegated credentialing. The MCO and any such entity
                shall be
                required to cooperate in the performance of financial, quality or
                other
                audits conducted by the DEPARTMENT or its agent(s). Any subcontracted
                entity shall maintain a credentialing file for each participating
                provider, as set forth above.

            

    

     

    g.
       The
      MCO
      must adhere to the additional credentialing requirements set forth in Appendix
      D.

     

    3.12
      Specialist Providers and the Referral Process

     

    
      	a.	
              The
                MCO shall contract with a sufficient number and mix of specialists
                so that
                the
                Member population's anticipated specialty care needs can be substantially
                met within the MCO's network of providers. The MCO will also be required
                to have a system to refer Members to out-of-network specialists if
                appropriate participating specialists are not available. The MCO
                shall
                make specialist referrals available to its Members when it is medically
                necessary and medically appropriate and shall assume all financial
                responsibility for any such referrals whether they are in-network
                or
                out-of-network. The MCO must have policies and written procedures
                for the
                coordination of care and the arrangement, tracking and documentation
                of
                all referrals to specialty
                providers.

            

    

     

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      	b.	
              For
                Members enrolled in HUSKY Plus, the MCO is required to coordinate
                the
                specialty care services and specialty provider referral process with
                the
                HUSKY Plus programs to ensure access to care. Refer to Section 3.19
                for
                specific guidance on the referral
                process.

            

    

     

    3.13
      PCP Selection, Scheduling and Capacity

     

    
      	a.	
              The
                MCO shall provide Members with the opportunity to select a PCP within
                thirty
                (30) days of enrollment. The MCO shall assign a Member to a PCP when
                a
                Member fails to choose a PCP within thirty (30) days after being
                requested
                to do so. The assignment must be appropriate to the Member's age,
                gender,
                and residence.

            

    

     

    b.
       The
      MCO
      shall ensure that the PCPs in its network adhere to the following PCP scheduling
      practices:

     

    1.
      Emergency cases shall be seen immediately or referred to an emergency
      facility;

    2.
      Urgent
      cases shall be seen within forty-eight (48) hours of PCP
      notification;

    3.
      Routine cases shall be seen within ten (10) days of PCP
      notification;

    4.
      Well-care visits shall be scheduled within six (6) weeks of PCP
      notification;

    5.
      All
      well-child visits, comprehensive health screens and immunizations shall be
      scheduled in accordance with the American Academy of Pediatrics' (AAP)
      periodicity schedule and the Advisory Committee on Immunization Practice's
      (ACIP) immunization schedules; and

    6.
      Waiting times at PCP sites are kept to a minimum.

     

    
      
        	c.	
                The
                  MCO shall report quarterly on each PCP's panel size, group practice
                  and
                  hospital affiliations in a format specified by the DEPARTMENT.
                  The
                  DEPARTMENT will aggregate reports received from all MCOs for both
                  HUSKY A
                  and HUSKY B. In the event that the DEPARTMENT finds a PCP with
                  more than
                  1,200 HUSKY (combined HUSKY A and HUSKY B) panel Members, the DEPARTMENT
                  will notify the MCO if the PCP is part of the MCO's network. The
                  DEPARTMENT expects that the MCO will take appropriate action to
                  ensure
                  that patient access to the MCO is
                  assured.

              

      

    

     

    
      
        	d.	
                The
                  MCO shall maintain a record of each Member's PCP assignments for
                  a period
                  of two (2) years.

              

      

    

     

    e. 
      The
      MCO
      shall educate each Member on the benefits of a usual source of
      care.

     

    f.  
      If the Member has not received any primary care services, the MCO shall contact
      the Member to encourage regular well-care visits.

     

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    Performance
      Measure:
      PCP Appointment Availability. The DEPARTMENT or its agent will routinely monitor
      appointment availability as measured by b(l) through b(5) by using test cases
      to
      arrange appointments of various kinds with selected PCPs.

     

    3.14
      Family Planning Access and Confidentiality

     

    
      	a.	
              The
                MCO shall notify and give each Member, including adolescents, the
                opportunity to use family planning services without requiring a referral
                or authorization. The MCO shall make a reasonable effort to subcontract
                 with all local family planning clinics and providers, including
                those
                funded by Title X of the Public Health Services
                Act.

            

    

     

    b.
      The
      MCO shall keep family planning information and records for each individual
      patient confidential, even if the patient is a minor.

     

    
      
        	c.	
                Pursuant
                  to federal law, 42 U.S.C. Section 1397ee(c)(l) and (7), 42 CFR
                  457.475 and
                  the State of Connecticut's State Child Health Plan under Title
                  XXI of the
                  Social Security Act, ("the HUSKY Plan"), the DEPARTMENT may seek
                  federal
                  funding for abortions only if the pregnancy is the result of an
                  act of
                  rape or incest or necessary to save the life of the mother. The
                  MCO shall
                  cover all abortions that fall within these
                  circumstances.

              

      

    

     

    d.
       The
      DEPARTMENT and the MCO shall enter into a separate contract for abortions that
      do not qualify for federal matching funds.

     

    e.
       The
      MCO
      shall not charge copayments for any abortion.

     

    Sanction:
      If the
      MCO fails to comply with the provisions in (c), and fails to accurately maintain
      and submit accurate records of those abortions which meet the federal definition
      for funding, the DEPARTMENT may impose a Class A sanction, pursuant to Section
      9.05.

     

    3.15
      Pharmacy Access

     

    a.
      Pharmacies must be available and accessible on a statewide basis. The MCO
      shall:

     

    1.
      Maintain a comprehensive provider network of pharmacies that will within
      available resources assure twenty-four (24) hour access to a full range of
      pharmaceutical goods and services;

     

    2.
      Have
      established protocols to respond to urgent requests for
      medications;

     

    3.
      Monitor and take steps to correct excessive utilization of regulated
      substances;

     

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            	4.	
              Have
                established protocols in place to assure the timely provision of
                pharmacy
                goods and to determine client eligibility and MCO affiliation services
                (by
                contacting the DEPARTMENT or
                its agent via telephone or fax) when there is a discrepancy between
                the
                information in the MCO's eligibility system and information given
                to the
                pharmacists by the Member, the Member's physician or other third
                party;
                and

            

    

     

    5.
      Monitor quality assurance measures to assure that Member abuse of pharmacy
      benefits is corrected in a timely fashion.

     

    
      	b.	
              The
                MCO shall require that its provider network of pharmacies offers
                medically
                necessary goods and services to the MCO's Members. The MCO may have
                a drug
                management program that includes a prescription drug formulary. If
                the MCO
                has a drug formulary, the MCO shall have a prior authorization process
                to
                permit access at a minimum to all medically necessary and appropriate
                drugs covered for the Medicaid fee-for-service population. The MCO
                drug
                formulary must include only Food and Drug Administration approved
                drug
                products and be sufficiently broad enough in scope to meet the needs
                of
                the MCO's Members. The MCO drug formulary shall consist of a reasonable
                selection of drugs which do not require prior approval for each specific
                therapeutic drug class.

            

    

     

    
      	c.	
              The
                MCO shall submit a copy of its formulary to the DEPARTMENT no later
                than
                thirty (30) days after the effective date of this contract. The MCO
                shall
                submit any subsequent deletions to the formulary to the DEPARTMENT
                thirty
                (30) days prior to making any change. The MCO shall also submit subsequent
                additions to the formulary immediately without seeking prior approval
                by
                the DEPARTMENT. The DEPARTMENT reserves the right to identify deficiencies
                in the content or operation of the formulary. In this instance, the
                MCO
                shall have thirty (30) days to address in writing the identified
                deficiencies to the department's
                satisfaction.
                The MCO may request to meet with the DEPARTMENT prior to the submission
                of
                the written response.

            

    

     

    
      	d.	
              The
                MCO shall ensure that Members using maintenance drugs (drugs usually
                prescribed to treat long-term or chronic conditions including, but
                not
                limited to, diabetes, arthritis and high blood pressure) are informed
                in
                advance, but no less than thirty (30) days in advance of any changes
                to
                the prescription drug formulary related to such maintenance drugs
                if the
                Member using the drug will not be able to continue using the drug
                without
                a new authorization.

            

    

     

    e.
       The
      MCO
      shall require that its provider network of pharmacies adheres to the provisions
      of Connecticut General Statutes Section 20-619 (b) and (c) related to generic
      substitutions.

     

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    3.16
      Mental Health and Substance Abuse Access

     

    
      	a.	
              The
                MCO shall provide, to its Members, all behavioral health care services
                (mental
                health and substance abuse) covered by the HUSKY B program that are
                medically necessary and medically appropriate. These services may
                be
                provided by the MCO through contracts with providers of services
                or
                through subcontracted relationships with specialized behavioral health
                management entities. A Member will not need a PCP referral to obtain
                services; self-referral will be sufficient to obtain an initial service
                visit. The MCO may require authorization for an ongoing course of
                treatment.

            

    

     

    b.
       Notwithstanding
      any contractual arrangement with a specialized management agency, the MCO is
      wholly responsible to ensure that medically necessary and medically appropriate
      services are provided to its HUSKY B Members.

     

    
      	c.	
              The
                MCO shall contract with a consultant or employ a doctoral level mental
                health
                professional staff person within the plan with appropriate qualifications,
                credentials and decision making authority who will have specific
                responsibilities for exercising oversight of the delivery of behavioral
                health services by the plan or its subcontractors. Such person shall
                be
                responsible for promoting efforts to better integrate and coordinate
                the
                provision of behavioral health care with other services. The individual
                shall be available by phone for consultation on an as needed basis,
                dedicated to the Connecticut Members, as well as have an extensive
                understanding of the provisions of this
                contract.

            

    

     

    
      
        	d. 
                	
                In
                  reference to services for children with psychiatric/mental health
                  and
                  substance abuse needs, the MCO and any subcontracted entity is
                  required to
                  contract with and refer to qualified HUSKY B
                  providers.

              

      

    

     

    
      	e.	
              The
                MCO and any subcontractor entity will cooperate in the identification
                and
                improvement of processes working toward the development and
                standardization of administrative procedures. The MCO and any
                subcontracted entity shall take steps to promote successful
                provider-Member relationships and will monitor the effectiveness
                of these
                relationships.

            

    

     

    
      
        	f.	
                The
                  MCO is responsible for monitoring the performance of its network
                  providers
                  and for monitoring and ensuring contract compliance and HUSKY B
                  policy/compliance with any subcontracted entity. Such monitoring
                  will
                  ensure that providers and subcontractors observe all contractual
                  and
                  policy requirements as well as measuring performance relating to
                  such
                  areas as access to care and ensuring quality of care. The MCO and
                  any
                  subcontracted entity are required to cooperate in the performance
                  of
                  financial, quality or other audits conducted by the DEPARTMENT
                  or its
                  agent(s).

              

      

    

     

     

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    3.17
      Children's Issues and Preventive Care and Services

     

    
      The
        MCO
        shall ensure access to preventive care and services of the HUSKY B benefit
        package as follows:

       

      
        	
                a.
                  

              	
                The
                  MCO shall provide preventive care and services consisting of the
                  services
                  described in this section and in accordance with the standards
                  and
                  schedules specified in Appendixes A and E. Any changes in the standards
                  and schedule subsequent to the effective date of this contract
                  shall be
                  provided to the MCO sixty (60) days before the effective date of
                  the
                  change. The MCO shall not require prior authorization of preventive
                  care
                  and services. Preventive care and services consist of the
                  following:

              

      

    

    1.
      Child
      preventive care consisting of:

    a.
       periodic
      well-child visits based on the schedule for such visits recommended by the
      American Academy of Pediatrics (AAP), see Appendix E, American Academy of
      Pediatrics Recommendations for Preventative Periodic Health Care;

    b.
       office
      visits related to periodic well-child visits;

    c.
       routine
      childhood immunizations based on the recommendations of the Advisory Committee
      on Immunization Practices (ACIP), see Appendix A;

    d.
       health
      screenings; and e. routine laboratory tests.

    

    2.
      Prenatal Care, including care of all complications of pregnancy;

    3.
      All
      healthy newborn inpatient physician visits, including routine inpatient and
      outpatient screenings and attendance at high-risk deliveries;

    4.
      WIC
      evaluations, as applicable;

    5.
      Child
      abuse assessments required under Sections 17a-106a and 46b-129a of the
      Connecticut General Statutes;

    6.
      Preventive dental care based on the recommendations of the American Academy
      of
      Pediatric Dentistry (AAPD) and consisting of:

    a.
      Oral
      exams and prophylaxis;

    b.
      Fluoride treatments;

    c.
      Sealants, and 

    d.
      X-rays

     

    
      	
              b.
                

            	
              The
                MCO shall provide office visits related to periodic well-child visits
                when
                medically necessary to determine the existence of a physical or mental
                illness or condition. The MCO shall not require prior authorization
                of
                such visits:

            

    

     

    
      	
              c.
                

            	
              The
                MCO shall provide periodic well-child visits that at a minimum,
                include:

            

    

     

    1.
      a
      comprehensive health and developmental history (including assessment of both
      physical and mental health development and assessment of nutritional
      status);

     

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    2.
      a
      comprehensive unclothed or partially draped physical exam;

    3.
      appropriate immunizations as set forth in the ACIP recommendations and schedule
      at Appendix A;

    4.
      laboratory tests, as set forth in the AAP recommendations and schedule at
      Appendix E;

    5.
      vision
      and hearing screenings as set forth in the AAP schedule at Appendix
      E;

    6.
      dental
      assessments as set forth in the AAP recommendations and schedule at Appendix
      E;
      and

    7.
      health
      education, including anticipatory guidance.

     

    d.
      No
      later than sixty (60) days after enrollment in the plan and annually thereafter,
      the MCO shall use a combination of oral and written methods including methods
      for communicating with Members with limited English proficiency. Members who
      cannot read, and Members who are visually or hearing impaired, to:

     

    1.
      Inform
      its Members about the availability of preventive care and services;

    2.
      Inform
      its Members about the importance and benefits of preventive care and
      services;

    3.
      Inform
      its Members about how to obtain preventive care and services; and

    4.
      Inform
      its Members that assistance with scheduling appointments is available, and
      inform them how to obtain this assistance.

     

    The
      MCO
      shall require PCPs to obtain all available vaccines free of charge from the
      Department of Public Health under the state-funded Vaccines for Children
      program

     

    3.18
      Well-Care Services for Adolescents

     

    On
      or
      before February 1, 2004, the MCO shall submit an action plan to improve the
      delivery of well-child care to adolescents. This plan shall include measures
      to
      increase the volume of well-child screenings provided to adolescent members
      and
      to improve the quality and the completeness of those screenings according to
      the
      guidelines provided by the American Academy of Pediatrics. Emphasis should
      be
      placed on improving health risk assessment and anticipatory guidance during
      these visits. Following the submission of these plans, the MCOs will meet with
      the department and representatives of other state agencies to develop a best
      practice model for the delivery of adolescent health care.

    

    3.19
      HUSKY PLUS a. Overview

     

    
      	
              1.
                
 	
               

            	
              HUSKY
                Plus is comprised of two (2) supplemental health insurance programs
                which
                provide services to children whose special medical needs cannot be
                accommodated within the benefit package offered under HUSKY B. One
                of the
                HUSKY Plus programs provides supplemental coverage to children with
                intensive physical health needs (HUSKY Plus Physical) , while the
                other
                program

            

    

     

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    supplements
      coverage for those children with intensive behavioral health needs (HUSKY Plus
      Behavioral)

     

    
      	
              2.
                

            	
              HUSKY
                Plus Physical is administered by the Centers for Children with Special
                Health Care Needs at Connecticut Children's Medical
                Center.

            

    

     

    HUSKY
      Plus Behavioral services are provided by the MCO in which the Member is
      enrolled. The MCO shall provide the services described in Appendix B to Members
      eligible for HUSKY Plus Behavioral.

     

    
      	
              3.
                

            	
              HUSKY
                Plus is available for children with special health care needs who
                are
                enrolled in HUSKY B and fall within income bands 1 and 2. HUSKY B
                Members
                who fall into income band 3 are excluded from the HUSKY Plus program.
                .

            

    

     

    
      	
              4.
                

            	
              The
                MCO shall have final decision-making authority for those services
                for
                which they are at financial risk. The HUSKY Plus Physical program
                shall
                have final decision-making authority for those supplemental services
                for
                which they are at financial risk. The HUSKY Plus Physical program
                shall be
                the documented payor of last
                resort.

            

    

     

    
      	
              5.
                

            	
              Any
                dispute between the participating MCO and the HUSKY Plus Physical
program
                concerning the responsibility for reimbursement of a service authorized
                under the treatment plan shall be referred to the DEPARTMENT for
                resolution.

            

    

     

    b.
      MCO's Responsibility to Maximize HUSKY Plus Physical
      Services

     

    The
      MCO
      shall coordinate care with HUSKY Plus Physical so as to maximize the Member's
      coverage of special health needs. Such coordination shall include, but not
      be
      limited to, a monthly conference, either in person or by telephone or other
      interactive means, between the MCO case manager, the HUSKY Plus case manager,
      and the Member or his/her representative.

     

    c.
      HUSKY B MCO Case Management Responsibilities

     

    The
      HUSKY
      Plus case management team will develop a global plan of care when a Member
      is
      receiving HUSKY Plus services. A case manager with appropriate qualifications,
      credentials and decision-making authority shall be assigned by the MCO to the
      HUSKY Plus case management team.

     

    The
      global plan of care shall be based on the comprehensive diagnostic needs
      assessment, periodic reassessments, and treatment plans from the MCO and HUSKY
      Plus programs providing services to the Member.

     

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    The
      global plan of care shall integrate HUSKY B services as set forth in Appendix
      A
      and HUSKY Plus services as set forth in Appendices B and C. The MCO shall be
      responsible for managing the utilization of HUSKY B services contained in the
      global plan of care.

     

    The
      MCO
      case manager shall actively participate with the HUSKY Plus case management
      team
      to ensure that all medically necessary HUSKY Plus program services identified
      in
      the global plan of care, which are also covered in the HUSKY B benefit package,
      are exhausted first under HUSKY B.

     

    d.
      Disenrollment

     

    The
      MCO
      shall assign a liaison who will coordinate all communication related to
      disenrollment to the HUSKY Plus programs.

     

    e.
      Quality Assurance

     

    The
      MCO
      shall provide summary data reports to the DEPARTMENT or its agent in an agreed
      upon format on the utilization of physical and/or behavioral health services
      for
      HUSKY Plus Members on an as needed basis, but no more frequently.

     

    The
      MCO
      shall designate a representative to the HUSKY Plus Physical Quality Assurance
      Subcommittees.

     

    f.
      Payment

     

    The
      MCO
      shall seek prior authorization from the DEPARTMENT for all HUSKY Plus Behavioral
      Services. The DEPARTMENT shall designate a contact person for such authorization
      process. The DEPARTMENT shall compensate the MCO for the cost of each authorized
      service. The MCO shall not request, and the DEPARTMENT shall not authorize
      any
      additional funds for administration of the HUSKY Plus Behavioral
      services.

     

    Sanction:
      If the
      MCO fails to have a procedure to identify potential HUSKY Plus Members or fails
      to assign a case manager to the HUSKY Plus Physical program, the DEPARTMENT
      may
      impose a strike towards a Class A sanction pursuant to Section
      9.05.

     

    3.20
      Prenatal Care

     

    a.
      In
      order to promote healthy birth outcomes, the MCO or its contracted providers
      shall:

     

    1.
      Identify enrolled pregnant women as early as possible in the
      pregnancy;

    2.
      Conduct prenatal risk assessments in order to identify high-risk pregnant women,
      arrange for specialized prenatal care and support services tailored to
      risk
      status, and begin care coordination that will continue throughout the pregnancy
      and early weeks postpartum;

     

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    3.
      Refer
      enrolled pregnant women to the WIC program, as applicable;

    4.
      Offer
      case management services with obtaining prenatal care appointments, WIC
      services, as applicable, and other support services as necessary;

    5.
      Offer
      prenatal health education materials and/or programs aimed at promoting health
      birth outcomes;

    6.
      Offer
      HIV testing and counseling and all appropriate prophylaxis and treatment to
      all
      enrolled pregnant women;

    7.
      Refer
      any pregnant Member who is actively abusing drugs or alcohol to a behavioral
      health subcontractor or provider of behavioral health/substance abuse services
      and treatment; and

    8.
      Educate new mothers about the importance of the postpartum visit and well-baby
      care.

     

    Performance
      Measure:
      Early
      access to prenatal care: Percentage of enrolled women who had a live birth,
      who
      were continuously enrolled in the MCO for 280 days prior to delivery who had
      a
      prenatal visit on or between 176 to 280 days prior to delivery.

     

    Performance
      Measure:
      Adequacy
      of prenatal care: Percentage of women with live births who were continuously
      enrolled during pregnancy who had more than eighty (80) percent of the prenatal
      visits recommended by the American College of Obstetrics and Gynecology,
      adjusted for gestational age at enrollment and delivery.

     

    3.21
      Dental Care

     

    a.
      The
      MCO shall contract with a sufficient number of dentists throughout the state
      to
      assure access to oral health care. The MCO shall;

     

    
      	1.	
              Maintain
                an adequate dental provider network throughout the state's eight
                (8)
                counties;

            

    

     

    
      
        	2.	
                For
                  the purpose of enrollment capacity a dental hygienist meeting the
                  criteria
                  of Connecticut General Statutes Section 20-1261 with two (2) years
                  experience, working in an institution (other than hospital), a
                  community
                  health
                  center, a group home or a school setting shall be counted as fifty
                  (50)
                  percent of a general dentist. If the MCO's provider network includes
                  dental hygienists acting independently within their scope of
                  practice to provide preventive services to Members, the MCO shall
                  require that dental hygienists make appropriate referrals to in-network
                  dentists for appropriate restorative and diagnostic
                  services;

              

      

       

      
        	3.	
                Implement plan that includes a
                  systematic
                  approach for enhancing access to dental care through monitoring
                  appointment availability, provision of training to providers around
                  issues
                  of cultural diversity and any other specialized
                  programs

              

      

       

       

      
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      	4.	
              Implement
                incentives and/or sanctions to ensure that access standards are met
                with
                respect to dental screens and appointment availability. The MCO shall
                ensure that the scheduling of a routine dental visit is six (6)
                weeks;

            

    

     

    
      	5.	
              Certify
                that all dentists in the MCO's network shall take Members and that
                MCO's
                HUSKY Members shall be assured the same access to providers as non-HUSKY
                Members. Nothing in this section shall preclude the implementation
                of
                limits on panel size by providers;

            

    

     

    
      	6.	
              Implement
                procedures to provide all Members with the opportunity to choose
                a general
                dentist;

            

    

     

    
      	7.	
              Educate
                Members about the importance of regular dental care, with a focus
                on
                accessing preventive care such as screenings and cleanings at least
                twice
                a year; and

            

    

     

    
      	8.	
              Provide
                for sufficient access to dental services for different age
                groups.

            

    

     

    3.22
      Pre-Existing Conditions

     

    There
      is
      no exclusion for pre-existing conditions.

     

    The
      MCO
      shall assume responsibility for all HUSKY B covered services as outlined in
      Appendix A for each Member as of the effective date of coverage under the
      contract.

     

    3.23
      Prior Authorization

     

    Prior
      authorization of services covered in the HUSKY B benefit package shall be
      determined by the MCO based on individual care plans, medical necessity and
      medical appropriateness, except that the following services in the benefit
      package shall not require prior authorization.

     

    (1)
      preventive care, including:

    (a)
      periodic and well-child visits;

    (b)
      immunizations; and

    (c)
      prenatal care;

     

    (2)
      preventive family planning services including:

    (a)
      reproductive health exams;

    (b)
      Member counseling;

    (c)
      Member education;

     

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    (d)
       lab
      tests
      to detect the presence of conditions affecting reproductive health;
      and

    (e)
       screening,
      testing and treatment of pre and post-test counseling for sexually transmitted
      diseases and HIV, and

     

    (3)
      emergency ambulance services or emergency care.

     

    Further
      details about HUSKY B prior authorization requirements are set forth in Appendix
      A.

     

    3.24
      Newborn Enrollment and Minimum Hospital Stays

     

    
      	a.	
              The
                MCO shall accept Membership of a newborn child as of the child's
                date of
                birth, if the application is submitted on behalf of the child with
                in
                thirty (30) days of the child's date of birth in accordance with
                C.G.S.
                17b-292(f). Additionally, the MCO shall be responsible for providing
                coverage of the benefit package beginning with the child's date of
                birth.

            

    

     

    
      	b.	
              The
                MCO shall comply with requirements of the Newborns' and Mothers'
                Health
                Protection Act of 1996 regarding requirements for minimum hospital
                stays
                for mothers and newborns in accordance with 45 CFR. 146.130 and
                148.170.

            

    

     

    
      	c.	
              The
                MCO shall provide the newborn Member's family with reasonable notice
                of
                any premium to be paid for the first months of coverage, as provided
                by
                section 4.09.

            

    

     

    3.25
      Acute Care Hospitalization at Time of Enrollment or
      Disenrollment

     

    
      	a.	
              The
                MCO is responsible to ensure continuation of care for acute care
                requiring
                an inpatient stay at a hospital.

            

    

     

    
      	b.	
              The
                MCO shall be responsible for inpatient coverage as of the effective
                date
                of enrollment for newly enrolled HUSKY B Members who were
                uninsured.

            

    

     

    
      	c.	
              The
                MCO shall be responsible to provide continuing coverage for an inpatient
                hospital stay up to the point of discharge for any Member who was
                admitted
                as an inpatient in a hospital while enrolled in the MCO and is disenrolled
                from the MCO for any reason during the same inpatient stay, except
                as
                provided in paragraph g below.

            

    

     

    
      	d.	
              The
                continuation of care for the disenrolled Member shall only pertain
                to the
                daily inpatient rate charged by such hospital providing the Member's
                inpatient care.

            

    

     

    
      	e.	
              The
                MCO shall participate in and coordinate the discharge planning process
                with the MCO involved in the Member's care for Members who fall within
                sections b, c, and d above.

            

    

     

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      	f.	
              As
                outlined in Appendix J, upon recategorization of a Member's eligibility
                from the HUSKY A to the HUSKY B program, the MCO shall provide continued
                coverage for an inpatient hospital stay as part of the HUSKY A coverage
                as
                of the effective date of the individual's enrollment into the MCO
                as a
                HUSKY B Member. In the instances where the inpatient stay was covered
                through the HUSKY A reinsurance program at the time of recategorization,
                the HUSKY A reinsurance ends effective the date of disenrollment
                of the
                individual as a HUSKY A Member.

            

    

     

    
      	g.	
              As
                outlined in Appendix J, upon recategorization of Members eligibility
                from
                the HUSKY B to the HUSKY A program, the MCO shall provide continued
                coverage for an inpatient hospital stay as part of the HUSKY A coverage
                as
                of the effective date of the individual's enrollment into the MCO
                as a
                HUSKY A Member. In the instances where the inpatient stay qualifies
                for
                HUSKY A reinsurance, the reinsurance day count starts with the
                individual's effective date of enrollment as a HUSKY A
                Member.

            

    

     

    3.26
      Open Enrollment

     

    
      	a.	
              The
                MCO shall conduct continuous open enrollment during which the MCO
                shall
                accept recipients eligible for coverage under this
                contract.

            

    

     

    
      	b.	
              The
                MCO shall not discriminate in enrollment activities on the basis
                of health
                status or the recipient's need for health care services or on any
                other
                basis, and shall not attempt to discourage or delay enrollment with
                the
                MCO or encourage disenrollment from the MCO of eligible HUSKY B
                Members.

            

    

     

    
      	c.	
              If
                the MCO discovers that a Member's new or continued enrollment was
                in
                error, the MCO shall notify the DEPARTMENT or its agent within sixty
                (60)
                days of the discovery or sixty (60) days from the date that the MCO
                had
                the data to determine that the enrollment was in error, whichever
                occurs
                first. Disenrollment of the Member will be made retroactive to the
                month
                during which the Member's circumstances changed to cause ineligibility,
                or
                if the Member never met eligibility requirements, to the date of
                initial
                enrollment. Failure to notify the DEPARTMENT or its agent within
                the
                parameters defined in this section will result in the retention of
                the
                Member by the MCO for the erroneous retroactive period of
                enrollment.

            

    

     

    3.27
      Special Disenrollment

     

    
      	a.	
              The
                MCO may request in writing and the DEPARTMENT may approve disenrollment
                for specific persons when there is good cause. The request shall
                cite the
                specific event(s), date(s) and other pertinent information substantiating
                the MCO's request. Additionally, the MCO shall submit any other
                information concerning
                the MCO's request that the DEPARTMENT may require in order to make
                a
                determination in the case.

            

    

     

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      	b.	
              Good
                cause is defined as a case in which a
                Member:

            

    

     

    
      	
            	1.	
              Exhibits
                uncooperative or disruptive behavior. If, however, such behavior
                results
                from the Member's special needs, good cause may only be found if
                the
                Member's continued enrollment seriously impairs the MCO's 

              ability
                to furnish services to either the particular Members;
                or

            

    

     

    
      	
            	2.	
              Permits
                others to use or loans his or her Membership card to others to obtain
                care
                or services.

            

    

     

    c.
      The
      following shall not constitute good cause:

     

    1.
      extensive or expensive health care needs;

    2.
      a
      change in the member's health status;

    3.
      me
      Member's diminished mental capacity; or

    4.
      uncooperative or disruptive behavior related to a medical condition, except
      as
      described in b. 1., above.

     

    d.
      The
      DEPARTMENT will notify an MCO prior to enrollment if a Member was previously
      disenrolled for cause from another MCO pursuant to this section.

     

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    3.28
      Linguistic Access

     

    
      	a.	
              The
                MCO shall take appropriate measures to ensure adequate access to
                services
                by Members with limited English proficiency. These measures shall
                include,
                but not be limited to the promulgation and implementation of policies
                on
                linguistic accessibility for MCO staff, network providers and
                subcontractors; the identification of a single individual at the
                MCO for
                ensuring compliance with linguistic accessibility policies; identification
                of persons with limited English proficiency as soon as possible following
                enrollment; provisions for translation services; and the provision
                of a
                Member handbook, and information in languages other than
                English.

            

    

     

    
      	b.	
              Member
                educational materials must also be available in languages other than
                English and Spanish when more than five (5) percent of the MCO's
                HUSKY B
                Members served by the MCO speaks the alternative language, provided,
                however, this requirement shall not apply if the alternative language
                has
                no written form. The MCO may rely upon initial enrollment and monthly
                enrollment data from the DEPARTMENT or its agent to determine the
                percentage of Members who speak alternative languages. All Member
                educational materials must be made available in alternate formats
                to the
                visually impaired.

            

    

     

    
      	c.	
              The
                MCO shall also take appropriate measures to ensure access to services
                by
                persons with visual and hearing
                disabilities

            

    

     

    Sanction:
      For each
      documented instance of failure to provide appropriate linguistic accessibility
      to Members, the DEPARTMENT may impose a strike towards a Class A sanction
      pursuant to Section 9.

     

    3.29
      Services to Members

     

    
      
        	a.	
                The
                  MCO shall have in place an ongoing process of Member education
                  which
                  includes, but is not limited to, development of a Member handbook;
                  provider directory; newsletter; and other Member educational materials.
                  All written materials and correspondence to Members shall be culturally
                  sensitive and written at no higher than a seventh grade reading
                  level. All
                  Member educational materials must be in both English and
                  Spanish.

              

      

    

    
       

      
        	b.	
                The
                  MCO shall mail the Member handbook and provider directory to Members
                  within one week of enrollment notification. The Member handbook
                  shall
                  address and explain, at a minimum, the
                  following:

              

      

    

    1.
      Covered services;

    2.
      Restrictions on services (including limitations and services not
      covered);

    3.
      Prior
      authorization process;

    4.
      Definition of and distinction between emergency care and urgent
      care;

     

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    5.
      Policies on the use of emergency and urgent care services including a phone
      number which can be used for assistance in obtaining emergency
      care;

    6.
      How to
      access care twenty-four (24) hours;

    7.
      Assistance locating an appropriate provider;

    8.
      Member
      rights and responsibilities;

    9.
      Member
      services, including hours of operation;

    10.
      Enrollment, disenrollment and plan changes;

    11.
      Procedures for selecting and changing PCP;

    12.
      Availability of provider network directory and updates;

    13.
      Limited liability for services from out-of-network providers;

    14.
      Access and availability standards;

    15.
      Special access and other MCO features of the health plan's program;

    16.
      Family planning services;

    17.
      Case
      management services targeted to Members as medically necessary and
      appropriate;

    18.
      Copayments;

    19.
      Allowances;

    20.
      Maximum annual aggregate cost-sharing;

    21.
      Premiums;

    22.
      Involuntary disenrollments;

    23.
      Appeals and complaints (internal MCO appeal process, external DOIappeal
      process);

    24.
      Preventive health guidelines; and

    25.
      Description of the drug formulary and prior approval process, if
      applicable.

     

    
      	c.	
              All
                Member educational materials must be prior approved by the DEPARTMENT.
                Educational materials include, but are not limited to Member handbook;
                Membership card; introductory and other text language from the provider
                directory; and all communications to Members that include HUSKY B
                program
                information. The MCO must wait until receiving DEPARTMENT written
                approval
                or thirty (30) days from the date of submittal before disseminating
                educational materials to Members.

            

    

     

    
      	d.	
              The
                MCO must provide periodic updates to the handbook or inform Members,
                as
                needed, of changes to the Member information discussed above. The
                MCO
                shall update its Member handbook to incorporate all provisions and
                requirements of this contract within six (6) weeks of the effective
                date.
                The MCO shall distribute the Member handbook within six (6) weeks
                of
                receiving the department's
                written
                approval.

            

    

     

    
      	e.	
              The
                MCO shall maintain an adequately staffed Member Services Department
                to
                receive telephone calls from Members in order to answer Members'
                questions, respond to Members' complaints and resolve problems
                informally.

            

    

     

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      	f.	
              The
                MCO shall identify to the DEPARTMENT the individual who is responsible
                for
                the performance of the Member Services
                Department.

            

    

     

    
      	g.	
              The
                MCO's Member Services Department shall include bilingual staff (Spanish
                and English) and translation services for non-English speaking Members.
                The MCO shall also make available translation services at provider
                sites
                either directly or through a contractual obligation with the service
                provider.

            

    

     

    
      	h.	
              The
                MCO shall require members of the Member Services Department to identify
                themselves to Members when responding to Members' questions or complaints.
                At a minimum, ninety (90) percent of all incoming calls shall be
                answered
                by a staff Member within the first minute and the call abandonment
                rate
                shall not exceed five (5) percent. The MCO shall submit call response
                and
                abandonment reports for the preceding six (6) month period to the
                DEPARTMENT upon request.

            

    

     

    
      	i.	
              When
                Members contact the Member Services Department to ask questions about,
                or
                complain about, the MCO's failure to respond promptly to a request
                for
                goods or services, or the denial, reduction, suspension or termination
                of
                goods or services, the MCO shall: attempt to resolve such concerns
                informally, and inform Members of the MCO's internal appeal
                process.

            

    

     

    
      	j.	
              The
                MCO shall maintain a log of complaints resolved informally, which
                shall be
                made available to the DEPARTMENT upon request, and which shall be
                a short
                dated summary of the problem, the response and the
                resolution.

              At
                the time of enrollment and at least annually thereafter, the MCO
                shall
                inform its Members of the procedural steps for filing an internal
                appeal
                and requesting an external
                review.

            

    

     

    k.
      The
      MCO shall monitor and track PCP transfer requests and follow up on complaints
      made by Members as necessary.

     

    
      	1.	
              The
                MCO will participate in two (2) Member surveys. The first such survey
                will
                be an analysis of Members with special needs as defined by the DEPARTMENT
                after consultation with the Children's Health Council, EQRO, and
                the MCO,
                to be conducted at the department's
                expense.
                The survey will be developed and the sample will be chosen by the
                Children's Health Council, with input from the MCOs and the DEPARTMENT.
                The other survey will be an NCQA Consumer Assessment of Health Plans
                Survey (CAHPS) of combined HUSKY A and B Members using an independent
                vendor and paid for by the MCO.

            

    

     

    
      	m.	
              The
                MCO may provide outreach to its current Members at the time of the
                Member's renewal of eligibility. The outreach may involve special
                mailings
                or phone calls as reminders that the Member must complete the HUSKY
                renewal forms to ensure continued
                coverage.

            

    

     

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    3.30
      Information to Potential Members

    

    a.
      The
      MCO shall, upon request, make the following information available to potential
      Members:

     

    1.
      the
      identity, locations, qualifications and availability of MCO's
      network;

    2.
      rights
      and responsibilities of Members;

    3.
      appeal
      procedures; and

    4.
      all
      covered items and services that are available either directly or indirectly
      or
      through referral and prior authorization.

     

    3.31.
      DSS Marketing Guidelines

     

    DSS
      marketing restrictions apply to subcontractors and providers of care as well
      as
      to the MCOs. The MCO shall notify all its subcontractors and network providers
      of the department's
      marketing
      restrictions. The detailed marketing guidelines are set forth in Appendix
      F,

     

    a.
      Prohibited Marketing Activities

     

    The
      following activities are prohibited, in all forms of communication, regardless
      of whether they are performed by the MCO directly, by its contracted providers,
      or its subcontractors:

    

    1.
      Asserting or implying that a Member will lose or not qualify for HUSKY benefits
      unless he/she enrolls in the MCO, or creating other threatening scenarios that
      do not accurately depict the consequences of choosing a different
      MCO;

     

    2.
      Discriminating (in marketing or in the course of the enrollment process) against
      any eligible individual on the basis of health status or need for future health
      care services.

     

    3.
      Making
      inaccurate, misleading or exaggerated statements (e.g. about the nature of
      the
      eligibility or enrollment process, the positive attributes of the MCO, or about
      the disadvantages of competing MCOs);

     

    4.
      Any
      unsolicited personal contact, including telephonic, door-to-door marketing
      or
      other cold call marketing or enrollment activities to potential
      Members;

     

    5.
      Failing to submit for approval marketing materials or marketing approaches
      when
      such approval is required by DSS (see Appendix F). MCOs and their providers
      must
      wait until receiving DSS written approval before
      disseminating any such information to potential Members. DSS reserves the right
      to request revisions or changes in material at any time;

     

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    6.
      Making
      any statements or assertions that the MCO is endorsed by the DEPARTMENT or
      CMS
      or any other governmental entity;

     

    7.
      Seeking to influence enrollment in conjunction with the sale or offering of
      private insurance; and

     

    8.
      Conducting any form of individual or group solicitation activity other than
      those expressly permitted under Appendix F, the DSS Marketing Guidelines, unless
      prior approval is obtained from DSS.

     

    b.
       Any
      type
      of marketing activity which has not been clearly specified as permissible under
      these guidelines should be assumed to be prohibited. The MCO shall contact
      the
      DEPARTMENT for guidance and approval for any activity not clearly permissible
      under these guidelines.

     

    c.
       The
      MCO
      shall ensure that, before enrolling. Members receive accurate written
      information needed to make an informed decision on whether to
      enroll;

     

    d.
       The
      MCO
      shall distribute marketing materials on a statewide basis.

     

    Sanction:
      If the
      MCO or its providers engage in inappropriate marketing activities, the
      DEPARTMENT may impose a sanction up to and including a Class C sanction pursuant
      to Section 9.05 as it deems appropriate.

     

    3.32
      Health Education

     

    The
      MCO
      must routinely, but no less frequently than annually, remind and encourage
      Members to utilize benefits including physical examinations which are available
      and designed to prevent illness. The MCO shall keep a record of all activities
      it has conducted to satisfy this requirement.

     

    3.33
      Quality Assessment and Performance Improvement

     

    
      	a.	
              The
                MCO is required to provide a quality level of care for all services,
                which
                it provides and for which it contracts. These services are expected
                to be
                medically necessary and may be provided by participating providers.
                The
                MCO shall implement a Quality Assessment and Performance Improvement
                program to assure the quality of care. The EQRO shall monitor the
                MCO's
                compliance with all requirements in this
                section.

            

    

     

    
      	b.	
              The
                MCO shall comply with DEPARTMENT requirements concerning Quality
                Assessment and Performance Improvement set forth below. The MCO will
                develop and implement an internal Quality Assessment and Performance
Improvement
                program consistent with the Quality Assessment and Performance Improvement
                program guidelines, as provided in Appendix
                G.

            

    

     

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    c.
      The
      MCO must have a Quality Assessment and Performance Improvement system
      which:

    1.
      Provides for review by appropriate health professionals of the processes
      followed in providing health services;

    2.
      Provides for systematic data collection of performance and participant
      results;

    3.
      Provides for interpretation of these data to the practitioners;

    4.
      Provides for making needed changes;

    5.
      Provides for the performance of at least one performance improvement project
      of
      the MCO's own choosing;

    6.
      Provides for participation in at least one performance improvement project
      conducted by the EQRO; and

    7.
      Has in
      effect mechanisms to detect both under utilization and over utilization of
      services.

     

    d.
      The
      MCO shall provide descriptive information on the operation, performance and
      success of its Quality Assessment and Performance Improvement system to the
      DEPARTMENT or its agent upon request.

     

    e.
      The
      MCO shall maintain and operate a Quality Assessment and Performance Improvement
      program which includes at least the following elements:

     

    1.
      A
      quality assessment and performance improvement assurance plan;

     

    2.
      A
      Quality Assessment and Performance Improvement Director who is responsible
      for
      the operation and success of the Quality Assessment and Performance Improvement
      Program. This person shall have adequate experience to ensure successful Quality
      Assessment and Performance Improvement, and shall be accountable for the Quality
      Assessment and Performance Improvement systems for all the MCO's providers,
      as
      well as the MCO's subcontractors;

     

    3.
      The
      Quality Assessment and Performance Improvement Director shall spend an adequate
      proportion of time on Quality Assessment and Performance Improvement activities
      to ensure that a successful Quality Assessment and Performance Improvement
      Program will exist. Under the Quality Assessment and Performance Improvement
      program, there shall be access on an as-needed basis to the full compliment
      of
      health professions (e.g., pharmacy, physical therapy, nursing, etc.) and
      administrative staff. Oversight of the program shall be provided by a Quality
      Assessment and Performance Improvement committee which includes representatives
      from:

     

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    a.
      Variety of medical disciplines (e.g., medicine, surgery, mental health, etc.)
      and administrative staff; and 

    b.
      Board
      of Directors of the MCO.

     

    4.
      The
      Quality Assessment and Performance Improvement committee shall be organized
      operationally within the MCO such that it can be responsible for all aspects
      of
      the Quality Assessment and Performance Improvement program.

     

    5.
      Quality Assessment and Performance Improvement activities shall be sufficiently
      separate from Utilization Review activities, so that Quality Assessment and
      Performance Improvement activities can be distinctly identified as
      such.

     

    6.
      The
      Quality Assessment and Performance Improvement activities of the MCO providers
      and subcontractors, if separate from the MCO's Quality Assessment and
      Performance Improvement activities shall be integrated into the overall MCO
      Quality Assessment and Performance Improvement program, and the MCO shall
      provide feedback to the providers/subcontractors regarding the operation of
      any
      such independent Quality Assessment and Performance Improvement effort. The
      MCO
      shall remain however, fully accountable for all Quality Assessment and
      Performance Improvement relative to its providers and
      subcontractors.

     

    7.
      The
      Quality Assessment and Performance Improvement committee shall meet at least
      quarterly and produce written documentation of committee activities to be shared
      with the DEPARTMENT or its agent.

     

    8.
      The
      results of the Quality Assessment and Performance Improvement activities shall
      be reported in writing at each meeting of the Board of Directors.

     

    9.
      The
      MCO shall have a written procedure for following up on the results of Quality
      Assessment and Performance Improvement activities to determine success of
      implementation. Follow-up shall be documented in writing.

     

    10.
      If
      the DEPARTMENT determines that a Quality Assessment and Performance Improvement
      plan does not meet the above requirements, the DEPARTMENT may provide the MCO
      with a model plan. The MCO agrees to modify its Quality Assessment and
      Performance Improvement plan based on negotiations with the
      DEPARTMENT.

     

    11.
      The
      MCO shall monitor access to and quality of health care goods and services for
      its Member population, and, at a minimum, use this mechanism to capture and
      report all of the DEPARTMENT'S required utilization data. The MCO shall be
      subject to an annual medical audit by the department's
      EQRO
      and
      shall provide access to the data and records requested.

     

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    12.
      To
      the extent permitted under federal and state law, the MCO certifies that all
      data and records requested shall, upon reasonable notice, be made available
      to
      the DEPARTMENT or its agent.

     

    13.
      The
      MCO will be an active participant in at least one of the EQRO's performance
      improvement focus studies each year.

     

    14.
      The
      MCO must comply with external quality review that will be implemented by an
      organization contracted by the DEPARTMENT. This may include participating in
      the
      design of the external review, collecting data including, but not limited to,
      administrative and medical data, HEDIS measures, and/or making data available
      to
      the review organization.

     

    15.
      The
      MCO must conduct at least one performance improvement project that includes
      the
      following:

     

    a.
      the
      project shall focus upon at one of the following areas:

    1)
      prevention and care of acute and chronic conditions;

    2)
      high
      volume services;

    3)
      continuity and coordination of care;

    4)
      appeals and complaints; and

    5)
      access
      to and availability of services.

     

    b.
      measurement of performance using quality indicators that are:

    1)
      objective;

    2)
      clearly and unambiguously defined;

    3)
      based
      on current clinical knowledge or health services research;

    4)
      valid
      and reliable;

    5)
      systematically collected; and

    6)
      capable of measuring outcomes such as changes in health status or Member
      satisfaction, or valid proxies of those outcomes.

    

    c.
      implementation of system interventions to achieve quality
      improvement;

    d.
      evaluation of the effectiveness of the interventions;

    e.
      planning and initiation of activities for increasing or sustaining improvement;
      and

    f.
      represent the entire population to which the quality indicator is
      relevant.

     

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    16.
      With
      the approval of the DEPARTMENT, the MCO may conduct performance
      improvement projects for the combined HUSKY A and HUSKY B
      population.

     

    3.34
      Inspection of Facilities

     

    
      	a.	
              The
                MCO shall provide the State of Connecticut and any other legally
                authorized governmental entity, or their authorized representatives,
                the
                right to enter at all reasonable times the MCO's premises or other
                places,
                including the premises of any subcontractor, where work under this
                contract is performed to inspect, monitor or otherwise evaluate work
                performed pursuant to this contract. The MCO shall provide reasonable
                facilities and assistance for the safety and convenience of the persons
                performing those duties. The DEPARTMENT and its authorized agents
                will
                request access in advance in writing except in case of suspected
                fraud and
                abuse.

            

    

     

    
      	b.	
              In
                the event right of access is requested under this section, the MCO
                or
                subcontractor shall upon request provide and make available staff
                to
                assist in the audit or inspection effort, and provide adequate space
                on
                the premises to reasonably accommodate the State or Federal
                representatives conducting the audit or inspection
                effort.

            

    

     

    
      	c.	
              The
                MCO shall be given ten (10) business days to respond to any findings
                of an
                audit before the DEPARTMENT shall finalize its findings. All information
                so obtained will be accorded confidential treatment as provided under
                applicable law.

            

    

     

    3.35
      Examination of Records

     

    
      
        
          	a.	
                  The
                    MCO shall develop and keep such records as are required by law
                    or other
                    authority or as the DEPARTMENT determines are necessary or useful
                    for
                    assuring quality performance of this contract. The DEPARTMENT
                    shall have
                    an unqualified right of access to such records in accordance
                    with Part II
                    Section 3.34.

                

        

      

    

     

    
      	b.	
              Upon
                non-renewal or termination of this contract, the MCO shall turn over
                or
                provide
                copies to the DEPARTMENT or to a designee of the DEPARTMENT all documents,
                files and records relating to persons receiving services and to the
                administration of this contract that the DEPARTMENT may request,
                in
                accordance with Part I Section
                3.34.

            

    

     

    
      	c.	
              The
                MCO shall provide the DEPARTMENT and its authorized agents with
                reasonable
                access to records the MCO maintains for the purposes of this contract.
                The
                DEPARTMENT and its authorized agents will request access in writing
                except
                in cases of suspected fraud and abuse. The MCO must make all requested
                medical records available within thirty (30) days of the department's
                request. Any contract with a subcontractor must include a provision
                specifically authorizing access in accordance with the terms set
                forth in
                Part I Section 3.35.

            

    

     

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      	d.	
              The
                MCO shall maintain the confidentiality of patients' records in conformance
                with this contract and state and federal statutes and regulations,
                including, but not limited to, the Health Insurance Portability and
                Accountability Act (HIPAA), 42 U.S.C. 1320d-2 et seq., 45 CFR pts.
                160 and 164, the Connecticut Insurance Information and Privacy Act,
                Section 38a-975 et seq.
                of
                the Connecticut General Statutes, and as applicable the Gramm-Leach-Bliley
                Act, 15 U.S.C. 6801 et seq.

            

    

     

    
      	e.	
              The
                MCO, for purposes of audit or investigation, shall provide the State
                of
                Connecticut,
                the Secretary of HHS and his/her designated agent, and any other
                legally
                authorized governmental entity or their authorized agents access
                to all
                the MCO's materials and information pertinent to the services provided
                under this contract and Member health claims and payment data, at
                any
                time, until the expiration of three (3) years from the completion
                date of
                this contract as extended.

            

    

    
       

      
        	f.	
                The
                  State and its authorized agents may record any information and
                  make copies
                  of any materials necessary for the
                  audit.

              

      

    

     

    
      	g.	
              Retention
                of Records: The MCO and its subcontractors shall retain financial
                records,
                supporting documents, statistical records and all other records supporting
                the services provided under this contract for a period of five (5)
                years
                from the completion date of this contract. The MCO shall make the
                records
                available at all reasonable times at the MCO's general offices. The
                DEPARTMENT and its authorized agents will request access in writing
                except
                in cases of suspected fraud and abuse. If any litigation, claim or
                audit
                is started before the expiration of the five (5) year period, the
                records
                must be retained until all litigation, claims or audit findings involving
                the records have been resolved. The MCO must make all requested records
                available within thirty (30) days of the department's
                request.

            

    

     

    
      	h.	
              The
                MCO shall not avoid costs for services covered in this contract by
                referring Members to publicly supported health care
                resources.

            

    

     

    3.36
      Medical Records

     

    
      	a.	
              In
                compliance with all state and federal law governing the privacy of
                individually identifiable health care information including the Health
                Insurance Portability and Accountability Act (HIPAA), 42 USC Sections
                1320d-2 et seq.. 45 CFR pts. 160 and 164, the MCO shall establish
                a
                confidential, centralized record, for each Member, which includes
                information of all medical goods and services received. The MCO may
                delegate maintenance of the centralized medical record to the Member's
                PCP, provided however, that the record shall be made available upon
                request and reasonable notice, to the DEPARTMENT or its agent(s)
                at a
                centralized location. The medical record shall meet the department's
                medical
                record requirements as defined by the DEPARTMENT in its regulations,
                and
                shall comply with the requirements of the National Committee on Quality
                Assurance (NCQA) or other national accrediting body with a recognized
                expertise in managed care. The MCO shall establish a confidential,
                centralized record, which includes the medical record, for all Members
                including all goods and services received. The MCO may delegate
                maintenance of the centralized medical record to the Member's
                PCP,
                provided however, that the record shall be made available upon request
                and
                reasonable notice, to the DEPARTMENT or its agent(s) at a centralized
                location. The MCO or PCP shall maintain the medical records in compliance
                with all state and federal law governing the privacy of individually
                identifiable health care information including the Health Insurance
                Portability and Accountability Act (HIPAA), 42 U.S.C. 1320d-2 et
                sea., 45
                CFR pts. 160 and 164. The medical record shall meet the department's
                medical
                record requirements as defined by the DEPARTMENT in its regulations,
                and
                shall comply with the requirements of the
                NCQA.

            

    

     

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      	b.	
              The
                MCO shall not turn over or provide documents, files and records pertaining
                to a Member to another health plan unless the Member has changed
                enrollment to the other plan and the MCO has been so notified by
                the
                DEPARTMENT or its agent.

            

    

     

    3.37
      Audit Liabilities

     

    In
      addition to and not in any way in limitation of the obligation of the contract,
      it is understood and agreed by the MCO that the MCO shall be held liable for
      any
      finally determined State or Federal audit exceptions and shall return to the
      DEPARTMENT all payments made under the contract to which exception has been
      taken or which have been disallowed because of such an exception.

     

    3.38
      Clinical Data Reporting

     

    
      	a.	
              Utilization
                Reporting: The MCO shall submit reports to the DEPARTMENT or its
                agent in
                the areas listed below. The purpose of the reports is to assist the
                DEPARTMENT in its efforts to assess and evaluate the performance
                of the
                HUSKY B program and the MCO.

            

    

     

    
      	b.	
              Utilization
                reports shall cover, but not be limited to, the following
                areas:

            

    

     

    1.
      well-child visits;

    2.
      immunizations;

    3.
      maternal and prenatal care;

    4.
      preventive care;

    5.
      inpatient and outpatient services;

    6.
      dental
      services;

    7.
      behavioral health and substance abuse services;

    8.
      HEDIS/CAHPS; and

    9.
      other
      services.

     

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      	c.	
              The
                DEPARTMENT shall consult with the MCO, through a workgroup comprised
                of the DEPARTMENT, its agent, and MCO representatives that meets
                on a
                periodic basis, or as needed, to discuss the necessary data, methods
                of
                collecting the data, and the format and media for new reports or
                changes
                to existing reports.

            

    

     

    
      	d.	
              The
                MCO shall submit reports, which comply with the department's
                standards,
                to the DEPARTMENT or its agent. For each report the DEPARTMENT shall
                consider using any HEDIS standards promulgated by the NCQA which
                covers
                the same or similar subject matter. The DEPARTMENT reserves the right
                to
                modify HEDIS standards, or not use them at all, if in the department's
                judgment,
                the objectives of the HUSKY B program can be better served by using
                other
                methods.

            

    

     

    
      	e.	
              The
                DEPARTMENT or its agent, will choose a random sample of administrative
                and
                medical records each year, in order to measure utilization of services.
                The MCO will make required records available to the DEPARTMENT or
                agent,
                at a location upon reasonable notice. The agent shall review the
                records
                and report back to the DEPARTMENT on the extent to which the reporting
                measure results are validated through comparison with the records.
                Prior
                to making its report to the DEPARTMENT, its agent shall afford the
                MCO
                reasonable opportunity to suggest corrections to or comment upon
                the
                agent's findings.

            

    

     

    
      	f.	
              The
                DEPARTMENT shall provide the MCO with final specifications for submitting
                all reports no less than ninety (90) days before the reports are
                due. The
                MCO shall submit reports on a schedule to be determined by the DEPARTMENT,
                but not more frequently than quarterly. Before the beginning of each
                calendar year, the DEPARTMENT shall provide the MCO with a schedule
                of
                utilization reports, which shall be due that calendar year. Due dates
                for
                the reports shall be at the discretion of the DEPARTMENT, but not
                earlier
                than ninety (90) days after the end of the period that they
                cover.

            

    

     

    Sanction:
      Failure
      to comply with the above reporting requirements in a complete and timely manner
      may result in a strike towards a Class A sanction, pursuant to Section
      9.05.

     

    3.39
      Utilization Management

    
       

      
        
          	a.	
                  The
                    MCO and any subcontractor is required to be licensed by the Connecticut
                    Department of Insurance as a utilization review company. The
                    MCO may
                    subcontract with a licensed utilization review company to perform
                    some or
                    all of the MCO's utilization management
                    functions.

                

        

      

    

    
      	 	
               

            	
            

    

     

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      	b.	
              If
                the MCO subcontracts for any portion of the utilization management
                function, the MCO shall provide a copy of any such subcontract to
                the
                DEPARTMENT and any such subcontract shall be subject to the provisions
                of
                Section 7.08 of this contract. The DEPARTMENT will review and approve
                the
                subcontract, subject to the provisions of Section 3.44, to ensure
                the
                appropriateness of the subcontractor's policies and procedures. The
                MCO is
                required to conduct regular and comprehensive monitoring of the
                utilization management
                subcontractor.

            

    

     

    The
      MCO
      and its subcontractors shall comply with the utilization review provisions
      of
      Connecticut General Statutes Section 38a-226c.

     

    3.40
      Financial Records

     

    a.
       The
      MCO
      shall maintain for the purpose of this contract, an accounting system of
      procedures and practices that conforms to Generally Accepted Accounting
      Principles.

     

    
      	b.	
              The
                MCO shall permit audits or reviews by the DEPARTMENT and HHS or their
                agent(s), of the MCO's financial records related to the performance
                of
                this contract and the MCO's subcontrators' financial records related
                to
                the performance of this contract. In addition, the MCO will be required
                to
                provide Claims Aging Inventory Reports, Claims Turn Around Time Reports,
                cost, and other reports as outlined in sections (c) and (d) below
                or as
                directed by the DEPARTMENT.

            

    

     

    
      	c.	
              Reports
                specific to the MCO's HUSKY line of business shall be provided in
                formats
                developed by the DEPARTMENT. All reports described in Section 3.40
                (c)(l)
                and 3.40(c)(2) shall contain separate sections for HUSKY A and B.
                It is
                anticipated that the requirements in this area will be modified to
                enable
                the DEPARTMENT to respond to inquiries that the DEPARTMENT receives
                regarding the financial status of the HUSKY program, to determine
                the
                relationship of capitation payments to actual appropriations for
                the
                program, and to allow for proper oversight of fiscal issues related
                to the
                managed care programs. The MCO will cooperate with the DEPARTMENT
                or its
                agent(s) to meet these objectives. The following is a list of required
                reports:

            

    

     

    
      	
            	1.	
              Audited
                financial reports per MCO HUSKY line of business. If the MCO is licensed
                as a health care center or insurance company, both the annual audited
                financial reports for the MCO and the audited financial reports per
                MCO
                HUSKY line of business shall be conducted and reported in accordance
                with
                C.G.S. Section 38a-54. If the MCO is not licensed as a health care
                center
                or insurance company, the annual audited financial reports for the
                MCO and
                the audited financial reports per MCO line of business shall be completed
                in accordance with generally accepted auditing principles. The
                MCO may elect to combine HUSKY A and HUSKY B in the audited financial
                statement. If this election is made, the MCO shall also submit the
                following: a separate unaudited income statement for HUSKY A and
                HUSKY B,
                which will be compared to the audited financial
                statement.

            

    

     

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            	2.	
              Unaudited
                financial reports, HUSKY line of business (formats shown in Appendix
                H).
                The reports shall be submitted quarterly, forty-five (45) days subsequent
                to the end of each quarter. Every line of the requested report must
                contain a dollar figure or an indication that said line is not
                applicable.

            

    

     

    
      	
            	3.	
              Annual
                and Quarterly Statements. If the MCO is licensed as a health care
                center
                or insurance company, the MCO is required to submit Annual and Quarterly
                Statements to the Department of Insurance in accordance with the
                C.G.S.
                Section 38a-53. One copy of each statement shall be submitted to
                the
                DEPARTMENT in accordance with Department of Insurance submittal
                schedule.

            

    

     

    
      	
            	4.	
              Claims
                Aging Inventory Report (format shown in Appendix H or any other
                format approved by the DEPARTMENT). The report will include all HUSKY
                claims outstanding as of the end of each quarter, by type of claim,
                claim
                status and aging categories. If a subcontractor is used to provide
                services and adjudicate claims or a vendor is used to adjudicate
                claims,
                the MCO is responsible for providing a claims aging report in the
                required
                format for 

              each
                current or prior subcontractor who has claims outstanding. The Claims
                Aging Inventory reports will be submitted to the DEPARTMENT forty-five
                (45) days subsequent to the end of each
                quarter.

            

    

     

    
      	
            	5.	
              Claims
                Turn Around Time Report (format shown in Appendix H or any other
                format
                approved by the DEPARTMENT). For those claims processed in forty-six
                (46)
                or more days, indicate if interest was paid in accordance 

              with
                the Section 3.43 of the contract. If a subcontractor is used to provide
                services and adjudicate claims or a vendor is used to adjudicate
                claims,
                the MCO is responsible for providing a Claims Turn Around Time Report
                for
                each current or prior subcontractor who has claims outstanding. The
                Claims
                Turn Around Time Report will be submitted to the DEPARTMENT forty-five
                (45) days subsequent to the end of each
                quarter.

            

    

     

    
      	d.	
              The
                MCO shall maintain accounting records in a manner which will enable
                the
                DEPARTMENT to easily audit and examine any books, documents, papers
                and
                records maintained in support of the contract. All such documents
                shall be
                made available to the DEPARTMENT at its request, and shall be clearly
                identifiable as pertaining to the
                contract.

            

    

     

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        	e.	
                The
                  MCO shall make available on request all financial reports required
                  by the
                  terms of any current contract with any other state agency(s) provided
                  that
                  said agency agrees that such information may be shared with the
                  DEPARTMENT.

              

      

       

    

    3.41
      Insurance

     

    The
      MCO,
      its successors and assignees shall procure and maintain such insurance as is
      required by currently applicable federal and state law and regulation. Such
      insurance shall include, but not be limited to, the following:

     

    1.
      liability insurance (general, errors and omissions, and directors and officers
      coverage);

    2.
      fidelity bonding or coverage of persons entrusted with handling of
      funds;

    3.
      workers compensation; and

    4.
      unemployment insurance.

     

    The
      MCO
      shall name the State of Connecticut as an additional insured party under any
      insurance, except for professional liability, workers compensation, unemployment
      insurance, and fidelity bonding maintained for the purposes of this contract.
      However, the MCO shall name the State of Connecticut as either a loss payee
      or
      additional insured for fidelity bonding coverage.

     

    3.42
      Subcontracting for Services

     

    
      	a.	
              Licensed
                health care facilities, group practices and licensed health care
                professionals
                operating within the scope of their practice may contract with the
                MCO
                directly or indirectly through a subcontractor who directly contracts
                with
                the MCO. The MCO shall be held directly accountable and liable for
                all of
                the contractual provisions under this contract regardless of whether
                the
                MCO chooses to subcontract its responsibilities to a third party.
                No
                subcontract shall operate to terminate the legal responsibility of
                the MCO
                to assure that all activities carried out by the subcontractor conform
                to
                the provisions of this contract. Subcontracts shall not terminate
                the
                legal liability of the MCO under this
                contract.

            

    

     

    
      	b.	
              The
                MCO may subcontract for any function, excluding Member Services,
                covered
                by this contract, subject to the requirements of this contract. All
                subcontracts shall be in writing, shall include any general requirements
                of this contract that are appropriate to the services being provided,
                and
                shall assure that all delegated duties of the MCO under this contract
                are
                performed. All subcontracts shall also provide for the right of the
                DEPARTMENT or another governmental entity to enter the subcontractor's
                premises to inspect, monitor or otherwise evaluate the work being
                performed as a delegated duty of this contract, as specified in Section
                3.33, Inspection of Facilities.

            

    

     

    
      
        	c.	
                With
                  the exception of subcontracts specifically excluded by the DEPARTMENT,
                  all
                  subcontracts shall include verbatim the HUSKY B definitions of
                  Medical
                  Appropriateness/Medically
                  Appropriate and Medically Necessary/Medical Necessity as set forth
                  in the
                  Definitions, Part I, Section 1 of this contract. All subcontracts
                  shall
                  require the use of these definitions by subcontractors in all requests
                  for
                  approval of coverage of goods or services made on behalf of HUSKY
                  B
                  Members. All subcontracts shall also provide that decisions concerning
                  both acute and chronic care must be made according to these
                  definitions.

              

      

    

     

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      	d.	
              Within
                fifteen (15) days of the effective date of this contract the MCO
                shall
                provide
                the DEPARTMENT with a report of those functions under this contract
                that
                the MCO will be providing through subcontracts and copies of the
                contracts
                between the MCO and the subcontractor. Such report shall identify
                the
                names of the subcontractors, their addresses and a summary of the
                services
                they will be providing. If the MCO enters into any additional subcontracts
                after the MCO's initial compliance with this section, the MCO shall
                obtain
                the advance written approval of the DEPARTMENT. The MCO shall provide
                the
                DEPARTMENT with a draft of the proposed subcontract thirty (30) days
                in
                advance of the completion of the MCO's negotiation of such subcontract.
                In
                addition, amendments to any such subcontract, excluding those of
                a
                technical nature, shall require the pre-review and approval of the
                DEPARTMENT.

            

    

     

    
      	e.	
              All
                behavioral health and dental subcontracts, which include the payment
                of
                claims
                on behalf of HUSKY B Members for the provision of goods or services
                to
                HUSKY B Members shall require a performance bond, letter of credit,
                statement of financial reserves or payment withhold requirements.
                The
                performance bond, letter of credit, statement of financial reserves
                or
                payment withhold requirements shall be in a form to be mutually agreed
                upon by the MCO and the subcontractor. The amount of the performance
                bond
                shall be sufficient to ensure the completion of the subcontractor's
                claims
                processing and provider payment obligations under the subcontract
                in the
                event the contract between the MCO and the subcontractor is terminated.
                The MCO shall submit reports to the DEPARTMENT upon the department's
                request
                related to any payments made from the performance bonds or any payment
                withholds.

            

    

     

    
      
        	f.	
                All
                  subcontracts shall include provisions for a well-organized transition
                  in
                  the event of termination of the subcontract for any reason. Such
                  provisions shall ensure that an adequate provider network will
                  be
                  maintained at all times during any such transition period and that
                  continuity of care is maintained for all
                  Members.

              

      

       

      
        
          	g.	
                  Prior
                    to the approval by the DEPARTMENT of any subcontract with a behavioral
                    health or dental subcontractor, the MCO shall submit a plan to
                    the
                    DEPARTMENT for the resolution of any outstanding claims submitted
                    by
                    providers to the MCO's previous behavioral health or dental subcontractor.
                    Such plan shall meet the requirements described in subsection
                    (h)
                    below.

                

        

      

    

     

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      	h.	
              In
                the event that a subcontract is terminated, the MCO shall submit
                a written
                transition
                plan to the DEPARTMENT sixty (60) days in advance of the scheduled
                termination. The transition plan shall include provisions concerning
                financial responsibility for the final settlement of provider claims
                and
                data reporting, which at a minimum must include a claims aging report
                prepared in accordance with Section 3.40 (c)(5) of this contract,
                with
                steps to ensure the resolution of the outstanding amounts. This plan
                shall
                be submitted prior to the department's
                approval.

            

    

     

    
      	i.	
              All
                subcontracts shall also include a provision that the MCO will withhold
                a
                portion of the final payment to the subcontractor, as a surety bond
                to
                ensure compliance under the terminated
                subcontract.

            

    

     

    
      	j.	
              The
                MCO shall have no right to and shall not assign, transfer or delegate
                this
                contract
                in its entirety, or any right or duty arising under this contract
                without
                the prior written approval of the DEPARTMENT. The DEPARTMENT in its
                discretion may grant such written approval of an assignment, transfer
                or
                delegation provided, however, that this paragraph shall not be construed
                to grant the MCO any right to such
                approval.

            

    

     

    3.43
      Timely Payment of Claims

     

    If
      the
      MCO or any other subcontractor or vendor who adjudicates claims fails to pay
      a
      clean claim within forty-five (45) days of receipt, or as otherwise stipulated
      by a provider contract, the MCO, vendor or subcontractor shall pay the provider
      the amount of such clean claims plus interest at the rate of fifteen (15)
      percent per annum or as stipulated by a provider contract. In accordance with
      Section 3.40 (c)(5), Financial Records, the MCO shall provide to the DEPARTMENT
      information related to interest paid beyond the forty-five (45) day timely
      filing limit, or as otherwise stipulated by provider contracts.

     

    3.44
      Insolvency Protection

     

    The
      MCO
      must maintain protection against insolvency as required by the DEPARTMENT
      including demonstration of adequate initial capital and ongoing reserve
      contributions. The MCO must provide financial data to the DEPARTMENT in
      accordance with the department's
      required
      formats and timing.

     

    3.45
      Fraud and Abuse

     

    
      
        	a.	
                The
                  MCO shall not knowingly take any action or failure to take action
                  that
                  could result in an unauthorized benefit to the MCO, its employees,
                  its
                  subcontractors, its vendors, or to a
                  Member.

              

      

       

      
        
          	b.	
                  The
                    MCO commits to preventing, detecting, investigating, and reporting
                    potential fraud and abuse occurrences, and shall assist the DEPARTMENT
                    and
                    HHS inpreventing
                    and prosecuting fraud and abuse in the HUSKY B
                    program.

                

        

      

    

     

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      	c.	
              The
                MCO acknowledges that the DEPARTMENT and HHS, Office of the Inspector
                General, has the authority to impose civil monetary penalties on
                individuals and entities that submit false and fraudulent claims
                to the
                HUSKY B program.

            

    

     

    
      	d.	
              The
                MCO shall immediately notify the DEPARTMENT when it detects a situation
                of potential fraud or abuse, including, but not limited to, the
                following:

            

    

     

    1.
      False
      statements, misrepresentation, concealment, failure to disclose, and conversion
      of benefits;

     

    2.
      Any
      giving or seeking of kickbacks, rebates, or similar remuneration;

     

    3.
      Charging or receiving reimbursement in excess of that provided by the
      DEPARTMENT; and

     

    4.
      False
      statements or misrepresentation made by a provider, subcontractor, or Member
      in
      order to qualify for the HUSKY program.

     

    
      	e.	
              Upon
                written notification of the DEPARTMENT, the MCO shall cease any conduct
                that the DEPARTMENT or its agent deems to be abusive of the HUSKY
                program,
                and to take any corrective actions requested by the DEPARTMENT or
                its
                agent.

            

    

     

    
      	f.	
              The
                MCO attests to the truthfulness, accuracy, and completeness of all
                data
                submitted to the DEPARTMENT, based on the MCO's best knowledge,
                information, and belief. This data certification requirement includes
                encounter data and also applies to the MCO's
                subcontractors.

            

    

     

    
      	g.	
              The
                MCO shall establish a fraud and abuse plan, including, but not necessarily
                limited to, the following efforts:

            

    

     

    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, providers, and subcontractors about fraud and abuse and
      how
      to report it;

     

    4.
      effectively organizing resources to respond to complaints of fraud and
      abuse;

     

    5.
      establishing procedures to process fraud and abuse complaints; and

     

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    6.
      establishing procedures for reporting information to the
      DEPARTMENT.

     

    
      	h.	
              The
                MCO shall examine publicly available data, including but not limited
                to
                the HCFA Medicare/Medicaid Sanction Report and the HCFA website
                (http://www.oig.hhs.gov) to determine whether any potential or current
                employees, providers, or subcontractors have been suspended or excluded
                or
                terminated from the Medicare or Medicaid programs and shall comply
                with,
                and give effect to, any such suspension, exclusion, or termination
                in
                accordance with the requirements of state and federal
                law.

            

    

     

    
      	i.	
              The
                MCO must provide full and complete information on the identity of
                each
                person
                or corporation with an ownership or controlling interest (five (5)
                percent) in the managed care plan, or any subcontractor in which
                the MCO
                has a five (5) percent or more ownership
                interest.

            

    

     

    
      	j.	
              The
                MCO must immediately provide full and complete information when it
becomes
                aware of any employee or subcontractor who has been convicted of
                a civil
                or criminal offense related to that person's involvement under Medicare,
                Medicaid, or any other federal or state assistance program prior
                to
                entering into or renewing this
                contract.

            

    

     

    Sanction:
      The
      DEPARTMENT may impose a sanction up to an including a Class C sanction for
      the
      failure to comply with any provision of this section, or take any other action
      set forth in Section 9.05 of this contract, including terminating or refusing
      to
      renew this contract, or any other remedy allowed by federal or state
      law.

     

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    4.
      MCO RESPONSIBILITY CONCERNING PAYMENTS MADE ON BEHALF OF THE
      MEMBER

     

    4.01
      Deductibles, Coinsurance, Annual Benefit Maximums, and Lifetime Benefit
      Maximums

     

    The
      MCO
      shall not apply deductibles, coinsurance, or annual or lifetime benefit maximums
      to any covered goods and services provided to Members in HUSKY B.

     

    4.02
      Payments for Noncovered Services

     

    The
      MCO
      may allow a provider to charge for noncovered goods or services provided to
      a
      Member only if the parent or applicant knowingly elects to receive the goods
      or
      services and enters into an agreement in writing to pay for such goods or
      services prior to receiving them. For purposes of this section, noncovered
      services are services other than those described in Appendix A of this contract,
      services that are provided in the absence of appropriate authorization by the
      MCO, and services that are provided out-of-network unless otherwise specified
      in
      the contract or regulation.

     

    No
      payment made for non-covered services shall be considered cost-sharing for
      purposes of determining the family's maximum annual aggregate cost-sharing
      limit.

     

    4.03
      Cost-Sharing Exemption for American Indian/Alaskan Native
      Children

     

    Families
      of American Indian/ Alaskan Native (AI/AN) children who are Members of a
      Federally recognized tribe and who are in Income Band 1 or 2 are exempted from
      paying HUSKY B premiums or copayments.

     

    The
      DEPARTMENT or its agent will determine each AI/AN family's eligibility for
      HUSKY
      B and the appropriate Income Band, and will also determine whether or not a
      family's children qualify for the AI/AN cost-sharing exemption. The DEPARTMENT
      or its agent will then notify the MCO whether the Member is qualified for the
      exemption and the appropriate Income Band for the family. The MCO shall ensure
      that the family is not charged any premiums or copayments for qualified AI/AN
      children as of the date the DEPARTMENT or its agent makes that
      determination.

     

    The
      MCO
      shall notify its providers and subcontractors of the AI/AN exemption from
      premiums and copayments. Member handbooks and information handouts developed
      by
      the MCO shall include information about the AI/AN exclusion from premiums and
      copayments. The MCO shall refer any Members who believe they qualify for the
      AI/AN exemption to the DEPARTMENT or its agent for a determination of their
      qualification.

     

    The
      MCO
      shall provide all qualified AI/AN children in Income Bands 1 and 2 with
      Membership identification cards stating "no copayments" and the MCO shall inform
      their

     

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    HUSKY
      B
      providers and subcontractors that children with Membership cards so noted shall
      not be charged copayments.

     

    If
      the
      family has paid premiums and/or copayments for qualified AI/AN children, it
      is
      the responsibility of the MCO to repay the premiums and/or copayments to the
      family within three (3) months of the MCO's determination that they were paid.
      It is the responsibility of the MCO to review the Member accounts quarterly
      to
      determine which families have paid premiums and/or copayments for qualified
      AI/AN children. The quarterly review must be completed no later than fifteen
      (15) days after the end of each quarter. The MCO shall make the review available
      to the DEPARTMENT upon request.

     

    Sanction:
      If the
      MCO fails to repay the overpayment to the family within three (3) months of
      the
      determination that the premium payment liability has been reached or if the
      MCO
      fails to exempt AI/AN children from premiums or copayments, the DEPARTMENT
      may
      impose a sanction up to and including a Class B sanction pursuant to Section
      9.05.

     

    4.04
      Copayments

     

    The
      MCO
      shall allow providers to collect copayments for the following goods and services
      only: outpatient physician visits, except for well child visits; powered
      wheelchairs; hearing examinations; nurse midwife visits; nurse practitioner
      visits; podiatrist
      visits; chiropractor visits; naturopathic visits; eye care exams; oral
      contraceptives; generic and brand name prescriptions; mental health outpatient
      visits; outpatient
      behavioral health visits for substance abuse; and non-emergency care provided
      in
      a hospital emergency department or urgent care facility, except for a condition
      such that a prudent layperson, acting reasonably, would have believed that
      emergency medical treatment is needed. The amounts of these copayments are
      detailed in Appendix A.

     

    4.05
      Copayments Prohibited

     

    No
      copayment shall be charged for preventive care and services, including all
      well-baby and well-child services as described in 42 CFR 457.520; family
      planning services, excluding oral contraceptives; inpatient physician services;
      inpatient hospital services; outpatient
      surgical visits; ambulance for emergency medical conditions; skilled nursing;
      home
      health services; hospice and short-term rehabilitation; physical therapy,
      occupational therapy and speech therapy; laboratory and x-ray services,
      including diagnostic and treatment radiology and ultrasound treatment;
      preadmission testing; prosthetic
      devices; durable medical equipment other than powered wheelchairs; emergency
      medical conditions; and the following dental services: oral exams, prophylaxis,
      x-rays, fillings, fluoride treatments, sealants, and oral surgery.

     

    4.06
      Maximum Annual Limits for Copayments

     

    The
      maximum annual limit for copayments is $650 for families in Income Bands 1
      and
      2. Effective February 1, 2004, the maximum aggregate cost-sharing limit for
      co-
payments
      will increase to $760 for families in Income Bands 1 and 2. For these families,
      the MCO shall not allow copayments to be charged once the family has reached
      its
      maximum annual limit for copayments.

     

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    The
      maximum annual limit applies to the entire family regardless of the number
      of
      eligible children in such family who are enrolled in the MCO. The maximum annual
      limit applies to each eligibility period. The eligibility period is the one-year
      period following the Member's initial eligibility date or, for subsequent years,
      the one year-period following the anniversary of the initial eligibility
      date.

     

    It
      is the
      responsibility of the MCO to review the Member accounts at a minimum on a
      quarterly basis to determine which families have reached their maximum annual
      limit for copayments. The review must be completed no later than fifteen (15)
      days after the end of each review period. The MCO shall make the review
      available to the DEPARTMENT upon request.

     

    If
      the
      family has paid more than the allowed limits for copayments, it is the
      responsibility of the MCO to repay the overpayment to the family within three
      (3) months of the MCO's determination that the maximum annual limit for
      copayments had been met.

     

    There
      is
      no maximum annual limit for copayments for families in Income Band
      3.

     

    Sanction:
      If the
      MCO fails to have an effective tracking system for the maximum annual co-payment
      provisions, the DEPARTMENT may impose a Class B sanction pursuant to Section
      9.05.

     

    4.07
      Tracking Copayments

     

    The
      MCO
      shall establish and maintain a system to track the copayments incurred by each
      family in Income Bands 1 and 2 in order to adhere to the requirements of the
      maximum annual aggregate cost-sharing limit for copayments. The MCO shall
      require their providers and subcontractors to verify whether a family has
      reached the maximum annual limit for copayments before charging a
      copayment.

     

    The
      MCO
      shall carry over the tracking of the copayment from one Income Band to the
      other
      within the annual period for families who move between Income Bands 1 and 2.
      For
      families moving within the annual period into Income Bands 1 or 2 from Income
      Band 3, the tracking begins with the enrollment in Income Band 1 or
      2.

     

    If
      the
      Member is disenrolled due to nonpayment of premiums, the MCO shall maintain
      the
      tracked information on file for costs incurred through the date of disenrollment
      in the event the Member is re-enrolled after payment of the premium within
      the
      annual period. If the Member is re-enrolled within the annual period, the MCO
      will resume tracking the copayments paid by the family throughout the remainder
      of the annual period.

     

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    Families
      in Income Bands 1 and 2 shall not be charged copayments once the maximum annual
      limits have been met. When a family in Income Bands 1 or 2 reaches the maximum
      annual limits for copayments, the MCO shall inform the providers and
      subcontractors that the copayment limit has been met, that the providers and
      subcontractors cannot charge further copayments within the annual period, and
      the date when the annual period ends. The MCO shall provide this same
      information to the parent and the applicant.

     

    The
      MCO
      shall send a monthly file to the DEPARTMENT or its agent showing the premiums
      and copayments paid by the family. The DEPARTMENT or its agent will keep
      information regarding the amount of copayments each family incurs within the
      annual period and if the children of the family disenroll and enroll in another
      MCO within the annual period, the DEPARTMENT or its agent will forward the
      family copayment totals for the annual period to the new MCO.

     

    If
      a
      family believes it has reached the maximum annual limit for copayments, it
      may
      request, in writing, that the MCO review the copayments that have been paid
      by
      the family. The MCO shall then review the copayments made by the family and
      respond to the family, in writing, within three (3) weeks of the date of the
      family's written request. If the family disagrees with the MCOs determination,
      the family may request, in writing, a review by the DEPARTMENT. The MCO and
      the
      family shall abide by the decision of the DEPARTMENT. The MCO shall include
      a
      summary of this right and the appropriate procedures to request the review
      in
      its Member Handbook.

     

    If
      the
      family has paid more than the allowed limits for copayments, it is the
      responsibility of the MCO to repay the overpayment to the family within three
      (3) months of the determination that the maximum annual limit has been
      met.

     

    Sanction:
      Any one
      of the following may give rise to a strike towards a Class A Sanction pursuant
      to Section 9.05:

     

    If
      the
      MCO fails to inform its subcontractors, providers, and the family when the
      family has met its maximum annual limit for copayments;

     

    If
      the
      MCO fails to submit a file to the DEPARTMENT or its agent reporting on copayment
      and premium amount of its Members within thirty (30) days of the close of the
      preceding month; or

     

    If
      the
      MCO fails to monitor the tracking system to determine if any family has reached
      the maximum annual limits.

     

    4.08
      Amount of Premium Payment

     

    The
      amount a family shall be required to pay in premium payments for the HUSKY
      B
      benefit package shall vary according to the family income. Prior to February
      1,
      2004, the MCO shall not charge or collect a premium for families in Income
      Band
      1. On and after

     

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    February
      1, 2004, the premium charged and collected for families within Income Band
      1
      shall be $30 per month for families with one child and $50 per month for
      families with more than one child. The premium charged and collected for
      families within Income Band 2 shall be $30 per month for families with one
      child
      or $50 per month for families with more than one child. On and after February
      1,
      2004, the premium charged and collected for families within Income Band 2 shall
      be $50 per month for families with one child or $75 per month for families
      with
      more than one child. The premium charged and collected for families in Income
      Band 3 will be the rate negotiated with the DEPARTMENT per month, per child.
      The
      premium provisions and amount are subject to change. The DEPARTMENT will give
      the MCO sixty (60) days advance notice of any premium changes unless a statutory
      change precludes such advance notice.

     

    4.09
      Billing and Collecting the Premium Payments

     

    The
      MCO
      shall bill the applicant or member for the premium payments and shall collect
      the premium payments . The applicant may be billed up to thirty (30) days in
      advance of the coverage period. The coverage period shall be no less than one
      month and no more than one year. The MCO shall offer all applicants or members
      the option of a schedule of monthly premium payments.. . The initial bill to
      new
      members may include billing for multiple months of membership to allow members
      the opportunity to make payments current to the first prospective coverage
      month.

     

    4.10
      Notification of Premium Payments Due

     

    The
      MCO
      shall provide the applicant or member with reasonable prior notice of any
      premiums to be paid. The notice shall contain: the amount of the premium due;
      the date the premium is due; the effective date of disenrollment in case of
      failure to pay the premium by the due date; information concerning lock-out
      if
      there is disenrollment for failure to pay the premium; an instruction for the
      applicant to immediately contact the DEPARTMENT or its agent if the applicant
      cannot pay the premium by the due date because of a decrease in family income
      or
      other changes in family circumstances; and any additional information required
      to be included in the notice by the DEPARTMENT.

     

    Sanction:
      If the
      MCO fails to provide prior notice as required in this Section, the DEPARTMENT
      may impose a strike towards a Class A sanction pursuant to Section
      9.05.

     

    4.11
      Notification of Non-payment of the Premium Payments

     

    The
      MCO
      shall notify, in writing, the applicant or member and the custodial parent,
      if
      applicable, if a premium is not received by the due date. The notice shall
      contain: the amount of the premium that is due; the date the premium was due;
      the effective date of disenrollment for failure to pay the premium; information
      concerning lock-out; an instruction for the applicant to immediately contact
      the
      DEPARTMENT or its agent if the applicant cannot pay the premium by the due
      date
      because of a decrease in income or

     

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    other
      change in family circumstances; and any additional information required to
      be
      included in the notice by the DEPARTMENT.

     

    The
      MCO
      shall collaborate with the DEPARTMENT and its agent to establish billing and
      collection procedures. The MCO shall notify the Department or its agent pursuant
      to the agreed upon procedures if a premium is not received by the due
      date.

     

    Sanction:
      If the
      MCO fails to provide prior notice, as described above, or if the MCO fails
      to
      notify the DEPARTMENT or its agent of failure to pay a premium by the due date,
      the DEPARTMENT may impose a strike towards a Class A sanction pursuant to
      Section 9.05.

     

    4.12
      Past Due Premium Payments Paid

     

    If
      the
      MCO receives premium payments after the Member has been disenrolled, the MCO
      shall notify the DEPARTMENT or its agent within fifteen (15) days of the receipt
      of the payment that the payment was received and when it was
      received.

     

    Sanction:
      If the
      MCO fails to notify the DEPARTMENT or its agent as required in this Section,
      the
      DEPARTMENT may impose a sanction pursuant to Section 9.

     

    4.13
      Resumption of Services if the Child is Re-enrolled

     

    If
      a
      child is re-enrolled in HUSKY B, the MCO shall resume providing goods and
      services to that child.

     

    4.14
      Overpayment of Premium

     

    The
      MCO
      shall not bill or collect premiums in excess of the monthly amounts set forth
      in
      Section 4.08.

     

    If
      the
      MCO has received more than the allowed premium rate, it is the responsibility
      of
      the MCO to repay the overpayment to the family within three (3) months ,or
      apply
      the excess to future coverage months, whichever is preferred by the applicant
      or
      member.

     

    Sanction:
      If the
      MCO fails to repay the overpayment to the family within three (3) months of
      the
      determination that the premium payment liability has been reached, the
      DEPARTMENT may impose a strike towards a Class A sanction pursuant to Section
      9.05.

     

    4.15
      Member Premium Share Paid by Another Entity

     

    The
      MCO
      may accept funds from private or tribal organizations for the purpose of
      subsidizing the payment of premiums. To ensure that the payment is not received
      from an employer attempting to shift coverage from the employer to the HUSKY
      B
      program, the

     

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    MCO
      shall
      conduct periodic audits of received payments. The audits shall be conducted
      in
      accordance with DSS and MCO agreed upon criteria and schedule.

     

    Sanction:
      If the
      MCO fails to conduct audits in accordance to the agreed upon criteria and
      schedule, the DEPARTMENT may impose sanctions up to and including a Class B
      sanction.

     

    4.16
      Tracking Premium Payments

     

    The
      MCO
      shall establish and maintain a system to track the premium payments received
      for
      each family in Income Bands 1 and 2.

     

    The
      MCO
      shall cease tracking premium payments for families in Income Bands 1 and 2
      who
      are moved into Income Band 3 when the move has been completed. For families
      moving into Income Band 1 or 2 from Income Band 3, the tracking begins when
      the
      family moves into Income Band 1 or 2.

     

    The
      MCO
      shall send a monthly file to the DEPARTMENT or its agent showing the premiums
      and copayments received for the family. The DEPARTMENT or its agent will
      maintain the information regarding the amount of premiums received for each
      family within the annual period and if the children of the family disenroll
      and
      then enroll in another MCO within the annual period, the DEPARTMENT or its
      agent
      will forward the family premium totals for the annual period to the new
      MCO.

     

    If
      a
      family believes it has overpaid premiums, it may request that the MCO review
      the
      premiums that have been paid by the family. This request shall be in writing.
      The MCO shall then review the premium payments made by the family and respond
      to
      the family, in writing, within three (3) weeks of the date of the family's
      written request. If the family disagrees with the MCO's determination, the
      family may request, in writing, a review by the DEPARTMENT. The MCO and family
      shall abide by the decision of the DEPARTMENT. The MCO shall include a summary
      of this right and the appropriate procedures to request the review in its Member
      Handbook.

     

    If
      the
      Member is disenrolled due to nonpayment of premiums, the MCO may cease tracking
      the premium payments, but will keep the tracked information on file in case
      the
      Member is re-enrolled after payment of the premium within the annual period.
      If
      the Member is re-enrolled the MCO shall resume tracking the premium payments
      paid, throughout the remainder of the annual period.

     

    Sanction:
      If the
      MCO fails to comply with any of the provisions of this section, the DEPARTMENT
      may impose sanctions up to and including a Class B sanction pursuant to Section
      9.05.

     

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    5.
      LIMITED COVERAGE OF SOME GOODS AND SERVICES AND ALLOWANCES

     

    5.01
      Limited Coverage of Some Benefits

     

    a.
      Some
      goods and services are covered only up to a specified dollar limit, as set
      forth
      in Appendix A. This dollar limit is the allowance for which the MCO is
      responsible. If the Member decides to access these goods and services, the
      MCO
      must cover them up to the specified allowance. The Member's family is
      responsible for paying any remaining balance beyond the covered
      allowance.

     

    b.
      For
      the limited goods and services described in Appendix A, the MCO is responsible
      for ensuring that the Member's family is not charged the amount of the covered
      allowance.

     

    c.
      The
      amount a family pays toward the fee of the goods and services described in
      this
      section shall not be considered when calculating the maximum annual aggregate
      cost-sharing.

     

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    6.
      FUNCTIONS AND DUTIES OF THE DEPARTMENT

     

    6.01
      Eligibility Determinations

     

    The
      DEPARTMENT or its agent will determine the initial and ongoing eligibility
      for
      the HUSKY B program of each Member enrolled under this contract in accordance
      with the department's
      eligibility
      policies.

     

    6.02
      Ineligibility Determinations

     

    The
      MCO
      shall inform the DEPARTMENT or its agent within thirty (30) days of its
      knowledge of information which may render a child ineligible for HUSKY B. The
      information that shall be reported to the DEPARTMENT or its agent includes
      age,
      residency, insurance status, and death.

     

    6.03
      Enrollment/DisenroIlment

     

    
      	a.	
              Enrollment,
                disenrollment and initial selection of PCP's Members will be handled
                by
                the DEPARTMENT through a contract with a central enrollment broker.
                Coverage for new Members will be effective the first of the month
                and
                coverage for disenrolled Members will terminate on the last day of
                the
                month. Members remain continuously enrolled throughout the term of
                this
                contract, except in situations where clients change MCOs, become
                delinquent on their premium payments or lose their HUSKY B eligibility.
                Disenrollments due to loss of eligibility become effective as of
                the last
                day of the month during which the Member's circumstances changed
                to cause
                ineligibility or, if the Member never met eligibility requirements,
                as of
                the date of initial enrollment. The DEPARTMENT or its agent will
                notify
                the MCO of enrollments and disenrollments specific to the MCO via
                a daily
                data file. The enrollments and disenrollments processed on any given
                day
                will be made available to the MCO via the data file the following
                day
                (i.e. after the daily overnight batching has been
                processed).

            

    

     

    
      	b.	
              in
                addition to the daily data file, a full file of all the Members will
                be
                made available
                on a monthly basis. Both the daily data file and the monthly foil
                file can
                be accessed by the MCO electronically via
                dial-up.

            

    

     

    6.04
      Lock-In/Open Enrollment

     

    
      	a.	
              Upon
                enrollment into an MCO, Members will be locked-in to that MCO for
                a
                period
                of up to twelve (12) months. Members will not be allowed to change
                plan
                enrollment during the lock-in period except for good cause, as defined
                below. The lock-in period is subject to the following
                provisions:

            

    

     

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    1.
      The
      first ninety (90) days of enrollment into a new MCO will be designated as the
      free-look period during which time the Member may change plans.

     

    2.
      The
      last sixty (60) days of the lock-in period will be an open enrollment period,
      during which time Members may change plans.

     

    3.
      Plan
      changes made during the open enrollment period will go into effect on the first
      day of the month following the end of the lock-in period.

     

    4.
      Members who do not change plans during the open enrollment period will continue
      the enrollment in the same MCO and be assigned to a new twelve (12) month
      lock-in period.

    
       

      
        	b.	
                The
                  following shall constitute good cause for a Member to disenroll
                  from the
                  plan during the lock-in period.

              

      

       

    

    1.
      Unfavorable resolution of a Member complaint adjudicated through the MCO's
      internal complaint process and continued dissatisfaction due to repeated
      incidents of any of the following:

     

    a.
      documented long waiting times for appointments;

    b.
      more
      than a forty-five (45) day wait for scheduling a well-care visit;

    c.
      more
      than a two (2) business day wait for non-urgent, symptomatic office
      visit;

    d.
      unavailability of same day office visit or same day referral to an emergency
      provider for emergency care services;

    e.
      documented inaccessibility of MCO by phone or mail;

    f.
      phone
      calls not answered promptly;

    g.
      caller
      placed on hold for extended periods of time;

    h.
      phone
      messages and letters not responded to promptly; and i. rude and demeaning
      treatment by MCO staff.

     

    2.
      Prior
      to pursuing the MCO's internal complaint process and without filing an appeal
      through the plan, dissatisfaction due to any of the following:

     

    a.
      discriminatory treatment as documented in a complaint filed with the State
      of
      Connecticut, Commission on Human Rights and Opportunities (CHRO) or the
department's
      Affirmative
      Action Division;

     

    b.
      PCP
      able to serve Member's specific individual needs (i.e. language or physical
      accessibility) is no longer participating with the MCO and there is no other
      suitable PCP within reasonable distance to the Member; or

     

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    c.
      Member
      has a pending lawsuit against the MCO; verification of pending lawsuit must
      be
      provided.

     

    6.05
      Capitation Payments to the MCO

     

    
      	a.	
              In
                full consideration of contract services rendered by the MCO, the
                DEPARTMENT agrees to pay the MCO monthly payments based on the capitation
                rate specified in Appendix I, effective for the period 07/01/05 through
                06/30/06. The DEPARTMENT will make the payments in the month following
                the
                month to which the capitation applies. The Department shall conduct
                a
                reconciliation of the rate that has been paid to the Contractor since
                July
                1, 2005 with the rate that should have been paid to the Contractor
                since
                July 1, 2005 and remit to the Contractor a lump sum payment of the
                difference. Such payment shall be made to the Contractor before March
                31,
                2006.

            

    

     

    1.
      Capitation payments to the MCO shall be based on a passive billing system.
      The
      MCO is not required to submit claims for the capitation billing for its HUSKY
      B
      Membership.

     

    2.
      Payments to the MCO shall be based on each month's enrollment data as determined
      by the DEPARTMENT or its agent. The DEPARTMENT or its agent will supply to
      the
      MCO, on a monthly basis a capitation roster, which includes all Members for
      whom
      capitation payments are made to the MCO. The MCO will be responsible for
      detecting any inconsistency between the capitation roster and the MCO Membership
      records. The MCO must notify the DEPARTMENT of any inconsistency between
      enrollment and payment data. The DEPARTMENT agrees to provide to the MCO
      information needed to determine the source of the , inconsistency within sixty
      (60) working days after receiving written notice of the request to furnish
      such
      information. The DEPARTMENT will recoup overpayments or reimburse underpayments.
      The adjusted payment for each month of coverage shall be included in the next
      monthly capitation payment and roster.

     

    3.
      Any
      retrospective adjustments to prior capitation payments will be made in the
      form
      of an addition to or subtraction from the next month's capitation
      payment.

     

    4.
      In
      instances where enrollment is disputed the DEPARTMENT will be the final arbiter
      of Membership status and reserves the right to recover inappropriate capitation
      payments. Capitation payments for retroactive enrollment adjustments will made
      to the MCO pursuant to rules outlined in Section a 3, noted above.

     

    
      	b.	
              The
                parties acknowledge that a rate adjustment for the period 07/01/06
                to
                06/30/07 will be determined by the Department following the passage
                of a
                budget for fiscal year 2007 and that such rate adjustment will be
                applied
                to the Contractor's rate in effect on June 30, 2006. The rate shall
                be, at
                a minimum, no less than the rate in effect as of June 30, 2006. If
                following the Department's release of the rate adjustment to be effective
                July 1, 2006 for the period 07/01/06 to 06/30/07, the
                Contractor

            

    

     

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              determines
                that its rate would be insufficient for the Contractor to continue
                providing services in accordance with the terms of this contract
                through
                the anticipated expiration date of 06/3 0/07, or if no rate adjustment
                has
                been released by June 30, 2006, then the Contractor may notify the
                Department that the Contractor will terminate this Contract. The
                Contractor's notice of intent to terminate must be submitted to the
                Department no later than sixty (60) days after the Department's release
                of
                the rate adjustment or by August 31, 2006, whichever is earlier.
                The
                effective date of the termination may be no sooner than six (6) months
                after the Contractor's notice of termination. In the event that the
                Contractor notifies the Department of its intent to terminate the
                contract
                because the Contractor has deemed that the rate adjustment is insufficient
                or has not been communicated to Contractor by the Department, the
                Department agrees to reimburse the Contractor at the Contractor's
                rate as
                increased by the rate adjustment determined by the Department from
                July 1,
                2006, the effective date of the rate adjustment, through the termination
                date of the contract as established by the Contractor's notice of
                intent
                to terminate.

            

    

     

    
      	c.	
              The
                Department and the Contractor acknowledge that the Department has
                executed
                and that the Office of the Attorney General has approved, a contract
                with
                an administrative services organization (ASO) for the administration
                of
                behavioral health services and that as of January 1, 2006, the Contractor
                shall no longer be responsible for the provision of behavioral health
                services (the "carve-out" date). The Department and the Contractor
                shall,
                in advance of the carve-out date, begin to negotiate an amendment
                to this
                contract to reflect the impact of the removal of the Contractor's
                responsibility for the administration of behavioral health services
                under
                this contract, including any impact to the capitation rates. The
                Department and the Contractor shall work to complete negotiations
                and
                execute an amendment memorializing the negotiations by February 15,
                2006.
                The Department and the Contractor farther agree that any changes
                to the
                capitation rate necessitated by the removal of the Contractor's
                responsibility for the provision of behavioral health services shall
                not
                be implemented until such time as the amendment to the contract has
                been
                fully negotiated and executed by the parties. Thereafter the Department
                shall conduct a reconciliation of the capitation rate to accurately
                reflect the removal of the responsibility for the provision of behavioral
                health services as of January 1, 2006. The Contractor shall pay in
                lump
                sum the amount owed to the Department as a result of such reconciliation
                no later than forty-five (45) following the parties' agreement on
                the
                reconciliation.

            

    

     

    
      	d.	
              The
                Department agrees that if, during the 2006 legislative session there
                are
                changes to the scope or services to be performed by the Contractor
                under
                the terms of this agreement and/or to the capitation rate, the Department,
                in a subsequent amendment to this contract which may be entered into
                prior
                to the expiration of this amendment, shall amend the scope of services
                and
                the capitation rate to reflect such revisions and shall make any
                necessary
                adjustments to capitation payment made to the Contractor since the
                effective date of the revised capitation
                rate.

            

    

     

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    6.06 Newborn
      Retroactive Adjustments

     

    a.
      The
      DEPARTMENT shall determine the eligibility of a newborn child retroactively
      to
      the date of his or her birth, for an application filed within thirty (30) days
      following birth.

     

    b.
      For
      the purpose of determining the capitation payment to the MCO for the month
      in
      which the child was born, the effective date for such enrollment shall be the
      first of the month in which the child was born.

     

    6.07
      Information

     

    The
      DEPARTMENT will make known to each MCO information which relates to pertinent
      statutes, regulations, policies, procedures, and guidelines affecting the
      operation of this contract. This information shall be available either through
      direct transmission to the MCO or by reference to public resource files
      accessible to the MCO personnel.

     

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    7. DECLARATIONS
      AND MISCELLANEOUS PROVISIONS

     

    7.01
      Competition Not Restricted

     

    In
      signing this Contract, the MCO asserts that no attempt has been made or will
      be
      made by the MCO to induce any other person or firm to submit or not to submit
      an
      application for the purpose of restricting competition.

     

    7.02
      Nonsegregated Facilities

     

    
      	a.	
              The
                MCO certifies that it does not and will not maintain or provide for
                its
                employees any segregated facilities at any of its establishments;
                and that
                it does not permit its employees to perform their services at any
                location, under its control, where segregated facilities are maintained.
                As Contractor, the MCO agrees that a breach of this certification
                is a
                violation of Equal Opportunity in Federal employment. In addition,
                Contractor must comply with the Federal Executive Order 11246 entitled
                "Equal Employment Opportunity" as amended by Executive Order 11375
                and as
                supplemented in the United States Department of Labor Regulations
                (41 CFR
                pt. 30). As used in this certification, the term "segregated facilities"
                includes any waiting rooms, restaurants and other eating areas, parking
                lots, drinking fountain, recreation or entertainment areas,
                transportation, and housing facilities provided for employees which
                are
                segregated on the basis of race, color, religion, or national origin,
                because of habit, local custom, national origin or
                otherwise.

            

    

     

    
      	b.	
              The
                MCO further agrees, (except where it has obtained identical certifications
                from proposed subcontractors for specific time periods) that it will
                obtain identical certifications from proposed subcontractors which
                are not
                exempt from the provisions for Equal Employment Opportunity; that
                it will
                retain such certifications in its files; and that it will forward
                a copy
                of this clause to such proposed subcontractors (except where the
                proposed
                subcontractors have submitted identical certifications for specific
                time
                periods).

            

    

     

    7.03
      Offer of Gratuities

     

    The
      MCO,
      its agents and employees, certify that no elected or appointed
      official
      or employee
      of the DEPARTMENT has or will benefit financially or materially from this
      contract. The contract may be terminated by the DEPARTMENT if it is determined
      that gratuities of any kind were either offered to or received by any of the
      aforementioned officials or employees of the MCO, its agent or
      employee.

     

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    7.04
      Employment/Affirmative Action Clause

     

    The
      MCO
      agrees to supply employment/affirmative action information as required for
      agency compliance with Title VI and VII of the Civil Rights Acts of 1964 and
      Connecticut General Statutes, Section 46a-68 and Section 46a-71.

     

    7.05
      Confidentiality

     

    
      	a.	
              The
                MCO agrees that all material and information, and particularly information
                relative to individual applicants or recipients of assistance through
                the
                DEPARTMENT, provided to the Contractor by the State or acquired by
                the
                Contractor in performance of the contract whether verbal, written,
                recorded magnetic media, cards or otherwise shall be regarded as
                confidential information and all necessary steps shall be taken by
                the
                Contractor to safeguard the confidentiality of such material or
                information in conformance with federal and state statutes and
                regulations.

            

    

     

    
      	b.	
              The
                MCO agrees not to release any information provided by the DEPARTMENT
                or
                providers or any information generated by the MCO without the express
                written consent of the Contract Administrator, except as specified
                in this
                contract and permitted by applicable state
                law.

            

    

     

    7.06
      Independent Capacity

     

    The
      MCO,
      its officers, employees, subcontractors, or any other agent of the Contractor
      in
      performance of this contract will act in an independent capacity and not as
      officers or employees of the State of Connecticut or of the
      DEPARTMENT.

     

    7.07
      Liaison

     

    Both
      parties agree to have specifically named liaisons at all times. These
      representatives of the parties will be the first contacts regarding any
      questions and problems which arise during implementation and operation of the
      contract.

     

    7.08
      Performance of a Governmental Function and Freedom of
      Information

     

    a.
      Performance of a Governmental Function

     

    1.
       In performing any acts required by this Contract, the Contractor shall be
      considered to be performing a governmental function for the Department, as
      that
      term is defined in section 1-200(11) of the Connecticut General Statutes.
      Pursuant to section 1-218 of the Connecticut General Statutes, therefore, the
      Department is entitled to receive a copy of records and files related to the
      performance of the governmental function, as set forth in this Contract. Such
      records and files are subject to the Freedom of Information Act and may be
      disclosed by the Department pursuant to the Freedom of Information Act. Requests
      to inspect or copy such records or files shall be made to DSS in accordance
      with
      the Freedom of Information Act. Accordingly, if the Contractor is in receipt
      of
      a request made pursuant to the Freedom of Information Act

     

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    to
      inspect or copy such records or files, the Contractor shall forward that request
      to DSS.

     

    2.  Upon
      receipt of a Freedom of Information Act request by the Department that seeks
      records or files related to the performance of the governmental function
      performed by the Contractor for the Department, the Department shall send such
      request to the Contractor. The Contractor shall review the request and, with
      reasonable promptness, search its records and files for documents that are
      responsive to the request. The Contractor shall send to the Department a copy
      of
      those documents that are responsive to the request. If, upon review of the
      request, the Contractor determines that it will require more than fourteen
      (14)
      days to search for and provide copies of responsive documents to the Department,
      the Contractor shall contact the Department within seven (7) days of the receipt
      of the request from the Department.

     

    3.
       If
      the
      Contractor concludes that any of the responsive documents may be exempt from
      disclosure pursuant to section l-210(b) of the Connecticut General Statutes,
      the
      Contractor shall mark said documents prior to sending them to the Department
      and
      explain the basis for its conclusion. The Department shall review the
      Contractor's explanation and, as necessary, discuss said conclusion with the
      Contractor. If the Department agrees that the marked documents may be exempt
      under section l-210(b) of the Connecticut General Statutes, the Department
      shall
      not release those documents in its response to the Freedom of Information
      request. If, however, the Department disagrees, in good faith, with the
      conclusion by the Contractor that said documents may be exempt pursuant to
      section l-210(b) of the Connecticut General Statutes, the Department shall
      notify the Contractor, in writing, that it intends to release the documents
      fourteen (14) days from the date of the notice.

     

    4.  If
      the
      Contractor concludes that a document is protected by the attorney-client or
      work
      product privilege, the Contractor may decline to produce the document and must
      specifically assert the privilege by identifying the nature of the document
      and
      claiming the privilege.

     

    5.
       If
      the
      Contractor asserts an exemption under paragraph 3 or a privilege
      under

    paragraph
      4 of this Contract, and the Department honors said claim, the Contractor shall
      seek to intervene in order to defend the claim for an exemption or privilege
      m
      any subsequent Freedom of Information Commission proceeding challenging the
      Department's refusal to disclose said documents.

     

    6.
       This
      Paragraph A of Section 7.08 of this Contract is a result of orders of the
      Freedom of Information Commission. If, at any time, such orders are reversed
      or
      otherwise declared not legal and binding, this paragraph shall no longer be
      in
      effect.

     

    7.
       To
      the
      extent that this Paragraph A of Section 7.08 conflicts with any other provisions
      of the Contract, this paragraph supersedes those provisions.

     

    b.
      Freedom of Information: Due regard will be given for the protection of
      proprietary information contained in all documents received by the DEPARTMENT;
      however, the MCO is aware that all materials associated with the contract are
      subject to the terms of the state Freedom of Information Act, Conn. Gen. Stat.
      Sections 1-200, et seq., and all rules, regulations and

     

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    interpretations
      resulting therefrom. When materials are submitted by the MCO or a subcontractor
      to the DEPARTMENT and the MCO or subcontractor believes that the materials
      are
      proprietary or confidential in some way and that they should not be subject
      to
      disclosure pursuant to the Freedom of Information Act, it is not sufficient
      to
      protect the materials from disclosure for the MCO to state generally that the
      material is proprietary in nature and, therefore, not subject to release to
      third parties. If the MCO or the MCO or the subcontractor believes that any
      portions of the materials submitted to the DEPARTMENT are proprietary or
      confidential or constitute commercial of financial information, given in
      confidence, those portions or pages or sections the MCO believes to be
      proprietary must be specifically identified as such. Convincing explanation
      and
      rationale sufficient to justify each claimed exemption from release, consistent
      with section 1-210 of the Connecticut General Statutes, must accompany the
      documents when they are submitted to the DEPARTMENT. The explanation and
      rationale must be stated in terms of the prospective harm to the MCO's or
      subcontractor's competitive position that would result if the identified
      materials were to be released and the reasons why the materials are legally
      exempt from release pursuant to the above-cited statute. The final
      administrative authority to release or exempt any or all material so identified
      by the MCO or subcontractor rests with the DEPARTMENT. The DEPARTMENT is not
      obligated to protect the confidentiality of materials or documents submitted
      to
      it by the MCO or the subcontractor if said materials or documents are not
      identified in accordance with the above-described procedure.

     

    7.09
      Waivers

     

    Except
      as
      specifically provided in any section of this contract, no covenant, condition,
      duty, obligation or undertaking contained in or made a part of the Contract
      shall be waived except by the written agreement of the parties, and forbearance
      or indulgence in any form or manner by the DEPARTMENT or the MCO in any regard
      whatsoever shall not constitute a waiver of the covenant, condition, duty,
      obligation or undertaking to be kept, performed, or discharged by the DEPARTMENT
      or the MCO; and not withstanding any such forbearance or indulgence, until
      complete performance or satisfaction of all such covenants, conditions, duties,
      obligations and undertakings, the DEPARTMENT or MCO shall have the right to
      invoke any remedy available under the contract, or under law or
      equity.

     

    7.10
      Force Majeure

     

    The
      MCO
      shall be excused from performance hereunder for any period that is prevented
      from providing, arranging for, or paying for services as a result of a
      catastrophic occurrence or natural disaster including but not limited to an
      act
      of war, and excluding labor disputes.

     

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    7.11
      Financial Responsibilities of the MCO

     

    The
      MCO
      must maintain at all times financial reserves in accordance with the Connecticut
      Health Centers Act under Section 38a-175 et seq.
      of the
      Connecticut General Statutes, and with the requirements outlined in the
department's
      Request
      for Application.

     

    7.12
      Capitalization and Reserves

     

    a.
      The
      MCO shall comply with and maintain capitalization and reserves as required
      by
      the appropriate regulatory authority.

     

    b.
      If the
      MCO is licensed by the State of Connecticut, the MCO shall establish and
      maintain capitalization and reserves as required by the Connecticut
      DOI.

     

    c.
      If the
      MCO is majority-owned by federally qualified health centers (FQHCs) and not
      licensed by the State of Connecticut, the MCO will establish and maintain
      sequestered capital of $500,000 plus two (2) percent of ongoing annual
      capitation premiums.

     

    1.
      These
      funds shall be placed in a restricted account for the duration of the FQHC
      plan's existence, to be accessed only in the event such funds are needed to
      meet
      unpaid claims liabilities.

    2.
      This
      restricted account shall be established such that any withdrawals or transfers
      of funds will require signatures of authorized representatives of the FQHC
      plan
      and the DEPARTMENT.

    3.
      The
      initial $500,000 must be deposited into the account by the beginning of the
      MCO's first enrollment period.

    4.
      The
      MCO must make quarterly deposits into this account so that the account balance
      is equal to $500,000 plus two (2) percent of the premiums received during the
      preceding twelve (12) months.

     

    7.13
      Members Held Harmless

     

    The
      MCO
      shall not hold a Member liable for:

     

    1.
      The
      debts of the MCO in the event of the MCO's insolvency;

    2.
      The
      cost of HUSKY B covered services provided pursuant to this contract, other
      than
      cost-sharing permitted under this contract, to the Member if the MCO or provider
      fails to receive payment; and/or

    3.
      Payments to a provider which exceed the amount that would be owed if the MCO
      directly provided the service.

     

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    7.14
      Compliance with Applicable Laws, Rules And Policies

     

    The
      MCO
      in performing this contract shall comply with all applicable federal and state
      laws, regulations and written policies, including those pertaining to
      licensing.

     

    7.15
      Federal Requirements and Assurances

     

    General

     

    
      	a.	
              The
                MCO shall comply with those federal requirements and assurances for
                recipients
                of federal grants provided in 0MB Standard Form 424B (4-88) which
                are
                applicable to the MCO. The MCO is responsible for determining which
                requirements and assurances are applicable to the MCO. Copies of
                the form
                are available from the DEPARTMENT. The MCO shall comply with all
                applicable provisions of 45 CFR 74.48 and all applicable requirements
                of
                45 CFR 74.48 Appendix A.

            

    

     

    
      	b.	
              The
                MCO shall provide for the compliance of any subcontractors with applicable
                federal requirements and
                assurances.

            

    

     

    Lobbying

     

    
      	a.	
              The
                MCO, as provided by 31 U.S.C. 1352 and 45 CFR 93.100 et seq., shall
                not
                pay federally appropriated funds to any person for influencing or
                attempting to influence an officer or employee of any agency, a Member
                of
                the U.S. Congress, an officer or employee of the U.S. Congress or
                an
                employee of a Member of the U.S. Congress in connection with the
                awarding
                of any federal contract, the making of any cooperative agreement
                or the
                extension, continuation, renewal, amendment or modification of any
                federal
                contract, grant, loan or cooperative
                agreement.

            

    

     

    
      	b.	
              The
                MCO shall submit to the DEPARTMENT a disclosure form as provided
                in 45 CFR
                93.110 and Appendix B to 45 CFR Pt. 93, if any funds other than federally
                appropriated funds have been paid or will be paid to any person for
                influencing or attempting to influence an officer or employee of
                any
                agency, a Member of the U.S. Congress, an officer or employee of
                the U.S.
                Congress or an employee of a Member of the U.S. Congress in connection
                with this contract.

            

    

     

    Title
      XXI and SCHIP Regulations

     

    The
      MCO
      shall comply with all applicable provisions of Title XXI of the Social Security
      Act and 42 CFR pt. 457

     

    Clean
      Air and Water Acts

     

    The
      MCO
      shall comply with all applicable standards, orders or regulations issued
      pursuant to the Clean Air Act as amended, 42 U.S.C. 7401, et seq.
      and the
      Federal Water Pollution Control Act as amended, 33 U.S.C. 1251 et seq.

     

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    Energy
      Standards

     

    The
      MCO
      shall comply with all applicable standards and policies relating to energy
      efficiency which are contained in the state energy plan issued in compliance
      with the federal Energy Policy and Conservation Act, 42 USC Sections 6231 -
      6246. The MCO further covenants that no federally appropriated funds have been
      paid or will be paid on behalf of the DEPARTMENT or the contractor to any person
      for influencing or attempting to influence an officer or employee of any federal
      agency, a Member of Congress, an officer or employee of Congress, or an employee
      of a Member of Congress in connection with the awarding of any federal contract,
      the making of any federal grant, the making of any federal loan, the entering
      into of any cooperative agreement, or the extension, continuation, renewal,
      amendment, or modification of any federal contract, grant, loan, or cooperative
      agreement. If any funds other than federally appropriated funds have been paid
      or will be paid to any person for influencing or attempting to influence an
      officer or employee of any federal agency, a Member of Congress, or an employee
      of a Member of Congress in connection with this contract, grant, loan, or
      cooperative agreement, the contractor shall complete and submit Standard Form
      -
      LLL, "Disclosure Form to Report Lobbying," in accordance with its
      instructions.

     

    Maternity
      Access and Mental Health Parity

     

    The
      MCO
      shall comply with the maternity access and mental health requirements of the
      Public Health Services Act, Title XXVII, Subpart 2, Part A, Section 2704, as
      added September 26, 1996, 42 U.S.C. Section 300gg-4, 300gg-5, and the
      implementing regulations at 45 CFR 146.136, insofar as such requirements apply
      to providers of group health insurance.

     

    7.16
      Civil Rights Federal Authority

     

    The
      MCO
      shall comply with the Civil Rights Act of 1964 (42 U.S.C. Section 2000d, et
      sec[.), the Age Discrimination Act of 1975 (42 U.S.C. 6101, et seq.), the
      Americans with Disabilities Act of 1990 (42 U.S.C. Section 12101, et sea.)
      and
      Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, et
seq.

     

    Discrimination

     

    Persons
      may not, on the grounds of race, color, national origin, creed, sex, religion,
      political ideas, marital status, age or disability be excluded from employment
      in, denied participation in, denied benefits or be otherwise subjected to
      discrimination under any program or activity connected with the implementation
      of this contract. The MCO shall use hiring processes that foster the employment
      and advancement of qualified persons with disabilities.

     

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    Merit
      Qualifications

     

    All
      hiring done in connection with this contract must be on the basis of merit
      qualifications genuinely related to competent performance of the particular
      occupational task. The MCO, in accordance with Federal Executive Order 11246,
      dated September 24, 1965 entitled "Equal Employment Opportunity", as amended
      by
      Federal Executive Order 11375 and as supplemented in the United States
      Department of Labor Regulations, 41 CFR Part 60-1, et seq., must provide for
      equal employment opportunities in its employment practices.

     

    Confidentiality

     

    The
      MCO
      shall, in accordance with relevant laws, regulations and policies, protect
      the
      confidentiality of any material and information concerning an applicant for
      or
      recipient of services funded by the DEPARTMENT. Access to patient information,
      records, and data shall be limited to the purposes outlined in 42 CFR
      434.6(a)(8). All requests for data or patient records for participation in
      studies, whether conducted by the MCO or outside .parties, are subject to
      approval by the DEPARTMENT .

     

    7.17
      Statutory Requirements

     

    a.
      State
      licensed MCO shall retain at all times during the period of this contract a
      valid Certificate of Authority issued by the State Commissioner of
      Insurance.

     

    b.
      The
      MCO shall adhere to the provisions of the Clinical Laboratory Improvement
      Amendments of 1988 (CLIA) Public Law 100-578, 42 USC Section
      1395aa.

     

    7.18
      Disclosure of Interlocking Relationships

     

    An
      MCO
      which is not also a Federally-qualified Health Plan or a Competitive Medical
      Plan under the Public Health Service Act must report on request to the State,
      to
      the Secretary and the Inspector General of DHHS, and the Comptroller General,
      a
      description of transactions between the MCO and parties in interest including
      related parties as defined by federal and state law. Transactions that must
      be
      reported include: (a) any sale, exchange, or leasing of property; (b) any
      furnishing for consideration of goods, services or facilities (but not salaries
      paid to employees); and (c) any loans or extensions of credit.

     

    7.19
      department's
      Data
      Files

     

    
      	a.	
              The
                department's
                data
                files and data contained therein shall be and remain the department's
                property
                and shall be returned to the DEPARTMENT by the MCO upon the termination
                of
                this contract at the department's
                request,
                except that any DEPARTMENT data files no longer required by the MCO
                to
                render
                services under this contract shall be returned upon such determination
                at
                the department's
                request.

            

    

     

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      	b.	
              The
                department's
                data
                shall not be utilized by the MCO for any purpose other than that
                of
                rendering services to the DEPARTMENT under this contract, nor shall
                the
                department's
                data
                or any part thereof be disclosed, sold, assigned, leased or otherwise
                disposed of to third parties by the MCO unless there has been prior
                written DEPARTMENT approval. The MCO may disclose material and information
                to subcontractors and vendors, as necessary to fulfill the obligations
                of
                this contract.

            

    

     

    c.
      The
      DEPARTMENT shall have the right of access and use of any data files retained
      or
      created by the MCO for systems operation under this contract subject to the
      access procedures defined in Part I Section 3.34.

     

    d.
      The
      MCO shall establish and maintain at all times reasonable safeguards against
      the
      destruction, loss or alteration of the department's
      data
      and
      any other data in the possession of the MCO necessary to the performance of
      operations under this contract.

     

    7.20
      Hold Harmless

     

    The
      MCO
      agrees to indemnify, defend and hold harmless the State of Connecticut as well
      as all departments,
      officers,
      agents and employees of the State from all claims, losses or suits accruing
      or
      resulting to any contractors, subcontractors, laborers and any person, firm
      or
      corporation who may be injured or damaged through the fault of the MCO in the
      performance of the contract.

     

    The
      MCO,
      at its own expense, shall defend any claims or suits which are brought against
      the DEPARTMENT or the State for the infringement of any patents, copyrights,
      or
      other proprietary rights arising from the MCO's or the State's use of any
      material or information prepared or developed by the MCO in conjunction with
      the
      performance of this contract; provided any such use by the State is expressly
      contemplated by this contract and approved by the MCO. The State, its
departments,
      officers,
      employees, contractors, and agents shall cooperate fully in the MCO's defense
      of
      any such claim or suit as directed by the MCO. The MCO shall, in any such suit,
      satisfy any damages for infringement assessed against the State or the
      DEPARTMENT, be it resolved by settlement negotiated by the MCO, final judgment
      of a court with jurisdiction after exhaustion of available appeals, consent
      decree, or any other manner approved by the MCO.

     

    7.21
      Executive Orders

     

    a.
       This
      Agreement is subject to the provisions
      of Executive Order
      No.
      3 of Governor Thomas J. Meskill promulgated June 16, 1971,
      and, as
      such, this Agreement may be cancelled, terminated or suspended by the state
      labor

     

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    commissioner
      for violation of or noncompliance with said Executive Order No. Three, or any
      state or federal law concerning nondiscrimination, notwithstanding mat the
      labor
      commissioner is not a party to this contract. The Parties to this Agreement,
      as
      part of the consideration hereof, agree that said Executive Order No. Three
      is
      incorporated herein by reference and made a part hereof. The Parties agree
      to
      abide by said Executive Order and agree that the state labor commissioner shall
      have continuing jurisdiction in respect to contract performance in regard to
      nondiscrimination, until the contract is completed or terminated prior to
      completion. The CONTRACTOR agrees, as part consideration hereof, that this
      Agreement is subject to the Guidelines and Rules issued by the state labor
      commissioner to implement Executive Order No. Three, and that it will not
      discriminate in its employment practices or policies, will file all reports
      as
      required, and will fully cooperate with the State of Connecticut and the state
      labor commissioner.

     

    b.
       This
      Agreement is subject to the provisions
      of Executive OrderNo.
      17
      of Governor Thomas J. Meskill promulgated February 15,1973,
      and, as
      such, this Agreement may be cancelled, terminated or suspended by the
      contracting agency or the State Labor Commissioner for violation of or
      noncompliance with said Executive Order No. Seventeen, notwithstanding that
      the
      Labor Commissioner may not be a party to this Agreement. The Parties to this
      Agreement, as part of the consideration hereof, agree that Executive Order
      No.
      Seventeen is incorporated herein by reference and made a part hereof. The
      Parties agree to abide by said Executive Order and agree that the contracting
      agency and the State Labor Commissioner shall have joint and several continuing
      jurisdiction in respect to contract performance in regard to listing all
      employment openings with the Connecticut State Employment Service.

     

    c.
       This
      Agreement is subject to the provisions
      of Executive Order No. 16 of Governor John G. Rowland promulgated
      August4,1999,
      and, as
      such, the Agreement may be canceled, terminated or suspended by the state for
      violation of or noncompliance with said Executive Order No. Sixteen. The Parties
      to this Agreement, as part of the consideration hereof, agree that

     

    i.
      The
      CONTRACTOR shall prohibit employees from bringing into the state work site,
      except as may be required as a condition of employment, any weapon or dangerous
      instrument as defined in (ii):

     

    ii.
      Weapon means any firearm, including a BB gun, whether loaded or unloaded, any
      knife (excluding a small pen or pocket knife), including a switchblade or other
      knife having an automatic spring release device, a stiletto, any police baton
      or
      nightstick or any martial arts weapon or electronic defense weapon. Dangerous
      instrument means any instrument, article, or substance that, under

     

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    the
      circumstances, is capable of causing death or serious physical
      injury.

     

    iii.
      The
      CONTRACTOR shall prohibit employees from attempting to use, or threaten to
      use,
      any such weapon or dangerous instrument in the state work site and employees
      shall be prohibited from causing, or threatening to cause, physical injury
      or
      death to any individual in the state work site.

     

    iv.
      The
      CONTRACTOR shall adopt the above prohibitions as work rules, violations of
      which
      shall subject the employee to disciplinary action up to and including discharge.
      The CONTRACTOR shall insure and require that all employees are aware if such
      work rules.

     

    v.
      The
      CONTRACTOR agrees that any subcontract it enters into in furtherance of the
      work
      to be performed hereunder shall contain provisions (i) through (iv) of this
      Section.

     

    d.
       This
      Agreement is subject to
      Executive Order No. 7B of Governor Jodi M. Roll, promulgated on November 16,
      2005.
      The
      Parties to this Agreement, as part of the consideration hereof, agree
      that:

     

    i.
      The
      State Contracting Standards Board ("the Board") may review this contract and
      recommend to the state contracting agency termination of the contract for cause.
      The state contracting agency shall consider the recommendations and act as
      required or permitted in accordance with the contract and applicable law. The
      Board shall provide the results of its review, together with its
      recommendations, to the state contracting agency and any other affected party
      in
      accordance with the notice provisions in the contract no later than fifteen
      (15)
      days after the Board finalizes its recommendation. For the purposes of this
      Section, "for cause" means:

    (a),
      a
      violation of the State Ethics Code (Conn. Gen. Stat. Chapter 10) or Section
      4A-100 of the Conn. Gen. Statutes or

    (b).
      wanton or reckless disregard of any state contracting and procurement process
      by
      any person substantially involved in such contract or state contracting
      agency.

     

    ii.
      For
      the purposes of this Section, "contract" shall not include real property
      transactions involving less than a fee simple interest or financial assistance
      comprised of state or federal funds, the form of which may include but is not
      limited to grants, loans, loan guarantees, and participation interests in loans,
      equity investments and tax credit programs. Notwithstanding the foregoing,
      the
      Board shall not have any authority to recommend the termination of
      a

     

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    contract
      for the sale or purchase of a fee simple interest in real property following
      transfer of title.

     

    iii.
      Effective January 1, 2006, notwithstanding the contract value listed in Conn.
      Gen. Stat. §§ 4-250 and 4-251, all procurements between state agencies and
      private entities with a value of $50,000 (fifty thousand dollars) or more in
      a
      calendar or fiscal year shall comply with the gift affidavit requirements of
      said Sections. Certification by agency officials or employees required by Conn.
      Gen. Stat. § 4-252 shall not be affected by this Section.

     

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    8.
      MCO RESPONSIBILITIES CONCERNING INTERNAL AND EXTERNAL
      APPEALS

     

    8.01
      MCO Responsibilities Concerning Internal and External Appeals and Notices of
      Denial

     

    Members
      shall have the opportunity to request an internal appeal of a decision made
      by
      the MCO regarding the denial of goods and services covered in the basic benefit
      package. The MCO shall have an internal appeal process for receiving and acting
      upon these requests. This internal appeals process may consist of more than
      one
      level of review, m addition, the MCO shall provide for an expedited internal
      appeals process as set forth in Section 8.06 below. The MCO shall also provide
      information to Members concerning the external appeal process available through
      the State of Connecticut Department of Insurance (DOI). The MCO shall also
      have
      a process for provider appeals, as set forth in Section 8.08.

     

    8.02
      Internal Appeal Process Required

     

    
      	a.	
              The
                MCO shall have a timely and organized internal appeal process. The
                internal appeal process shall be available for resolution of disputes
                between the MCO or MCO subcontractors and Members concerning the
                denial of
                a request for goods and services covered under the HUSKY B benefit
                package. In addition the MCO shall provide for an expedited internal
                appeal process as set forth in Section 8.06 below. The MCO shall
                be
                responsible for ensuring compliance with the internal appeal process
                requirements set forth herein, whether the goods or services are
                denied by
                the MCO or one of its
                subcontractors.

            

    

     

    
      	b.	
              The
                MCO shall designate one primary and one back-up contact person for
                its
                internal appeal process.

            

    

     

    8.03
      Denial Notice

     

    a.
      The
      MCO shall provide a written denial notice to the Member, which includes the
      MCO's
      denial
      decision as well as notice of the Member's right to appeal.The
      denial
      notice shall be sent to the Member's last known address.

     

    b.
      All
      denial notices shall clearly state or explain:

    1.
      what
      goods and/or services are being denied;

    2.
      the
      reasons for the denial; 

    3.
      the
      contract section that supports the denial;

    4.
      the
      address and toll-free number of the MCO's Member Services
      Department;

    5.
      the
      Member's right to challenge the denial by filing an internal appeal with the
      MCO-

     

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    6.
       the
      procedure and timeframe for commencing each level of the MCO's internal appeals
      process, including the address to which any written request for appeal may
      be
      mailed;

    7.
      the
      availability of expedited internal appeal;

    8.
      the
      external appeal process available through the DOI;

    9.
      specifications and assistance as to the format in which the Member may file
      a
      request for an internal appeal.

    10.
      that
      the Member will lose his or her right to challenge the denial with the MCO
      within sixty (60) days from" the date the MCO mailed the denial
      notice;

    11.
      that
      for each level of its appeals process, the MCO must issue a decision regarding
      an appeal no more than thirty (30) days following the date that the MCO receives
      the request for review

    12.
      that
      the MCO must be responsive to questions which the Member may have about the
      denial;

    13.
      that
      the Member may submit additional documentation or written material for the
      MCO's
      consideration; and

    14.
      mat
      the MCO's review may be based solely on information available to the MCO and
      its
      providers, unless the Member requests a meeting or the opportunity to submit
      additional information.

     

    8.04
      Internal Appeal Process

     

    
      	a.	
              The
                MCO shall develop written policies and procedures for each component
                of
                its internal appeals process. The MCO's policies and procedures must
                include the elements specified in this contract and must be approved
                by
                the DEPARTMENT in writing. The MCO shall not be excused from meeting
                the
                requirements for the policies, procedures and pending the department's
                written
                approval of these documents.

            

    

     

    
      	b.	
              The
                MCO shall maintain a record keeping system for each level of its
                appeal
                process, which shall include a copy of the Member's request for review,
                the response and the resolution, which the MCO shall make available
                to the
                DEPARTMENT upon request.

            

    

     

    
      	c.	
              The
                MCO shall clearly specify in its Member handbook/packet, the procedural
                steps and timeframes for each level of its internal appeals process
                and
                for filing an external appeal through the DOI. The MCO shall provide
                information on its internal appeals process and on the external DOI
                appeal
                process to providers and subcontractors, as it relates to
                Members.

            

    

     

    
      	d.	
              The
                MCO shall develop and make available to Members and potential Members
                appropriate alternative language versions of internal appeal materials,
                including but not limited to, the standard information contained
                in denial
                notices. Such materials shall be made available in Spanish, English
                and
                any other language(s) if more than five (5) percent of the MCO's
                Members
                in the State of Connecticut served by the MCO speak the alternative
                language. The MCO must submit such alternative language materials
                to the
                DEPARTMENT and the DEPARTMENT must approve any such materials in
                writing
                prior to use by the MCO.

            

    

     

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      	e.	
              Internal
                appeals shall be filed by the applicant, the Member, the Member's
                authorized representative, or the Member's conservator. The Member
                Handbook shall state that requests for all levels of the internal
                appeals
                process shall be mailed or faxed to a single
                address.

            

    

     

    
      	f.	
              If
                the internal appeal contains a request for expedited review, the
                MCO shall
                follow the procedure described in Section 8.06
                below.

            

    

     

    
      	g.	
              An
                individual or individuals having final decision-making authority
                shall
                conduct the final level of the MCO's review. One or more physicians
                who
                were not involved in the denial determination must decide any appeal
                arising from an action based on a determination of medical
                necessity.

            

    

     

    
      	h.	
              The
                MCO may decide an appeal on the basis of written documentation available
                to the MCO at the time of the request, unless the Member requests
                an
                opportunity to meet with the individual or individuals conducting
                the
                internal appeal on behalf of the MCO and/or requests the opportunity
                to
                submit additional written documentation or other written material.
                The MCO
                shall inform the Member that the MCO's review may be based solely
                on
                information available to the MCO and its providers, unless the Member
                requests a meeting or the opportunity to submit additional
                information.

            

    

     

    i.
      If the
      Member wishes to meet with the decisionmaker, the meeting may be held via
      telephone or at a location accessible to the Member.

     

    j.
      The
      MCO shall date stamp the form when it is received by the MCO. The postmark
      date
      on the denial notice envelope will be used to determine whether an appeal was
      timely filed.

     

    8.05
      Written Decision

     

    
      	a.	
              The
                MCO shall issue a written decision for each level of its internal
                appeals
                process. Each decision shall be sent to the Member by certified mail.
                The
                MCO shall send a copy of each decision to the DEPARTMENT. The appeal
                decision shall be sent no later than thirty (30) days from the date
                on
                which the MCO received the appeal.

            

    

     

    
      	b.	
              The
                MCO's written decision must include the Member's name and address;
                the
                provider's name and address; the MCO name and address; a complete
                statement of the MCO's findings and conclusions, including the section
                number and text of any statute or regulation that supports the decision;
                a
                clear statement of the MCO's disposition of the appeal; a statement
                that
                the Member has exhausted the MCO's internal appeal procedure concerning
                the denial at issue; and relevant information
                concerning the external appeals process available through the DOI,
                as
                described in Section 8.07,
                below.

            

    

     

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      	c.	
              For
                each level of its internal appeals process, the MCO shall issue a
                decision
                within thirty (30) days. If the MCO fails to issue a decision within
                thirty (30) days, the DEPARTMENT will deem the decision to be a denial
                and
                the Member may file an external appeal with the DOI, as more fully
                discussed in Section 8.07, below.

            

    

     

    8.06
      Expedited Review

     

    
      	a.	
              Subject
                to Section 8.02 above, the internal appeals process must allow for
                expedited review. If a Member requests an expedited review, the MCO
                must
                determine within one business day of receipt of the request, whether
                to
                expedite the review or whether to perform the review according to the
                standard timeframes.

            

    

     

    
      	b.	
              An
                expedited review must be performed when the standard timeframes for
                determining an appeal could jeopardize the life or health of the
                Member or
                the Member's ability to regaining maximum functioning. The MCO must
                expedite its review in all cases in which such a review is requested
                by
                the Member's treating physician or primary care provider, functioning
                within his or her scope of practice as defined under state law, or
                by the
                DEPARTMENT.

            

    

     

    8.07
      External Appeal Process through the DOI

     

    a.
       A
      Member
      who has exhausted the internal appeal mechanisms of the MCO and is not satisfied
      with the outcome of the MCO's final decision may file an appeal with the
      DOI.

     

    b.
       The
      MCO
      shall include the following information concerning the DOI external appeal
      process in its member handbook:

     

    1.
      If the
      Member has exhausted the MCO's internal appeals process and has received a
      final
      written decision from the MCO upholding the MCO's original denial of the good
      or
      service, the Member may file an external appeal with the DOI within thirty
      (30)
      days of receiving the final written appeal decision;

     

    2.
      The
      Member may be required to file a filing fee for the DOI appeal. The DEPARTMENT
      shall pay the filing fee on behalf of any Member whose family economic filing
      unit income exceeds 185 percent of the federal poverty level but does not exceed
      300 percent of the federal poverty level (Members in Income Bands 1 and 2).
      If
      the Member's family economic filing unit's income exceeds 300 percent of the
      federal poverty level (Income Band 3), the filing unit shall be responsible
      for
      the payment of the filing fee;

     

    

     

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    3.
      The
      non-refundable filing fee for an external appeal through the DOI is $25;

     

    4.
      The
      Member will be asked to submit certain information in support of his or her
      appeal request, including a photocopy of his or her HUSKY B enrollment card.
      The
      Member (or the Member's legal representative) will also be asked to sign a
      release of medical records;

     

    5.
      The
      DOI will assign the appeal to an outside, independent entity. The reviewers
      will
      conduct a preliminary review and determine whether the appeal meets eligibility
      for review. The Member will be notified within five (5) business days of the
      DOI's receipt of the request whether the appeal has been accepted or denied
      for
      full review;

     

    6.
      The
      MCO shall advise Members that they may obtain information about the external
      review process and request a form from the DOI, P.O. Box 816, Hartford, CT
      06142
      or at (860) 297-3862; and

     

    7.
      A copy
      of the DOI External Appeal Consumer Guide. 

     

    c.
      The
      MCO shall be bound by the DOI's external appeal decision. 

     

    8.08
      Provider Appeal Process

     

    a.
      The
      MCO shall have an internal appeal process through which a health care provider
      may grieve the MCO decision on behalf of a Member. The MCO shall provide
      information on the availability of this process to the providers in the MCO's
      network.

     

    b.
      The
      health care provider appeal process shall not include any appeal rights to
      the
      DEPARTMENT or any rights to an external appeal through the DOI.

     

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    9.
      CORRECTIVE ACTION AND CONTRACT TERMINATION

     

    9.01
      Performance Review

     

    
      	a.	
              A
                designated representative of the MCO and a designated representative
                of
                the DEPARTMENT shall meet on an annual basis, and as requested by
                either
                party, to review the performance of the MCO under this contract.
                Written
                minutes of such meetings shall be kept. In the event of any disagreement
                regarding the performance of services by the MCO under this contract,
                the
                designated representatives shall discuss the problem and shall negotiate
                in good faith in an effort to resolve the
                disagreement.

            

    

     

    
      	b.	
              In
                the event that no such resolution is achieved within a reasonable
                time,
                the matter
                shall be referred to the Contract Administrator as provided under
                Section
                9.02, the Disputes clause of this contract. If the Contract Administrator
                determines that the MCO has failed to perform as measured against
                applicable contract provisions, the Contract Administrator may impose
                sanctions or any other penalty, set forth in this Section including
                the
                termination of this contract in whole or in part, as provided under
                this
                Section.
                 

              

            

    

    9.02
      Settlement of Disputes

     

    Any
      dispute arising under the contract which is not disposed of by agreement shall
      be decided by the Contract Administrator whose decision shall be final and
      conclusive subject to any rights the MCO may have in a court of law. The
      foregoing shall not limit any right the MCO may have to present claims under
      Connecticut General Statutes Section 4-141 et. seq. or successor provisions
      regarding the Claims Commissioner, including without limitation Connecticut
      General Statutes Section 4-160 regarding authorization of actions. In connection
      with any appeal to the Contract Administrator under this paragraph, the MCO
      shall be afforded an opportunity to be heard and to offer evidence in support
      of
      its appeal. Pending final decision of a dispute, the MCO shall proceed
      diligently with the performance of the contract in accordance with the Contract
      Administrator's decision.

     

    9.03
      Administrative Errors

     

    The
      MCO
      shall be liable for the actual amount of any costs in excess of $5,000 incurred
      by the DEPARTMENT as the result of any administrative error (e.g., submission
      of
      capitation, encounter or reinsurance data) of the MCO or its subcontractors.
      The
      DEPARTMENT may request a refund of, or recoup from subsequent capitation
      payments, the actual amount of such costs.

     

    9.04
      Suspension of New Enrollment

     

    Whenever
      the DEPARTMENT determines that the MCO is out of compliance with this contract,
      unless corrective action is taken to the satisfaction of the DEPARTMENT,
      the

     

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    DEPARTMENT
      may suspend enrollment of new Members under this contract. The DEPARTMENT,
      when
      exercising this option, must notify the MCO in writing of its intent to suspend
      new enrollment at least thirty (30) days prior to the beginning of the
      suspension period. The suspension period may be for any length of time specified
      by the DEPARTMENT, or may be indefinite. The suspension period may extend up
      to
      the contract expiration date as provided under PART I. (The DEPARTMENT may
      also
      notify existing Members of MCO non-compliance and provide an opportunity to
      disenroll from the MCO and to re-enroll in another MCO.)

     

    9.05
      Sanctions

     

    It
      is
      agreed by the DEPARTMENT and the MCO that if by any means, including any report,
      filing, examination, audit, survey, inspection or investigation, the MCO is
      determined to be out of compliance with this contract, damage to the DEPARTMENT
      may or could result. Consequently, the MCO agrees that the DEPARTMENT may impose
      any of the following sanctions for noncompliance under this contract. Unless
      otherwise provided in this contract, sanctions imposed under this section shall
      be deducted from capitation payment or, at the discretion of the DEPARTMENT,
      paid directly to the DEPARTMENT.

     

    a.
      Sanctions for Noncompliance

     

    1.
      Class A Sanctions. Three (3) Strikes. Sanctions Warranted After Three (3)
      Occurrences.

     

    For
      noncompliance of the contract which does not rise to the level warranting Class
      B sanctions as defined in subsection a (2) of this section or Class C sanctions
      as defined in subsection (b) of this section, including, but not limited to,
      those violations defined as Class A sanctions in any provision of this contract,
      the following course of action will be taken by the DEPARTMENT:

     

    Each
      time
      the MCO fails to comply with the contract on an issue warranting a Class A
      sanction, the MCO receives a strike. The MCO will be notified each time a strike
      is imposed. After the third strike for the same contract provision a sanction
      may be imposed. If no specific time frame is set forth in any such contractual
      provision, the time frame is deemed to be the full length of the
      contract.

     

    The
      MCO
      will be notified in writing at least thirty (30) days in advance of any sanction
      being imposed and will be given an opportunity to meet with the DEPARTMENT
      to
      present its position as to the department's
      determination
      of a violation warranting a Class A sanction. At the department's
      discretion,
      a sanction will thereafter be imposed. Said sanction will be no more than $2,500
      after the first three strikes. The next strike for noncompliance of the same
      contractual provision will result in a sanction of no more than $5,000 and
      any
      subsequent strike for noncompliance of the same contractual provision will
      result in a Class A sanction of no more than $ 10,000.

     

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    2.
      Class B Sanctions. Sanctions Warranted Upon Single
      Occurrence.

     

    For
      noncompliance with the contract which does not warrant the imposition of Class
      C
      sanctions as defined in subsection (b) of this section, including, but not
      limited to, those violations defined as Class B sanctions in any provision
      of
      this contract, the following course of action will be taken by the
      DEPARTMENT:

     

    The
      DEPARTMENT may impose a sanction at the DEPARTMENT'S discretion if, after at
      least thirty (30) days notice to the MCO and an opportunity to meet with the
      DEPARTMENT to present the MCO's position as to the department's
      determination
      of a violation warranting a Class B sanction, the DEPARTMENT determines that
      the
      MCO has failed to meet a performance measure which merits the imposition of
      a
      Class B sanction not to exceed $ 10,000.

     

    b.
      Class C Sanctions. Sanctions Related to Noncompliance Potentially Resulting
      in
      Harm to an Individual Member

     

    (i)
      The
      DEPARTMENT may impose a Class C sanction on the MCO for noncompliance
      potentially resulting in harm to an individual Member, including, but not
      limited to, the following:

     

    1.
      failing to substantially authorize medically necessary items and services that
      are covered (under law or under this contract) to be provided to a Member
      covered under this contract, up to any applicable allowance;

     

    2.
      imposing a premium or copay on Members in excess of that specifically permitted
      under provisions of the contract;

     

    3.
      discriminating among Members on the basis of their health status or requirements
      for health care services, including expulsion or refusal to re-enroll an
      individual, except as permitted by law or under this contract, or engaging
      in
      any practice that would reasonably be expected to have the effect of denying
      or
      discouraging enrollment with the MCO by eligible individuals whose medical
      condition or history indicates a need for substantial future medical
      services;

     

    4.
      misrepresenting or falsifying information that is furnished to the Secretary,
      the DEPARTMENT, Member, potential Member, or a health care provider;
      and

     

    
    

    5.
       distributing
      directly or through any agent or independent contractor marketing materials
      containing false or misleading information.

     

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    (ii) 
      Class C sanctions for noncompliance with the contract under this subsection
      includes the following:

     

    1.
      withholding the next month's capitation payment to the MCO in full or in
      part;

     

    2.
      assessment of liquidated damages:

    a.
      for
      each determination that the MCO fails to substantially provide medically
      necessary services, not more than $25,000;

     

    b.
      for
      each determination that the MCO discriminates among Members on the basis of
      their health status or requirements for health care services or engages in
      any
      practice that has the effect of denying or discouraging enrollment with the
      MCO
      by eligible individuals based on their medical condition or history that
      indicates a need for substantial future medical services, or the MCO
      misrepresents or falsifies information furnished to the Secretary, DEPARTMENT,
      Member, potential Member or health care provider, not more than
      $100,000;

     

    c.
      for
      each determination that the MCO has discriminated among Members or engaged
      in
      any practice that has denied or discouraged enrollment, $15,000 for each
      individual not enrolled as a result of the practice up to a total of $100,000;
      for a determination that the MCO has imposed premiums or copayments on Members
      in excess of the premiums or copayments permitted, double the excess amount.
      The
      excess amount charged in such a circumstance must be deducted from the penalty
      and returned to the Member concerned;

     

    3.
       freeze
      on
      new enrollment and/or alter the current enrollment; or

     

    4.
      appointment of temporary management upon a finding by the

    DEPARTMENT
      that there is continued egregious behavior by the MCO or there is a substantial
      risk to the health of the Members. After a finding pursuant to this subsection,
      Members enrolled with the MCO must be permitted to terminate enrollment without
      cause and the MCO shall be responsible for notification of such right to
      terminate enrollment. Nothing in this subsection shall preclude the DEPARTMENT
      from proceeding under the termination provisions of the contract rather than
      appointing . temporary management. If however, the DEPARTMENT chooses not to
      first terminate the contract and repeated violations occur, the DEPARTMENT
      must
      than appoint temporary management of the MCO and allow individuals to disenroll
      without cause.

     

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    (iii)  
      Prior to imposition of any Class C sanction, the MCO will be notified at least
      thirty (30) days in advance and provided, at a minimum, an opportunity to meet
      with the DEPARTMENT to present its position as to me department's
      determination
      of a violation warranting a Class C Sanction. For any contract violation under
      this subsection, at the DEPARTMENT's discretion, the MCO may be permitted to
      submit a corrective action plan within twenty (20) days of the notice to the
      MCO
      of the violation. Immediate compliance (within thirty (30) days) under any
      such
      corrective action plan may result in the imposition of a lesser sanction on
      the
      MCO. If any sanction issued under this subsection is equivalent to termination
      of the contract, the MCO shall be offered a hearing to contest the imposition
      of
      such a sanction.

     

    c.
      Other Remedies

     

    1.
       Notwithstanding
      the provisions of this section, failure to provide required services will place
      the MCO in default of this contract, and the remedies in this section are not
      a
      substitute for other remedies for default which the DEPARTMENT may impose as
      set
      forth in this contract.

     

    2.
       The
      imposition of any sanction under this section does not preclude the DEPARTMENT
      from obtaining any other legal relief to which it may be entitled pursuant
      to
      state or federal law.

     

    9.06
      Payment Withhold, Class C Sanctions

     

    
      	a.	
              The
                DEPARTMENT may withhold capitation payments from the MCO as provided
                in Section 9.05 or terminate the contract for cause. Cause shall
                include,
                but not be limited to: 1) use of funds and/or personnel for purposes
                other
                than those described in the HUSKY B program and this contract and
                2) if a
                civil action or suit if federal or state court involving allegations
                of
                health fraud of violation of 18 U.S.C. Section. 1961 et seq is brought
                on
                behalf of the DEPARTMENT.

            

    

     

    
      	b.	
              Whenever
                the DEPARTMENT determines that the MCO has failed to provide one
                or more
                of the medically necessary contract services required, the DEPARTMENT
                may
                withhold an estimated portion of the MCO's capitation payment in
                subsequent months, such withhold to be equal to the amount of money
                the
                DEPARTMENT expects to pay for such services, plus any administrative
                costs
                involved. The MCO may not elect to withhold any required services
                in order
                to receive adjusted payment levels. Failure to provide required services
                will place the MCO in default of this contract, and the remedies
                in this
                section are not a substitute for other remedies for default which
                the
                DEPARTMENT may impose as set forth in this contract. The MCO shall
                be
                given at least seven (7) days written notice prior to the withholding
                of
                any capitation payment.

            

    

     

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      	c.	
              When
                it withholds payments under this section, the DEPARTMENT must submit
                to
                the MCO a list of the Members for whom payment is being withheld,
                the
                nature of service(s) denied, and payments the DEPARTMENT must make
                to
                provide medically necessary services. When all payments have been
                made by
                the DEPARTMENT for the MCO contracted services, the DEPARTMENT will
                reconcile the estimated withhold against actual
                payments.

            

    

     

    
      	d.	
              The
                DEPARTMENT may also adjust payment levels accordingly if the MCO
                has
                failed to maintain or make available any records or reports required
                under
                this contract which the DEPARTMENT needs to determine whether the
                MCO is
                providing required contract services. The MCO will be given at least
                thirty (30) days notice prior to taking any action set forth in this
                paragraph.

            

    

     

    9.07
      Emergency Services Denials

     

    If
      the
      MCO has a pattern of inappropriately denying payments for emergency services
      as
      defined in Part I, Definitions, it may be subject to suspension of new
      enrollments, withholding of capitation payments, contract termination, or
      refusal to contract in a future time period. This applies not only to cases
      where the DEPARTMENT has ordered payment after appeal, but also to cases where
      no appeal has been made (i.e., the DEPARTMENT is knowledgeable about documented
      abuse from other sources.)

     

    9.08
      Termination For Default

     

    
      	a.	
              The
                DEPARTMENT may terminate performance of work under this contract
                in whole,
                or in part, whenever the MCO materially defaults in performance of
                this
                contract and fails to cure such default or make progress satisfactory
                to
                the DEPARTMENT toward contract performance within a period of thirty
                (30)
                days (or such longer period as the DEPARTMENT may allow). Such termination
                shall be referred to herein as "Termination for
                Default."

            

    

     

    
      	b.	
              If
                after notice of termination of the contract for default, it is determined
                by me DEPARTMENT or a court that the MCO was not in default, the
                notice of
                termination shall be deemed to have been rescinded and the contract
                reinstated for the balance of the
                term.

            

    

     

    
      	c.	
              In
                the event the DEPARTMENT terminates the contract in full or in part
                as
                provided
                in this clause, the DEPARTMENT may procure services similar to those
                terminated, and the MCO shall be liable to the DEPARTMENT for any
                excess
                costs for such similar services for any calendar month for which
                the MCO
                has been paid to provide services to HUSKY B Members. In addition,
                the MCO
                shall be liable to the DEPARTMENT for administrative costs incurred
                by the
                DEPARTMENT in procuring such similar services. Provided, however,
                that the
                MCO
                shall not be liable for any excess costs or administrative costs
                if the
                failure to perform the contract arises out of causes beyond the control
                and without error or negligence of the MCO or any of its
                subcontractors.

            

    

     

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      	d.	
              In
                the event of a termination for default, the MCO shall be financially
                responsible for Members in the current month at the applicable capitation
                rate.

            

    

     

    
      	e.	
              The
                rights and remedies of the DEPARTMENT provided in this clause shall
                not be
                exclusive and are in addition to any other rights and remedies provided
                by
                law or under this contract.

            

    

     

    
      	f.	
              In
                addition to the termination rights under Part II Section E5, the
                MCO may
                terminate this contract on ninety (90) days written notice in the
                event
                that the DEPARTMENT fails to (a) pay capitation claims in accordance
                with
                Part I Section 6.05 and Part I Section 3.01 of this contract (b)
                provide
                eligibility or enrollment/disenrollment information and shall fail
                to cure
                such default or make progress satisfactory to the MCO within a period
                of
                sixty (60) days of such default.

            

    

     

    9.09
      Termination for Mutual Convenience

     

    The
      DEPARTMENT and the MCO may terminate this contract at any time if both parties
      mutually agree in writing to termination. At least sixty (60) days shall be
      allowed. The effective date must be the first day of a month. The MCO shall,
      upon such mutual agreement being reached, be paid at the capitation rate for
      enrolled Members through the termination of the contract.

     

    9.10
      Termination for Financial Instability of the MCO

     

    In
      the
      event of financial instability of the MCO, the DEPARTMENT shall have the right
      to terminate the contract upon the same terms and conditions as a Termination
      for Default.

     

    9.11
      Termination for Unavailability of Funds

     

    
      	a.	
              The
                DEPARTMENT at its discretion may terminate at any time the whole
                or any
                part of this contract or modify the terms of the contract if federal
                or
                state funding for the contract or for the HUSKY B program as a whole
                is
                reduced or terminated for any reason. Modification of the contract
                includes, but is not limited to, reduction of the rates or amounts
                of
                consideration, reducing services covered by the MCO or the alteration
                of
                the manner of the performance in order to reduce expenditures under
                the
                contract. Whenever possible, the MCO will be given thirty (30) days
                notification of termination.

            

    

     

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      	b.	
              In
                the event of a reduction in the appropriation from the state or federal
                budget for the Division of Health Care Financing of the Department
                of
                Social Services or an across-the-board budget reduction affecting
                the
                Department of Social Services, the DEPARTMENT may either re-negotiate
                this
                contract or terminate with thirty (30) days' written notice. Any
                reduction
                in the capitation rates that is agreed upon by the parties or any
                subsequent termination of this contract by the DEPARTMENT in accordance
                with this provision shall only affect capitation payments or portions
                thereof for covered services purchased on or after the effective
                date of
                any such reduction or termination. Should the DEPARTMENT elect to
                renegotiate the contract, the DEPARTMENT will provide the MCO with
                those
                contract modifications, including capitation rate revisions, it would
                deem
                acceptable.

            

    

     

    
      	c.	
              The
                MCO shall have the right not to extend the contract if the new contract
                terms are deemed to be insufficient notwithstanding any other provision
                of
                this contract. The MCO shall have a minimum of sixty (60) days to
                notify
                the DEPARTMENT regarding its desire to accept new terms. If the new
                capitation rates and any other contract modifications are not established
                at least sixty (60) days prior to the expiration of the initial or
                extension agreement, the DEPARTMENT will reimburse the MCO at the
                higher
                of the new or current capitation rates for that period during which
                the
                new contract period had commenced and the MCO's 60-day determination
                and
                notification period had not been completed, and the MCO will be held
                to
                the terms of the executed contract.

            

    

     

    9.12
      Termination for Collusion in Price Determination

     

    
      	a.	
              In
                competitive bidding markets, the MCO has previously certified that
                the
                prices presented in its proposal were arrived at independently, without
                consultation, communication, or agreement with any other bidder for
                the
                purpose of restricting competition; that, unless otherwise required
                by
                law, the prices quoted have not been knowingly disclosed by the MCO,
                prior
                to bid opening, directly or indirectly to any other bidder or to
                any
                competitor; and that no attempt has been made by the MCO to induce
                any
                other person or firm to submit or not to submit a proposal for the
                purpose
                of restricting competition.

            

    

     

    
      	b.	
              In
                the event that such action is proven, the DEPARTMENT shall have the
                right
                to terminate this contract upon the same terms and conditions as
                a
                Termination for Default.

            

    

     

    9.13
      Termination Obligations of Contracting Parties

     

    
      	a.	
              The
                MCO shall be provided the opportunity for a hearing prior to any
                termination of this contract pursuant to any provision of this contact.
                The DEPARTMENT may notify Members of the MCO and permit such Members
                to
                disenroll immediately without cause during the hearing
                process.

            

    

     

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      	b.	
              Upon
                contract termination, the MCO shall allow the DEPARTMENT, its agents
                and
                representatives full access to the MCO's facilities and records to
                arrange
                the orderly transfer of the contracted activities. These records
                include
                the information necessary for the reimbursement of any outstanding
                HUSKY B
                claims.

            

    

     

    c.
       If
      this
      contract is terminated for any reason other than default by the
      MCO:

     

    1.
      The
      MCO shall ensure that an adequate provider network will be maintained at all
      times during the transition period and that continuity of care is maintained
      for
      all Members;

    2.
      The
      MCO shall submit a written transition plan to the DEPARTMENT sixty (60) days
      in
      advance of the scheduled termination;

    3.
      The
      DEPARTMENT shall be responsible for notifying all Members of the date of
      termination and process by which the Members will continue to receive
      services;

    4.
      The
      DEPARTMENT shall be responsible for all expenses relating to said
      notification;

    5.
      The
      MCO shall notify all providers and be responsible for all expenses related
      to
      such notification; and

    6.
      The
      DEPARTMENT shall withhold a portion, not to exceed $ 100,000, of the last
      month's capitation payment as a surety bond for a six (6) month period to ensure
      compliance under the contract.

     

    9.14
      Waiver of Default

     

    Waiver
      of
      any default shall not be deemed to be a waiver of any subsequent default. Waiver
      of breach of any provision of the contract shall not be deemed to be a waiver
      of
      any other or subsequent breach and shall not be construed to be a modification
      of the terms of the contract unless stated to be such in writing, signed by
      an
      authorized representative of the DEPARTMENT, and attached to the original
      contract.

     

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    10.
      OTHER PROVISIONS

     

    10.01
      Severability

     

    If
      any
      provision of this procurement or the resultant contract is declared or found
      to
      be illegal, unenforceable, or void, then both parties shall be relieved of
      all
      obligations under that provision. The remainder of this procurement or the
      resultant contract shall be enforced to the fullest extent permitted by
      law.

     

    10.02
      Effective Date

     

    This
      contract is subject to review for form and substance by and will not become
      effective until it is approved by the DEPARTMENT.

     

    10.03
      Order of Precedence

     

    This
      contract shall be read together to achieve one harmonious whole. However, should
      any irreconcilable conflict arise between Part I and Part II of this contract.
      Part I shall prevail.

     

    10.04
      Correction of Deficiencies

     

    This
      contract does not release the MCO from its obligation to correct any and all
      outstanding certification deficiencies. Failure to correct all outstanding
      material deficiencies may cause the MCO to be determined in Default of this
      contract.

     

    10.05
      This is not a Public Works Contract

     

    The
      DEPARTMENT and the MCO as parties to this purchase of service Contract mutually
      covenant, acknowledge and agree that this contract does not constitute and
      shall
      not be construed to constitute a public works contract. The DEPARTMENT and
      the
      MCO's mutual agreement that this contract is not a public works contract shall
      have full force and effect on Part I Section 32 and other Sections of this
      contract as applicable.

     

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    12/12/03
      HUSKY B

     

    11.0
      APPENDICES

     

    The
      following documents that were appended to the August 11, 2001 HUSKY B Purchase
      of Service Contract between the DEPARTMENT and the MCO have not changed since
      that date, and are hereby incorporated by reference as if fully set forth
      herein: Appendix C, HUSKY Plus Physical; Appendix D, Provider Credentialing
      and
      Enrollment Requirements; Appendix E, American Academy of Pediatrics
      Recommendations for Preventative Pediatric Health Care; Appendix F, DSS
      Marketing Guidelines; Appendix G, Quality Improvement System for Managed Care;
      Appendix H, Unaudited Quarterly Financial Reports; Appendix J, Recategorization
      Chart. Appendix A, Appendix B and Appendix I are attached hereto.

     

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    II.
      MANDATORY TERMS AND CONDITIONS 

     

    The
      Contractor agrees to comply with the following mandatory terms and
      conditions.

     

    A.
      CLIENT-RELATED SAFE GUARDS

     

    1.
      Inspection of Work Performed
      The
      Department or its authorized representative shall at all times have the right
      to
      enter into the contractor's premises, or such other places where duties under
      the contract are being performed, to inspect, to monitor or to evaluate the
      work
      being performed. The contractor and all subcontractors must provide all
      reasonable facilities and assistance for Department representatives. All
      inspections and evaluations shall be performed in such a manner as will not
      unduly delay work The contractor shall disclose information on clients,
      applicants and their families as requested unless otherwise prohibited by
      federal or state law. Written evaluations pursuant to this section shall be
      made
      available to the contractor.

    2.
      Safeguarding Client Information
      The
      Department and the contractor agree to safeguard the use, publication and
      disclosure of information on all applicants for and all clients who receive
      service under this contract with all applicable federal and state law concerning
      confidentiality.

    3.
      Reporting of Client Abuse or Neglect The
      contractor shall comply with all reporting requirements relative to client
      abuse
      and neglect, including but not limited to requirements as specified in C.G.S.
      17a-101 through 103, 19a-216, 46b-120 related to children; CG.S. 46a-llb
      relative to persons with mental retardation and C.G.S. 17b-407 relative to
      elderly persons.

     

    B.
      CONTRACTOR OBLIGATIONS

    1.
      Credits and Rights in Data

    (a)
      Unless expressly waived in writing by the Department, all documents, reports,
      and other publications for public distribution during or resulting from the
      performances of this contract shall include a statement acknowledging the
      financial support of the state and the Department and, where applicable, the
      federal government. All such publications shall be released in conformance
      with
      applicable federal and state law and all regulations regarding confidentiality.
      Any liability arising from such a release by the contractor shall be the sole
      responsibility of the contractor and the contractor shall indemnify the
      Department, unless the Department or its agents co-authored said publication
      and
      said release is done with the prior written approval of the commissioner of
      the
      Department. Any publication shall contain the following statement: "This
      publication does not express the views of the Department or the State of
      Connecticut. The views and opinions expressed are those of the authors." The
      contractor or any of its agents shall not copyright data and information
      obtained under the terms and conditions of this contract, unless expressly
      authorized in writing by the Department. The Department shall have the right
      to
      publish, duplicate, use and disclose all such data in any manner, and may
      authorize others to do so. The Department may copyright any data without prior
      notice to the contractor. The contractor does not assume any responsibility
      for
      the use, publication or disclosure solely by the Department of such
      data.

    (b)
      "Data" shall mean all results, technical information and materials developed
      and/or obtained in the performance of the services hereunder, including but
      not
      limited to all reports, surveys, plans, charts, recordings (video and/or sound),
      pictures, curricula, public awareness or prevention campaign materials,
      drawings, analyses, graphic representations, computer programs and printouts,
      notes and memoranda, and documents, whether finished
      or unfinished,
      which result from or are prepared in connection with the services performed
      hereunder.

     

    2.
      Organizational Information (NEW), Conflict of Interest, IRS Form
      990:

    Annually
      during the term of the Contract, the Contractor shall submit to the Department
      the following:

    (a)
      a
      copy of its most recent IRS Form 990 submitted to the federal Internal Revenue
      Service, and

    (b)
      its
      most recent Annual Report as filed with the Office of the Secretary of the
      State
      or such other information that the Department deems appropriate with respect
      to
      the organization and affiliation of the Contractor and related
      entities.

     

    3.
      Prohibited Interest
      The
      Contractor warrants that
      no
      state
      appropriated funds have been paid or will be paid by or on behalf of the
      Contractor to contract with or retain any company or person, other than bona
      fide employees working solely for the Contractor, to influence or attempt to
      influence an officer or employee of any state

     

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    agency
      in
      connection -with the awarding, extension, continuation, renewal, amendment,
      or
      modification of this agreement, or to pay or agree to pay any company or person,
      other than bona fide employees working solely for the Contractor, any fee,
      commission, percentage, brokerage fee, gift or any other consideration
      contingent upon or resulting from the award or making of this
      Agreement.

     

    4.
      Offer of Gratuities
      (NEW) By
      its agreement to the terms of this contract, the contractor certifies that
      no
      elected or appointed official or employee of the State of Connecticut has or
      will benefit financially or materially from this contract. The Department may
      terminate this contract if it is determined that gratuities of any kind were
      either offered
      or
      received
      by any of the aforementioned officials
      or
      employees from the contractor or its agents or employees.

     

    5.
      Related Party Transactions (NEW) The contractor shall report all
      related (party transactions, as defined in this Section, to the Department
      on an
      annual basis in the appropriate fiscal report as specified in Part II of this
      contract.
      "Related
      party"
      means a person or organization related through marriage, ability to control,
      ownership, family or business association. Past exercise of influence or control
      need not be shown, only the potential or ability to directly or indirectly
      exercise influence or control. "Related party transactions" between a
      contractor, its employees, Board members or members of the contractor's
      governing body, and a related party include, but are not limited to, (a) real
      estate sales or leases; (b) leases for equipment, vehicles or household
      furnishings; (c) mortgages, loans and working capital loans, and (d) contracts
      for management, consultant and professional services as well as for materials,
      supplies and other services purchased by the contractor.

     

    6.
      Insurance:
      The
      contractor will carry insurance, (liability, fidelity bonding or surety bonding
      and/or other), as specified in this agreement, during the term of this contract
      according to the nature of the work to be performed to "save harmless" the
      State
      of Connecticut from any claims, suits or demands that maybe asserted against
      it
      by reason of any act or omission of the contractor, subcontractor or employees
      in providing services hereunder, including but not limited to any claims or
      demands for malpractice. Certificates of such insurance shall be filed with
      the
      Department prior to the performance of services.

     

    7.
      Reports
      (NEW)
      The contractor shall provide the Department with such statistical, financial
      and
      programmatic information necessary to monitor and evaluate compliance with
      the
      contract. All requests for such information shall comply with all applicable
      state and federal confidentiality laws. The Contractor agrees to provide the
      Department with such reports as the Department requests.

     

    8.
      Delinquent Reports
      The
      contractor will submit required reports by the designated due dates as
      identified in this agreement. After notice to the contractor and an opportunity
      for a meeting with a Department representative, the Department reserves the
      right to withhold payments for services performed under this contract if the
      Department has not received acceptable progress reports, expenditure reports,
      refunds, and/or audits as required by this agreement or previous agreements
      for
      similar or equivalent services the contractor has entered into with the
      Department.

     

    9.
      Record Keeping and
      Access
      The contractor shall maintain books, records, documents, program and individual
      service records and other evidence of its accounting and billing procedures
      and
      practices which sufficiently and properly reflect all direct and indirect costs
      of any nature incurred in the performance of this contract. These records shall
      be subject at all reasonable times to monitoring, inspection, review or audit
      by
      authorized employees or agents of the state or, where applicable, federal
      agencies. The contractor shall retain all such records concerning this contract
      for a period of three (3) years after the completion and submission to the
      state
      of the contractor's annual financial audit.

     

    10.
      Workforce Analysis
      The
      Contractor shall provide a workforce analysis affirmative action report related
      to employment practices and procedures.

     

    11.
      Audit Requirements
      The
      contractor shall provide for an annual financial audit acceptable to the
      Department for any expenditure of state-awarded funds made by the contractor.
      Such audit shall include management letters and audit recommendations. The
      State
      Auditors of Public Accounts shall have access to all records and accounts for
      the fiscal year(s) in which the award was made. The contractor will comply
      with
      federal and state single audit standards as applicable.

     

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      of 114

     

    

      12.
        Litigation
        The
        contractor shall provide written notice to the Department of any litigation
        that
        relates to the services directly or indirectly financed under this contract
        or
        that has the potential to impair the ability of the contractor to fulfill
        the
        terms and conditions of this contract, including but not limited to financial,
        legal or any other situation which may prevent the contractor from meeting
        its
        obligations under the contract.

       

      The
        contractor shall provide -written notice to the Department of any final decision
        by any tribunal or state or federal agency or court which is adverse to the
        contractor or which results in a settlement, compromise or claim or agreement
        of
        any kind for any action or proceeding brought against the contractor or its
        employee or agent under the Americans with Disabilities Act of 1990, executive
        orders Nos. 3 & 17 of Governor Thomas J. Meskill and any other provisions of
        federal or state law concerning equal employment opportunities or
        nondiscriminatory practices.

       

      13.
        Lobbying
        The
        contractor agrees to abide by state and federal lobbying laws, and further
        specifically agrees not to include in any claim for reimbursement any
        expenditures associated with activities to influence, directly or indirectly,
        legislation pending before Congress, or the Connecticut General Assembly
        or any
        administrative or regulatory body unless otherwise required by this
        contract.

    

     

    C.
      STATUTORY AND REGULATORY COMPLIANCE

     

    1.
      Compliance with Law and Policy
      (NEW)
      Contractor shall comply with all pertinent provisions of local, state and
      federal laws and regulations as well as Departmental policies and procedures
      applicable to contractor's programs as specified in this contract. The
      Department shall notify the contractor of any applicable new or revised laws,
      regulations, policies or procedures which the Department has responsibility
      to
      promulgate or enforce.

     

    2.
      Federal Funds
      (NEW) The contractor shall comply with requirements relating to the
      receipt or use of federal funds. The Department shall specify all such
      requirements in Part II of this contract.

     

    3.
      Facility Standards and Licensing Compliance:
      The
      contractor will comply with all applicable local, state and federal licensing,
      zoning, building, health, fire and safety regulations or ordinances, as well
      as
      standards and criteria of pertinent state and federal authorities. Unless
      otherwise provided bylaw, the contractor is not relieved of compliance while
      formally contesting the authority to require such standards, regulations,
      statutes, ordinance or criteria.

     

    4.
      Suspension or Debarment (NEW language from State Auditors)

    (a)
      Signature on contract certifies the Contractor or any person (including
      subcontractors) involved in the administration of Federal or State
      funds:

    (1)
      are
      not presently debarred, suspended, proposed for debarment, declared ineligible,
      or voluntarily excluded by any governmental department or agency (Federal,
      State
      or local);

    (2)
      within a three year period preceding this Contract, has not been convicted
      or
      had a civil judgment rendered against him/her for commission of fraud or a
      criminal offense in connection with obtaining, attempting to obtain or
      performing a public (Federal, State or local) transaction or contract under
      a
      public transaction; violation of Federal or State antitrust statutes or
      commission of embezzlement, theft, forgery, bribery, falsification or
      destruction of records, making false statements or receiving stolen
      property,

    (3)
      is
      not presently indicted for or otherwise criminally or civilly charged by a
      governmental entity (Federal, State or local) with commission of any of the
      above offenses;

    (4)
      has
      not within a three year period preceding this agreement had one or more public
      transactions terminated for cause or fault.

    (b)
      Any
      change in the above status shall be immediately reported to the
      Department.

     

    5.
      Non-discrimination Regarding Sexual Orientation
      Unless
      otherwise provided by Conn. Gen. Stat. § 46a-81p, the contractor agrees to the
      following provisions required pursuant to § 4a-60a of the Conn. Gen.
      Stat.:

    (a)
      (1)
      The contractor agrees and warrants that in the performance of the contract
      such
      contractor will not discriminate or permit discrimination against any person
      or
      group of persons on the grounds of sexual orientation, in
      any
      manner prohibited by the laws of the United States or of the State of
      Connecticut, and that employees are treated when employed without regard to
      their sexual orientation;

     

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    (2)
      the
      contractor agrees to provide each labor union or representatives of workers
      with
      which such contractor has a collective bargaining agreement or other contract
      or
      understanding and each vendor "with which such contractor has a contract or
      understanding a notice to be provided by the commission on human rights and
      opportunities advising the labor union or workers' representative of the
      contractor's commitments under this section, and to post copies of the notice
      in
      conspicuous places available to employees and applicants for
      employment;

    (3)
      the
      contractor agrees to comply with each provision of this section and with each
      regulation or relevant order issued by said commission pursuant to § 46a-56 of
      the Conn. Gen. Stat.;

    (4)
      the
      contractor agrees to provide the commission on human rights and opportunities
      with such information requested by the commission, and permit access to
      pertinent books, records and accounts concerning the employment practices and
      procedures of the contractor which relate to provisions of this section and
§
46a-56 of the Conn, Gen. Stat.

    (b)
      The
      contractor shall include the provisions of subsection (a) of this section in
      every subcontract or purchase order entered into in order to fulfill any
      obligation of a contract with the state and such provisions shall be binding
      on
      a subcontractor, vendor or manufacturer unless exempted by regulations or orders
      of the commission. The contractor shall take such action with respect to any
      such subcontract or purchase order as the commission may direct as a means
      of
      enforcing such provisions including sanctions for noncompliance in accordance
      -with § 46a-56 of the Conn. Gen. Stat. provided, if such contractor becomes
      involved in, or is threatened with, litigation with a subcontractor or vendor
      as
      a result of such direction by the commission, the contractor may request the
      State of Connecticut to enter into any such litigation or negotiation prior
      thereto to protect the interests of the state and the state may so
      enter.

     

    6.
      Executive Orders Nos. 3,16,17 and 7b

     

    (a)
      Executive Order No. 3: Nondiscrimination This contract is subject to the
      provisions of Executive Order No. Three of Governor Thomas J. Meskill
      promulgated June 16,1971, and, as such, this contract maybe canceled, terminated
      or suspended by the State Labor Commissioner for violation of or noncompliance
      with said Executive Order No. Three, or any state or federal law concerning
      nondiscrimination, notwithstanding that the Labor Commissioner is not a party
      to
      this contract. The parties to this contract, as part of the consideration
      hereof, agree that said Executive Order No. Three is incorporated herein by
      reference and made a part hereof. The parties agree to abide by said Executive
      Order and agree that the State Labor Commissioner shall have continuing
      jurisdiction in respect to contract performance in regard to nondiscrimination,
      until the contract is completed or terminated prior to completion. The
      contractor agrees, as part consideration hereof, that this contract is subject
      to the Guidelines and Rules issued by the State Labor Commissioner to implement
      Executive Order No. Three and that the contractor will not discriminate in
      employment practices or policies, will file all reports as required, and will
      fully cooperate with the State of Connecticut and the State Labor
      Commissioner.

     

    (b)
      Executive Order No. 16: Violence in the Workplace Prevention Policy This
      contract is also subject to provisions of Executive Order No. Sixteen of
      Governor John J. Rowland promulgated August 4, 1999, and, as such, this contract
      maybe cancelled, terminated or suspended by the contracting agency or the State
      for violation of or noncompliance with said Executive Order No. Sixteen. The
      parties to this contract, as part of the consideration hereof, agree that:
      (1)
      contractor shall prohibit employees from bringing into the state work site,
      except as maybe required as a condition of employment, any weapon/dangerous
      instrument defined in Section 2 to follow,

    (2)
      weapon means any firearm, including a BB gun, whether loaded or unloaded, any
      knife (excluding a small pen or pocket knife), including a switchblade or other
      knife having an automatic spring release device, a stiletto, any police baton
      or
      nightstick or any martial arts weapon or electronic defense weapon. Dangerous
      instrument means any instrument, article or substance that, under the
      circumstances, is capable of causing death or serious physical
      injury,

    (3)
      contractor shall prohibit employees from attempting to use, or threaten to
      use,
      any such weapon or dangerous instrument in the state work site and employees
      shall be prohibited from causing, or threatening to cause, physical injury
      or
      death to any individual in the state work site; (4) contractor shall adopt
      the
      above prohibitions as work rules, violation of which shall subject the employee
      to disciplinary action up to and including discharge. The Contractor shall
      require that all employees are aware of such work rules; (5) contractor agrees
      that any subcontract it enters into in the furtherance of the work to be
      performed hereunder shall contain the provisions 1 through 4,
      above.

     

    Page
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    (c)
      Executive Order No. 17: Connecticut State Employment Service Listings
      This contract is also subject to provisions of Executive Order No. Seventeen
      of
      Governor Thomas J. Meskill promulgated February 15,1973, and, as such, this
      contract maybe canceled, terminated or suspended by the contracting agency
      or
      the State Labor Commissioner for violation of or noncompliance with said
      Executive Order Number Seventeen, notwithstanding that the Labor Commissioner
      may not be a party to this contract. The parties to this contract, as part
      of
      the consideration hereof, agree that Executive Order No. Seventeen is
      incorporated herein by reference and made a part hereof. The parties agree
      to
      abide by said Executive Order and agree that the contracting agency and the
      State Labor Commissioner shall have joint and several continuing jurisdiction
      in
      respect to contract performance in regard to listing all employment openings
      -with the Connecticut State Employment Service.

     

    (d)
      Executive Order No. 7b: Contracting Standards Board
      This
      contract is also subject to provisions of
      Executive Order No. 7b of Governor Jodi M. Rell, promulgated on November
      16,2005.
      The
      Parties to this Agreement, as part of the consideration hereof, agree that:
      (1.)
      The State Contracting Standards Board ("the Board") may review this contract
      and
      recommend to the state contracting agency termination of the contract for cause.
      The state contracting agency shall consider the recommendations and act as
      required or permitted in accordance with the contract and applicable law. The
      Board shall provide the results of its review, together with its
      recommendations, to the state contracting agency and any other affected party
      in
      accordance with the notice provisions in the contract no later than fifteen
      (15)
      days after the Board finalizes its recommendation. For the purposes of this
      Section, "for cause" means: (i.) a violation of the State Ethics Code (Conn.
      Gen. Stat. Chapter 10) or Section 4A-100 of the Conn. Gen. Statutes or (ii.)
      wanton or reckless disregard of any state contracting and procurement process
      by
      any person substantially involved in such contract or state contracting agency.
      (2.) For the purposes of this Section, "contract" shall not include real
      property transactions involving less than a fee simple interest or financial
      assistance comprised of state or federal funds, the form of which may include
      but is not limited to grants, loans, loan guarantees, and participation
      interests in loans, equity investments and tax credit programs. Notwithstanding
      the foregoing, the Board shall not have any authority to recommend the
      termination of a contract for the sale or purchase of a fee simple interest
      in
      real property following transfer of title. (3.) Effective January 1, 2006,
      notwithstanding the contract value listed in Conn. Gen. Stat. §§ 4-250 and
      4-251, all procurements between state agencies and private entities with a
      value
      of $50,000 (fifty thousand dollars) or more in a calendar or fiscal year shall
      comply with the gift affidavit requirements of said Sections. Certification
      by
      agency officials or employees required by Conn. Gen. Stat. § 4-252 shall not be
      affected by this Section.

     

    7.
      Nondiscrimination and Affirmative Action Provisions in Contracts of the State
      and Political Subdivisions Other Than Municipalities The contractor agrees
      to
      comply with provisions of § 4a-60 of the Connecticut General
      Statues.

    (a)
      Every
      contract to which the state or any political subdivision of the state other
      that
      a municipality is a party shall contain the following provisions:

    (1)
      The
      contractor agrees and warrants that in the performance of the contract such
      contractor will not discriminate or permit discrimination against any person
      or
      group of persons on the grounds of race, color, religious creed, age, marital
      status, national origin, ancestry, sex, mental retardation or physical
      disability, including, but not limited to, blindness, unless it is shown by
      such
      contractor that such disability prevents performance of the work involved,
      in
      any manner prohibited by the laws of the United States or of the state of
      Connecticut. The contractor further agrees to take affirmative action to insure
      that applicants with job-related qualifications are employed and that employees
      are treated when employed without regard to their race, color, religious creed,
      age, marital status, national origin, ancestry, sex, mental retardation, or
      physical disability, including, but not limited to, blindness, unless it is
      shown by such contractor that such disability prevents performance of the work
      involved; (2) the contractor agrees, in all solicitations or advertisements
      for
      employees placed by or on behalf of the contractor, to state that is an
      "affirmative action-equal opportunity employer" in accordance with regulations
      adopted by the commission; (3) the contractor agrees to provide each labor
      union
      or representative of workers with which such contractor has a collective
      bargaining agreement or other contract or understanding and each vendor with
      which such contractor has a contract or understanding, a notice to be provided
      by the commission advising the labor union or workers' representative of the
      contractor's commitments under this section, and to post copies of the notice
      in
      conspicuous places available to employees and applicants for employment; (4)
      the
      contractor agrees to comply with each provision of this section and Conn. Gen.
      Stat. §§ 46a-68e and 46a-68f and with each regulation or relevant order issued
      by said commission pursuant to Conn. Gen. Stat. §§ 46a-56,46a-68e and 46a-68f;
      (5) the contractor agrees to provide the commission of Page 105 of
      114

    

    

    human
      rights and opportunities -with such information requested by the commission,
      and
      permit access to pertinent books, records and accounts, concerning the
      employment practices and procedures of the contractor as relate to the
      provisions of this section and Conn. Gen. Stat. § 46a-56. If the contract is a
      public works contract, the contractor agrees and warrants that he will make
      good
      faith efforts to employ minority business enterprises as subcontractor's and
      suppliers of materials on such public works project.

    (b)
      For
      the purposes of this section, "minority business enterprise" means any small
      contractor or supplier of materials fifty-one per cent or more of capital stock,
      if any, or assets of which is owned by a person or persons: (1) Who are active
      in the daily affairs of the enterprise, (2) who have the power to direct the
      management and policies of the enterprise and (3) who are members of a minority,
      as such term is defined in subsection (a) of Conn. Gen. Stat. § 32-9n; and "good
      faith" means that degree of diligence which a reasonable person would exercise
      in the performance of legal duties and obligations. "Good faith efforts" shall
      include, but not be limited to, those reasonable initial efforts necessary
      to
      comply with statutory or regulatory requirements and additional or substituted
      efforts when it is determined that such initial efforts will not be sufficient
      to comply with such requirements.

    (c)
      Determinations of the contractor's good faith efforts shall include but shall
      not be limited to the following factors: The contractor's employment and
      subcontracting policies, patterns and practices; affirmative action advertising;
      recruitment and training; technical assistance activities and such other
      reasonable activities or efforts as the commission may prescribe that are
      designed to ensure the participation of minority business enterprises in public
      works projects.

    (d)
      The
      contractor shall develop and maintain adequate documentation, in a manner
      prescribed by the commission, of its good faith efforts.

    (e)
      Contractor shall include the provisions of subsection (a) of this section in
      every subcontract or purchase order entered into in order to fulfill any
      obligation of a contract with the state and such provision shall be binding
      on a
      subcontractor, vendor or manufacturer unless exempted by regulations or orders
      of the commission. The contractor shall take such action with respect to any
      such subcontract or purchase order as the commission may direct as a means
      of
      enforcing such provisions including sanctions for noncompliance in accordance
      with Conn. Gen. Stat. § 46a-56; provided, if such contractor becomes involved
      in, or is threatened with, litigation with a subcontractor or vendor as a result
      of such direction by the commission, the contractor may request the state of
      Connecticut to enter into such litigation or negotiation prior thereto to
      protect the interests of the state and the state may so enter.

     

    8.
      Americans with Disabilities Act of
      1990
      This clause applies to those contractors which are or will come tobe
      responsible for compliance with the terms of the Americans with Disabilities
      Act
      of 1990 (42 USCS §§ 12101-12189 and §§12201-12213) (Supp. 1993); 47 USCS §§225,
      611 (Supp. 1993). During the term of the contract, the contractor represents
      that it is familiar with the terms of this Act and that it is in compliance
      with
      the law. The contractor warrants that it will hold the state harmless from
      any
      liability which maybe imposed upon the state as a result of any failure of
      the
      contractor to be in compliance with this Act. As applicable, the contractor
      agrees to abide by provisions of Sec. 504 of the federal Rehabilitation Act
      of
      1973, as amended, 29 U.S.G § 794 (Supp. 1993), regarding access to programs and
      facilities by people with disabilities.

     

    9.
      Utilization
      of
      Minority Business Enterprises It is the policy of the state that minority
      business enterprises should have the maximum opportunity to participate in
      the
      performance of government contracts. The contractor agrees to use best efforts
      consistent with 45 CF.PL 74.160 et seq. (1992) and paragraph 9 of Appendix
      G
      thereto for the administration of programs or activities using HHS funds; and
§§
13a-95a, 4a-60, to 4a-62, 4b-95(b), and 32-9e of the Conn. Gen. Stat. to carry
      out this policy in the award of any subcontracts.

     

    10.
      Priority Hiring
      Subject
      to the contractor's exclusive right to determine the qualifications for all
      employment positions, the contractor shall use its best efforts to ensure that
      it gives priority to hiring welfare recipients who are subject to time limited
      welfare and must find employment. The contractor and the Department will work
      cooperatively to determine the number and types of positions to which this
      paragraph shall apply. The Department of Social Services regional office staff
      or staff of Department of Social Service contractors will undertake to counsel
      and screen an adequate number of appropriate candidates for positions targeted
      by the contractor as suitable for individuals in the time limited welfare
      program. The success of the contractor's efforts will be considered when
      awarding and evaluating contracts.

     

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    11.
      Non-smoking
      If the
      contractor is an employer subject to the provisions of § 31-40q of the Conn.
      Gen. Stat., the contractor agrees to provide upon request the Department with
      a
      copy of its written rules concerning smoking. Evidence of compliance with the
      provisions of section 31-40q of the Conn. Gen. Stat. must be received prior
      to
      contract approval by the Department.

     

    12.
      Government Function; Freedom of Information (NEW)
      If the
      amount of this contract exceeds two million five hundred thousand dollars
      ($2,500,000), and the contract is for the performance of a governmental
      function, as that term is defined in Conn. Gen. Stat. Sec. 1-200(11), as amended
      by Pubic Act 01-169, the Department is entitled to receive a copy of the records
      and files related to the contractor's performance of the governmental function,
      and maybe disclosed by the Department pursuant to the Freedom of Information
      Act.

     

    13.
      HIPAA Requirements(NEW,
      revised
      effective
      4/20/05)

     

    NOTE:
      Numbering in this Section may not be consistent with the remainder cf this
      contract: as much of it is presented verbatim
      from the federal source.

     

    (a.)
      If
      the Contactor is a Business Associate under HIPAA, the Contractor must comply
      with all terms and conditions of this Section of the Contract. If the Contractor
      is not a Business Associate under HIPAA, this Section of the Contract does
      not
      apply to the Contractor for this Contract.

    (b.)
      The
      Contractor is required to safeguard the use, publication and disclosure of
      information on all applicants for, and all clients who receive, services under
      the contract in accordance "with all applicable federal and state law regarding
      confidentiality, which includes but is not limited to the requirements of the
      Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), more
      specifically with the Privacy and Security Rules at 45 C.F.R. Part 160 and
      Part
      164, subparts A, C, and E; and

    (c.)
      The
      State of Connecticut Department named on page 1 of this Contract (hereinafter
      "Department")
      is a
      "covered entity" as that term is defined in 45 C.F.R. § 160.103; and

    (d.)
      The
      Contractor, on behalf of the Department, performs functions that involve the
      use
      or disclosure
      of "individually identifiable health information," as that term is defined
      in 45
      C.F.R § 160.103; and

    (e.)
      The
      Contractor is a "business associate" of the Department, as that term is defined
      in 45 CF.R § 160.103;^

    (f.)
      The
      Contractor and the Department agree to the following in order to secure
      compliance with the Health Insurance Portability and Accountability Act of
      1996
      ("HIPAA"), more specifically with the Privacy and Security Rules at 45 CF.R
      Part
      160 and Part 164, subparts A, C, and E:

     

    I.
      DEFINITIONS

     

    A.
      Business Associate.
      "Business Associate" shall mean the Contractor.

    B.
      Covered Entity.
      "Covered
      Entity" shall mean the Department of the State of Connecticut named on page
      1 of
      this Contract.

    C.
      Designated Record
      Set.
      "Designated Record Set" shall have the same meaning as the term "designated
      record set" in 45 CF.R § 164.501.

    D.
      Individual.
      "Individual" shall have the same meaning as the term "individual"' in 45 C.F.R.
      § 160.103 and shall include a person who qualifies as a personal representative
      as defined in 45 CF.R § 164.502(g).^

    E.
      Privacy Rule.
      "Privacy
      Rule" shall mean the Standards for Privacy of Individually Identifiable Health
      Information at 45 C.F.R. part 160 and parts 164, subparts A and E.

    F.
      Protected Health Information.
      "Protected Health Information" or "PHI" shall have the same meaning as the
      term
      "protected health information" in 45 CF.R § 160.103, limited to information
      created or received by the Business Associate from or on behalf of the Covered
      Entity.

    G.
      Required
      by
      Law.
      "Required by Law"' shall have the same meaning as the term "required bylaw"
      in
      45 C.F.R § 164.103.

    H.
      Secretary.
      "Secretary" shall mean the Secretary of the Department of Health and Human
      Services or his designee.

    I.
      More Stringent
      "More
      stringent" shall have the same meaning as the term "more stringent" in 45 C.F.R.
      § 160.202.

     

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    J.
      Section of Contract  "This Section of the Contract" refers to the
      HIPAA Provisions stated herein, in their entirety.

    K.
      Security Incident "Security Incident" shall have the same meaning as
      the term "security incident" i; 45
      CF.R.
§ 164.304.

    L.
      Security Rule.
      "Security Rule" shall mean the Security Standards for the Protection of
      Electronic Protected Health Information at 45 C.F.R. part 160 and parts 164,
      subpart A and C.

     

    II
      OBLIGATIONS AND ACTIVITIES OF BUSINESS ASSOCIATES

     

    A.
      Business
      Associate agrees not to use or disclose PHI other than as permitted or required
      by this Section of the Contract or as Required by Law.

    B.
      Business Associate agrees to use appropriate safeguards to prevent use or
      disclosure of PHI other than as provided for in this Section of the
      Contract.

    Bl.
      (NEW)
      Business Associate agrees to use administrative, physical and technical
      safeguards that reasonably and appropriately protect the confidentiality,
      integrity, and availability of electronic protected health information that
      it
      creates, receives, maintains, or transmits on behalf of the Covered
      Entity.

    C.
      Business Associate agrees to mitigate, to the extent practicable, any harmful
      effect that is known to the Business Associate of a use or disclosure of PHI
      by
      Business Associate in-violation of this Section of the Contract.

    D.
      Business Associate agrees to report to Covered Entity any use or disclosure
      of
      PHI not provided for by this Section of the Contract or any security incident
      of
      which it becomes aware.

    E.
      Business Associate agrees to insure that any agent, including a subcontractor,
      to whom it provides PHI received from, or created or received by Business
      Associate, on behalf of the Covered Entity, agrees to the same restrictions
      and
      conditions that apply through this Section of the Contract to Business Associate
      with respect to such information.

    F.
      Business Associate agrees to provide access, at the request of the Covered
      Entity, and in the time and manner agreed to by the parties, to PHI in a
      Designated Record Set, to Covered Entity or, as directed by Covered Entity,
      to
      an Individual in order to meet the requirements under 45 CF.R. §
164.524.

    G.
      Business Associate agrees to make any amendments to PHI in a Designated Record
      Set that the Covered Entity directs or agrees to pursuant to 45 CF.R. § 164.526
      at the request of the Covered Entity, and in the time and manner agreed to
      by
      the parties.

    H.
      Business Associate agrees to make internal practices, books, and records,
      including policies and procedures and PHI, relating to the use and disclosure
      of
      PHI received from, or created or received by, Business Associate on behalf
      of
      Covered Entity, available to Covered Entity or to the Secretary in a time and
      manner agreed to by the parties or designated by the Secretary, for purposes
      of
      the Secretary determining Covered Entity's compliance with the Privacy
      Rule.

    I.
      Business Associate agrees to document such disclosures of PHI and information
      related to such disclosures as would be required for Covered Entity to respond
      to a request by an Individual for an accounting of disclosures of PHI in
      accordance with 45 CF.R. § 164.528.

    J.
      Business Associate agrees to provide to Covered Entity, in a time and manner
      agreed to by the parties, information collected in accordance with paragraph
      I
      of this Section of the Contract, to permit Covered Entity to respond to a
      request by an Individual for an accounting of disclosures of PHI in accordance
      with 45 CF.R § 164.528.

    K.
      Business Associate agrees to comply with any state law that is more stringent
      than the Privacy Rule.

     

    Ill
      PERMITTED USES AND DISCLOSURE BY BUSINESS ASSOCIATE

     

    A.
      General
      Use and Disclosure Provisions Except as otherwise limited in this Section of
      the
      Contract, Business Associate may use or disclose PHI to perform functions,
      activities, or services for, or on behalf of. Covered Entity as specified in
      this Contract, provided that such use or disclosure would not violate the
      Privacy Rule if done by Covered Entity or the minimum necessary policies and
      procedures of the Covered Entity.

     

    B.
      Specific Use and Disclosure Provisions

     

    1.
      Except
      as otherwise limited in this Section of the Contract, Business Associate may
      use
      PHI for the proper management and administration of Business Associate or to
      carry out the legal responsibilities of Business Associate.

     

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    2.
      Except
      as otherwise limited in this Section of the Contract, Business Associate may
      disclose PHI for the proper management and administration of Business Associate,
      provided that disclosures are Required by Law, or Business Associate obtains
      reasonable assurances from the person to whom the information is disclosed
      that
      it will remain confidential and used or further disclosed only as Required
      by
      Law or for the purpose for which it was disclosed to the person, and the person
      notifies Business Associate of any instances of which it is aware in which
      the
      confidentiality of the information has been breached.

    3.
      Except
      as otherwise limited in this Section of the Contract, Business Associate may
      use
      PHI to provide Data Aggregation services to Covered Entity as permitted by
      45
      CF.R. § 164.504(e)(2)(i)(B).

     

    IV
      OBLIGATIONS OF COVERED ENTITY

     

    A.
      Covered Entity shall notify Business Associate of any limitations in its notice
      of privacy practices of Covered Entity, in accordance with 45 CF.R. 164.520,
      or
      to the extent that such limitation may affect Business Associate's use or
      disclosure of PHI.

    B.
      Covered Entity shall notify Business Associate of any changes in, or revocation
      of, permission by Individual to use or disclose PHI, to die extent that such
      changes may affect Business Associate's use or disclosure of PHI.

    C.
      Covered Entity shall notify Business Associate of any restriction to the use
      or
      disclosure of PHI that Covered Entity has agreed to in accordance with 45 CF.R
§
164.522, to the extent that such restriction may affect Business Associate's
      use
      or disclosure of PHI.

     

    V.
       PERMISSABLE REQUESTS BY COVERED ENTITY

     

    Covered
      Entity shall not request Business Associate to use or disclose PHI in any manner
      that would not be permissible under the Privacy Rule if done by the Covered
      Entity, except that Business Associate may use and disclose PHI for data
      aggregation, and management and administrative activities of Business Associate,
      as permitted under this Section of the Contract.

     

    VI
      TERM AND TERMINATION

     

    A-
      Term
      The Term
      of this Section of the Contract shall be effective as of the date the Contract
      is effective and shall terminate when all of the PHI provided by Covered Entity
      to Business Associate, or created or received by Business Associate on behalf
      of
      Covered Entity, is destroyed or returned to Covered Entity, or, if it is
      infeasible to return or destroy PHI, protections are extended to such
      information, in accordance with the termination provisions in this
      Section.

     

    B.
      Termination for Cause
      Upon
      Covered Entity's knowledge of a material breach by Business Associate, Covered
      Entity shall either:

    1.
      Provide an opportunity for Business Associate to cure the breach or end the
      violation and terminate the Contract if Business Associate does not cure the
      breach or end the violation within the time specified by the Covered Entity,
      or

    2.
      Immediately terminate the Contract if Business Associate has breached a material
      term of this Section of the Contract and cure is not possible; or

    3.
      If
      neither termination nor cure is feasible. Covered Entity shall report the
      violation to the Secretary. 

     

    C.
      Effect of Termination

     

    1.
      Except
      as provided in paragraph (2) of this subsection C, upon termination of this
      Contract, for any reason, Business Associate shall return or destroy all PHI
      received from Covered Entity, or created or received by Business Associate
      on
      behalf of Covered Entity. This provision shall apply to PHI that is in the
      possession of subcontractors or agents of Business Associate, Business Associate
      shall retain no copies of the PHI.

    2.
      In the
      event that Business Associate determines that returning or destroying the PHI
      is
      infeasible, Business Associate shall provide to Covered Entity notification
      of
      the conditions that make return or destruction infeasible. Upon documentation
      by
      Business Associate that return of destruction of PHI is infeasible, Business
      Associate shall extend the protections of this Section of the Contract to such
      PHI and limit further uses and disclosures of PHI to those purposes that
      make

     

     

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    return
      or
      destruction infeasible, for as long as Business Associate maintains such PHI.
      Infeasibility of the return or destruction of PHI includes, but is not limited
      to, requirements under state or federal law that the Business Associate
      maintains or preserves the PHI or copies thereof.

     

     

    A.
      Regulatory References
      A
      reference in this Section of the Contract to a section in the Privacy Rule
      means
      the section as in effect or as amended.

    B.
      Amendment The Parties agree to take such action as in necessary to
      amend this Section of the Contract from time to time as is necessary for Covered
      Entity to comply with requirements of the Privacy Rule and the Health Insurance
      Portability and Accountability Act of 1996, Pub. L. No. 104-191.

    C.
      Survival
      The
      respective rights and obligations of Business Associate under Section VI,
      Subsection C of this Section of the Contract shall survive the termination
      of
      this Contract.

    D.
      Effect
      on
      Contract
      Except
      as specifically required to implement the purposes of this Section of the
      Contract, all other terms of the contract shall remain in force and
      effect.

    E.
      Construction
      This
      Section of the Contract shall be construed as broadly as necessary to implement
      and comply with the Privacy Standard. Any ambiguity in this Section of the
      Contract shall be resolved in favor of a meaning that complies, and is
      consistent with, the Privacy Standard.

    F.
      Disclaimer Covered Entity makes no warranty or representation that
      compliance with this Section of the Contract will be adequate or satisfactory
      for Business Associate's own purposes. Covered Entity Shall not be liable to
      Business Associate for any claim, loss or damage related to or arising from
      the
      unauthorized use or disclosure of PHI by Business Associate or any of its
      officers, directors, employees, contractors or agents, or any third party to
      whom Business Associate has disclosed PHI pursuant to paragraph II D of this
      Section of the Contract. Business Associate is solely responsible for all
      decisions made, and actions taken, by Business Associate regarding the
      safeguarding, use and disclosure of PHI within its possession, custody or
      control.

    G.
      Indemnification
      The
      Business Associate shall indemnify and hold the Covered Entity harmless from
      and
      against all claims, liabilities, judgments, fines, assessments, penalties,
      awards, or other expenses, of any kind or nature whatsoever, including, without
      limitation, attorney's fees, expert witness fees, and costs of investigation,
      litigation or dispute resolution, relating to or arising out of any violation
      by
      the Business Associate and its agents, including subcontractors, of any
      obligation of Business Associate and its agents, including subcontractors,
      under
      this Section of the Contract.

     

    D.
      MISCELLANEOUS PROVISIONS

     

    1.
      Liaison
      Each
      party shall designate a liaison to facilitate a cooperative working relationship
      between the contractor and the Department in the performance and administration
      of this contract.

     

    2.
      Choice of Law andChoice
      of Forum The contractor agrees to be bound by the law of the State of
      Connecticut and the federal government where applicable, and agrees that this
      contract shall be construed and interpreted in accordance with Connecticut
      law
      and federal law where applicable.

     

    3.
      Subcontracts For purposes of this clause subcontractors shall be
      defined as providers of direct human services. Vendors of support services,
      not
      otherwise known as human service providers or educators, shall not be considered
      subcontractors, e.g. lawn care, unless such activity is considered part of
      a
      training, vocational or educational program. The subcontractor's identity,
      services to be rendered and costs shall be detailed in PART II of this contract.
      Notwithstanding the execution of this contract prior to a specific subcontractor
      being identified or specific costs being set, no subcontractor may be used
      or
      expense under this contract incurred prior to identification of the
      subcontractor or inclusion of a detailed budget statement as to subcontractor
      expense, unless expressly provided in PART II of this contract. Identification
      of a subcontractor or budget costs for such subcontractor shall be deemed to
      be
      a technical amendment if consistent with the description of each contained
      in
      PART II of this contract. No subcontractor shall acquire any direct right of
      payment from the Department by virtue of the provisions of this paragraph or
      any
      other paragraph of this contract. The use of subcontractors, as defined in
      this
      clause, shall not

     

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    relieve
      the contractor of any responsibility or liability under this contract. The
      contractor shall make available copies of all subcontracts to the Department
      upon request.

     

    4.
      Mergers and Acquisitions (NEW)

    (a)
      Contracts in whole or in part are not transferable or assignable -without the
      prior -written agreement of the Department.

    (b)
      At
      least ninety (90) days prior to the effective date of any fundamental changes
      in
      corporate status, including merger, acquisition, transfer of assets, and any
      change in fiduciary responsibility, the contractor shall provide the Department
      with written notice of such changes.

    (c)
      The
      Contractor shall comply with requests for documentation deemed necessary by
      the
      Department to determine whether the Department will provide prior written
      agreement as required by Section III.D.33 (a) above. The Department shall notify
      the Contractor of such determination not later than forty-five (45) business
      days from the date the Department receives such requested
      documentation.

     

    5.
      Equipment (NEW) In the event this contract is terminated or not
      renewed, the Department reserves the right to recoup any equipment, deposits
      or
      down payments made or purchased with start-up funds or other funds specifically
      designated for such purpose under this contract. For purposes of this provision,
      equipment means tangible personal property with a normal useful life of at
      least
      one year and a value of at least $2,500. Equipment shall be considered purchased
      from Contractor funds and not from Department funds if the equipment is
      purchased for a program that has other sources of income equal to or greater
      than the equipment purchase price.

     

    6.
      Independent Capacity of Contractor
      (NEW)
      The contractor, its officers, employees, subcontractors, or any other agent
      of
      the contractor in the performance of this contract will act in an independent
      capacity and not as officers or employees of the state of Connecticut or of
      the
      Department.

     

    7.
      Settlement of Disputes and Claims Commission (NEW)

    (a)
      Any
      dispute concerning the interpretation or application of this contract shall
      be
      decided by the commissioner of the Department or his/her designee whose decision
      shall be final subject to any rights the contractor may have pursuant to state
      law. In appealing a dispute to the commissioner pursuant to this provision,
      the
      contractor shall be afforded an opportunity to be heard and to offer evidence
      in
      support of its appeal. Pending final resolution of a dispute, the contractor
      and
      the Department shall proceed diligently with the performance of the
      contract.

    (b)
      Claims
      Commission.
      The
      Contractor agrees that the sole and exclusive means for the presentation of
      any
      claim against the State arising from this contract shall be in accordance with
      Chapter 53 of the Connecticut General Statutes (Claims Against the State) and
      the Contractor further agrees not to initiate legal proceedings except as
      authorized by that
      Chapter
      in any
      State or Federal Court in addition to or in lieu of said Chapter 53
      proceedings.

     

    E.
      REVISIONS, REDUCTION, DEFAULT AND CANCELLATION

     

    1.
      Contract Re-visions and Amendments

    (a)
      A
      formal contract amendment, in writing, shall not be effective until executed
      by
      both parties to the contract, and, where applicable, the Attorney General.
      Such
      amendments shall be required for extensions to the final date of the contract
      period and to terms and conditions specifically stated in Part II of this
      contract, including but not limited to revisions to the maximum contract
      payment, to the unit cost of service, to the contract's objectives, services,
      or
      plan, to due dates for reports, to completion of objectives or services, and
      to
      any other contract revisions determined material by the Department.

    (b)
      The
      contractor shall submit to the Department in writing any proposed revision
      to
      the contract and the Department shall notify the contractor of receipt of the
      proposed revision. Any proposal deemed material shall be executed pursuant
      to
      (a) of this section. The Department may accept any proposal as a technical
      amendment and notify the contractor in writing of the same. A technical
      amendment shall be effective on the date approved by the Department, unless
      expressly stated otherwise.

    (c)
      No
      amendments maybe made to a lapsed contract.

     

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    2.
      Contract
      Reduction

    (a)
      The
      Department reserves the right to reduce the contracted amount of compensation
      at
      any time in the event that: (1) the Governor or the Connecticut General Assembly
      rescinds, reallocates, or in anyway reduces the total amount budgeted for the
      operation of the Department during the fiscal year for -which such funds are
      withheld;
      or
      (2)
      federal funding reductions result in reallocation of funds within the
      Department.

    (b)
      The
      contractor and the Department agree to negotiate on the implementation of the
      reduction within thirty (30) days of receipt of formal notification of intent
      to
      reduce the contracted amount of compensation from the Department. If agreement
      on the implementation of the reduction is not reached within 30 calendar days
      of
      such formal notification and a contract amendment has not been executed, the
      Department may terminate the contract sixty (60) days from receipt of such
      formal notification. The Department will formally notify the contractor of
      the
      termination date.

     

    3.
      Default by the Contractor

    (a)
      If
      the contractor defaults as to, or otherwise fails to comply with, any of the
      conditions of this contract the Department may; (1) withhold payments until
      the
      default is resolved to the satisfaction of the Department; (2) temporarily
      or
      permanently discontinue services under the contract; (3) require that unexpended
      funds be returned to the Department; (4) assign appropriate state personnel
      to
      execute the contract until such time as the contractual defaults have been
      corrected to the satisfaction of the Department; (5) require that contract
      funding be used to enter into a sub-contract arrangement with a person or
      persons designated by the Department in order to bring the program into
      contractual compliance; (6) terminate this contract; (7) take such other actions
      of any nature whatsoever as maybe deemed appropriate for the best interests
      of
      the state or the program(s) provided under this contract or both; (8) any
      combination of the above actions.

    (b)
      In
      addition to the rights and remedies granted to the Department by this contract,
      the Department shall have all other rights and remedies granted to it by law
      in
      the event of breach of
      or default
      by the contractor under the terms of this contract.

    (c)
      Prior
      to invoking any of the remedies for default specified in this paragraph except
      when the Department deems the health or welfare of service recipients is
      endangered as specified in clause 8 of this agreement or has not met
      requirements as specified in clause 27, the Department shall notify the
      contractor in writing of the specific facts and circumstances constituting
      default or failure to comply with the conditions of this contract and proposed
      remedies. Within five (5) business days of receipt of this notice, the
      contractor shall correct any contractual defaults specified in the notice and
      submit written documentation of correction to the satisfaction of the Department
      or request in writing a meeting with the commissioner of the Department or
      his/her designee. Any such meeting shall be held within five (5) business days
      of the written request. At the meeting, the contractor shall be given an
      opportunity to respond to the Department's notice of default and to present
      a
      plan of correction with applicable time frames. Within five (5) business days
      of
      such meeting, the commissioner of the Department shall notify the contractor
      m
      writing of his/her response to the information provided including acceptance
      of
      the plan of correction and, if the commissioner finds continued contractual
      default for which a satisfactory plan of corrective action has not been
      presented, the specific remedy for default the Department intends to invoke.
      This action of the commissioner shall be considered final

    (d)
      If at
      any step in this process the contractor fails to comply with the procedure
      and,
      as applicable, the agreed upon plan of correction, the Department may proceed
      with default remedies.

     

    4.
      Non-enforcement not to constitute waiver
      The
      failure of either party to insist upon strict performance of any terms or
      conditions of this agreement shall not be deemed a waiver of the term or
      condition or any remedy that each party has with respect to that term or
      condition nor shall it preclude a subsequent default by reason of the failure
      to
      perform.

     

    5.
      Cancellation and Recoupment

    (a)
      This
      agreement shall remain in full force and effect for the entire term of the
      contract period specified in Section LA, above, unless either party provides
      written notice ninety (90) days or more from the date of termination, except
      that no cancellation by the contractor may be effective for failure to provide
      services for the agreed

     

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    price
      or
      rate and cancellation by the Department shall not be effective against services
      already rendered, so long as the services were rendered in compliance with
      the
      contract during the term of the contract.

    (b)
      In
      the event the health or welfare of the service recipients is endangered, the
      Department may cancel the contract and take any immediate action without notice
      it deems appropriate to protect the health and welfare of service recipients.
      The Department shall notify the contractor of the specific reasons for taking
      such action in writing within five (5) business days of cancellation. "Within
      five (5) business days
      of
      receipt of this notice, the contractor may request in writing a meeting with
      the
      commissioner of the Department or his/her designee. Any such meeting shall
      be
      held within five (5) business days of the written request. At the meeting,
      the
      contractor shall be given an opportunity to present information on why the
      Department's actions should be reversed or modified. Within five (5) business
      days of such meeting, the commissioner of the Department shall notify the
      contractor in writing of his/her decision upholding, reversing or modifying
      the
      action of the Department. This action of the commissioner shall be considered
      final.

    (c)
      The
      Department reserves the right to cancel the contract without prior notice when
      the funding for the contract is no longer available.

    (d)
      The
      Department reserves the right to recoup any deposits, prior payment, advance
      payment or down payment made if the contract is terminated by either party.
      Allowable costs incurred to date of termination for operation or transition
      of
      program(s) under this contract shall not be subject to recoupment. The
      contractor agrees to return to the Department any funds not expended in
      accordance with the terms and conditions of the contract and, if the contractor
      fails to do so upon demand, the Department may recoup said funds from any future
      payments owing under this contract or any other contract between the state
      and
      the contractor.

     

    6.
      Transition after Termination or Expiration of Contract In the event
      that this contract is terminated for any reason except where the health and
      welfare of service recipients is endangered or if the Department does not offer
      the contractor a new contract for the same or similar service at the contract's
      expiration, the contractor will assist in the orderly transfer of clients served
      under this contract as required by the Department and will assist in the orderly
      cessation of operations under this contract. Prior to incurring expenses related
      to the orderly transfer or continuation of services to service recipients beyond
      the terms of the contract, the Department and the contractor agree to negotiate
      a termination amendment to the existing agreement to address current program
      components and expenses, anticipated expenses necessary for the orderly transfer
      of service recipients and changes to the current program to address service
      recipient needs. The contractual agreement may be amended as necessary- to
      assure transition requirements are met during the term of this contract. If
      the
      transition cannot be concluded during this term, the Department and the
      contractor may negotiate an amendment to extend die term of the current contract
      until the transition may be concluded.

     

    7.
      Program Cancellation
      Where
      applicable, the cancellation or termination of any individual program or
      services under this contract will not, in and of itself, in anyway affect the
      status of any other program or service in effect under this
      contract.

     

    Page
      113
      of 114

     

     

    

      [
        ]
        Original Contract

      [
        ]
        Amendment #
        __
(For
        Internal Use Only)

       

      ACCEPTANCES
        AND APPROVALS

       

      The
        Contractor herein IS or IS NOT a Business Associate under
        HIPAA:

      (circle
        one)

       

      By
        the Contractor:

      

      

      
        	
                WellCare
                  of Connecticut, Inc.

              	 
	
                         
                  /s/ Todd S.
                  Farha           
                            
                  

                Signature
                  (authorized Official)

              	
                4/25/06     
                  

                Date

              
	
                 

                Todd
                  S.
                  Farha                                    
                  

                Typed
                  Name of Authorized Official

              	
                President
                  & CEO     

                Title

              
	
                 

                Document
                  necessary to demonstrate the authorization to sign must be
                  attached

              
	
                 

                By
                  the Department:

                 

              	 
	
                Department
                  of Social Services

                Department
                  Name

                 

              	 
	
                /s/
                  Michael P.
                  Starkowski                  

                Signature
                  (Authorized Official)

                 

              	
                5/1/06

                Date

              
	
                Michael
                  P.
                  Starkowski                       
                  

                Michael
                  P. Starkowski

              	
                 

                Deputy
                  Commissioner

              
	
                 

                By
                  the Office of the Attorney General: (approved
                  as to form & legal sufficiency)

              
	
                 

                Assistant
                  / Associate Attorney General

              	
                4/25/06     
                  

                Date

              
	
                 

                (Print
                  name)

              	 
	 	 

      

      

      ____
        If
        checked, this
        contract used a template for Part I which was reviewed and approved by the
        Office of the Attorney General (OAG)
        and is listed
        in
        the Waiver from AOG review in the Memorandum of Agreement currently in effect
        with the Department

      

       

      Page
        114
        of 114

    

     

    

    
       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

        

          STATE
            OF CONNECTICUT DEPARTMENT OF SOCIAL SERVICES

           

          Authorization
            of Signature Document

           

          I,
            Thaddeus Bereday, Senior Vice President, General Counsel and Secretary
            of
            WellCare of Connecticut, Inc. (f/k/a/ FirstChoice Health Plans of Connecticut,
            Inc.), a corporation organized under the laws of the State of Connecticut,
            hereby certifies that the following is a full and true copy of a resolution
            adopted at a meeting of the Board of Directors of said company, duly
            held on the
            30th
            day of
            March, 2005:

           

          "RESOLVED
            that Todd S. Farha, President and Chief Executive Officer is hereby authorized
            to make, execute and approve on behalf of this company, any and all contracts
            and amendments and to execute and approve on behalf of this company,
            other
            instruments, a part of or incident to such contracts and amendments effective
            until otherwise ordered by the Board of Directors".

           

          Also,
            I
            do further certify that the above resolution has not been in anyway altered,
            amended or repealed, and is now in full force and effect. IN WITNESS
            WHEREOF, I
            have hereunto set my hand and affixed the corporate seal of said company
            this
            26th
            day of
            April, 2006.

           

          

          

          
            	
                           
                      /s/ Thaddeus Bereday       
                      

                  	
                        
                      4/26/06       

                  
	
                    Authorized
                      Signature, Title

                  	
                    Date

                  

          

          

          

          

           

          (Seal
            or
            L.S.)

           

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          GIFT
            AFFIDAVIT

          (CONTRACT
            - NO PREVIOUS BID OR PROPOSAL)

          

          Gift
            affidavit to accompany state procurements with a value of $50,000 or
            more in a
            calendar year or fiscal year and licensing arrangements with a cost to
            the State
            greater than $50,000 in a calendar year, pursuant Conn. Stat. §4-250
            and 251, Governor M. Jodi Rell’s Executive Order No. 7B, para.
            10.

          

          

           

          

          
            	
                    Contractor:
                      WELLCARE of CONNECTICUT, Inc.

                  	
                    Amount:

                  
	
                    Contract
                      #: 093-HUS-WCC-2

                  	
                    Period:
                      07/01/05 - 06/30/07

                  

          

          

          

           

          I
            Todd S.
            Farha, of WellCare of Connecticut, Inc., hereby swear that during the
            two-year
            period preceding the date this contract was executed that neither myself
            nor any
            principals or key personnel of the contracting firm or corporation who
            participated directly, extensively and substantially in the negotiation
            of this
            contract, nor any agent of the above, gave a gift as defined in Conn.
            Gen. Stat.
§1-79(e), including a life event gift as defined in Conn. Gen. Stat. § 1-79(e)
            (12), to (1) any public official or state employee of the state agency
            or
            quasi-public agency who executed or participated directly, extensively,
            and
            substantially in the negotiation or award of the contract or (2) to any
            public
            official or state employee who has supervisory or appointing authority
            over the
            state agency or quasi-public agency executing this contract, except the
            gifts
            listed below:

           

          
            	
                    Benefactor

                  	
                    Recipient

                  	
                    Description
                      of Gift

                  	
                    Value

                  	
                    Date

                  
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 

          

           

          Further,
            neither I nor any principals or key personnel of the contracting firm
            or
            corporation who participated directly, extensively and substantially
            in the
            negotiation or award of this contract know of any action to circumvent
            this gift
            affidavit.

           

          

          

          Sworn
            as
            true to the best of my knowledge and belief subject to the penalties
            of false
            statement.

          

          
            	
                          
                      /s/ Todd S. Farha       
                      

                    Signature

                  	
                     4/26/06 
                      

                    Date

                  
	
                    Sworn
                      and subscribed before me in this 26th
                      day of April
                      , 2006 

                                      
                      /s/ Rebecca
                      Neal            
                                  

                    Commissioner
                      of the Superior Court Notary

                    Commission
                      Expires 6/19/07Exhibit 10.2

    
      Back
        to Form 8-K

      
        

      

    

    Exhibit
      10.2

     

     

    

      STATE
        OF CONNECTICUT 

      DEPARTMENT
        OF SOCIAL SERVICES 

      CONTRACT
        AMENDMENT

       

       

      

        
          	
                  Amendment
                    Number:

                	
                  15

                
	
                  Contract
                    #:

                	
                  093-MED-WCC-l

                
	
                  Contract
                    Period:

                	
                  08/11/2001
                    - 06/30/2007

                
	
                  Contractor
                    Name:

                	
                  WELLCARE
                    OF CONNECTICUT, INC.

                
	
                  Contractor
                    Address:

                	
                  116
                    Washington Avenue, 2nd
                    Floor, North Haven, CT
                    06473

                

        
 

        
          

        

      

       

      In
        response to the Orders by the Freedom of Information Commission, issued December
        14,2005 and April 12, 2006, contract number 093-MED-WCC-l by and between
        the
        Department of Social Services (the "Department") and WELLCARE of CONNECTICUT,
        Inc. (the "Contractor") for the provision of services under the HUSKY A program
        as amended by Amendments 1,2, 3,4,5,6,7, 8, 9,10,11,12,13 and 14 is hereby
        further amended as follows:

      

      1.
        In
        performing any acts required or described by this Contract, the Contractor
        shall
        be considered to be performing a governmental function for the Department,
        as
        that term is defined in section 1-200(11) of the Connecticut General Statutes.
        Pursuant to section 1-218 of the Connecticut General Statutes, therefore,
        the
        Department is entitled to receive a copy of records and files related to
        the
        performance of the governmental function, as set forth in this Contract.
        Such
        records and files are subject to the Freedom of Information Act and may be
        disclosed by the Department pursuant to the Freedom of Information Act. Requests
        to inspect or copy such records or files shall be made to DSS in accordance
        with
        the Freedom of Information Act. Accordingly, if the Contractor is in receipt
        of
        a request made pursuant to the Freedom of Information Act to inspect or copy
        such records or files, the Contractor shall forward that request to
        DSS.

       

      2.
        Upon
        receipt of a Freedom of Information Act request by the Department that seeks
        records or files related to the performance of the governmental function
        performed by the Contractor for the Department, the Department shall send
        such
        request to the Contractor. The Contractor shall review the request and, with
        reasonable promptness, search its records and files for documents that are
        responsive to the request. The Contractor shall send to the Department a
        copy of
        those documents that are responsive to the request. If, upon review of the
        request, the Contractor determines that it will require more than fourteen
        (14)
        days to search for and provide copies of responsive documents to the Department,
        the Contractor shall contact the Department within seven (7) days of the
        receipt
        of the request from the Department.

       

      3.
        If the
        Contractor concludes that any of the responsive documents may be exempt from
        disclosure pursuant to section l-210(b) of the Connecticut General Statutes,
        the
        Contractor shall mark said documents prior to sending them to the Department
        and
        explain the basis for its conclusion. The Department shall review the
        Contractor's explanation and, as necessary, discuss said conclusion with
        the
        Contractor. If the Department agrees that the marked documents may be exempt
        under section l-210(b) of the Connecticut General Statutes, the Department
        shall
        not release those documents in its response to the Freedom of Information
        request. If, however, the Department disagrees, in good faith, with the
        conclusion by the Contractor that said documents may be exempt pursuant to
        section l-210(b) of the Connecticut General Statutes, the Department shall
        notify the Contractor, in writing, that it intends to release the documents
        fourteen (14) days from the date of the notice.

       

      4.
        If the
        Contractor concludes that a document is protected by the attorney-client
        or work
        product privilege, the Contractor may decline to produce the document and
        must
        specifically assert the privilege by identifying the nature of the document
        and
        claiming the privilege.

      5.
        If the
        Contractor asserts an exemption under paragraph 3 or a privilege under paragraph
        4 of this Contract, and the Department honors said claim, the Contractor
        shall
        seek to intervene in order to defend the claim for an exemption or privilege
        in
        any subsequent Freedom of Information Commission proceeding challenging the
        Department's refusal to disclose said documents.

       

      6.
        This
        Amendment is entered into as a result of orders of the Freedom of Information
        Commission..If,
        at
        any time, such orders are reversed or otherwise declared not legal and binding,
        this Amendment shall no longer be in effect.

       

      7.
        To the
        extent that this amendment conflicts with any other provisions of the Contract,
        this amendment supersedes those provisions. Otherwise, the other provisions
        of
        the Contract remain intact.

       

      ACCEPTANCES
        AND APPROVALS

       

      This
        document constitutes an amendment to the above numbered contract. All provisions
        of that contract, except those explicitly changed or described above by this
        amendment, shall remain in full force and effect.

       

      

      
        	
                 

                CONTRACTOR

              	 	
                 

                DEPARTMENT

              
	
                WellCare
                  of Connecticut, Inc

              	 	 Department
                of Social Services
	
                 

                /s/
                  Todd S.
                  Farha                                                           
                  4/25/06                     
                  

              	 	
                 

                    
                  /s/ Michael
                  Starkowski                                                  
                  5/1/06 

              
	
                Signature
                  ( Authorized
                  Official)                                    
                  (Date)

              	 	
                Signature
                  ( Authorized
                  Official)                                         (Date)

              
	
                 

                OFFICE
                  OF THE ATTORNEY GENERAL

              	 	 
	 	 	 
	
                 

                Attorney
                  General (as to form)

              	 	 
	
                 

                ( 
                  )This contract does require the signature of the Attorney General
                  pursuant
                  to an agreement between the Department and the Office of the Attorney
                  General dated: _____

              

      

       

    

    
       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

        

          
            
              
                

                  STATE
                    OF CONNECTICUT DEPARTMENT OF SOCIAL SERVICES

                   

                  Authorization
                    of Signature Document

                   

                  I,
                    Thaddeus Bereday, Senior Vice President, General Counsel and
                    Secretary of
                    WellCare of Connecticut, Inc. (f/k/a/ FirstChoice Health Plans
                    of Connecticut,
                    Inc.), a corporation organized under the laws of the State of
                    Connecticut,
                    hereby certifies that the following is a full and true copy of
                    a resolution
                    adopted at a meeting of the Board of Directors of said company,
                    duly held on the
                    30th
                    day of
                    March, 2005:

                   

                  "RESOLVED
                    that Todd S. Farha, President and Chief Executive Officer is
                    hereby authorized
                    to make, execute and approve on behalf of this company, any and
                    all contracts
                    and amendments and to execute and approve on behalf of this company,
                    other
                    instruments, a part of or incident to such contracts and amendments
                    effective
                    until otherwise ordered by the Board of Directors".

                   

                  Also,
                    I
                    do further certify that the above resolution has not been in
                    anyway altered,
                    amended or repealed, and is now in full force and effect. IN
                    WITNESS WHEREOF, I
                    have hereunto set my hand and affixed the corporate seal of said
                    company this
                    26th
                    day of
                    April, 2006.

                   

                  

                  

                  
                    	
                               
                               /s/ Thaddeus Bereday     

                          	
                             
                              4/26/06  

                          
	
                            Authorized
                              Signature, Title

                          	
                            Date

                          

                  

                  

                  

                  

                   

                  (Seal
                    or
                    L.S.)

                   

                  

                  
                    
                      
                      

                    

                    
                      
                      

                      
                        

                      

                    

                    
                      
                      

                    

                  

                   

                  GIFT
                    AFFIDAVIT

                  (CONTRACT
                    - NO PREVIOUS BID OR PROPOSAL)

                  

                  Gift
                    affidavit to accompany state procurements with a value of $50,000
                    or more in a
                    calendar year or fiscal year and licensing arrangements with
                    a cost to the State
                    greater than $50,000 in a calendar year, pursuant Conn. Stat.
§4-250
                    and 251, Governor M. Jodi Rell’s Executive Order No. 7B, para.
                    10.

                  

                   

                  

                  
                    	
                            Contractor:
                              WELLCARE of CONNECTICUT, Inc.

                          	
                            Amount:

                          
	
                            Contract
                              #: 093-MED-WWC-1

                          	
                            Period:
                              08/11/01 - 06/30/07

                          

                  

                  

                  

                   

                  I
                    Todd S.
                    Farha, of WellCare of Connecticut, Inc., hereby swear that during
                    the two-year
                    period preceding the date this contract was executed that neither
                    myself nor any
                    principals or key personnel of the contracting firm or corporation
                    who
                    participated directly, extensively and substantially in the negotiation
                    of this
                    contract, nor any agent of the above, gave a gift as defined
                    in Conn. Gen. Stat.
§1-79(e), including a life event gift as defined in Conn. Gen.
                    Stat. § 1-79(e)
                    (12), to (1) any public official or state employee of the state
                    agency or
                    quasi-public agency who executed or participated directly, extensively,
                    and
                    substantially in the negotiation or award of the contract or
                    (2) to any public
                    official or state employee who has supervisory or appointing
                    authority over the
                    state agency or quasi-public agency executing this contract,
                    except the gifts
                    listed below:

                   

                   

                  
                    	
                            Benefactor

                          	
                            Recipient

                          	
                            Description
                              of Gift

                          	
                            Value

                          	
                            Date

                          
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 

                  

                   

                  Further,
                    neither I nor any principals or key personnel of the contracting
                    firm or
                    corporation who participated directly, extensively and substantially
                    in the
                    negotiation or award of this contract know of any action to circumvent
                    this gift
                    affidavit.

                   

                  

                  

                  Sworn
                    as
                    true to the best of my knowledge and belief subject to the penalties
                    of false
                    statement.

                  

                  
                    	
                                   /s/
                              Todd S. Farha          
                              

                            Signature

                          	
                             
                              4/26/06  

                            Date

                          
	
                            Sworn
                              and subscribed before me in this 26th
                              day of April
                              , 2006 

                                         
                              /s/ Rebecca
                              Neal                 
                                                                                                              
                              

                            Commissioner
                              of the Superior Court Notary

                            Commission
                              Expires  6/19/07

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